#HEJC for 26/02/2015

The next #HEJC discussion will take place Thursday 26th February, at 11pm London time on Twitter. To see what this means for your time zone visit Time.is or join the Facebook event. For more information about the Health Economics Journal Club and how to take part, click here.

The paper for discussion is a working paper published by the Canadian Centre for Health Economics (CCHE). The authors are Koffi-Ahoto Kpelitse, Rose Anne Devlin and Sisira Sarma. The title of the paper is:

The effect of income on obesity among Canadian adults

Following the meeting, a transcript of the Twitter discussion can be downloaded here.

Links to the article

Direct: http://www.canadiancentreforhealtheconomics.ca/wp-content/uploads/2014/08/Sisira-et-al.pdf

RePEc: https://ideas.repec.org/p/cch/wpaper/14c002.html

Summary of the paper

This is the first paper to examine the causal relationship between income and obesity in the Canadian context. To do so, they examined data from five biennial Canadian Community Health Survey (from 2000/01 to 2009/10), a nationally representative survey collecting information on over 100,000 individuals each survey.

Initially, the paper explored the Grossman model, which suggested increasing income would promote healthy lifestyle investments, and thus lead to a negative relationship between income and obesity. Previous studies that examined this link were discussed, some (eg. Lindahl (2005)) demonstrating a negative relationship; some (eg. Schmeiser (2009)) demonstrating a positive relationship; some (eg. Cawley (2010)) finding no evidence of a causal relationship.

Additionally, education and employment were explored. Again, the Grossman model was used as a basis, predicting i) a negative relationship between education level and obesity with a greater income effect amongst educated people and ii) a negative relationship between employment level and obesity. However, regarding education, prior studies discussed have shown “mixed results”, and regarding employment, the authors were not aware of any study to examine this causal relationship, but suggested the relationship was ambiguous.

Finally, the relationship between gender and obesity were discussed. Numerous studies have shown negative association between income and BMI amongst women, but for men, the relationship is unclear (some showing positive relationship, some negative, and some no significant relationship at all). The importance of the effect of obesity on labour market outcomes (outlining the “large” empirical literature showing obese women more likely to suffer discrimination in the labour market) was outlined.

In this study, the authors found that:

  • From 2000/01 to 2009/10, BMI and obesity rates amongst both men and women have risen.
    • For men, the obesity rate rises from 19.48% for those with income below $10k to 26.09% for those with income over $80k.
    • For women obesity falls from 26.71% for those below $10k to 17.38% for those with income over $80k.
  • For men, a 1% rise in household income leads to 0.027 point decrease in BMI (2SLS estimate); 0.084kg reduction and 0.27% point decrease in probability of being obese (linear IV procedure).
  • For women, a 1% rise in household income leads to 0.113 point decrease in BMI (much higher than for men; this used a 2SLS estimate); 0.300kg reduction; and 0.76% point decrease in probability of being obese (linear IV procedure).
  • For men the effect of income on BMI was only demonstrated at higher BMI distribution, while for women the effect of income on BMI was found throughout with a larger effect at higher BMI.
  • Education had a variable relationship amongst both men and women, not consistent with the theoretical prediction that the effect would be larger amongst educated people.
  • The effect of employment for men was mixed, with a negative effect of income on BMI only in employed men and a negative effect of income on obesity probability only in unemployed men.
  • The effect of employment for women was more consistent with theoretical predictions, showing negative effects of income on both BMI and on the probability of being obese across employment status.
  • Higher BMI and probability of obesity was associated with older age, marriage (much greater effect in women), household size (much greater effect in women) and home ownership.
  • Lower BMI and probability of obesity was associated with being widowed/separated/divorced, being an immigrant and living in urban area (in men).

In summary, this study supports the findings of Lindahl, and stands in contrast to Schmeiser, Cawley and other related studies.

Discussion points

  • Why might there be significant variation in findings between the different studies discussed?
  • Are there ways in which unemployment and neighbourhood income might directly influence BMI?
  • Is the set of control variables used in the authors’ models satisfactory?
  • Is it of concern that policies to increase household income could be regarded a pure, explicit public health policy?
  • Are there relevant studies from other countries?
  • To what extent are these findings generalisable?

Can’t join in with the Twitter discussion? Add your thoughts on the paper in the comments below.

#HEJC for 24/10/2014

The next #HEJC discussion will take place Friday 24th October, at 1pm London time on Twitter. To see what this means for your time zone visit Time.is or join the Facebook event. For more information about the Health Economics Journal Club and how to take part, click here.

The paper for discussion is a working paper published by Glasgow Caledonian University’s Yunus Centre. The authors are Neil McHugh and colleagues. The title of the paper is:

Extending life for people with a terminal illness: a moral right or an expensive death? Exploring societal perspectives

Following the meeting, a transcript of the Twitter discussion can be downloaded here.

Links to the article

Direct: http://www.gcu.ac.uk/media/gcalwebv2/ycsbh/yunuscentre/Extending%20Life%20for%20People%20with%20a%20Terminal%20Illness.pdf

RePEc: https://ideas.repec.org/p/yun/hewpse/201403.html

Summary of the paper

A lot of research effort has been spent on whether health economists’ most ingrained normative assumption should hold; is a QALY of equal value regardless of to whom it accrues. In the UK, the National Institute for Health and Care Excellence has given weighting to ‘special cases’; namely, life-extending drugs for patients near the end of their life (mainly for cancer). However, existing empirical research about whether societal values support such a weighting has given conflicting results.

McHugh et al, in their new working paper, present the first major mixed methods study of societal perspectives for QALY-weighting. The authors use Q methodology – which involves the ranking of opinion statements according to agreement – to elicit societal perspectives on the relative value of life extension for people with terminal illness. Opinion statements were collected from 4 sources:

  • newspaper articles
  • a NICE public consultation
  • 16 interviews with key informants
  • 3 focus groups with the general public

The Q sort was conducted with people from academia, the pharmaceutical industry, charities, patient groups, religious groups, clinicians, people with experience of terminal illness and a sample of the general public. The authors’ final sample included 61 Q sorts and factor analysis identified 3 distinguishable perspectives, which can be summarised as:

  1. A population perspective (value for money, no special cases)
  2. An individual perspective (value of life, not cost)
  3. A mixed perspective

Factor 1 individuals are unlikely to support any QALY-weighting, maintaining a utilitarian-type health-maximising perspective. Factor 2 respondents reject the denial of life extending treatments and assert that patients and their families should decided whether or not they wish to receive the treatment; regardless of cost. This group appear to disagree with cost-effectiveness analysis altogether. Factor 3 represents a more nuanced view, asserting that value is broader than health gain alone. However, factor 3 was associated with a focus on quality of life, and so support for expensive life-extending treatment would depend on this. It is unclear whether QALY-weighting would adequately achieve this.

Discussion points

  • Is the question of QALY-weighting a normative one or a positive one?
  • Are the three factors likely to be robust across ethical dilemmas other than terminal illness?
  • To what extent are the opinions associated with the 3 factors likely to be robust to further deliberation?
  • Are factor 2 respondents simply wrong?
  • Should QALY-weighting be based on democratic processes?
  • Is it of concern that current policy appears to reflect the views of health economists better than other groups?
  • Where do you stand?

Can’t join in with the Twitter discussion? Add your thoughts on the paper in the comments below.

New year’s resolutions

In 2013 we published 34 posts and got about 12,000 hits. While we’re by no means disappointed with this, we know we can do better.

Our primary goal is to publish more posts, while ensuring that articles maintain a high quality. I hope that this year you will consider becoming a contributor and writing for the blog. It’s a great way to present any issues you’ve been pondering that just won’t formulate into a journal submission, or to simply pose tricky questions to the health economics community.

We hope to cultivate more of a community around the blog, and the Health Economics Journal Club will become a primary means of achieving this. We will be experimenting with new platforms for #HEJC discussions, such as Google Hangouts, and new formats, including guest authors. If you’d like to help put together a future discussion, please get in touch.

You’ll now also find a new Resources page in the menu above. A links page is an oft-requested feature for the site. While other websites already provide links pages, many are outdated, incomplete or simply too huge to be of value. We hope this one will prove more useful, but do let us know what you think.