Rita Faria’s journal round-up for 15th April 2019

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.

Emulating a trial of joint dynamic strategies: an application to monitoring and treatment of HIV‐positive individuals. Statistics in Medicine [PubMed] Published 18th March 2019

Have you heard about the target trial approach? This is a causal inference method for using observational evidence to compare strategies. This outstanding paper by Ellen Caniglia and colleagues is a great way to get introduced to it!

The question is: what is the best test-and-treat strategy for HIV-positive individuals? Given that patients weren’t randomised to each of the 4 alternative strategies, chances are that their treatment was informed by their prognostic factors. And these also influence their outcome. It’s a typical situation of bias due to confounding. The target trial approach consists of designing the RCT which would estimate the causal effect of interest, and to think through how its design can be emulated by the observational data. Here, it would be a trial in which patients would be randomly assigned to one of the 4 joint monitoring and treatment strategies. The goal is to estimate the difference in outcomes if all patients had followed their assigned strategies.

The method is fascinating albeit a bit complicated. It involves censoring individuals, fitting survival models, estimating probability weights, and replicating data. It is worthy of a detailed read! I’m very excited about the target trial methodology for cost-effectiveness analysis with observational data. But I haven’t come across any application yet. Please do get in touch via comments or Twitter if you know of a cost-effectiveness application.

Achieving integrated care through commissioning of primary care services in the English NHS: a qualitative analysis. BMJ Open [PubMed] Published 1st April 2019

Are you confused about the set-up of primary health care services in England? Look no further than Imelda McDermott and colleagues’ paper.

The paper starts by telling the story of how primary care has been organised in England over time, from its creation in 1948 to current times. For example, I didn’t know that there are new plans to allow clinical commissioning groups (CCGs) to design local incentive schemes as an alternative to the Quality and Outcomes Framework pay-for-performance scheme. The research proper is a qualitative study using interviews, telephone surveys and analysis of policy documents to understand how the CCGs commission primary care services. CCG Commissioning is intended to make better and more efficient use of resources to address increasing demand for health care services, staff shortage and financial pressure. The issue is that it is not easy to implement in practice. Furthermore, there seems to be some “reinvention of the wheel”. For example, from one of the interviewees: “…it’s no great surprise to me that the three STPs that we’ve got are the same as the three PCT clusters that we broke up to create CCGs…” Hum, shall we just go back to pre-2012 then?

Even if CCG commissioning does achieve all it sets out to do, I wonder about its value for money given the costs of setting it up. This paper is an exceptional read about the practicalities of implementing this policy in practice.

The dark side of coproduction: do the costs outweight the benefits for health research? Health Research Policy and Systems [PubMed] Published 28th March 2019

Last month, I covered the excellent paper by Kathryn Oliver and Paul Cairney about how to get our research to influence policy. This week I’d like to suggest another remarkable paper by Kathryn, this time with Anita Kothari and Nicholas Mays, on the costs and benefits of coproduction.

If you are in the UK, you have certainly heard about public and patient involvement or PPI. In this paper, coproduction refers to any collaborative working between academics and non-academics, of which PPI is one type, but it includes working with professionals, policy makers and any other people affected by the research. The authors discuss a wide range of costs to coproduction. From the direct costs of doing collaborative research, such as organising meetings, travel arrangements, etc., to the personal costs on an individual researcher to manage conflicting views and disagreements between collaborators, of having research products seen to be of lower quality, of being seen as partisan, etc., and costs to the stakeholders themselves

As a detail, I loved the term “hit-and-run research” to describe the current climate: get funding, do research, achieve impact, leave. Indeed, the way that research is funded, with budgets only available for the period that the research is being developed, does not help academics to foster relationships.

This paper reinforced my view that there may well be benefits to coproduction, but that there are also quite a lot of costs. And there tends to be not much attention to the magnitude of those costs, in whom they fall, and what’s displaced. I found the authors’ advice about the questions to ask oneself when thinking about coproduction to be really useful. I’ll keep it to hand when writing my next funding application, and I recommend you do too!


Analysing Patient-Level Data using HES Workshop

This intensive workshop introduces participants to HES (Hospital Episode Statistics) data and how to handle and manipulate these very large patient-level data sets using computer software. Understanding and interpreting the data is a key first step for using these data in economic evaluation or evaluating health care policy and practice. Participants will engage in lectures and problem-solving exercises, analysing the information in highly interactive sessions. Data manipulation and statistical analysis will be taught and demonstrated using Stata.

This workshop is offered to people in the academic, public and commercial sectors.  It is useful for analysts who wish to harness the power of HES non-randomised episode level patient data to shed further light on such things as patient costs and pathways, re-admissions and outcomes and provider performance.  The workshop is suitable for individuals working in NHS hospitals, commissioning organisations, NHS England, Monitor, and the Department of Health and Social Care, pharmaceutical companies or consultancy companies and for health care researchers and PhD students.  Overseas participants may find the tuition helpful for their own country, but note that the course is heavily oriented towards understanding HES data for England.

The workshop fee is 900GBP for the public sector; 1,400GBP for the commercial sector. This includes all tuition, course materials, lunches, the welcome and drinks reception, the workshop dinner and refreshments, but does not include accommodation.

Online registration is now open; further information and registration is at: https://www.york.ac.uk/che/courses/patient-data/

Subsidised places are available for full-time PhD students. If this is applicable to you, please email the workshop administrators and request an Application Form.

Contact: Gillian or Louise, Workshop Administrators, at: che-apd@york.ac.uk;  tel: +44 (0)1904 321436

Sam Watson’s journal round-up for 12th February 2018

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.

Tuskegee and the health of black men. The Quarterly Journal of Economics [RePEc] Published February 2018

In 1932, a study often considered the most infamous and potentially most unethical in U.S. medical history began. Researchers in Alabama enrolled impoverished black men in a research program designed to examine the effects of syphilis under the guise of receiving government-funded health care. The study was known as the Tuskegee syphilis experiment. For 40 years the research subjects were not informed they had syphilis nor were they treated, even after penicillin was shown to be effective. The study was terminated in 1972 after its details were leaked to the press; numerous men died, 40 wives contracted syphilis, and a number of children were born with congenital syphilis. It is no surprise then that there is distrust among African Americans in the medical system. The aim of this article is to examine whether the distrust engendered by the Tuskegee study could have contributed to the significant differences in health outcomes between black males and other groups. To derive a causal estimate the study makes use of a number of differences: black vs non-black, for obvious reasons; male vs female, since the study targeted males, and also since women were more likely to have had contact with and hence higher trust in the medical system; before vs after; and geographic differences, since proximity to the location of the study may be informative about trust in the local health care facilities. A wide variety of further checks reinforce the conclusions that the study led to a reduction in health care utilisation among black men of around 20%. The effect is particularly pronounced in those with low education and income. Beyond elucidating the indirect harms caused by this most heinous of studies, it illustrates the importance of trust in mediating the effectiveness of public institutions. Poor reputations caused by negligence and malpractice can spread far and wide – the mid-Staffordshire hospital scandal may be just such an example.

The economic consequences of hospital admissions. American Economic Review [RePEcPublished February 2018

That this paper’s title recalls that of Keynes’s book The Economic Consequences of the Peace is to my mind no mistake. Keynes argued that a generous and equitable post-war settlement was required to ensure peace and economic well-being in Europe. The slow ‘economic privation’ driven by the punitive measures and imposed austerity of the Treaty of Versailles would lead to crisis. Keynes was evidently highly critical of the conference that led to the Treaty and resigned in protest before its end. But what does this have to do with hospital admissions? Using an ‘event study’ approach – in essence regressing the outcome of interest on covariates including indicators of time relative to an event – the paper examines the impact hospital admissions have on a range of economic outcomes. The authors find that for insured non-elderly adults “hospital admissions increase out-of-pocket medical spending, unpaid medical bills, and bankruptcy, and reduce earnings, income, access to credit, and consumer borrowing.” Similarly, they estimate that hospital admissions among this same group are responsible for around 4% of bankruptcies annually. These losses are often not insured, but they note that in a number of European countries the social welfare system does provide assistance for lost wages in the event of hospital admission. Certainly, this could be construed as economic privation brought about by a lack of generosity of the state. Nevertheless, it also reinforces the fact that negative health shocks can have adverse consequences through a person’s life beyond those directly caused by the need for medical care.

Is health care infected by Baumol’s cost disease? Test of a new model. Health Economics [PubMed] [RePEcPublished 9th February 2018

A few years ago we discussed Baumol’s theory of the ‘cost disease’ and an empirical study trying to identify it. In brief, the theory supposes that spending on health care (and other labour-intensive or creative industries) as a proportion of GDP increases, at least in part, because these sectors experience the least productivity growth. Productivity increases the fastest in sectors like manufacturing and remuneration increases as a result. However, this would lead to wages in the most productive sectors outstripping those in the ‘stagnant’ sectors. For example, salaries for doctors would end up being less than those for low-skilled factory work. Wages, therefore, increase in the stagnant sectors despite a lack of productivity growth. The consequence of all this is that as GDP grows, the proportion spent on stagnant sectors increases, but importantly the absolute amount spent on the productive sectors does not decrease. The share of the pie gets bigger but the pie is growing at least as fast, as it were. To test this, this article starts with a theoretic two-sector model to develop some testable predictions. In particular, the authors posit that the cost disease implies: (i) productivity is related to the share of labour in the health sector, and (ii) productivity is related to the ratio of prices in the health and non-health sectors. Using data from 28 OECD countries between 1995 and 2016 as well as further data on US industry group, they find no evidence to support these predictions, nor others generated by their model. One reason for this could be that wages in the last ten years or more have not risen in line with productivity in manufacturing or other ‘productive’ sectors, or that productivity has indeed increased as fast as the rest of the economy in the health care sector. Indeed, we have discussed productivity growth in the health sector in England and Wales previously. The cost disease may well then not be a cause of rising health care costs – nevertheless, health care need is rising and we should still expect costs to rise concordantly.