Meeting round-up: Health Economists’ Study Group (HESG) Winter 2019

2019 started with aplomb with the HESG Winter meeting, superbly organised by the Centre for Health Economics, University of York.

Andrew Jones kicked off proceedings with his brilliant course on data visualisation in health econometrics. The eager audience learnt about Edward Tufte’s and others’ ideas about how to create charts that help to make it much easier to understand information. The course was tremendously well received by the HESG audience. And I know that I’ll find it incredibly useful too, as there were lots of ideas that apply to my work. So I’m definitely going to be looking further into Andrew’s chapter on data visualisation to know more.

The conference proper started in the afternoon. I had the pleasure to chair the fascinating paper by Manuela Deidda et al on an economic evaluation using observational data on the Healthy Start Voucher, which was discussed by Anne Ludbrook. We had an engaging discussion, that not only delved into the technical aspects of the paper, such as the intricacies of implementing propensity score matching and regression discontinuity, but also about the policy implications of the results.

I continued with the observational data theme by enjoying the discussion led by Panos Kasteridis on the Andrew McCarthy et al paper. Then I quickly followed this by popping over to catch Attakrit Leckcivilize’s excellent discussion of Padraig Dixon’s et al paper on the effect of obesity on hospital costs. This impressive paper uses Mendelian randomisation, which is a fascinating approach using a type of instrumental variable analysis with individuals’ genetic variants as the instrument.

The meeting continued in the stunning setting of the Yorkshire Museum for the plenary session, which also proved a fitting location to pay tribute to the inspirational Alan Maynard, who sadly passed away in 2018. Unfortunately, I was unable to hear the tributes to Alan Maynard in person, but fellow attendees were able to paint a moving portrait of the event on Twitter, that kept me in touch.

The plenary was chaired by Karen Bloor and included presentations by Kalipso Chalkidou, Brian Ferguson, Becky Henderson and Danny PalnochJane Hall, Steve Birch and Maria Goddard gave personal tributes.

The health economics community was united in gratitude to Professor Alan Maynard, who did so much to advance and disseminate the discipline. It made for a wonderful way to finish day 1!

Day 2 started bright and was full of stimulating sessions to choose from.

I chose to zone in on the cost-effectiveness topic in particular. I started with the David Glynn et al paper about using “back of the envelope” calculations to inform funding and research decisions, discussed by Ed Wilson. This paper is an excellent step towards making value of information easy to use.

I then attended Matthew Quaife’s discussion of Matthew Taylor’s paper on the consequences of assuming independence of parameters to decision uncertainty. This is a relevant paper for the cost-effectiveness world, in particular for those tasked with building and appraising cost-effectiveness models.

Next up it was my turn in the hot seat, as I presented the Jose Robles-Zurita et al paper on the economic evaluation of diagnostic tests. This thought-provoking paper presents a method to account for the effect of accuracy on the uptake of the test, in the context of maximising health.

As always, we were spoilt for choice in the afternoon. The paper “Drop dead: is anchoring at ‘dead’ a theoretical requirement in health state valuation” by Chris Sampson et al, competed very strongly with “Is it really ‘Grim up North’? The causes and consequences of inequalities on health and wider outcomes” by Anna Wilding et al, for the most provocative title. “Predicting the unpredictable? Using discrete choice experiments in economic evaluation to characterise uncertainty and account for heterogeneity”, from Matthew Quaife et al, also gave them a run for their money! I’ll leave a sample here of the exciting papers in discussion, so you can make your own mind up:

Dinner was in the splendid Merchant Adventurers’ Hall. Built in 1357, it is one of the finest Medieval buildings in the UK. Another stunning setting that provided a beautiful backdrop for a wonderful evening!

Andrew Jones presented the ‘Health Economics’ PhD Poster Prize, sponsored by Health Economics Wiley. Rose Atkins took the top honours by winning the Wiley prize for best poster. With Ashleigh Kernohan’s poster being highly commended, given its brilliant use of technology. Congratulations both!

Unfortunately, the vagaries of public transport meant I had to go home straight after dinner, but I heard from many trustworthy sources, on the following day, that the party continued well into the early hours. Clearly, health economics is a most energising topic!

For me, day 3 was all about cost-effectiveness decision rules. I started with the paper by Mark Sculpher et al, discussed by Chris Sampson. This remarkable paper sums up the evidence on the marginal productivity of the NHS, discussing how to use it to inform decisions, and proposes an agenda for research. There were many questions and comments from the floor, showing how important and challenging this topic is. As are so many papers in HESG, this is clearly one to look out for when it appears in print!

The next paper was on a very different way to solve the problem of resource allocation in health care. Philip Clarke and Paul Frijters propose an interesting system of auctions to set prices. The paper was well discussed by James Lomas, which kick-started an animated discussion with the audience about practicalities and implications for investment decisions by drug companies. Great food for thought!

Last, but definitely not least, I took in the paper by Bernarda Zamora et al on the relationship between health outcomes and expenditure across geographical areas in England. David Glynn did a great job discussing the paper, and especially in explaining data envelopment analysis. As ever, the audience was highly engaged and put forward many questions and comments. Clearly, the productivity of the NHS is a central question for health economics and will keep us busy for some time to come.

As always, this was a fantastic HESG meeting that was superbly organised, providing an environment where authors, discussants and participants alike were able to excel.

I really felt a feeling of collegiality, warmth and energy permeate the event. We are part of such an amazing scientific community. Next stop, HESG Summer meeting, hosted by the University of East Anglia. I’m already looking forward to it!

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Chris Sampson’s journal round-up for 23rd July 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.

Quantifying life: understanding the history of quality-adjusted life-years (QALYs). Social Science & Medicine [PubMed] Published 3rd July 2018

We’ve had some fun talking about the history of the QALY here on this blog. The story of how the QALY came to be important in health policy has been obscured. This paper seeks to address that. The research adopts a method called ‘multiple streams analysis’ (MSA) in order to explain how QALYs caught on. The MSA framework identifies three streams – policy, politics, and problems – and considers the ‘policy entrepreneurs’ involved. For this study, archival material was collected from the National Archives, Department of Health files, and the University of York. The researchers also conducted 44 semi-structured interviews with academics and civil servants.

The problem stream highlights shocks to the UK economy in the late 1960s, coupled with growth in health care costs due to innovations and changing expectations. Cost-effectiveness began to be studied and, increasingly, policymaking was meant to be research-based and accountable. By the 80s, the likes of Williams and Maynard were drawing attention to apparent inequities and inefficiencies in the health service. The policy stream gets going in the 40s and 50s when health researchers started measuring quality of life. By the early 60s, the idea of standardising these measures to try and rank health states was on the table. Through the late 60s and early 70s, government economists proliferated and proved themselves useful in health policy. The meeting of Rachel Rosser and Alan Williams in the mid-70s led to the creation of QALYs as we know them, combining quantity and quality of life on a 0-1 scale. Having acknowledged inefficiencies and inequities in the health service, UK politicians and medics were open to new ideas, but remained unconvinced by the QALY. Yet it was a willingness to consider the need for rationing that put the wheels in motion for NICE, and the politics stream – like the problem and policy stream – characterises favourable conditions for the use of the QALY.

The MSA framework also considers ‘policy entrepreneurs’ who broker the transition from idea to implementation. The authors focus on the role of Alan Williams and of the Economic Advisers’ Office. Williams was key in translating economic ideas into forms that policymakers could understand. Meanwhile, the Economic Advisers’ Office encouraged government economists to engage with academics at HESG and later the QoL Measurement Group (which led to the creation of EuroQol).

The main takeaway from the paper is that good ideas only prevail in the right conditions and with the right people. It’s important to maintain multi-disciplinary and multi-stakeholder networks. In the case of the QALY, the two-way movement of economists between government and academia was crucial.

I don’t completely understand or appreciate the MSA framework, but this paper is an enjoyable read. My only reservation is with the way the authors describe the QALY as being a dominant aspect of health policy in the UK. I don’t think that’s right. It’s dominant within a niche of a niche of a niche – that is, health technology assessment for new pharmaceuticals. An alternative view is that the QALY has in fact languished in a quiet corner of British policymaking, and been completely excluded in some other countries.

Accuracy of patient recall for self‐reported doctor visits: is shorter recall better? Health Economics [PubMed] Published 2nd July 2018

In designing observational studies, such as clinical trials, I have always recommended that self-reported resource use be collected no less frequently than every 3 months. This is partly based on something I once read somewhere that I can’t remember, but partly also on some logic that the accuracy of people’s recall decays over time. This paper has come to tell me how wrong I’ve been.

The authors start by highlighting that recall can be subject to omission, whereby respondents forget relevant information, or commission, whereby respondents include events that did not occur. A key manifestation of the latter is ‘telescoping’, whereby events are included from outside the recall period. We might expect commission to be more likely in short recalls and omission to be more common for long recalls. But there’s very little research on this regarding health service use.

This study uses data from a large trial in diabetes care in Australia, in which 5,305 participants were randomised to receive either 2-week, 3-month, or 12-month recall for how many times they had seen a doctor. Then, the trial data were matched with Medicare data to identify the true levels of resource use.

Over 92% of 12-month recall participants made an error, 76% of the 3-month recall, and 46% of the 2-week recall. The patterns of errors were different. There was very little under-reporting in the 2-week recall sample, with 3-month giving the most over-reporting and 12-month giving the most under-reporting. 12-month recall was associated with the largest number of days reported in error. However, when the authors account for the longer period being considered, and estimate a relative error, the impact of misreporting is smallest for the 12-month recall and greatest for the 2-week recall. This translates into a smaller overall bias for the longest recall period. The authors also find that older, less educated, unemployed, and low‐income patients exhibit higher measurement errors.

Health surveys and comparative studies that estimate resource use over a long period of time should use 12-month recall unless they can find a reason to do otherwise. The authors provide some examples from economic evaluations to demonstrate how selecting shorter recall periods could result in recommending the wrong decisions. It’s worth trying to understand the reasons why people can more accurately recall service use over 12 months. That way, data collection methods could be designed to optimise recall accuracy.

Who should receive treatment? An empirical enquiry into the relationship between societal views and preferences concerning healthcare priority setting. PLoS One [PubMed] Published 27th June 2018

Part of the reason the QALY faces opposition is that it has been used in a way that might not reflect societal preferences for resource allocation. In particular, the idea that ‘a QALY is a QALY is a QALY’ may conflict with notions of desert, severity, or process. We’re starting to see more evidence for groups of people holding different views, which makes it difficult to come up with decision rules to maximise welfare. This study considers some of the perspectives that people adopt, which have been identified in previous research – ‘equal right to healthcare’, ‘limits to healthcare’, and ‘effective and efficient healthcare’ – and looks at how they are distributed in the Netherlands. Using four willingness to trade-off (WTT) exercises, the authors explore the relationship between these views and people’s preferences about resource allocation. Trade-offs are between quality vs quantity of life, health maximisation vs equality, children vs the elderly, and lifestyle-related risk vs adversity. The authors sought to test several hypotheses: i) that ‘equal right’ respondents have a lower WTT; ii) ‘limits to healthcare’ people express a preference for health gains, health maximisation, and treating people with adversity; and iii) ‘effective and efficient’ people support health maximisation, treating children, and treating people with adversity.

A representative online sample of adults in the Netherlands (n=261) was recruited. The first part of the questionnaire collected socio-demographic information. The second part asked questions necessary to allocate people to one of the three perspectives using Likert scales based on a previous study. The third part of the questionnaire consisted of the four reimbursement scenarios. Participants were asked to identify the point (in terms of the relevant quantities) at which they would be indifferent between two options.

The distribution of the viewpoints was 65% ‘equal right’, 23% ‘limits to healthcare’, and 7% ‘effective and efficient’. 6% couldn’t be matched to one of the three viewpoints. In each scenario, people had the option to opt out of trading. 24% of respondents were non-traders for all scenarios and, of these, 78% were of the ‘equal right’ viewpoint. Unfortunately, a lot of people opted out of at least one of the trades, and for a wide variety of reasons. Decisionmakers can’t opt out, so I’m not sure how useful this is.

The authors describe many associations between individual characteristics, viewpoints, and WTT results. But the tested hypotheses were broadly supported. While the findings showed that different groups were more or less willing to trade, the points of indifference for traders within the groups did not vary. So while you can’t please everyone in health care priority setting, this study shows how policies might be designed to satisfy the preferences of people with different perspectives.

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Meeting round-up: Health Economists’ Study Group (HESG) Summer 2018

HESG Summer 2018 was hosted by the University of Bristol at the Mercure Bristol Holland House on 20th-22nd June. The organisers did a superb job… the hotel was super comfortable, the food & drink were excellent, and the discussions were enlightening. So the Bristol team can feel satisfied with a job very well done, and one that has certainly set the bar high for the next HESG at York.

Day 1

I started by attending the engaging discussion by Mark Pennington on Tristan Snowsill’s paper on how to use moment-generating functions in cost-effectiveness modelling. Tristan has suggested a new method to model time-dependent disease progression, rather than using multiple tunnel states, or discrete event simulation. I think this could really be a game changer in decision modelling. But for me, the clear challenge will be in explaining the method in a simple way, so that modellers will feel comfortable in trying it out.

It was soon time to take the reins myself and chair the next session. The paper, by Joanna Thorn and colleagues, explored which items should be included in health economic analysis plans (HEAPs), with the discussion being led by David Turner. There was a very lively back-and-forth on the role of HEAPs and their relationship with the study protocol and statistical analysis plan. In my view, this highlighted how HEAPs can be a useful tool to set out the economic analysis, help plan resources and manage expectations from the wider project team.

My third session was the eye-opening discussion of Ian Ross’s paper on time costs of open defecation in India, led by Julius Ohrnberger. It was truly astonishing to learn how prevalent the practice of open defecation is, and the time costs involved to find a suitable location. The impact of which would never have crossed my mind without this fascinating paper.

My last session of the day took in the discussion by Aideen Ahern of the thought-provoking paper by Tessa Peasgood and colleagues on the process of identifying the dimensions that should be included in an instrument to measure health, social care and carer-related quality of life. Having an extended QALY-weight for health and care-related quality of life is almost the holy grail in preference measures. It would allow us to account for the impact of interventions in these two very related areas of quality of life. The challenge is in generating an instrument that it is both generic and sensitive. This extended-QALY weight is still under development at this point, with the next step being to select the final set of dimensions for valuation.

The evening plenary session was on the hot-button topic of “Opportunities and challenges of Brexit for health economists” and included presentations by Paula Lorgelly, Andrew Street and Ellen Rule. We found ourselves jointly commiserating about the numerous challenges that are being posed due to the increased demand of health care and decreased supply of health care professionals. But it wasn’t all doom and gloom fortunately, as Andrew Street suggested that future economic research may use Brexit as an exogenous shock. Clearly this is not enough for comfort but left the room in a positive mood to face dinner!

Day 2

It was time for one of my own papers on day 2, as we started with Nicky Welton discussing the paper by Alessandro Grosso, myself and other colleagues on the structural uncertainties in cost-effectiveness modelling. We were delighted that we received excellent comments that will help to improve our paper. The session also prompted us to think about whether we should separate the model from the structural uncertainty analysis element and create 2 distinct papers. This would allow us to explore and extend the latter even further. So, watch this space!

I attended Matthew Quaife’s discussion next, on the study by Katharina Diernberger and colleagues of expert elicitation to parameterise a cost-effectiveness model. Their expert elicitation had a whopping 47 responses, which allowed the team to explore different ways to aggregate the answers and demonstrate their impact on the results. This paper prompted a quick-fire discussion about how far to push decision modelling if data are scarce. Expert elicitation is often seen as the answer to scarce data but it is no silver bullet! Thanks to this paper, it is clear that the differing views among experts make a difference to the findings.

I continued along the modelling topic with the next session I’d chosen: Tracey Sach’s discussion on Ieva Skarda’s and colleagues excellent paper simulating the long-term consequences of interventions in childhood. The paper prompted a lot of interest regarding the use of the results to inform the extrapolation of trials with a short time duration. The authors are looking at developing a tool to facilitate the use of the model by external researchers, which I’m sure will have a high take-up.

After lunch, I attended Tristan Snowsill’s discussion of Felix Achana and colleagues’ paper on regression models for analysis of clinical trials data. Felix and colleagues propose multivariate generalised linear mixed effects models to account for the centre-specific heterogeneity and simultaneous estimation of the effect on the costs and outcomes. Although the analysis is quite complex, the method has strong potential to be very useful in multinational trials. I was excited to hear that the authors are developing functions in Stata and R, which will make it much easier for analysts to use the method.

Keeping to the cost-effectiveness topic, I then attended Ed Wilson’s discussion on the paper by Laura Flight and colleagues on the risk of bias of adaptive RCTs. The paper discusses how an adaptive trial may be stopped early depending on interim analysis. However, our attention must be drawn to the caveat that conducting multiple interim analysis requires adjustment for bias to inform the economic analysis. This is an opportune paper as we are seeing the use of adaptive trial designs rise, and definitely one I’ll make a note to refer to in the future.

For my final session of the day, I discussed Emma McManus‘s paper on establishing a definition of model replication. Replication has been subject to increased interest by the scientific community but its take-up has been slow in health economics, the exception being cost-effectiveness modelling of diabetes. Well done to Emma and the team for bringing the topic to the forum! The ensuing discussion interestingly revealed that we can often have quite different concepts of what replication is and its role in model validation. The authors are working on replicating published models, so I’m looking forward to hearing more about their experience in future meetings.

Day 3

The last day got off to a strong start when Andrew Street opened with a discussion of Joshua Kraindler and Ben Gershlick‘s study on the impact of capital investment on hospital productivity. The session was both thought-provoking and extremely engaging, with Andrew encouraging our involvement by asking us all to think about the shape of a production function, in order to better interpret the results. This timely discussion was centred around the challenges in measuring capital investment in the NHS, given the paucity of data.

My final session was Francesco Ramponi’s paper on cross-sectoral economic evaluations, discussed by Mandy Maredza. This session was quite a record-breaker for HESG Bristol, enjoying probably the largest audience of the conference. Opportunely, it was able to shine a spotlight on the interest in expanding economic evaluations beyond decisions in health care, and the role of economic evaluations when costs and outcomes relate to different budgets and decision makers.

This HESG, as always, was a testament to the breadth of topics covered by health economists, and their hard work in pushing this important science onward. I’m now very much looking forward to seeing so many interesting papers published, many of which I will certainly use and reflect upon with my own research. Of course, I’m also very much looking forward to the next new batch of new research at the HESG in York. The date is firmly in my diary!

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