Rita Faria’s journal round-up for 4th March 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.

Cheap and dirty: the effect of contracting out cleaning on efficiency and effectiveness. Public Administration Review Published 25th February 2019

Before I was a health economist, I used to be a pharmacist and worked for a well-known high street chain for some years. My impression was that the stores with in-house cleaners were cleaner, but I didn’t know if this was a true difference, my leftie bias or my small sample size of 2! This new study by Shimaa Elkomy, Graham Cookson and Simon Jones confirms my suspicions, albeit in the context of NHS hospitals, so I couldn’t resist to select it for my round-up.

They looked at how contracted-out services fare in terms of perceived cleanliness, costs and MRSA rate in NHS hospitals. MRSA is a type of hospital-associated infection that is affected by how clean a hospital is.

They found that contracted-out services are cheaper than in-house cleaning, but that perceived cleanliness is worse. Importantly, contracted-out services increase the MRSA rate. In other words, contracting-out cleaning services could harm patients’ health.

This is a fascinating paper that is well worth a read. One wonders if the cost of managing MRSA is more than offset by the savings of contracting-out services. Going a step further, are in-house services cost-effective given the impact on patients’ health and costs of managing infections?

What’s been the bang for the buck? Cost-effectiveness of health care spending across selected conditions in the US. Health Affairs [PubMed] Published 1st January 2019

Staying on the topic of value for money, this study by David Wamble and colleagues looks at the extent to which the increased spending in health care in the US has translated into better health outcomes over time.

It’s clearly reassuring that, for 6 out of the 7 conditions they looked at, health outcomes have improved in 2015 compared to 1996. After all, that’s the goal of investing in medical R&D, although it remains unclear how much of this difference can be attributed to health care versus other things that have happened at the same time that could have improved health outcomes.

I wasn’t sure about the inflation adjustment for the costs, so I’d be grateful for your thoughts via comments or Twitter. In my view, we would underestimate the costs if we used medical price inflation indices. This is because these indices reflect the specific increase in prices in health care, such as due to new drugs being priced high at launch. So I understand that the main results use the US Consumer Price Index, which means that this reflects the average increase in prices over time rather than the increase in health care.

However, patients may not have seen their income rise with inflation. This means that the cost of health care may represent a disproportionally greater share of people’s income. And that the inflation adjustment may downplay the impact of health care costs on people’s pockets.

This study caught my eye and it is quite thought-provoking. It’s a good addition to the literature on the cost-effectiveness of US health care. But I’d wager that the question remains: to what extent is today’s medical care better value for money that in the past?

The dos and don’ts of influencing policy: a systematic review of advice to academics. Palgrave Communications Published 19th February 2019

We all would like to see our research findings influence policy, but how to do this in practice? Well, look no further, as Kathryn Oliver and Paul Cairney reviewed the literature, summarised it in 8 key tips and thought through their implications.

To sum up, it’s not easy to influence policy; advice about how to influence policy is rarely based on empirical evidence, and there are a few risks to trying to become a mover-and-shaker in policy circles.

They discuss three dilemmas in policy engagement. Should academics try to influence policy? How should academics influence policy? What is the purpose of academics’ engagement in policy making?

I particularly enjoyed reading about the approaches to influence policy. Tools such as evidence synthesis and social media should make evidence more accessible, but their effectiveness is unclear. Another approach is to craft stories to create a compelling case for the policy change, which seems to me to be very close to marketing. The third approach is co-production, which they note can give rise to accusations of bias and can have some practical challenges in terms of intellectual property and keeping one’s independence.

I found this paper quite refreshing. It not only boiled down the advice circulating online about how to influence policy into its key messages but also thought through the practical challenges in its application. The impact agenda seems to be here to stay, at least in the UK. This paper is an excellent source of advice on the risks and benefits of trying to navigate the policy world.


Meeting round-up: Health Economists’ Study Group (HESG) Winter 2017

The perfect tonic to the January blues, this year’s winter HESG took us to Birmingham. Continuing the trend of recent years, 100+ health economists gathered in a major chain hotel to discuss 50 odd papers currently in progress in our little corner of academia. First thing I’ll say is that it was a great conference. It was flawlessly organised and the team helped create that unmistakable HESG buzz.

As we’ve come to expect from HESG, there was an impressive breadth of subject matter and methodologies on offer across the 4 or 5 parallel sessions throughout each day. From mental health to dentistry, from financial incentive schemes to integrated care, and from small-scale preference elicitation studies to regression analyses of millions of data points – that was just the first day.

I did the usual hat-trick duties of having a paper, giving a discussion and doing a bit of chairing; nothing compared to our own Sam Watson‘s herculean effort to tackle ‘the quad’ with two papers accepted. Despite my concern that it might just be a bit too boring, my paper – Systematic review and meta-analysis of health state utility values for diabetic retinopathy: implications for model-based economic evaluation – was well received on the first day. We discussed the reason and basis for a meta-analysis of utility values, and whether it makes more sense to target specific values or adopt a blanket approach. I’m very grateful to my discussant, Anthony Hatswell, and to the rest of the room for their feedback. The other highlight of the first day’s sessions for me was a paper by Uma Thomas that was discussed by Hareth Al-Janabi. The paper tried to tackle the very difficult problem of identifying ‘sophistication’ in the context of present bias and commitment contracts. Some people will be able to anticipate their own time-inconsistent preferences and should therefore demand commitment contracts. But as the discussion testified, identifying sophistication (or even understanding it) is no mean feat.

Day one ended with a very engaging plenary in which 4 speakers – Judith Smith, Matt Sutton, Andrew Street and Paula Lorgelly – discussed their short to medium-term priorities for the NHS. Generally, things looked bleak. Judith discussed the need to ‘get through the winter’, while Matt highlighted the apparent lack of attention given to evidence in the policy-making process. Andy warned us against getting sick in 2017 as the government demands impossible efficiency savings. Paula mentioned the ‘p’ word, attracting (jovial) hisses and boos. But she’s right – we really could do a better job of optimising NHS links with the private sector. The substance of the plenary as a whole was a call to arms. Health economists need to improve their communication to decision makers at all levels of the health service and of government. Numerous suggestions came from the floor and something seemed to be sparked in the room. I suspect we’ll hear more about this in the future.

My discussion on day 2 was of a paper by John Brazier and co, which fortuitously related to a paper that I previously discussed here on the blog. I was badly behaved, going well over time, but there were a lot of issues to grapple with around whether or not we should use ‘patient preferences’ in economic evaluation. The room was packed and provided a lively discussion. It’s a question that we’ll no doubt return to on this blog. I chaired a session in which Yan Feng discussed Liz Camacho‘s paper on the suitability of the EQ-5D for people at risk of developing psychosis. The take-home message of the discussion was that we need to stop considering ‘mental illness’ as a single diagnosis, and that while the EQ-5D might be valid in some groups it might not be in others.

A well-attended member’s meeting touched on some of the issues raised in the plenary, around the idea that HESG and its members might do more to influence decision makers and inform interested parties. What’s more, we learnt of some exciting news about HESG’s future that might facilitate action on this. There was the inevitable discussion of HESG’s controversial trip away, with the conclusion being that we probably won’t do it again for a few years (at least). This presents the exciting prospect that next year’s meeting – to be hosted by City University – might just end up in Cleethorpes.

The high quality of discussion was maintained into the last day. For me there was Penny Mullen’s discussion of Jytte Nielsen‘s paper describing a novel method by which to elicit people’s preferences for end of life treatment, without taking into account distributional concerns. And everything was wrapped up with champion HESG organiser Phil Kinghorn‘s discussion of Padraig Dixon‘s paper about the challenges of including carer spillover effects in economic evaluation. Phil gets the prize for inducing the most laughs during a presentation.

Yet another brilliant HESG that left me physically drained and mentally invigorated.