Brendan Collins’s journal round-up for 18th 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.

Evaluation of intervention impact on health inequality for resource allocation. Medical Decision Making [PubMed] Published 28th February 2019

How should decision-makers factor equity impacts into economic decisions? Can we trade off an intervention’s cost-effectiveness with its impact on unfair health inequalities? Is a QALY just a QALY or should we weight it more if it is gained by someone from a disadvantaged group? Can we assume that, because people of lower socioeconomic position lose more QALYs through ill health, that most interventions should, by default, reduce inequalities?

I really like the health equity plane. This is where you show health impacts (usually including a summary measure of cost-effectiveness like net health benefit or net monetary benefit) and equity impacts (which might be a change in slope index of inequality [SII] or relative index of inequality) on the same plane. This enables decision-makers to identify potential trade-offs between interventions that produce a greater benefit, but have less impact on inequalities, and those that produce a smaller benefit, but increase equity. I think there has been a debate over whether the ‘win-win’ quadrant should be south-east (which would be consistent with the dominant quadrant of the cost-effectiveness plane) or north-east, which is what seems to have been adopted as the consensus and is used here.

This paper showcases a reproducible method to estimate the equity impact of interventions. It considers public health interventions recommended by NICE from 2006-2016, with equity impacts estimated based on whether they targeted specific diseases, risk factors or populations. The disease distributions were based on hospital episode statistics data by deprivation (IMD). The study used equity weights to convert QALYs gained to different social groups into net social welfare. In this case, valuing the most disadvantaged fifth of people’s health at around 6-7 times that of the least disadvantaged fifth. I think there might still be work to be done around reaching consensus for equity weights.

The total expected effect on inequalities is small – full implementation of all recommendations would produce a reduction of the quality-adjusted life expectancy gap between the healthiest and least healthy from 13.78 to 13.34 QALYs. But maybe this is to be expected; NICE does not typically look at vaccinations or screening and has not looked at large scale public health programmes like the Healthy Child Programme in the whole. Reassuringly, where recommended interventions were likely to increase inequality, the trade-off between efficiency and equity was within the social welfare function they had used. The increase in inequality might be acceptable because the interventions were cost-effective – producing 5.6million QALYs while increasing the SII by 0.005. If these interventions are buying health at a good price, then you would hope this might then release money for other interventions that would reduce inequalities.

I suspect that public health folks might not like equity trade-offs at all – trading off equity and cost-effectiveness might be the moral equivalent of trading off human rights – you can’t choose between them. But the reality is that these kinds of trade-offs do happen, and like a lot of economic methods, it is about revealing these implicit trade-offs so that they become explicit, and having ‘accountability for reasonableness‘.

Future unrelated medical costs need to be considered in cost effectiveness analysis. The European Journal of Health Economics [PubMed] [RePEc] Published February 2019

This editorial says that NICE should include unrelated future medical costs in its decision making. At the moment, if NICE looks at a cardiovascular disease (CVD) drug, it might look at future costs related to CVD but it won’t include changes in future costs of cancer, or dementia, which may occur because individuals live longer. But usually unrelated QALY gains will be implicitly included; so there is an inconsistency. If you are a health economic modeller, you know that including unrelated costs properly is technically difficult. You might weight average population costs by disease prevalence so you get a cost estimate for people with coronary heart disease, diabetes, and people without either disease. Or you might have a general healthcare running cost that you can apply to future years. But accounting for a full matrix of competing causes of morbidity and mortality is very tricky if not impossible. To help with this, this group of authors produced the excellent PAID tool, which helps with doing this for the Netherlands (can we have one for the UK please?).

To me, including unrelated future costs means that in some cases ICERs might be driven more by the ratio of future costs to QALYs gained. Whereas currently, ICERs are often driven by the ratio of the intervention costs to QALYs gained. So it might be that a lot of treatments that are currently cost-effective no longer are, or we need to judge all interventions with a higher ICER willingness to pay threshold or value of a QALY. The authors suggest that, although including unrelated medical costs usually pushes up the ICER, it should ultimately result in better decisions that increase health.

There are real ethical issues here. I worry that including future unrelated costs might be used for an integrated care agenda in the NHS, moving towards a capitation system where the total healthcare spend on any one individual is capped, which I don’t necessarily think should happen in a health insurance system. Future developments around big data mean we will be able to segment the population a lot better and estimate who will benefit from treatments. But I think if someone is unlucky enough to need a lot of healthcare spending, maybe they should have it. This is risk sharing and, without it, you may get the ‘double jeopardy‘ problem.

For health economic modellers and decision-makers, a compromise might be to present analyses with related and unrelated medical costs and to consider both for investment decisions.

Overview of cost-effectiveness analysis. JAMA [PubMed] Published 11th March 2019

This paper probably won’t offer anything new to academic health economists in terms of methods, but I think it might be a useful teaching resource. It gives an interesting example of a model of ovarian cancer screening in the US that was published in February 2018. There has been a large-scale trial of ovarian cancer screening in the UK (the UKCTOCS), which has been extended because the results have been promising but mortality reductions were not statistically significant. The model gives a central ICER estimate of $106,187/QALY (based on $100 per screen) which would probably not be considered cost-effective in the UK.

I would like to explore one statement that I found particularly interesting, around the willingness to pay threshold; “This willingness to pay is often represented by the largest ICER among all the interventions that were adopted before current resources were exhausted, because adoption of any new intervention would require removal of an existing intervention to free up resources.”

The Culyer bookshelf model is similar to this, although as well as the ICER you also need to consider the burden of disease or size of the investment. Displacing a $110,000/QALY intervention for 1000 people with a $109,000/QALY intervention for a million people will bust your budget.

This idea works intuitively – if Liverpool FC are signing a new player then I might hope they are better than all of the other players, or at least better than the average player. But actually, as long as they are better than the worst player then the team will be improved (leaving aside issues around different positions, how they play together, etc.).

However, I think that saying that the reference ICER should be the largest current ICER might be a bit dangerous. Leaving aside inefficient legacy interventions (like unnecessary tonsillectomies etc), it is likely that the intervention being considered for investment and the current maximum ICER intervention to be displaced may both be new, expensive immunotherapies. It might be last in, first out. But I can’t see this happening; people are loss averse, so decision-makers and patients might not accept what is seen as a fantastic new drug for pancreatic cancer being approved then quickly usurped by a fantastic new leukaemia drug.

There has been a lot of debate around what the threshold should be in the UK; in England NICE currently use £20,000 – £30,000, up to a hypothetical maximum £300,000/QALY in very specific circumstances. UK Treasury value QALYs at £60,000. Work by Karl Claxton and colleagues suggests that marginal productivity (the ‘shadow price’) in the NHS is nearer to £5,000 – £15,000 per QALY.

I don’t know what the answer to this is. I don’t think the willingness-to-pay threshold for a new treatment should be the maximum ICER of a current portfolio of interventions; maybe it should be the marginal health production cost in a health system, as might be inferred from the Claxton work. Of course, investment decisions are made on other factors, like impact on health inequalities, not just on the ICER.

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Rita Faria’s journal round-up for 28th 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.

Appraising the value of evidence generation activities: an HIV modelling study. BMJ Global Health [PubMed] Published 7th December 2018

How much should we spend on implementing our health care strategy versus getting more information to devise a better strategy? Should we devolve budgets to regions or administer the budget centrally? These are difficult questions and this new paper by Beth Woods et al has a brilliant stab at answering them.

The paper looks at the HIV prevention and treatment policies in Zambia. It starts by finding the most cost-effective strategy and the corresponding budget in each region, given what is currently known about the prevalence of the infection, the effectiveness of interventions, etc. The idea is that the regions receive a cost-effective budget to implement a cost-effective strategy. The issue is that the cost-effective strategy and budget are devised according to what we currently know. In practice, regions might face a situation on the ground which is different from what was expected. Regions might not have enough budget to implement the strategy or might have some leftover.

What if we spend some of the budget to get more information to make a better decision? This paper considers the value of perfect information given the costs of research. Depending on the size of the budget and the cost of research, it may be worthwhile to divert some funds to get more information. But what if we had more flexibility in the budgetary policy? This paper tests 2 more budgetary options: a national hard budget but with the flexibility to transfer funds from under- to overspending regions, and a regional hard budget with a contingency fund.

The results are remarkable. The best budgetary policy is to have a national budget with the flexibility to reallocate funds across regions. This is a fascinating paper, with implications not only for prioritisation and budget setting in LMICs but also for high-income countries. For example, the 2012 Health and Social Care Act broke down PCTs into smaller CCGs and gave them hard budgets. Some CCGs went into deficit, and there are reports that some interventions have been cut back as a result. There are probably many reasons for the deficit, but this paper shows that hard regional budgets clearly have negative consequences.

Health economics methods for public health resource allocation: a qualitative interview study of decision makers from an English local authority. Health Economics, Policy and Law [PubMed] Published 11th January 2019

Our first paper looked at how to use cost-effectiveness to allocate resources between regions and across health care services and research. Emma Frew and Katie Breheny look at how decisions are actually made in practice, but this time in a local authority in England. Another change of the 2012 Health and Social Care Act was to move public health responsibilities from the NHS to local authorities. Local authorities are now given a ring-fenced budget to implement cost-effective interventions that best match their needs. How do they make decisions? Thanks to this paper, we’re about to find out.

This paper is an enjoyable read and quite an eye-opener. It was startling that health economics evidence was not much used in practice. But the barriers that were cited are not insurmountable. And the suggestions by the interviewees were really useful. There were suggestions about how economic evaluations should consider the local context to get a fair picture of the impact of the intervention to services and to the population, and to move beyond the trial into the real world. Equity was mentioned too, as well as broadening the outcomes beyond health. Fortunately, the health economics community is working on many of these issues.

Lastly, there was a clear message to make economic evidence accessible to lay audiences. This is a topic really close to my heart, and something I’d like to help improve. We have to make our work easy to understand and use. Otherwise, it may stay locked away in papers rather than do what we intended it for. Which is, at least in my view, to help inform decisions and to improve people’s lives.

I found this paper reassuring in that there is clearly a need for economic evidence and a desire to use it. Yes, there are some teething issues, but we’re working in the right direction. In sum, the future for health economics is bright!

Survival extrapolation in cancer immunotherapy: a validation-based case study. Value in Health Published 13th December 2018

Often, the cost-effectiveness of cancer drugs hangs in the method to extrapolate overall survival. This is because many cancer drugs receive their marketing authorisation before most patients in the trial have died. Extrapolation is tested extensively in the sensitivity analysis, and this is the subject of many discussions in NICE appraisal committees. Ultimately, at the point of making the decision, the correct method to extrapolate is a known unknown. Only in hindsight can we know for sure what the best choice was.

Ash Bullement and colleagues take advantage of hindsight to know the best method for extrapolation of a clinical trial of an immunotherapy drug. Survival after treatment with immunotherapy drugs is more difficult to predict because some patients can survive for a very long time, while others have much poorer outcomes. They fitted survival models to the 3-year data cut, which was available at the time of the NICE technology appraisal. Then they compared their predictions to the observed survival in the 5-year data cut and to long-term survival trends from registry data. They found that the piecewise model and a mixture-cure model had the best predictions at 5 years.

This is a relevant paper for those of us who work in the technology appraisal world. I have to admit that I can be sceptical of piecewise and mixture-cure models, but they definitely have a role in our toolbox for survival extrapolation. Ideally, we’d have a study like this for all the technology appraisals hanging on the survival extrapolation so that we can take learnings across cancers and classes of drugs. With time, we would get to know more about what works best for which condition or drug. Ultimately, we may be able to get to a stage where we can look at the extrapolation with less inherent uncertainty.

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Brendan Collins’s journal round-up for 3rd 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.

A framework for conducting economic evaluations alongside natural experiments. Social Science & Medicine Published 27th November 2018

I feel like Social Science & Medicine is publishing some excellent health economics papers lately and this is another example. Natural experiment methods, like instrumental variables, difference in difference, and propensity matching, are increasingly used to evaluate public health policy interventions. This paper provides a review and a framework for how to incorporate economic evaluation alongside this. And even better, it has a checklist! It goes into some detail in describing each item in the checklist which I think will be really useful. A couple of the items seemed a bit peculiar to me, like talking about “Potential behavioural responses (e.g. ‘nudge effects’)” – I would prefer a more general term like causal mechanism. And it has multi-criteria decision analysis (MCDA) as a potential method. I love MCDA but I think that using MCDA would surely require a whole new set of items on the checklist, for instance, to record how MCDA weights have been decided. (For me, saying that CEA is insufficient so we should use MCDA instead is like saying I find it hard to put IKEA furniture together so I will make my own furniture from scratch.) My hope with checklists is that they actually improve practice, rather than just being used in a post hoc way to include a few caveats and excuses in papers.

Autonomy, accountability, and ambiguity in arm’s-length meta-governance: the case of NHS England. Public Management Review Published 18th November 2018

It has been said that NICE in England serves a purpose of insulating politicians from the fallout of difficult investment decisions, for example recommending that people with mild Alzheimers disease do not get certain drugs. When the coalition government gained power in the UK in 2010, there was initially talk that NICE’s role of approving drugs may be reduced. But the government may have realised that NICE serve a useful role of being a focus of public and media anger when new drugs are rejected on cost-effectiveness grounds. And so it may be with NHS England (NHSE), which according to this paper, as an arms-length body (ALB), has powers that exceed what was initially planned.

This paper uses meta-governance theory, examining different types of control mechanisms and the relationship between the ALB and the sponsor (Department for Health and Social Care), and how they impact on autonomy and accountability. It suggests that NHSE is operating at a macro, policy-making level, rather than an operational, implementation level. Policy changes from NHSE are presented by ministers as coming ‘from’ the NHS but, in reality, the NHS is much bigger than NHSE. NHSE was created to take political interference out of decision-making and let civil servants get on with things. But before reading this paper, it had not occurred to me how much power NHSE had accrued, and how this may create difficulties in terms of accountability for reasonableness. For instance, NHSE have a very complicated structure and do not publish all of their meeting minutes so it is difficult to understand how investment decisions are made. It may be that the changes that have happened in the NHS since 2012 were intended to involve healthcare professionals more in local investment decisions. But actually, a lot of power in terms of shaping the balance of hierarchies, markets and networks has ended up in NHSE, sitting in a hinterland between politicians in Whitehall and local NHS organisations. With a new NHS Plan reportedly delayed because of Brexit chaos, it will be interesting to see what this plan says about accountability.

How health policy shapes healthcare sector productivity? Evidence from Italy and UK. Health Policy [PubMed] Published 2nd November 2018

This paper starts with an interesting premise: the English and Italian state healthcare systems (the NHS and the SSN) are quite similar (which I didn’t know before). But the two systems have had different priorities in the time period from 2004-2011. England focused on increasing activity, reducing waiting times and quality improvements while Italy focused on reducing hospital beds as well as reducing variation and unnecessary treatments. This paper finds that productivity increased more quickly in the NHS than the SSN from 2004-2011. This paper is ambitious in its scope and the data the authors have used. The model uses input-specific price deflators, so it includes the fact that healthcare inputs increase in price faster than other industries but treats this as exogenous to the production function. This price inflation may be because around 75% of costs are staff costs, and wage inflation in other industries produces wage inflation in the NHS. It may be interesting in future to analyse to what extent the rate of inflation for healthcare is inevitable and if it is linked in some way to the inputs and outputs. We often hear that productivity in the NHS has not increased as much as other industries, so it is perhaps reassuring to read a paper that says the NHS has performed better than a similar health system elsewhere.

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