Alastair Canaway’s journal round-up for 28th 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.

Information, education, and health behaviours: evidence from the MMR vaccine autism controversy. Health Economics [PubMed] Published 2nd May 2018

In 1998, Andrew Wakefield published (in the Lancet) his infamous and later retracted research purportedly linking the measles-mumps-rubella (MMR) vaccine and autism. Despite the thorough debunking and exposure of academic skulduggery, a noxious cloud of misinformation remained in the public mind, particularly in the US. This study examined several facets of the MMR fake news including: what impact did this have on vaccine uptake in the US (both MMR and other vaccines); how did state level variation in media coverage impact uptake; and what role did education play in subsequent decisions about whether to vaccinate or not. This study harnessed the National Immunization Survey from 1995 to 2006 to answer these questions. This is a yearly dataset of over 200,000 children aged between 19 to 35 months with detailed information on not just immunisation, but also maternal education, income and other sociodemographics. The NewsLibrary database was used to identify stories published in national and state media relating to vaccines and autism. Various regression methods were implemented to examine these data. The paper found that, unsurprisingly, for the year following the Wakefield publication the MMR vaccine take-up declined by between 1.1%-1.5% (notably less than 3% in the UK), likewise this fall in take-up spilled over into other vaccines take-up. The most interesting finding related to education: MMR take-up for children of college-educated mothers declined significantly compared to those without a degree. This can be explained by the education gradient where more-educated individuals absorb and respond to health information more quickly. However, in the US, this continued for many years beyond 2003 despite proliferation of research refuting the autism-MMR link. This contrasts to the UK where educational link closed soon after the findings were refuted, that is, in the UK, the educated responded to the new information refuting the MMR-Autism link. In the US, despite the research being debunked, MMR uptake was lower in the children of those with higher levels of education for many more years. The author speculates that this contrast to the UK may be a result of the media influencing parents’ decisions. Whilst the media buzz in the UK peaked in 2002, it had largely subsided by 2003. In the US however, the media attention was constant, if not increasing till 2006, and so this may have been the reason the link remained within the US. So, we have Andrew Wakefield and arguably fearmongering media to blame for causing a long-term reduction in MMR take-up in the US. Overall, an interesting study leaning on multiple datasets that could be of interest for those working with big data.

Can social care needs and well-being be explained by the EQ-5D? Analysis of the Health Survey for England. Value in Health Published 23rd May 2018

There is increasing discussion about integrating health and social care to provide a more integrated approach to fulfilling health and social care needs. This creates challenges for health economists and decision makers when allocating resources, particularly when comparing benefits from different sectors. NICE itself recognises that the EQ-5D may be inappropriate in some situations. With the likes of ASCOT, ICECAP and WEMWBS frequenting the health economics world this isn’t an unknown issue. To better understand the relationship between health and social care measures, this EuroQol Foundation funded study examined the relationship between social care needs as measured by the Barthel Index, well-being measured using WEMWBS and also the GGH-12, and the EQ-5D as the measure of health. Data was obtained through the Health Survey for England (HSE) and contained 3354 individuals aged over 65 years. Unsurprisingly the authors found that higher health and wellbeing scores were associated with an increased probability of no social care needs. Those who are healthier or at higher levels of wellbeing are less likely to need social care. Of all the instruments, it was the self-care and the pain/discomfort dimensions of the EQ-5D that were most strongly associated with the need for social care. No GHQ-12 dimensions were statistically significant, and for the WEMWBS only the ‘been feeling useful’ and ‘had energy to spare’ were statistically significantly associated with social care need. The authors also investigated various other associations between the measures with many unsurprising findings e.g. EQ-5D anxiety/depression dimension was negatively associated with wellbeing as measured using the GHQ-12. Although the findings are favourable for the EQ-5D in terms of it capturing to some extent social care needs, there is clearly still a gap whereby some outcomes are not necessarily captured. Considering this, the authors suggest that it might be appropriate to strap on an extra dimension to the EQ-5D (known as a ‘bolt on’) to better capture important ‘other’ dimensions, for example, to capture dignity or any other important social care outcomes. Of course, a significant limitation with this paper relates to the measures available in the data. Measures such as ASCOT and ICECAP have been developed and operationalised for economic evaluation with social care in mind, and a comparison against these would have been more informative.

The health benefits of a targeted cash transfer: the UK Winter Fuel Payment. Health Economics [PubMed] [RePEc] Published 9th May 2018

In the UK, each winter is accompanied by an increase in mortality, often known as ‘excess winter mortality’ (EWM). To combat this, the UK introduced the Winter Fuel Payment (WFP), the purpose of the WFP is an unconditional cash transfer to households containing an older person (those most vulnerable to EWM) above the female state pension age with the intent for this to used to help the elderly deal with the cost of keeping their dwelling warm. The purpose of this paper was to examine whether the WFP policy has improved the health of elderly people. The authors use the Health Surveys for England (HSE), the Scottish health Survey (SHeS) and the English Longitudinal Study of Ageing (ELSA) and employ a regression discontinuity design to estimate causal effects of the WFP. To measure impact (benefit) they focus on circulatory and respiratory illness as measured by: self-reports of chest infection, nurse measured hypertension, and two blood biomarkers for infection and inflammation. The authors found that for those living in a household receiving the payment there was a 6% point reduction (p<0.01) in the incidence of high levels of serum fibrinogen (biomarker) which are considered to be a marker of current infection and are associated with chronic pulmonary disease. For the other health outcomes, although positive, the estimated effects were less robust and not statistically significant. The authors investigated the impact of increasing the age of eligibility for the WFP (in line with the increase of women’s pension age). Their findings suggest there may be some health cost associated with the increase in age of eligibility for WFP. To surmise, the paper highlights that there may be some health benefits from the receipt of the WFP. What it doesn’t however consider is opportunity cost. With WFP costing about £2 billion per year, as a health economist, I can’t help but wonder if the money could have been better spent through other avenues.

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Ambulance and economics

I have recently been watching the BBC series AmbulanceIt is a fly-on-the-wall documentary following the West Midlands Ambulance Service interspersed with candid interviews with ambulance staff, much in the same vein as other health care documentaries like 24 Hours in A&EAs much as anything it provides a (stylised) look at the conditions on the ground for staff and illustrates how health care institutions are as much social institutions as essential services. In a recent episode, the cost of a hoax call was noted as some thousands of pounds. Indeed, the media and health services often talk about the cost of hoax calls in this way:

Warning for parents as one hoax call costs public £2,465 and diverts ambulance from real emergency call.

Frequent 999 callers cost NHS millions of pounds a year.

Nuisance caller cost the taxpayer £78,000 by making 408 calls to the ambulance service in two years.

But these are accounting costs, not the full economic cost. The first headline almost captures this by suggesting the opportunity cost was attendance at a real emergency call. However, given the way that ambulance resources are deployed and triaged across calls, it is very difficult to say what the opportunity cost is: what would be the marginal benefit of having an additional ambulance crew for the duration of a hoax call? What is the shadow price of an ambulance unit?

Few studies have looked at this question. The widely discussed study by Claxton et al. in the UK, looked at shadow prices of health care across different types of care, but noted that:

Expenditure on, for example, community care, A&E, ambulance services, and outpatients can be difficult to attribute to a particular [program budget category].

One review identified a small number of studies examining the cost-benefit and cost-effectiveness of emergency response services. Estimates of the marginal cost per life saved ranged from approximately $5,000 to $50,000. However, this doesn’t really tell us the impact of an additional crew, nor were many of these studies comparable in terms of the types of services they looked at, and these were all US-based.

There does exist the appropriately titled paper Ambulance EconomicsThis paper approaches the question we’re interested in, in the following way:

The centrepiece of our analysis is what we call the Ambulance Response Curve (ARC). This shows the relationship between the response time for an individual call (r) and the number of ambulances available and not in use (n) at the time the call was made. For example, let us suppose that 35 ambulances are on duty and 10 of them are being used. Then n has the value of 25 when the next call is taken. Ceteris paribus, as increases, we expect that r will fall.

On this basis, one can look at how an additional ambulance affects response times, on average. One might then be able to extrapolate the health effects of that delay. This paper suggests that an additional ambulance would reduce response times by around nine seconds on average for the service they looked at – not actually very much. However, the data are 20 years old, and significant changes to demand and supply over that period are likely to have a large effect on the ARC. Nevertheless, changes in response time of the order of minutes are required in order to have a clinically significant impact on survival, which are unlikely to occur with one additional ambulance.

Taken altogether, the opportunity cost of a hoax call is not likely to be large. This is not to downplay the stupidity of such calls, but it is perhaps reassuring that lives are not likely to be in the balance and is a testament to the ability of the service to appropriately deploy their limited resources.

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“Economists are the gods of global health.” Richard Horton at it again!

Richard Horton dislikes the economics discipline. That should not come as a shock to anyone. But worse still, this animus appears to arise from a misunderstanding of what economists actually do. Not so long ago, we discussed the fundamental errors in a piece in The Lancet Horton had published. Well, a new tweet from Horton leads us to yet another piece denigrating the economics profession:

The essence of Horton’s latest tirade is that (1) “economists silence the smaller voices of medicine”, (2) economists are responsible for austerity, (3) austerity has had a harmful effect both socially and economically, so that (4) “The task of health professionals is to resist and to oppose the egregious economics of our times.” The implication of the four points being that the influence of economists should be (at least partially) extricated from medicine and medical research. I would agree with point (3) here, as do a large consensus of academic economists (read this post and others from Simon Wren-Lewis for a good summary). But the other points don’t really stand up to close scrutiny.

One of the goals of academic economics is to provide evidence to support an optimal allocation of resources. From a macro perspective this may be the allocative efficiency of spending on different sectors like education and health care. Or, in a context used for much health economic analysis, how to allocate a health care budget fixed by the government through a political decision making process. What is considered ‘optimal’ in each of these circumstances is a normative decision and is, again, a political choice in practice. Perhaps this overlap with politics and economics has confused Horton, who mistakes one for the other with claims like

It is economists we must thank for the modern epidemic of austerity that has engulfed our world. Austerity is the calling card of neoliberalism.

But Horton also claims economics has displaced the “modest discipline of biology” in medicine. So, a reductio ad absurdum argument would have economists doing all the medical research and then implementing all medical and health care policy. Why do we need anyone else?

One can certainly claim this blog post is an apologia for economics. Of course would defend it. But it is true that there are good examples of poor economics and academic overreach. The work of the late Gary Becker was often criticized along these lines; his rational theory of addiction in particular. However, criticisms of the work of economists frequently come from economists themselves. I hope this blog serves as a case in point. More and more, health economists work as members of interdisciplinary teams, where a plurality of approaches, qualitative and quantitative, can aid in making sound inferences and supporting effective policy.

Horton’s views cannot unfortunately be dismissed as the ravings of the uninformed. He occupies an important position in medical research, serving as the editor-in-chief of one of the top medical journals, and his voice is influential. It serves no useful purpose to anyone and undermines the positions he advocates for, which many economists actually agree with, to publish false claims about economics.

 

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