Brendan Collins’s journal round-up for 14th January 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.

Income distribution and health: can polarization explain health outcomes better than inequality? The European Journal of Health Economics [PubMed] Published 4th December 2018

One of my main interests is health inequalities. I thought polarisation was intuitive; I had seen it in the context of the UK and the US employment market; an increase in poorly-paid ‘McJobs’ and an increase in well-paid ‘MacJobs’, with fewer jobs in the middle. But I hadn’t seen polarisation measured in a statistical way.

Traditional measures of population inequalities like Gini or Atkinson index measure the share of income or the ratio of richest to poorest. But polarisation goes a step further and looks whether there are discrete clusters or groups who have similar incomes. The theory goes that having discrete groups increases social alienation, conflict and socioeconomic comparison and increases health inequalities. Now, I get how you can test statistically for discrete income clusters, and there is an evidence base for the relationship between polarisation and social tension. But groups will cluster based on other factors besides income. I feel like it may be taking a leap to assume a statistical finding (income polarisation) will always represent a sociological construct (alienation) but I confess I don’t know the literature behind this.

China is a country with an increasing degree of polarisation as measured by the Duclos, Esteban and Ray (DER) polarisation indices, and this study suggests that it is related to health status. This study looked at trends in BMI and systolic blood pressure from 1991 to 2011 and found both to increase with increased polarisation. I imagine a lot of other social change went on in this time period in China. I think BMI might not be a good candidate for measuring the effect of polarisation, as being poor is associated with malnourishment and low weight as well as obesity. The authors found that social capital (based on increasing family size, community size, and living in the same community for a long time) had a protective effect against the effects of polarisation on health. Whether this study provides more evidence for the socioeconomic comparison or status anxiety theories of health inequalities, I am not sure; it could equally provide evidence for the neo-materialist (i.e. simply not having enough resources for a healthy life) theories – the relative importance will likely differ by country anyway.

Maybe we don’t need to add more measures of inequality to the mix but I am intrigued. I am just starting my journey with polarisation but I think it has promise.

Two-year evaluation of mandatory bundled payments for joint replacement. The New England Journal of Medicine [PubMed] Published 2nd January 2019

Joint replacements are a big cost to western healthcare systems and often delayed or rationed (partly because replacement joints may only have a 10-20 year lifespan on average). In the UK, for instance, joint replacements have been rationed based on factors like BMI or pain levels (in my opinion, often in an arbitrary way to save money).

This paper found that having a bundled payments and penalties model (Comprehensive Care for Joint Replacement; CJR) for optimal care around hip and knee replacements reduced Medicare spending per episode compared to areas that did not pilot the programme. The overall difference was small in absolute terms at $812 against a total cost of around $24,000 per episode. The programme involves the hospital meeting a set of performance measures, and if they can do so at a lower cost, any savings are shared between the hospital and the payer. Cost savings were mainly driven by a reduction in patients being discharged to post-acute care facilities. Rates of complex patients were similar between pilot and control areas – this is important because a lower rate of complex cases in the CJR trial areas might indicate hospitals ‘cherry picking’ easier to treat, less expensive cases. Also, rates of complications were not significantly different between the CJR pilot areas and controls.
This paper suggests that having this kind of bundled payment programme can save money while maintaining quality.

Association of the Hospital Readmissions Reduction Program with mortality among Medicare beneficiaries hospitalized for heart failure, acute myocardial infarction, and pneumonia. JAMA [PubMed] Published 25th December 2018

Nobody likes being in hospital. But sometimes hospitals are the best places for people. This paper looks at possible unintended consequences of a US programme; the Hospital Readmissions Reduction Program (HRRP) where the Centers for Medicare & Medicaid Services (CMS) impose financial penalties (almost $2billion dollars’ worth since 2012) on hospitals with elevated 30-day readmission rates for patients with heart failure, acute myocardial infarction, and pneumonia. This study compared four time periods (no control group) and found that, after the programme was implemented, death rates for people who had been admitted with pneumonia and heart failure increased, with these increased deaths occurring more in people who had not been readmitted to hospital. The analysis controlled for differences in demographics, comorbidities, and calendar month using propensity scores and inverse probability weighting.

The authors are clear that their results do not establish cause and effect but are concerning nonetheless and worthy of more analysis. Incidentally, there is another paper this week in Health Affairs which suggests that the benefits of the programme in reducing readmissions was overstated.

There has been a similar financial incentive in the English NHS where hospitals are subject to the 30-day readmission rule, meaning they are not paid for people who are readmitted as an emergency within 30 days of being discharged. This is shortly to be abolished for 2019/20. I wonder if there has been similar research on whether this also led to unintended consequences in the NHS. Maybe there is a general lesson here about thinking a bit deeper about the potential outcomes of incentives in healthcare markets?

In these last two papers, we have had two examples of financial incentive programmes from Medicare. The CJR, which seems to have worked, has been dampened down from a mandatory to a voluntary programme, while the HRRP, which may not have worked, has been extended.

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Harold Hastings’s journal round-up for 24th December 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.

Mandatory Medicare bundled payment program for lower extremity joint replacement and discharge to institutional postacute care: interim analysis of the first year of a 5-year randomized trial. JAMA [PubMed] Published 4th September 2018

I will focus on two themes: one local to the United States – bundled payments for Medicare, and one global – the economic burden of sepsis. Finkelstein, Ji, Mahoney, and Skinner described the results of a study aimed at assessing the effects of bundled Medicare payments (as opposed to payments for each component of treatment) upon care and costs of lower extremity joint replacement. Finkelstein et al. found only one significant difference between the bundled carte group and a control group: the percentage discharged to institutional care decreased from 33.7% in the control group to 30.8% in the bundled care group, that is, one fewer patient per 33 treated. There was no significant difference in costs or quality of care. In this sense I must differ from the optimism of an associated editorial; to me, a true success would include a significant reduction in cost together with an improvement in outcome. Thus, in terms of bundled Medicare payments, we are not at the end, not even the beginning of the end, but perhaps near the end of the beginning (my apologies to Winston Churchill).

Epidemiology and costs of sepsis in the United States—an analysis based on timing of diagnosis and severity level. Critical Care Medicine [PubMed] Published 1st December 2018

Epidemiology of sepsis in Brazil: incidence, lethality, costs, and other indicators for Brazilian Unified Health System hospitalizations from 2006 to 2015. PLoS One [PubMed] Published 13th April 2018

Sepsis care continues to pose among the most significant health challenges world-wide, both in terms of economics and mortality, with mortality ranging from 10% to almost 80% depending upon severity. In terms of cost, sepsis treatment in the US averages over $18,000 per hospitalization with almost 1 million cases admitted annually, while Brazil spends 1/30 of this amount (~$600 per hospitalization), and 1/10 of this amount for sepsis treatment in the ICU ($1,700 per hospitalization). Mortality in Brazil is higher than that in the US and higher in public hospitals than in private hospitals. The studies offer complementary suggestions for improvement: in the US study, Paoli et al. call for early detection of sepsis as a way to reduce its severity and thus its cost. In the Brazilian study, Neira et al. conclude that limited economic resources may contribute significantly to high mortality, an observation that should concern all of us interested in world-wide health. Clearly both improved detection and more effective, lower cost treatments are essential to address the health and economic burdens of sepsis. The following paper reviews a potential answer to the latter question – that of more effective, lower cost treatments.

Ascorbic acid, corticosteroids, and thiamine in sepsis: a review of the biologic rationale and the present state of clinical evaluation. Critical Care [PubMed] Published 29th October 2018

In terms of the cost of sepsis treatment, it is interesting to note that an intervention successful in a single-site, retrospective review involved a combination of three “cheap and readily available agents with a long safety record in clinical use since 1949.” Mortality decreased from 40% to 8.5%. The 2018 review describes mixed reaction based on informal cost/benefit/risk analysis while nine trials are underway. If these trials prove successful, it might be hoped that the low cost would spur world-wide incorporation of ascorbate-corticosteroid-thiamine therapy for sepsis – addressing world-wide incidence of 15 million cases annually and mortality approaching 60% in less developed countries. An optimist might even hope for reduced mortality at significantly reduced costs, reminiscent of oral rehydration therapy for diarrhoea developed in Bangladesh 50 years ago and responsible for a 90% relative reduction in mortality.

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Sam Watson’s journal round-up for 12th November 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.

Estimating health opportunity costs in low-income and middle-income countries: a novel approach and evidence from cross-country data. BMJ Global Health. Published November 2017.

The relationship between health care expenditure and population health outcomes is a topic that comes up often on this blog. Understanding how population health changes in response to increases or decreases in the health system budget is a reasonable way to set a cost-effectiveness threshold. Purchasing things above this threshold will, on average, displace activity with greater benefits. But identifying this effect is hard. Commonly papers use some kind of instrumental variable method to try to get at the causal effect with aggregate, say country-level, data. These instruments, though, can be controversial. Years ago I tried to articulate why I thought using socio-economic variables as instruments was inappropriate. I also wrote a short paper a few years ago, which remains unpublished, that used international commodity price indexes as an instrument for health spending in Sub-Saharan Africa, where commodity exports are a big driver of national income. This was rejected from a journal because of the choice of instruments. Commodity prices may well influence other things in the country that can influence population health. And a similar critique could be made of this article here, which uses consumption:investment ratios and military expenditure in neighbouring countries as instruments for national health expenditure in low and middle income countries.

I remain unconvinced by these instruments. The paper doesn’t present validity checks on them, which is forgiveable given medical journal word limitations, but does mean it is hard to assess. In any case, consumption:investment ratios change in line with the general macroeconomy – in an economic downturn this should change (assuming savings = investment) as people switch from consumption to investment. There are a multitude of pathways through which this will affect health. Similarly, neighbouring military expenditure would act by displacing own-country health expenditure towards military expenditure. But for many regions of the world, there has been little conflict between neighbours in recent years. And at the very least there would be a lag on this effect. Indeed, in all the models of health expenditure and population health outcomes I’ve seen, barely a handful take into account dynamic effects.

Now, I don’t mean to let the perfect be the enemy of the good. I would never have suggested this paper should not be published as it is, at the very least, important for the discussion of health care expenditure and cost-effectiveness. But I don’t feel there is strong enough evidence to accept these as causal estimates. I would even be willing to go as far to say that any mechanism that affects health care expenditure is likely to affect population health by some other means, since health expenditure is typically decided in the context of the broader public sector budget. That’s without considering what happens with private expenditure on health.

Strategic Patient Discharge: The Case of Long-Term Care Hospitals. American Economic Review. [RePEcPublished November 2018.

An important contribution of health economics has been to undermine people’s trust that doctors act in their best interest. Perhaps that’s a little facetious, nevertheless there has been ample demonstration that health care providers will often act in their own self-interest. Often this is due to trying to maximise revenue by gaming reimbursement schemes, but also includes things like doctors acting differently near the end of their shift so they can go home on time. So when I describe a particular reimbursement scheme that Medicare in the US uses, I don’t think there’ll be any doubt about the results of this study of it.

In the US, long-term acute care hospitals (LTCHs) specialise in treating patients with chronic care needs who require extended inpatient stays. Medicare reimbursement typically works on a fixed rate for each of many diagnostic related groups (DRGs), but given the longer and more complex care needs in LTCHs, they get a higher tariff. To discourage admitting patients purely to get higher levels of reimbursement, the bulk of the payment only kicks in after a certain length of stay. Like I said – you can guess what happened.

This article shows 26% of patients are discharged in the three days after the length of stay threshold compared to just 7% in the three days prior. This pattern is most strongly observed in discharges to home, and is not present in patients who die. But this may still be just by chance that the threshold and these discharges coincide. Fortunately for the authors the thresholds differ between DRGs and even move around within a DRG over time in a way that appears unrelated to actual patient health. They therefore estimate a set of decision models for patient discharge to try to estimate the effect of different reimbursement policies.

Estimating misreporting in condom use and its determinants among sex workers: Evidence from the list randomisation method. Health Economics. Published November 2018.

Working on health and health care research, especially if you conduct surveys, means you often want to ask people about sensitive topics. These could include sex and sexuality, bodily function, mood, or other ailments. For example, I work a fair bit on sanitation, where frequently self-reported diarrhoea in under fives (reported by the mother that is) is the primary outcome. This could be poorly reported particularly if an intervention includes any kind of educational component that suggests it could be the mother’s fault for, say, not washing her hands, if the child gets diarrhoea. This article looks at condom use among female sex workers in Senegal, another potentially sensitive topic, since unprotected sex is seen as risky. To try and get at the true prevalence of condom use, the authors use a ‘list randomisation’ method. This randomises survey participants to two sets of questions: a set of non-sensitive statements, or the same set of statements with the sensitive question thrown in. All respondents have to do is report the number of the statements they agree with. This means it is generally not possible to distinguish the response to the sensitive question, but the difference in average number of statements reported between the two groups gives an unbiased estimator for the population proportion. Neat, huh? Ultimately the authors report an estimate of 80% of sex workers using condoms, which compares to the 97% who said they used a condom when asked directly.

 

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