Paul Mitchell’s journal round-up for 15th May 2017

Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.

Informal care: choice or constraint. Scandinavian Journal of Caring Sciences [PubMed] Published 12th April 2017

The provision of social care in the UK has become a major economic issue, with recent increases in government spending and local authority taxation to help ease the burden on both the health and social care system in the short term. This study examines some of the issues surrounding informal carers (i.e. care of a family member), estimated to be approximately 10% of the UK population. In particular, it focuses on the role of choice and constraints involved with the decision to become a carer. Using a cross-sectional survey for a UK city, choice of caring was explored in terms of responses to care provision provided, asking if it was a free choice initially to provide care, and if there were constraints in terms of duty, lack of others or financial resources for paid care. The analysis focused on how perceived choice in the caring role was associated with socio-demographics and the type of caring role performed, as well as the role of perceived choice in caring and their wellbeing. Out of the 798 respondents to all four questions on caring choice, about 1 in 3 reported an entirely free choice in the decision, with half reporting having a free choice but also a constraint in terms of duty, other available carers or financial resources. Less than 1 in 5 reported not having a free choice. Only carers with bad health or receiving state benefits had an association with a constrained caring role. The more intense the care role was also associated with a more constrained choice. Higher levels of choice were associated with higher levels of wellbeing across measures of happiness, life satisfaction and capability. In multivariable regression analysis, it was found that having a free choice in the initial caring decision resulted in a higher impact on life satisfaction than educational qualifications and home ownership, whilst improved capability of comparable levels to that of home ownership, all else being equal. The authors thus recommend enhanced choice as a way for policy to improve carers wellbeing. Although the authors acknowledge limitations with the study design being cross-sectional and geographically limited to one city, the study shows there is plenty of scope for understanding the determinants of informal caring and consequences for those carers in much greater detail in future national surveys to help address policy in this area in the medium to longer term.

Experienced utility or decision utility for QALY calculation? Both. Public Health Ethics [PhilPapersPublished 6th May 2017

How health states should be valued in population health metrics, like QALYs and DALYs, will not be an unfamiliar topic of discussion for regular readers of this blog. Instead of arguing for decision utility (i.e. accounting for general population preferences for avoiding health states) or experienced utility (i.e. accounting for patient experiences of health states), the authors in this paper argue for a combined approach, reviving a suggestion previously put forward by Lowenstein & Ubel. The authors neatly summarise some of the issues of relying on either decision utility or experienced utility approaches alone and instead argue for better informed decision utility exercises by using deliberative democracy methods where experienced utility in health states are also presented. Unfortunately, there is little detail of how this process might actually work in practice. There are likely to be issues of what patient experiences are presented in such an exercise and how other biases that may influence decision utility responses are controlled for in such an approach. Although I am generally in favour of more deliberative approaches to elicit informed values for resource allocation, I find that this paper makes a convincing case for neither of the utility approaches to valuation, rather than both.

The value of different aspects of person-centred care: a series of discrete choice experiments in people with long-term conditions. BMJ Open [PubMed] Published 26th April 2017

The term “person-centred care” is one which is gaining some prominence in how healthcare is provided. What it means, and how important different aspects of person-centred care are, is explored in this study using discrete choice experiments (DCEs). Through focus groups and drawing from the authors’ own experience in this area, four aspects of person-centred care for self-management of chronic conditions make up the attributes in the DCE across two levels: (i) information (same information for all/personalised information); (ii) situation (little account of current situation/suggestions that fit current situation); (iii) living well (everyone wants the same from life/works with patient for what they want from life); (iv) communication (neutral professional way/friendly professional way). A cost attribute was also attached to the DCE that was given to patient groups with chronic pain and chronic lung disease. The overall findings suggest that person-centred care focused on situation and living well were valued most with personal communication style valued the least. Latent class analysis also suggested that 1 in 5 of those sampled valued personalised information the most. Those with lower earnings were likely to look to reduce the cost attribute the most. The authors conclude that the focus on communication in current clinician training on person-centred care may not be what is of most value to patients. However, I am not entirely convinced by this argument, as it could be that communication was not seen as an issue by the respondents, perhaps somewhat influenced due to the skills clinicians already have obtained in this area. Clearly, these process aspects of care are difficult to develop attributes for in DCEs, and the authors acknowledge that the wording of the “neutral” and “high” levels may have biased responses. I also found that dropping the “negative” third level for each of the attributes unconvincing. It may have proved more difficult to complete than two levels, but it would have shown in much greater depth how much value is attached to the four attributes relative to one another.

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Chris Sampson’s journal round-up for 3rd April 2017

Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.

Return on investment of public health interventions: a systematic review. Journal of Epidemiology & Community Health [PubMed] Published 29th March 2017

Cost-effectiveness analysis in the context of public health is tricky. Often the health benefits are small at the individual level and the returns to investment might be cross-sectoral. Lots of smart people believe that spending on public health is low in proportion to other health spending. Here we have a systematic review of studies reporting cost-benefit ratios (CBR) or return on investment (ROI) estimates for public health interventions. The stated aim of the paper is to demonstrate the false economy associated with cuts to public health spending. 52 titles were included from a search that identified 2957. The inclusion and exclusion criteria are not very clear, with some studies rejected on the basis of ‘poor generalisability to the UK’. There’s a bit too much subjectivity sneaking around in the methods for my liking.  Results for CBR and ROI estimates are presented according to local or national level and grouped by ‘specialism’. From all studies, the median CBR was 8.3 and the median ROI was 14.3. As we might have suspected, public health interventions are cost-saving in a big way. National health protection and legislative interventions offered the greatest return on investment. While there is wide variation in the results, all specialism groupings showed a positive return on average. I don’t doubt the truth of the study’s message – that cuts to public health spending are foolish. But the review doesn’t really demonstrate what the authors want it to demonstrate. We don’t know what (if any) disinvestment is taking place with respect to the interventions identified in the review. The results presented in the study represent a useful reference point for discussion and further analysis, but they aren’t a sufficient basis for supporting general increases in public health spending. That said, the study adds to an already resounding call and may help bring more attention to the issue.

Acceptable health and priority weighting: discussing a reference-level approach using sufficientarian reasoning. Social Science & Medicine Published 27th March 2017

In some ways, the moral principle of sufficiency is very attractive. It acknowledges a desire for redistribution from the haves to the have-nots and may also make for a more manageable goal than all-out maximisation. It may also be particularly useful in specific situations, such as evaluating health care for the elderly, for whom ‘full health’ is never achievable and not a meaningful reference point. This paper presents a discussion of the normative issues at play, drawing insights from the distributive justice literature. We’re reminded of the fair innings argument as a familiar sufficientarian flavoured allocation principle. The sufficientarian approach is outlined in contrast to egalitarianism and prioritarianism. Strict sufficientarian value weighting is not a good idea. If we suppose a socially ‘acceptable’ health state value of 0.7, such an approach would – for example – value an improvement from 0.69 to 0.71 for one person as infinitely more valuable than an improvement from 0.2 to 0.6 for the whole population. The authors go on to outline some more relaxed sufficiency weightings, whereby improvements below the threshold are attributed a value greater than 0 (though still less than those achieving sufficiency). The sufficientarian approach alone is (forgive me) an insufficient framework for the allocation of health care resources and cannot represent the kind of societal preferences that have been observed in the literature. Thus, hybrids are proposed. In particular, a sufficientarian-prioritarian weighting function is presented and the authors suggest that this may be a useful basis for priority setting. One can imagine a very weak form of the sufficientarian approach that corresponds to a prioritarian weighting function that is (perhaps) concave below the threshold and convex above it. Still, we have the major problem of identifying a level of acceptable health that is not arbitrary. The real question you need to ask yourself is this: do you really want health economists to start arguing about another threshold?

Emotions and scope effects in the monetary valuation of health. The European Journal of Health Economics [PubMed] Published 24th March 2017

It seems obvious that emotions could affect the value people attach to goods and services, but little research has been conducted with respect to willingness to pay for health services. This study considers the relationship between a person’s self-reported fear of being operated on and their willingness to pay for risk-reducing drug-eluting stents. A sample of 1479 people in Spain made a series of choices between bare-metal stents at no cost and drug-eluting stents with some out-of-pocket cost, alongside a set of sociodemographic questions and a fear of surgery Likert scale. Each respondent provided 8 responses with 4 different risk reductions and 2 different willingness to pay ‘bids’. The authors outline what they call a ‘cognitive-emotional random utility model’ including an ’emotional shift effect’. Four different models are presented to demonstrate the predictive value of the emotion levels interacting with the risk reduction levels. The sample was split roughly in half according to whether people reported high emotion (8, 9 or 10 on the fear Likert) or low emotion (<8). People who reported more fear of being operated on were willing to pay more for risk reductions, which is the obvious result. More interesting is that the high emotion group exhibited a lower sensitivity to scope – that is, there wasn’t much difference in their valuation of the alternative magnitudes of risk reduction. This constitutes a problem for willingness to pay estimates in this group as it may prevent the elicitation of meaningful values, and it is perhaps another reason why we usually go for collective approaches to health state valuation. The authors conclude that emotional response is a bias that needs to be corrected. I don’t buy this interpretation and would tend to the view that the bias that needs correcting here is that of the economist. Emotions may be a justifiable reflection of personality traits that ought to determine preferences, at least at the individual level. But I do agree with the authors that this is an interesting field for further research if only to understand possible sources of heterogeneity in health state valuation.

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Alastair Canaway’s journal round-up for 20th February 2017

Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.

The estimation and inclusion of presenteeism costs in applied economic evaluation: a systematic review. Value in Health Published 30th January 2017

Presenteeism is one of those issues that you hear about from time to time, but rarely see addressed within economic evaluations. For those who haven’t come across it before, presenteeism refers to being at work, but not working at full capacity, for example, due to your health limiting your ability to work. The literature suggests that given presenteeism can have large associated costs which could significantly impact economic evaluations, it should be considered. These impacts are rarely captured in practice. This paper sought to identify studies where presenteeism costs were included, examined how valuation was approached and the degree of impact of including presenteeism on costs. The review included cost of illness studies as well as economic evaluations, just 28 papers had attempted to capture the costs of presenteeism, these were in a wide variety of disease areas. A range of methods was used, across all studies, presenteeism costs accounted for 52% (range from 19%-85%) of the total costs relating to the intervention and disease. This is a vast proportion and significantly outweighed absenteeism costs. Presenteeism is clearly a significant issue, yet widely ignored within economic evaluation. This in part may be due to the health and social care perspective advised within the NICE reference case and compounded by the lack of guidance in how to measure and value productivity costs. Should an economic evaluation pursue a societal perspective, the findings suggest that capturing and valuing presenteeism costs should be a priority.

Priority to end of life treatments? Views of the public in the Netherlands. Value in Health Published 5th January 2017

Everybody dies, and thus, end of life care is probably something that we should all have at least a passing interest in. The end of life context is an incredibly tricky research area with methodological pitfalls at every turn. End of life care is often seen as ‘different’ to other care, and this is reflected in NICE having supplementary guidance for the appraisal of end of life interventions. Similarly, in the Netherlands, treatments that do not meet typical cost per QALY thresholds may be provided should public support be sufficient. There, however, is a dearth of such evidence, and this paper sought to elucidate this issue using the novel Q methodology. Three primary viewpoints emerged: 1) Access to healthcare as a human right – all have equal rights regardless of setting, that is, nobody is more important. Viewpoint one appeared to reject the notion of scarce resources when it comes to health: ‘you can’t put a price on life’. 2) The second group focussed on providing the ‘right’ care for those with terminal illness and emphasised that quality of life should be respected and unnecessary care at end of life should be avoided. This second group did not place great importance on cost-effectiveness but did acknowledge that costly treatments at end of life might not be the best use of money. 3) Finally, the third group felt there should be a focus on care which is effective and efficient, that is, those treatments which generate the most health should be prioritised. There was a consensus across all three groups that the ultimate goal of the health system is to generate the greatest overall health benefit for the population. This rejects the notion that priority should be given to those at end of life and the study concludes that across the three groups there was minimal support for the possibility of the terminally ill being treated with priority.

Methodological issues surrounding the use of baseline health-related quality of life data to inform trial-based economic evaluations of interventions within emergency and critical care settings: a systematic literature review. PharmacoEconomics [PubMed] Published 6th January 2017

Catchy title. Conducting research within emergency and critical settings presents a number of unique challenges. For the health economist seeking to conduct a trial based economic evaluation, one such issue relates to the calculation of QALYs. To calculate QALYs within a trial, baseline and follow-up data are required. For obvious reasons – severe and acute injuries/illness, unplanned admission – collecting baseline data on those entering emergency and critical care is problematic. Even when patients are conscious, there are ethical issues surrounding collecting baseline data in this setting, the example used relates to somebody being conscious after cardiac arrest, is it appropriate to be getting them to complete HRQL questionnaires? Probably not. Various methods have been used to circumnavigate this issue; this paper sought to systematically review the methods that have been used and provide guidance for future studies. Just 19 studies made it through screening, thus highlighting the difficulty of research in this context. Just one study prospectively collected baseline HRQL data, and this was restricted to patients in a non-life threatening state. Four different strategies were adopted in the remaining papers. Eight studies adopted a fixed health utility for all participants at baseline, four used only the available data, that is, from the first time point where HRQL was measured. One asked patients to retrospectively recall their baseline state, whilst one other used Delphi methods to derive EQ-5D states from experts. The paper examines the implications and limitations of adopting each of these strategies. The key finding seems to relate to whether or not the trial arms are balanced with respect to HRQL at baseline. This obviously isn’t observed, the authors suggest trial covariates should instead be used to explore this, and adjustments made where applicable. If, and that’s a big if, trial arms are balanced, then all of the four methods suggested should give similar answers. It seems the key here is the randomisation, however, even the best randomisation techniques do not always lead to balanced arms and there is no guarantee of baseline balance. The authors conclude trials should aim to make an initial assessment of HRQL at the earliest opportunity and that further research is required to thoroughly examine how the different approaches will impact cost-effectiveness results.

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