Paul Mitchell’s journal round-up for 17th July 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.

What goes wrong with the allocation of domestic and international resources for HIV? Health Economics [PubMedPublished 7th July 2017

Investment in foreign aid is coming under considered scrutiny as a number of leading western economies re-evaluate their role in the world and their obligations to countries with developing economies. Therefore, it is important for those who believe in the benefits of such investments to show that they are being done efficiently. This paper looks at how funding for HIV is distributed both domestically and internationally across countries, using multivariate regression analysis with instruments to control for reverse causality between financing and HIV prevalence, and domestic and international financing. The author is also concerned about countries free riding on international aid and estimates how countries ought to be allocating national resources to HIV using quintile regression to estimate what countries have fiscal space for expanding their current spending domestically. The results of the study show that domestic expenditure relative to GDP per capita is almost unit elastic, whereas it is inelastic with regards to HIV prevalence. Government effectiveness (as defined by the World Bank indices) has a statistically significant effect on domestic expenditure, although it is nonlinear, with gains more likely when moving up from a lower level of government effectiveness. International expenditure is inversely related to GDP per capita and HIV prevalence, and positively with government effectiveness, albeit the regression models for international expenditure had poor explanatory power. Countries with higher GDP per capita tended to dedicate more money towards HIV, however, the author reckons there is $3bn of fiscal space in countries such as South Africa and Nigeria to contribute more to HIV, freeing up international aid for other countries such as Cameroon, Ghana, Thailand, Pakistan and Columbia. The author is concerned that countries with higher GDP should be able to allocate more to HIV, but feels there are improvements to be made in how international aid is distributed too. Although there is plenty of food for thought in this paper, I was left wondering how this analysis can help in aiding a better allocation of resources. The normative model of what funding for HIV ought to be is from the viewpoint that this is the sole objective of countries of allocating resources, which is clearly contestable (the author even casts doubt as to whether this is true for international funding of HIV). Perhaps the other demands faced by national governments (e.g. funding for other diseases, education etc.) can be better reflected in future research in this area.

Can pay-for-performance to primary care providers stimulate appropriate use of antibiotics? Health Economics [PubMed] [RePEcPublished 7th July 2017

Antibiotic resistance is one of the largest challenges facing global health this century. This study from Sweden looks to see whether pay for performance (P4P) can have a role in the prescription practices of GPs when it comes to treating children with respiratory tract infection. P4P was introduced on a staggered basis across a number of regions in Sweden to incentivise primary care to use narrow spectrum penicillin as a first line treatment, as it is said to have a smaller impact on resistance. Taking advantage of data from the Swedish Prescribed Drug Register between 2006-2013, the authors conducted a difference in difference regression analysis to show the effect P4P had on the share of the incentivised antibiotic. They find a positive main effect of P4P on drug prescribing of 1.1 percentage points, that is also statistically significant. Of interest, the P4P in Sweden under analysis here was not directly linked to salaries of GPs but the health care centre. Although there are a number of limitations with the study that the authors clearly highlight in the discussion, it is a good example of how to make the most of routinely available data. It also highlights that although the share of the less resistant antibiotic went up, the national picture of usage of antibiotics did not reduce in line with a national policy aimed at doing so during the same time period. Even though Sweden is reported to be one of the lower users of antibiotics in Europe, it highlights the need to carefully think through how targets are achieved and where incentives might help in some areas to meet such targets.

Econometric modelling of multiple self-reports of health states: the switch from EQ-5D-3L to EQ-5D-5L in evaluating drug therapies for rheumatoid arthritis. Journal of Health Economics Published 4th July 2017

The EQ-5D is the most frequently used health state descriptive system for the generation of utility values for quality-adjusted life years (QALYs) in economic evaluation. To improve sensitivity and reduce floor and ceiling effects, the EuroQol team developed a five level version (5L) compared to the previous three level (3L) version. This study adds to recent evidence in this area of the unforeseen consequences of making this change to the descriptive system and also the valuation system used for the 5L. Using data from the National Data Bank for Rheumatic Diseases, where both 3L and 5L versions were completed simultaneously alongside other clinical measures, the authors construct a mapping between both versions of EQ-5D, informed by the response levels and the valuation systems that have been developed in the UK for the measures. They also test their mapping estimates on a previous economic evaluation for rheumatoid arthritis treatments. The descriptive results show that although there is a high correlation between both versions, and the 5L version achieves its aim of greater sensitivity, there is a systematic difference in utility scores generated using both versions, with an average 87% of the score of the 3L recorded compared to the 5L. Not only are there differences highlighted between value sets for the 3L and 5L but also the responses to dimensions across measures, where the mobility and pain dimensions do not align as one would expect. The new mapping developed in this paper highlights some of the issues with previous mapping methods used in practice, including the assumption of independence of dimension levels from one another that was used while the new valuation for the 5L was being developed. Although the case study they use to demonstrate the effect of using the different approaches in practice did not result in a different cost-effectiveness result, the study does manage to highlight that the assumption of 3L and 5L versions being substitutes for one another, both in terms of descriptive systems and value sets, does not hold. Although the authors are keen to highlight the benefits of their new mapping that produces a smooth distribution from actual to predicted 5L, decision makers will need to be clear about what descriptive system they now want for the generation of QALYs, given the discrepancies between 3L and 5L versions of EQ-5D, so that consistent results are obtained from economic evaluations.

Credits

Thesis Thursday: Raymond Oppong

On the third Thursday of every month, we speak to a recent graduate about their thesis and their studies. This month’s guest is Dr Raymond Oppong who graduated with a PhD from the University of Birmingham. If you would like to suggest a candidate for an upcoming Thesis Thursday, get in touch.

Title
Economic analysis alongside multinational studies
Supervisors
Sue Jowett, Tracy Roberts
Repository link
http://etheses.bham.ac.uk/7288/

What attracted you to studying economic evaluation in the context of multinational studies?

One of the first projects that I was involved in when I started work as a health economist was the Genomics to combat Resistance against Antibiotics in Community-acquired lower respiratory tract infections (LRTI) in Europe (GRACE) project. This was an EU-funded study aimed at integrating and coordinating the activities of physicians and scientists from institutions in 14 European countries to combat antibiotic resistance in community-acquired lower respiratory tract infections.

My first task on this project was to undertake a multinational costing study to estimate the costs of treating acute cough/LRTI in Europe. I faced quite a number of challenges including the lack of unit cost data across countries. Conducting a full economic evaluation alongside the interventional studies in GRACE also brought up a number of issues with respect to methods of analysis of multinational trials which needed to be resolved. The desire to understand and resolve some of these issues led me to undertake the PhD to investigate the implications of conducting economic evaluations alongside multinational studies.

Your thesis includes some case studies from a large multinational project. What were the main findings of your empirical work?

I used three main case studies for my empirical work. The first was an observational study aimed at describing the current presentation, investigation, treatment and outcomes of community-acquired lower respiratory tract infections and analysing the determinants of antibiotic use in Europe. The other 2 were RCTs. The first was aimed at studying the effectiveness of antibiotic therapy (amoxicillin) in community-acquired lower respiratory tract infections, whilst the second was aimed at assessing training interventions to improve antibiotic prescribing behaviour by general practitioners. The observational study was used to explore issues relating to costing and outcomes in multinational studies whilst the RCTs explored the various analytical approaches (pooled and split) to economic evaluation alongside multinational studies.

The results from the observational study revealed large variations in costs across Europe and showed that contacting researchers in individual countries was the most effective way of obtaining unit costs. Results from both RCTs showed that the choice of whether to pool or split data had an impact on the cost-effectiveness of the interventions.

What were the key analytical methods used in your analysis?

The overall aim of the thesis was to study the implications of conducting economic analysis alongside multinational studies. Specific objectives include: i) documenting challenges associated with economic evaluations alongside multinational studies, ii) exploring various approaches to obtaining and estimating unit costs, iii) exploring the impact of using different tariffs to value EQ-5D health state descriptions, iv) comparing methods that have been used to conduct economic evaluation alongside multinational studies and v) making recommendations to guide the design and conduct of future economic evaluations carried out alongside multinational studies.

A number of approaches were used to achieve each of the objectives. A systematic review of the literature identified challenges associated with economic evaluations alongside multinational studies. A four-stage approach to obtaining unit costs was assessed. The UK, European and country-specific EQ-5D value sets were compared to determine which is the most appropriate to use in the context of multinational studies. Four analytical approaches – fully pooled one country costing, fully pooled multicountry costing, fully split one country costing and fully split multicountry costing – were compared in terms of resource use, costs, health outcomes and cost-effectiveness. Finally, based on the findings of the study, a set of recommendations were developed.

You completed your PhD part-time while working as a researcher. Did you find this a help or a hindrance to your studies?

I must say that it was both a help and a hindrance. Working in a research environment was really helpful. There was a lot of support from supervisors and colleagues which kept me motivated. I might have not gotten this support if I was not working in a research/academic environment. However, even though some time during the week was allocated to the PhD, I had to completely put it on hold for long periods of time in order to deal with the pressures of work/research. Consequently, I always had to struggle to find my bearings when I got back to the PhD. I also spent most weekends working on the PhD especially when I was nearing submission.

On the whole, it should be noted that a part-time PhD requires a lot of time management skills. I personally had to go on time management courses which were really helpful.

What advice would you give to a health economist conducting an economic evaluation alongside a multinational study?

For a health economist conducting an economic evaluation alongside a multinational trial, it is important to plan ahead and understand the challenges that are associated with economic evaluations alongside multinational studies. A lot of the problems such as those related to the identification of unit costs can be avoided by ensuring adequate measures are put in place at the design stage of the study. An understanding of the various health systems of the countries involved in the study is important in order to make a judgement about the differences and similarities in resource use across countries. Decision makers are interested in results that can be applied to their jurisdiction; therefore it is important to adopt transparent methods e.g. state the countries that participated in the study, state the sources of unit costs and make it clear whether data from all countries (pooling) or from a subset (splitting) were used. To ensure that the results of the study are generalisable to a number of countries it may be advisable to present country-specific results and probably conduct the analysis from different perspectives.

Thesis Thursday: Thomas Allen

On the third Thursday of every month we speak to a recent graduate about their thesis and their studies. This month’s guest is Dr Thomas Allen who graduated with a PhD from the University of Manchester. If you would like to suggest a candidate for an upcoming Thesis Thursday, get in touch.

Title
The impact of provider incentives on professionals and patients
Supervisors
Matt Sutton, William Whittaker
Repository link
https://www.escholar.manchester.ac.uk/item/?pid=uk-ac-man-scw:296844

Let’s dive straight in: what was the most important or overarching finding of your research?

My thesis focused on a large financial incentive scheme for UK GPs. So the thesis is a collection of UK studies, but I think the main findings can be generalised reasonably well.

Two of these studies actually looked at how the non-financial incentives of the scheme affected GPs, namely reputation and peer effects. I found reputation became more important, compared to revenue, a few years into the scheme. My explanation for this: reputation matters once you can observe performance benchmarks.

As for peer effects, the focus was on how practices react to their peer groups getting larger, this was caused by mergers in PCTs (groups of practices). You might expect peer effects to shrink when the group gets larger and this is what I found. Practice performance is also pulled down by poor peers more than it is pulled up by good peers. An analogy to merging a good classroom with a bad classroom is helpful to imagine.

There is quite a lot of variation (at GP level) in the amount of income that was linked to performance, 10-30% in most cases, so the third study exploits this variation. The size of this exposure to performance pay does affect GPs working lives – their job satisfaction, working hours, intentions to quit etc.

The final study was pretty novel as it linked patient reported quality with practice reported quality. It seemed to be the case that as practices improved on the incentivised areas of quality (e.g. blood pressure test) they got worse on the non-incentivised areas (communication).

What were the main methodologies that you used and which researchers’ work did your study most depend on?

It was a quantitative thesis so various regression methods were used. I’ll admit there was nothing particularly special or new with the methods used, they were standard methods but I think they were applied in interesting ways. For example, two studies linked existing datasets in new ways so I could answer questions which would have otherwise been impossible, probably. One method used which is not so common was the continuous difference in differences from the job satisfaction chapter. It’s been used before by David Card and Carol Propper. It can be used when you have a continuous treatment variable, instead of the typical treatment vs control situation. Everyone is treated but there is some exogenous factor deciding the amount of treatment.

I’m not sure there is one researcher that my study most depended on. The four different empirical chapters were influenced by slightly different literatures. Two big influences were systematic reviews of financial incentives (Scott et al. 2011) and of the scheme which I studied (Steel & Willems 2010). Both helped to identify areas where I could add to the existing literature.

What was the most surprising thing that you discovered; was there anything odd or unexpected?

Lots of theories would suggest an effect of pay for performance on job satisfaction and working lives. For example, large financial incentives should crowd out internal motivation and so reduce job satisfaction. Pay for performance appeals more to risk seeking individuals; those who are risk averse should feel uncomfortable as more income is linked to performance. Pay for performance can often result in wage dispersion, where incomes differ because some individuals perform better, this is usually linked to lower job satisfaction. A section of Chapter 6 is dedicated to these theories but I found no effect of pay for performance on GPs’ job satisfaction or working lives. Even specific areas you would expect to be affected weren’t, like satisfaction with choice of working methods or levels of autonomy.

This was certainly an unexpected result but I think still very interesting. I was able to publish this quite recently in Social Science & Medicine.

What was the biggest challenge that you encountered during your PhD, and did it change the direction of your research?

I started to answer this saying I didn’t have any big challenges but then a few came to me. I guess looking back they don’t seem as significant as they were at the time.

In the first few weeks I realised one of the studies from the PhD proposal couldn’t be done – basically I wanted to use PROMs to analyse a policy but had glossed over the difference between hip fractures and hip replacements, which seems very obvious now. I had to think of Plan B.

Plan B turned into Plan C around the end of my second year. I was going to try linking three datasets to measure the impact of pay for performance using administrative data, patient data and GP data. Imagine a Venn diagram of the overlapping samples from these three datasets. In the end the sample covered by all three was too small.

I’m pleased with how the thesis turned out, these challenges ended up improving the finished product.

Have you any words of wisdom for any researchers who might be embarking on a similar programme of research?

On this research area… The incentive scheme I focused on, the QOF, has been around for 12 years. If you have a new research question maybe someone else already tried it and it doesn’t work. Review the literature well and talk to those who have done work on the scheme. My internal examiner was a GP. She gave some great insight which would have been helpful at the start of the PhD not the end! So if you can, talk with those affected by the incentive or policy you are evaluating – it might not work in the way described in policy documents.

On PhDs generally… Choose your supervisors wisely – they are more than just a boss/manager, so try and find someone you think you can work with, not for. If you can, have a professor and a less senior person. Matt and Will were a great combo. In the end you might find you are sick of the PhD topic, so make sure you at least start off liking it. Don’t just pick it because it is the only one going. Try and do some extra work: teaching, collaborate with others, blogs. But make sure you gain from it in some way. Plan your time well at the start. You won’t stick to it, but at least you’ll know how far you are behind.