James Lomas’s journal round-up for 21st May 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.

Decision making for healthcare resource allocation: joint v. separate decisions on interacting interventions. Medical Decision Making [PubMed] Published 23rd April 2018

While it may be uncontroversial that including all of the relevant comparators in an economic evaluation is crucial, a careful examination of this statement raises some interesting questions. Which comparators are relevant? For those that are relevant, how crucial is it that they are not excluded? The answer to the first of these questions may seem obvious, that all feasible mutually exclusive interventions should be compared, but this is in fact deceptive. Dakin and Gray highlight inconsistency between guidelines as to what constitutes interventions that are ‘mutually exclusive’ and so try to re-frame the distinction according to whether interventions are ‘incompatible’ – when it is physically impossible to implement both interventions simultaneously – and, if not, whether interventions are ‘interacting’ – where the costs and effects of the simultaneous implementation of A and B do not equal the sum of these parts. What I really like about this paper is that it has a very pragmatic focus. Inspired by policy arrangements, for example single technology appraisals, and the difficulty in capturing all interactions, Dakin and Gray provide a reader-friendly flow diagram to illustrate cases where excluding interacting interventions from a joint evaluation is likely to have a big impact, and furthermore propose a sequencing approach that avoids the major problems in evaluating separately what should be considered jointly. Essentially when we have interacting interventions at different points of the disease pathway, evaluating separately may not be problematic if we start at the end of the pathway and move backwards, similar to the method of backward induction used in sequence problems in game theory. There are additional related questions that I’d like to see these authors turn to next, such as how to include interaction effects between interventions and, in particular, how to evaluate system-wide policies that may interact with a very large number of interventions. This paper makes a great contribution to answering all of these questions by establishing a framework that clearly distinguishes concepts that had previously been subject to muddied thinking.

When cost-effective interventions are unaffordable: integrating cost-effectiveness and budget impact in priority setting for global health programs. PLoS Medicine [PubMed] Published 2nd October 2017

In my opinion, there are many things that health economists shouldn’t try to include when they conduct cost-effectiveness analysis. Affordability is not one of these. This paper is great, because Bilinski et al shine a light on the worldwide phenomenon of interventions being found to be ‘cost-effective’ but not affordable. A particular quote – that it would be financially impossible to implement all interventions that are found to be ‘very cost-effective’ in many low- and middle-income countries – is quite shocking. Bilinski et al compare and contrast cost-effectiveness analysis and budget impact analysis, and argue that there are four key reasons why something could be ‘cost-effective’ but not affordable: 1) judging cost-effectiveness with reference to an inappropriate cost-effectiveness ‘threshold’, 2) adoption of a societal perspective that includes costs not falling upon the payer’s budget, 3) failing to make explicit consideration of the distribution of costs over time and 4) the use of an inappropriate discount rate that may not accurately reflect the borrowing and investment opportunities facing the payer. They then argue that, because of this, cost-effectiveness analysis should be presented along with budget impact analysis so that the decision-maker can base a decision on both analyses. I don’t disagree with this as a pragmatic interim solution, but – by highlighting these four reasons for divergence of results with such important economic consequences – I think that there will be further reaching implications of this paper. To my mind, Bilinski et al essentially serves as a call to arms for researchers to try to come up with frameworks and estimates so that the conduct of cost-effectiveness analysis can be improved in order that paradoxical results are no longer produced, decisions are more usefully informed by cost-effectiveness analysis, and the opportunity costs of large budget impacts are properly evaluated – especially in the context of low- and middle-income countries where the foregone health from poor decisions can be so significant.

Patient cost-sharing, socioeconomic status, and children’s health care utilization. Journal of Health Economics [PubMed] Published 16th April 2018

This paper evaluates a policy using a combination of regression discontinuity design and difference-in-difference methods. Not only does it do that, but it tackles an important policy question using a detailed population-wide dataset (a set of linked datasets, more accurately). As if that weren’t enough, one of the policy reforms was actually implemented as a result of a vote where two politicians ‘accidentally pressed the wrong button’, reducing concerns that the policy may have in some way not been exogenous. Needless to say I found the method employed in this paper to be a pretty convincing identification strategy. The policy question at hand is about whether demand for GP visits for children in the Swedish county of Scania (Skåne) is affected by cost-sharing. Cost-sharing for GP visits has occurred for different age groups over different periods of time, providing the basis for regression discontinuities around the age threshold and treated and control groups over time. Nilsson and Paul find results suggesting that when health care is free of charge doctor visits by children increase by 5-10%. In this context, doctor visits happened subject to telephone triage by a nurse and so in this sense it can be argued that all of these visits would be ‘needed’. Further, Nilsson and Paul find that the sensitivity to price is concentrated in low-income households, and is greater among sickly children. The authors contextualise their results very well and, in addition to that context, I can’t deny that it also particularly resonated with me to read this approaching the 70th birthday of the NHS – a system where cost-sharing has never been implemented for GP visits by children. This paper is clearly also highly relevant to that debate that has surfaced again and again in the UK.

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Chris Sampson’s journal round-up for 7th May 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.

Building an international health economics teaching network. Health Economics [PubMedPublished 2nd May 2018

The teaching on my health economics MSc (at Sheffield) was very effective. Experts from our subdiscipline equipped me with the skills that I went on to use on a daily basis in my first job, and to this day. But not everyone gets the same opportunity. And there were only 8 people on my course. Part of the background to the new movement described in this editorial is the observation that demand for health economists outstrips supply. Great for us jobbing health economists, but suboptimal for society. The shortfall has given rise to people teaching health economics (or rather, economic evaluation methods) without any real training in economics. The main purpose of this editorial is to call on health economists (that’s me and you) to pull our weight and contribute to a collective effort to share, improve, and ultimately deliver high-quality teaching resources. The Health Economics education website, which is now being adopted by iHEA, should be the starting point. And there’s now a Teaching Health Economics Special Interest Group. So chip in! This paper got me thinking about how the blog could play its part in contributing to the infrastructure of health economics teaching, so expect to see some developments on that front.

Including future consumption and production in economic evaluation of interventions that save life-years: commentary. PharmacoEconomics – Open [PubMed] Published 30th April 2018

When people live longer, they spend their extra life-years consuming and producing. How much consuming and producing they do affects social welfare. The authors of this commentary are very clear about the point they wish to make, so I’ll just quote them: “All else equal, a given number of quality-adjusted life-years (QALYs) from life prolongation will normally be more costly from a societal perspective than the same number of QALYs from programmes that improve quality of life”. This is because (in high-income countries) most people whose life can be extended are elderly, so they’re not very productive. They’re likely to create a net cost for society (given how we measure value). Asserting that the cost is ‘worth it’ at any level, or simply ignoring the matter, isn’t really good enough because providing life extension will be at the expense of some life-improving treatments which may – were these costs taken into account – improve social welfare. The authors’ estimates suggest that the societal cost of life-extension is far greater than current methods admit. Consumption costs and production gains should be estimated and should be given some weight in decision-making. The question is not whether we should measure consumption costs and production gains – clearly, we should. The question is what weight they ought to be given in decision-making.

Methods for the economic evaluation of changes to the organisation and delivery of health services: principal challenges and recommendations. Health Economics, Policy and Law [PubMedPublished 20th April 2018

The late, great, Alan Maynard liked to speak about redisorganisations in the NHS: large-scale changes to the way services are organised and delivered, usually without a supporting evidence base. This problem extends to smaller-scale service delivery interventions. There’s no requirement for policy-makers to demonstrate that changes will be cost-effective. This paper explains why applying methods of health technology assessment to service interventions can be tricky. The causal chain of effects may be less clear when interventions are applied at the organisational level rather than individual level, and the results will be heavily dependent on the present context. The author outlines five challenges in conducting economic evaluations for service interventions: i) conducting ex-ante evaluations, ii) evaluating impact in terms of QALYs, iii) assessing costs and opportunity costs, iv) accounting for spillover effects, and v) generalisability. Those identified as most limiting right now are the challenges associated with estimating costs and QALYs. Cost data aren’t likely to be readily available at the individual level and may not be easily identifiable and divisible. So top-down programme-level costs may be all we have to work with, and they may lack precision. QALYs may be ‘attached’ to service interventions by applying a tariff to individual patients or by supplementing the analysis with simulation modelling. But more methodological development is still needed. And until we figure it out, health spending is likely to suffer from allocative inefficiencies.

Vog: using volcanic eruptions to estimate the health costs of particulates. The Economic Journal [RePEc] Published 12th April 2018

As sources of random shocks to a system go, a volcanic eruption is pretty good. A major policy concern around the world – particularly in big cities – is the impact of pollution. But the short-term impact of particulate pollution is difficult to identify because there is high correlation amongst pollutants. In this study, the authors use the eruption activity of Kīlauea on the island of Hawaiʻi as a source of variation in particulate pollution. Vog – volcanic smog – includes sulphur dioxide and is similar to particulate pollution in cities, but the fact that Hawaiʻi does not have the same levels of industrial pollutants means that the authors can more cleanly identify the impact on health outcomes. In 2008 there was a big increase in Kīlauea’s emissions when a new vent opened, and the level of emissions fluctuates daily, so there’s plenty of variation to play with. The authors have two main sources of data: emergency admissions (and their associated charges) and air quality data. A parsimonious OLS model is used to estimate the impact of air quality on the total number of admissions for a given day in a given region, with fixed effects for region and date. An instrumental variable approach is also used, which looks at air quality on a neighbouring island and uses wind direction to specify the instrumental variable. The authors find that pulmonary-related emergency admissions increased with pollution levels. Looking at the instrumental variable analysis, a one standard deviation increase in particulate pollution results in 23-36% more pulmonary-related emergency visits (depending on which measure of particulate pollution is being used). Importantly, there’s no impact on fractures, which we wouldn’t expect to be influenced by the particulate pollution. The impact is greatest for babies and young children. And it’s worth bearing in mind that avoidance behaviours – e.g. people staying indoors on ‘voggy’ days – are likely to reduce the impact of the pollution. Despite the apparent lack of similarity between Hawaiʻi and – for example – London, this study provides strong evidence that policy-makers should consider the potential savings to the health service when tackling particulate pollution.

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Chris Sampson’s journal round-up for 23rd October 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 is the evidence from past National Institute of Health and Care Excellence single-technology appraisals regarding company submissions with base-case incremental cost-effectiveness ratios of less than £10,000/QALY? Value in Health Published 18th October 2017

NICE have been looking into diversifying their HTA processes of late. One of the newly proposed rules is that technologies with a base-case ICER estimate of less than £10,000 per QALY should be eligible for a fast-track appraisal, so that patients can benefit as early as possible from a therapy that does not pose a great risk of wasting NHS resources. But what have NICE been doing up to this point for such technologies? For this study, the researchers analysed content from all NICE single technology appraisals (STAs) between 2009 and 2016, of which there were 171 with final reports available that reported a base-case ICER. 15% (26) of the STAs reported all base-case ICERs to be below £10,000, and of these 73% (19) received a positive recommendation at the first appraisal committee meeting. A key finding is that 7 of the 26 received a ‘Minded No’ judgment in the first instance due in part to inadequate evidence and – though all got a positive decision in the end – some recommendations were restricted to subgroups. The authors also had a look at STAs with base-case ICERs up to £15,000, of which there were 5 more. All of these received a positive recommendation at the first appraisal committee meeting. Another group of (28) STAs reported multiple ICERs that included estimates both below and above £10,000. These tell a different story. Only 13 received an unrestricted positive recommendation at the first appraisal committee. Positive recommendations eventually followed for all 28, but 7 were on the basis of patient access schemes. There are a few things to consider in light of these findings. It may not be possible for NICE to adequately fast-track some sub-£10k submissions because the ICERs are not estimated on the basis of appropriate comparisons, or because the evidence is otherwise inadequate. But there may be good grounds for extending the fast-track threshold to £15,000. The study also highlights some indicators of complexity (such as the availability of patient access scheme discounts) that might be used as a basis for excluding submissions from the fast-track process.

EQ-5D-5L versus EQ-5D-3L: the impact on cost-effectiveness in the United Kingdom. Value in Health Published 18th October 2017

Despite some protest from NICE, most UK health economists working on trial-based economic evaluations are probably getting on with using the new EQ-5D-5L (and associated value set) over its 3L predecessor. This shift could bring important changes to the distribution of cost-effectiveness results for evaluated technologies. In this study, the researchers sought to identify what these changes might be, by examining a couple of datasets which included both 3L and 5L response data. One dataset was produced by the EuroQol group, with 3,551 individuals from across Europe with a range of health states, and the other was a North American dataset collected from 5,205 patients with rheumatoid disease, which switched from 3L to 5L with a wave of overlap. The analysis employs a previously developed method with a series of ordinal regressions, in which 3L-5L pairs are predicted using a copula approach. The first thing to note is that there was variation in the distribution of responses between the different dimensions and between the two datasets, and so a variety of model specifications are needed. To investigate the implications of using the 5L instead of the 3L, the authors considered 9 cost-effectiveness analysis case studies. The 9 studies reported 13 comparisons. In almost all cases where 3L was replaced with the 5L, the intervention resulted in a smaller QALY gain and higher ICER. The only study in which use of the 5L increased the incremental QALYs was one in which life extension was the key driver of QALY gains. Generally speaking, use of the 5L increases index values and reduces the range, so quality of life improvements are ‘more difficult’ to achieve, while life extension is relatively more valuable than on the 3L. Several technologies move from being clearly cost-effective within NICE’s £20,000-£30,000 threshold to being borderline cases. Different technologies for different diseases will be impacted differently by the move from the 3L to the 5L. So while we should probably still start using the 5L and its value set (because it’s methodologically superior), we mustn’t forget how different our findings might be in comparison to our old ways.

Experience-based utility and own health state valuation for a health state classification system: why and how to do it. The European Journal of Health Economics [PubMedPublished 11th October 2017

There’s debate around whose values we ought to be using to estimate QALYs when making resource allocation decisions. Generally we use societal values, but some researchers think we should be using values from people actually in those health states. I’ve written before about some of the problems with this debate. In this study, the authors try to bring some clarity to the discussion. Four types of values are considered, defined by two distinctions: hypothetical vs own current state and general public vs patient values. The notion of experienced utility is introduced and the authors explain why this cannot be captured by (for example) a TTO exercise, because such exercises require hypothetical future scenarios of health improvement. Thus, the preferred terminology becomes ‘own health state valuation’. The authors summarise some of the research that has sought to compare the 4 types of values specified, highlighting that own health state valuations tend to give higher values associated with dysfunctional health states than do general population hypothetical valuations. The main point is that valuations can differ systematically according to whose values are being elicited. The authors describe some reasons why these values may differ. These could include i) poor descriptions of hypothetical states, ii) changing internal standards (e.g. response shift), and iii) adaptation. Next, the authors consider how to go about collecting own health state values. Two key challenges are specified: i) respondents may be unwilling where questions are complex or intrusive, and ii) there may be ethical concerns, particular where people are in terminal conditions. It is therefore difficult to sample for all possible health states. Selection bias may also rear its head. The tendency for more mild health states to be observed creates problems for the econometricians trying to model value sets. The authors propose some ways forward for identifying own health state value sets. One way would be to purposively sample EQ-5D health states from people representative within the states. However, some states are rarely observed, so we’d be looking at screening millions of people to identify the necessary participants from a general survey. So the authors suggest targeting people via other methods. Though this may still prove very difficult. A more effective (and favourable) approach – the authors suggest – could be to try and obtain better informed general population values. This could involve improving descriptive systems and encouraging deliberation. Evidence suggests that this can reduce the discrepancy between hypothetical and own state valuations. In particular, the authors recommend the use of citizens’ juries and multi-criteria decision analysis. This isn’t something we see being done in the literature, and so may be a fruitful avenue for future research.

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