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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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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Chris Sampson’s journal round-up for 5th March 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.

Healthy working days: the (positive) effect of work effort on occupational health from a human capital approach. Social Science & Medicine Published 28th February 2018

If you look at the literature on the determinants of subjective well-being (or happiness), you’ll see that unemployment is often cited as having a big negative impact. The same sometimes applies for its impact on health, but here – of course – the causality is difficult to tease apart. Then, in research that digs deeper, looking at hours worked and different types of jobs, we see less conclusive results. In this paper, the authors start by asserting that the standard approach in labour economics (on which I’m not qualified to comment) is to assume that there is a negative association between work effort and health. This study extends the framework by allowing for positive effects of work that are related to individuals’ characteristics and working conditions, and where health is determined in a Grossman-style model of health capital that accounts for work effort in the rate of health depreciation. This model is used to examine health as a function of work effort (as indicated by hours worked) in a single wave of the European Working Conditions Survey (EWCS) from 2010 for 15 EU member states. Key items from the EWCS included in this study are questions such as “does your work affect your health or not?”, “how is your health in general?”, and “how many hours do you usually work per week?”. Working conditions are taken into account by looking at data on shift working and the need to wear protective equipment. One of the main findings of the study is that – with good working conditions – greater work effort can improve health. The Marxist in me is not very satisfied with this. We need to ask the question, compared to what? Working fewer hours? For most people, that simply isn’t an option. Aren’t the people who work fewer hours the people who can afford to work fewer hours? No attention is given to the sociological aspects of employment, which are clearly important. The study also shows that overworking or having poorer working conditions reduces health. We also see that, for many groups, longer hours do not negatively impact on health until we reach around 120 hours a week. This fails a good sense check. Who are these people?! I’d be very interested to see if these findings hold for academics. That the key variables are self-reported undermines the conclusions somewhat, as we can expect people to adjust their expectations about work effort and health in accordance with their colleagues. It would be very difficult to avoid a type 2 error (with respect to the negative impact of effort on health) using these variables to represent health and the role of work effort.

Agreement between retrospectively and contemporaneously collected patient-reported outcome measures (PROMs) in hip and knee replacement patients. Quality of Life Research [PubMed] Published 26th February 2018

The use of patient-reported outcomes (PROMs) in elective care in the NHS has been a boon for researchers in our field, providing before-and-after measurement of health-related quality of life so that we can look at the impact of these interventions. But we can’t do this in emergency care because the ‘before’ is never observed – people only show up when they’re in the middle of the emergency. But what if people could accurately recall their pre-emergency health state? There’s some evidence to suggest that people can, so long as the recall period is short. This study looks at NHS PROMs data (n=443), with generic and condition-specific outcomes collected from patients having hip or knee replacements. Patients included in the study were additionally asked to recall their health state 4 weeks prior to surgery. The authors assess the extent to which the contemporary PROM measurements agree with the retrospective measurements, and the extent to which any disagreement relates to age, socioeconomic status, or the length of time to recall. There wasn’t much difference between contemporary and retrospective measurements, though patients reported slightly lower health on the retrospective questionnaires. And there weren’t any compelling differences associated with age or socioeconomic status or the length of recall. These findings are promising, suggesting that we might be able to rely on retrospective PROMs. But the elective surgery context is very different to the emergency context, and I don’t think we can expect the two types of health care to impact recollection in the same way. In this study, responses may also have been influenced by participants’ memories of completing the contemporary questionnaire, and the recall period was very short. But the only way to find out more about the validity of retrospective PROM collection is to do more of it, so hopefully we’ll see more studies asking this question.

Adaptation or recovery after health shocks? Evidence using subjective and objective health measures. Health Economics [PubMed] Published 26th February 2018

People’s expectations about their health can influence their behaviour and determine their future health, so it’s important that we understand people’s expectations and any ways in which they diverge from reality. This paper considers the effect of a health shock on people’s expectations about how long they will live. The authors focus on survival probability, measured objectively (i.e. what actually happens to these patients) and subjectively (i.e. what the patients expect), and the extent to which the latter corresponds to the former. The arguments presented are couched within the concept of hedonic adaptation. So the question is – if post-shock expectations return to pre-shock expectations after a period of time – whether this is because people are recovering from the disease or because they are moving their reference point. Data are drawn from the Health and Retirement Study. Subjective survival probability is scaled to whether individuals expect to survive for 2 years. Cancer, stroke, and myocardial infarction are the health shocks used. The analysis uses some lagged regression models, separate for each of the three diagnoses, with objective and subjective survival probability as the dependent variable. There’s a bit of a jumble of things going on in this paper, with discussions of adaptation, survival, self-assessed health, optimism, and health behaviours. So it’s a bit difficult to see the wood for the trees. But the authors find the effect they’re looking for. Objective survival probability is negatively affected by a health shock, as is subjective survival probability. But then subjective survival starts to return to pre-shock trends whereas objective survival does not. The authors use this finding to suggest that there is adaptation. I’m not sure about this interpretation. To me it seems as if subjective life expectancy is only weakly responsive to changes in objective life expectancy. The findings seem to have more to do with how people process information about their probability of survival than with how they adapt to a situation. So while this is an interesting study about how people process changes in survival probability, I’m not sure what it has to do with adaptation.

3L, 5L, what the L? A NICE conundrum. PharmacoEconomics [PubMed] Published 26th February 2018

In my last round-up, I said I was going to write a follow-up blog post to an editorial on the EQ-5D-5L. I didn’t get round to it, but that’s probably best as there has since been a flurry of other editorials and commentaries on the subject. Here’s one of them. This commentary considers the perspective of NICE in deciding whether to support the use of the EQ-5D-5L and its English value set. The authors point out the differences between the 3L and 5L, namely the descriptive systems and the value sets. Examples of the 5L descriptive system’s advantages are provided: a reduced ceiling effect, reduced clustering, better discriminative ability, and the benefits of doing away with the ‘confined to bed’ level of the mobility domain. Great! On to the value set. There are lots of differences here, with 3 main causes: the data, the preference elicitation methods, and the modelling methods. We can’t immediately determine whether these differences are improvements or not. The authors stress the point that any differences observed will be in large part due to quirks in the original 3L value set rather than in the 5L value set. Nevertheless, the commentary is broadly supportive of a cautionary approach to 5L adoption. I’m not. Time for that follow-up blog post.

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