Simon McNamara’s journal round-up for 6th August 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.

Euthanasia, religiosity and the valuation of health states: results from an Irish EQ5D5L valuation study and their implications for anchor values. Health and Quality of Life Outcomes [PubMed] Published 31st July 2018

Do you support euthanasia? Do you think there are health states worse than death? Are you religious? Don’t worry – I am not commandeering this week’s AHE journal round-up just to bombard you with a series of difficult questions. These three questions form the foundation of the first article selected for this week’s round-up.

The paper is based upon the hypothesis that your religiosity (“adherence to religious beliefs”) is likely to impact your support for euthanasia and, subsequently, the likelihood of you valuing severe health states as worse than death. This seems like a logical hypothesis. Religions tend to be anti-euthanasia, and so it appears likely that religious people will have lower levels of support for euthanasia than non-religious people. Equally, if you don’t support the principle of euthanasia, it stands to reason that you are likely to be less willing to choose immediate death over living in a severe health state – something you would need to do for a health state to be considered as being worse than death in a time trade-off (TTO) study.

The authors test this hypothesis using a sub-sample of data (n=160) collected as part of the Irish EQ-5D-5L TTO valuation study. Perhaps unsurprisingly, the authors find evidence in support of the above hypotheses. Those that attend a religious service weekly were more likely to oppose euthanasia than those who attend a few times a year or less, and those who oppose euthanasia were less likely to give “worse than death” responses in the TTO than those that support it.

I found this paper really interesting, as it raises a number of challenging questions. If a society is made up of people with heterogeneous beliefs regarding religion, how should we balance these in the valuation of health? If a society is primarily non-religious is it fair to apply this valuation tariff to the lives of the religious, and vice versa? These certainly aren’t easy questions to answer, but may be worth reflecting on.

E-learning and health inequality aversion: A questionnaire experiment. Health Economics [PubMed] [RePEc] Published 22nd July 2018

Moving on from the cheery topic of euthanasia, what do you think about socioeconomic inequalities in health? In my home country, England, if you are from the poorest quintile of society, you can expect to experience 62 years in full health in your lifetime, whilst if you are from the richest quintile, you can expect to experience 74 years – a gap of 12 years.

In the second paper to be featured in this round-up, Cookson et al. explore the public’s willingness to sacrifice incremental population health gains in order to reduce these inequalities in health – their level of “health inequality aversion”. This is a potentially important area of research, as the vast majority of economic evaluation in health is distributionally-naïve and effectively assumes that members of the public aren’t at all concerned with inequalities in health.

The paper builds on prior work conducted by the authors in this area, in which they noted a high proportion of respondents in health inequality aversion elicitation studies appear to be so averse to inequalities that they violate monotonicity – they choose scenarios that reduce inequalities in health even if these scenarios reduce the health of the rich at no gain to the poor, or they reduce the health of the poor, or they may reduce the health of both groups. The authors hypothesise that these monotonicity violations may be due to incomplete thinking from participants, and suggest that the quality of their thinking could be improved by two e-learning educational interventions. The primary aim of the paper is to test the impact of these interventions in a sample of the UK public (n=60).

The first e-learning intervention was an animated video that described a range of potential positions that a respondent could take (e.g. health maximisation, or maximising the health of the worst off). The second was an interactive spreadsheet-based questionnaire that presented the consequences of the participant’s choices, prior to them confirming their selection. Both interventions are available online.

The authors found that the interactive tool significantly reduced the amount of extreme egalitarian (monotonicity-violating) responses, compared to a non-interactive, paper-based version of the study. Similarly, when the video was watched before completing the paper-based exercise, the number of extreme egalitarian responses reduced. However, when the video was watched before the interactive tool there was no further decrease in extreme egalitarianism. Despite this reduction in extreme egalitarianism, the median levels of inequality aversion remained high, with implied weights of 2.6 and 7.0 for QALY gains granted to someone from the poorest fifth of society, compared to the richest fifth of society for the interactive questionnaire and video groups respectively.

This is an interesting study that provides further evidence of inequality aversion, and raises further concern about the practical dominance of distributionally-naïve approaches to economic evaluation. The public does seem to care about distribution. Furthermore, the paper demonstrates that participant responses to inequality aversion exercises are shaped by the information given to them, and the way that information is presented. I look forward to seeing more studies like this in the future.

A new method for valuing health: directly eliciting personal utility functions. The European Journal of Health Economics [PubMed] [RePEc] Published 20th July 2018

Last, but not least, for this round-up, is a paper by Devlin et al. on a new method for valuing health.

The relative valuation of health states is a pretty important topic for health economists. If we are to quantify the effectiveness, and subsequently cost-effectiveness, of an intervention, we need to understand which health states are better than others, and how much better they are. Traditionally, this is done by asking members of the public to choose between different health profiles featuring differing levels of fulfilment of a range of domains of health, in order to ‘uncover’ the relative importance the respondent places on these domains, and levels. These can then be used in order to generate social tariffs that assign a utility value to a given health state for use in economic evaluation.

The authors point out that, in the modern day, valuation studies can be conducted rapidly, and at scale, online, but at the potential cost of deliberation from participants, and the resultant risk of heuristic dominated decision making. In response to this, the authors propose a new method – direct elicitation of personal utility functions, and pilot its use for the valuation of EQ-5D in a sample of the English public (n=76).

The proposed approach differs from traditional approaches in three key ways. Firstly, instead of simply attempting to infer the relative importance that participants place on differing domains based upon choices between health profiles, the respondents are asked directly about the relative importance they place on differing domains of health, prior to validating these with profile choices. Secondly, the authors place a heavy emphasis on deliberation, and the construction, rather than uncovering, of preferences during the elicitation exercises. Thirdly, a “personal utility function” for each individual is constructed (in effect a personal EQ-5D tariff), and these individual utility functions are subsequently aggregated into a social utility function.

In the pilot, the authors find that the method appears feasible for wider use, albeit with some teething troubles associated with the computer-based tool developed to implement it, and the skills of the interviewers.

This direct method raises an interesting question for health economics – should we be inferring preferences based upon choices that differ in terms of certain attributes, or should we just ask directly about the attributes? This is a tricky question. It is possible that the preferences elicited via these different approaches could result in different preferences – if they do, on what grounds should we choose one or other? This requires a normative judgment, and at present, it appears both are (potentially) as legitimate as each other.

Whilst the authors apply this direct method to the valuation of health, I don’t see why similar approaches couldn’t be applied to any multi-attribute choice experiment. Keep your eyes out for future uses of it in valuation, and perhaps beyond? It will be interesting to see how it develops.


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.


Sam Watson’s journal round-up for 15th January 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.

Cost-effectiveness of publicly funded treatment of opioid use disorder in California. Annals of Internal Medicine [PubMed] Published 2nd January 2018

Deaths from opiate overdose have soared in the United States in recent years. In 2016, 64,000 people died this way, up from 16,000 in 2010 and 4,000 in 1999. The causes of public health crises like this are multifaceted, but we can identify two key issues that have contributed more than any other. Firstly, medical practitioners have been prescribing opiates irresponsibly for years. For the last ten years, well over 200,000,000 opiate prescriptions were issued per year in the US – enough for seven in every ten people. Once prescribed, opiate use is often not well managed. Prescriptions can be stopped abruptly, for example, leaving people with unexpected withdrawal syndromes and rebound pain. It is estimated that 75% of heroin users in the US began by using legal, prescription opiates. Secondly, drug suppliers have started cutting heroin with its far stronger but cheaper cousin, fentanyl. Given fentanyl’s strength, only a tiny amount is required to achieve the same effects as heroin, but the lack of pharmaceutical knowledge and equipment means it is often not measured or mixed appropriately into what is sold as ‘heroin’. There are two clear routes to alleviating the epidemic of opiate overdose: prevention, by ensuring responsible medical use of opiates, and ‘cure’, either by ensuring the quality and strength of heroin, or providing a means to stop opiate use. The former ‘cure’ is politically infeasible so it falls on the latter to help those already habitually using opiates. However, the availability of opiate treatment programs, such as opiate agonist treatment (OAT), is lacklustre in the US. OAT provides non-narcotic opiates, such as methadone or buprenorphine, to prevent withdrawal syndromes in users, from which they can slowly be weaned. This article looks at the cost-effectiveness of providing OAT for all persons seeking treatment for opiate use in California for an unlimited period versus standard care, which only provides OAT to those who have failed supervised withdrawal twice, and only for 21 days. The paper adopts a previously developed semi-Markov cohort model that includes states for treatment, relapse, incarceration, and abstinence. Transition probabilities for the new OAT treatment were determined from treatment data for current OAT patients (as far as I understand it). Although this does raise the question about the generalisability of this population to the whole population of opiate users – given the need to have already been through two supervised withdrawals, this population may have a greater motivation to quit, for example. In any case, the article estimates that the OAT program would be cost-saving, through reductions in crime and incarceration, and improve population health, by reducing the risk of death. Taken at face value these results seem highly plausible. But, as we’ve discussed before, drug policy rarely seems to be evidence-based.

The impact of aid on health outcomes in Uganda. Health Economics [PubMed] Published 22nd December 2017

Examining the response of population health outcomes to changes in health care expenditure has been the subject of a large and growing number of studies. One reason is to estimate a supply-side cost-effectiveness threshold: the health returns the health service achieves in response to budget expansions or contractions. Similarly, we might want to know the returns to particular types of health care expenditure. For example, there remains a debate about the effectiveness of aid spending in low and middle-income country (LMIC) settings. Aid spending may fail to be effective for reasons such as resource leakage, failure to target the right population, poor design and implementation, and crowding out of other public sector investment. Looking at these questions at an aggregate level can be tricky; the link between expenditure or expenditure decisions and health outcomes is long and causality flows in multiple directions. Effects are likely to therefore be small and noisy and require strong theoretical foundations to interpret. This article takes a different, and innovative, approach to looking at this question. In essence, the analysis boils down to a longitudinal comparison of those who live near large, aid funded health projects with those who don’t. The expectation is that the benefit of any aid spending will be felt most acutely by those who live nearest to actual health care facilities that come about as a result of it. Indeed, this is shown by the results – proximity to an aid project reduced disease prevalence and work days lost to ill health with greater effects observed closer to the project. However, one way of considering the ‘usefulness’ of this evidence is how it can be used to improve policymaking. One way is in understanding the returns to investment or over what area these projects have an impact. The latter is covered in the paper to some extent, but the former is hard to infer. A useful next step may be to try to quantify what kind of benefit aid dollars produce and its heterogeneity thereof.

The impact of social expenditure on health inequalities in Europe. Social Science & Medicine Published 11th January 2018

Let us consider for a moment how we might explore empirically whether social expenditure (e.g. unemployment support, child support, housing support, etc) affects health inequalities. First, we establish a measure of health inequality. We need a proxy measure of health – this study uses self-rated health and self-rated difficulty in daily living – and then compare these outcomes along some relevant measure of socioeconomic status (SES) – in this study they use level of education and a compound measure of occupation, income, and education (the ISEI). So far, so good. Data on levels of social expenditure are available in Europe and are used here, but oddly these data are converted to a percentage of GDP. The trouble with doing this is that this variable can change if social expenditure changes or if GDP changes. During the financial crisis, for example, social expenditure shot up as a proportion of GDP, which likely had very different effects on health and inequality than when social expenditure increased as a proportion of GDP due to a policy change under the Labour government. This variable also likely has little relationship to the level of support received per eligible person. Anyway, at the crudest level, we can then consider how the relationship between SES and health is affected by social spending. A more nuanced approach might consider who the recipients of social expenditure are and how they stand on our measure of SES, but I digress. In the article, the baseline category for education is those with only primary education or less, which seems like an odd category to compare to since in Europe I would imagine this is a very small proportion of people given compulsory schooling ages unless, of course, they are children. But including children in the sample would be an odd choice here since they don’t personally receive social assistance and are difficult to compare to adults. However, there are no descriptive statistics in the paper so we don’t know and no comparisons are made between other groups. Indeed, the estimates of the intercepts in the models are very noisy and variable for no obvious reason other than perhaps the reference group is very small. Despite the problems outlined so far though, there is a potentially more serious one. The article uses a logistic regression model, which is perfectly justifiable given the binary or ordinal nature of the outcomes. However, the authors justify the conclusion that “Results show that health inequalities measured by education are lower in countries where social expenditure is higher” by demonstrating that the odds ratio for reporting a poor health outcome in the groups with greater than primary education, compared to primary education or less, is smaller in magnitude when social expenditure as a proportion of GDP is higher. But the conclusion does not follow from the premise. It is entirely possible for these odds ratios to change without any change in the variance of the underlying distribution of health, the relative ordering of people, or the absolute difference in health between categories, simply by shifting the whole distribution up or down. For example, if the proportions of people in two groups reporting a negative outcome are 0.3 and 0.4, which then change to 0.2 and 0.3 respectively, then the odds ratio comparing the two groups changes from 0.64 to 0.58. The difference between them remains 0.1. No calculations are made regarding absolute effects in the paper though. GDP is also shown to have a positive effect on health outcomes. All that might have been shown is that the relative difference in health outcomes between those with primary education or less and others changes as GDP changes because everyone is getting healthier. The question of the article is interesting, it’s a shame about the execution.