Thesis Thursday: Elizabeth Lemmon

On the third Thursday of every month, we speak to a recent graduate about their thesis and their studies. This month’s guest is Dr Elizabeth Lemmon who has a PhD from the University of Stirling. If you would like to suggest a candidate for an upcoming Thesis Thursday, get in touch.

Title
Essays on the provision of long term care to older adults in Scotland
Supervisors
David Bell, Alasdair Rutherford
Repository link
http://hdl.handle.net/1893/29369

What long term care provision is available to older people in Scotland?

Long term care (LTC) in Scotland comprises both formal care and unpaid care. Formal care encompasses care provided by professionals in a person’s own home as well as care in a residential care setting. Unpaid care is care that is provided by family members, friends, or neighbours. Long term care is provided to older people who need help because they are ill, frail or have a disability. It might mean help with more administrative tasks such as filling in forms, paying bills, shopping, and housework, but can also mean help with things of a more personal nature such as washing and dressing. Since 2002, individuals living in Scotland aged 65 or over are entitled to free personal care (FPC) at home, subject to a needs assessment. This makes Scotland quite different to England, where personal care costs are borne by the service user and their families, and provides a unique opportunity to conduct research.

What were the pros and cons of your chosen data sources?

I used three data sources in my PhD. Those included the Family Resources Survey (FRS), the Scottish Government’s administrative Social Care Survey (SCS) and publically available data zone level data. The key benefit of using survey data like the FRS was that they captured information about care recipients and their caregivers. I used these data in my third paper to look at unpaid carers’ Standard of Living (SoL). The down side of the FRS is that it only captures a subset of the population, which might be systematically different from the population at large. At the same time, although there is information on carers and the person they are caring for, this information is very limited for those who are not living with the care recipient. On the other hand, the benefit of using the SCS, which I used in my first two papers, is that it captures population level information about the provision of LTC services. However, unlike the FRS, the SCS was designed for administrative purposes meaning that it lacks the richness of information on client circumstances and characteristics. One solution to this is to use data zone level information as a proxy for those characteristics, but often this is not enough. Overall, the PhD highlighted both the strengths and weaknesses of working with these different data sources, pointing to the potential of using linked administrative and survey data in future research.

How did you identify sources of inequity in the provision of long term care?

Inequity in the provision of LTC exists if there are differences in LTC provision after accounting for differences in need. I investigated this issue of inequity in my first paper. In particular, we observed from the raw data that there are big differences in FPC provision between the 32 Scottish local authorities. As I mentioned, FPC is available to anyone in Scotland aged 65+ who needs it. Perhaps those differences are due to differences in need. But I didn’t find that this was the case. It seemed that, even after accounting for the need of local authority populations, via the proportion of disability benefit claims, there were still large differences in provision of FPC. I modelled this inequity using a simple regression framework. The results from the regressions found that there is evidence of geographic inequity in the provision of FPC in Scotland. In particular, the analysis suggests that the differences between the FPC rate and the rate of disability are not consistent across local authorities, suggesting that a needy individual might be more or less likely to receive care depending on where they live. One explanation for this is that local authorities differ in terms of their practices for managing the demand for FPC. However, this is an area that would require more detailed investigation with individual local authorities to understand their practices.

What is the role of unpaid care, and how did you model that?

Unpaid care is defined as care that is provided by family members, partners, or friends to those who require help because they are ill, frail, or have a disability. The care that they provide is unpaid and often considered as having a zero cost in economic evaluations. This might lead to inefficient resource allocation and poor policy decisions. In my second paper, I tried to model the effect that unpaid carers have on the FPC use of the cared for. This was difficult due to the potential reverse causality that occurs between the two. I compared different models to try to estimate this effect. Overall, my findings suggest that unpaid carers likely complement FPC services in Scotland. This relationship might be due to unpaid carers advocating on behalf of the cared for, and demanding services from the local authority for them. They might do this because they require more support to enable them to remain in the labour force. It could also be that the type of care unpaid carers provide is different to that provided by formal carers.

Why did you use a ‘standard of living’ approach and what can it tell us about the cost of unpaid care?

The motivation for using the SoL approach, as implemented by Morciano et al (2015), was really that we felt it might capture more of the trade-offs that are involved in providing care. Specifically, it is expected that unpaid carers have to divert resources in order to pay for goods and services for the person they are caring for. Compared to the conventional costing methods which have focused on attaching a monetary value to the time a carer gives up in order to provide care, we argue that the SoL approach may capture a wider array of the trade-offs that are involved in providing unpaid care. For example, are unpaid carers less able to afford to go on holiday or to take part in a regular leisure activity? If it is the case that unpaid carers have to invest resources into providing care then they might have fewer resources to devote to their own needs and wants, resulting in unpaid carers having a lower SoL compared to non-carers. The results suggest that unpaid carers who are living with the person they are caring for would require compensation of £229 per week in order for them to reach the same SoL as a non-carer.

What are the key steps necessary to identify and address unmet need in this context?

My research highlighted that there is possibly unmet need for FPC in Scotland and that this could potentially be more likely for older people who don’t have an unpaid carer helping them to access FPC services. Understanding this unmet need is a key area which requires further research. Unfortunately, it is difficult to measure and we only ever observe the met need for care, i.e. those who end up receiving formal care services. Thus, prior to addressing unmet need, it is important that we can measure it. One step necessary in doing so would be to carry out detailed investigations with individual local authorities. This would help us understand more about the needs of those individuals who apply for FPC but who are turned down. But this is only part of the picture. Understanding where individuals need FPC but don’t apply, either due to transaction costs, a lack of information on how to access those services, or other reasons, is far more difficult. One approach to gaining insight on these individuals could be to conduct qualitative interviews with them and their families.

Thesis Thursday: Feng-An Yang

On the third Thursday of every month, we speak to a recent graduate about their thesis and their studies. This month’s guest is Dr Feng-An Yang who has a PhD from Ohio State University. If you would like to suggest a candidate for an upcoming Thesis Thursday, get in touch.

Title
Three essays on access to health care in rural areas
Supervisors
Daeho Kim, Joyce Chen
Repository link
http://rave.ohiolink.edu/etdc/view?acc_num=osu152353045188255

What are the policy challenges for rural hospitals in the US?

Rural hospitals have been financially vulnerable, especially after the implementation of Medicare Prospective Payment System (PPS) in 1983, under which hospitals receive a predetermined, fixed reimbursement for their inpatient services. Under the PPS, they suffer from financial losses as their costs tend to exceed the reimbursement rate due to their smaller size and lower patient volume than their urban counterparts (Medicare Payment Advisory Commission, 2001 [PDF]). As a result, a noticeable number of rural hospitals have closed since the implementation of PPS (Congressional Budget Office, 1991 [PDF]).

This closure trend has slowed down thanks to public payment policies such as the Critical Access Hospitals (CAH) program, but rural hospitals are continuing to close their doors and a total of 107 rural hospitals have closed from 2010 to present according to the North Carolina Rural Health Research Program. This issue has raised public concern for rural residents’ access to health services and health status, and how to keep rural hospitals open has become an important policy priority.

Which data sources and models did you use to identify key events?

My dissertation investigated the impact of the CAH program and hospital closure by compiling data from various sources. The primary data come from the Medicare cost report, which contains detailed financial statements for nearly every U.S. hospital. Historical data on health care utilization at the county-level are obtained from the Area Health Resource File. County-level mortality rates are calculated from the national mortality files. Lastly, the list of CAHs and closed hospitals is obtained from the Flex Monitoring Team and American Hospital Association Annual Survey, respectively. This list contains information on the hospital identifier and year of event which is key to my empirical strategy.

To identify the impact of key events (i.e., CAH conversion and hospital closure), I use an event-study approach exploiting the variation in the timing of events. This approach estimates the changes in outcome for the time relative to the ‘event time’. A primary advantage of this approach is that it allows a visual examination of the evolution of changes in outcome before and after the event.

How can policies relating to rural hospitals benefit patients?

This question is not trivial because public payment policies are not directly linked to patients. The primary objective of these policies is to strengthen rural hospitals’ financial viability by providing them with enhanced reimbursement. As a result, it has been expected that, under these policies, rural hospitals will improve their financial conditions and stay open, thereby maintaining the access to health services for rural residents. Broadly speaking, public payment policies can lead to an increase in accessibility if we compare patient access to health services between counties with at least one hospital receiving financial support and counties without any hospitals receiving financial support.

I look at patient benefits from three aspects: accessibility, health care utilization, and mortality. My research shows that the CAH program has substantially improved CAHs’ financial conditions and as a result, some CAHs that otherwise would have been closed have stayed open. This in turn leads to an increase in rural residents’ access to and use of health services. We then provide suggestive evidence that the increased access to and use of health care services have improved patient health in rural areas.

Did you find any evidence that policies could have negative or unexpected consequences?

Certainly. The second chapter of my dissertation focused on skilled nursing care which can be provided in either swing beds (inpatient beds that can be used interchangeably for inpatient care or skilled nursing care) or hospital-based skilled nursing facilities (SNFs). Since the services provided in swing beds and SNFs are equivalent, differential payments, if present, may encourage hospitals to use one over the other.

While the CAH program provides enhanced reimbursement to rural hospitals, it also changes the swing bed reimbursement method such that swing bed payments are more favorable than SNF payments. As a result, CAHs may have a financial incentive to increase the use of swing beds over SNFs. By focusing on CAHs with a SNF, my research shows a remarkable increase in swing bed utilization and this increase is fully offset by the decrease in SNF utilization. These results suggest that CAHs substitute swing beds for SNFs in response to the change in swing bed reimbursement method.

Based on your research, what would be your key recommendations for policymakers?

Based on my research findings, I would make two recommendations for policymakers.

First, my research speaks to the ongoing debate over the elimination of CAH designation for certain hospitals. Loss of CAH designation could have serious financial consequences and subsequently have potentially adverse impacts on patient access to and use of health care. Therefore, I would recommend policymakers to maintain the CAH designation.

Second, while the CAH program has improved rural hospitals’ financial conditions, it has also created a financial incentive for hospitals to use the service with a higher reimbursement rate. Thus, my recommendation to policymakers would be to consider potentially substitutable health care services when designing reimbursement rates.

Thesis Thursday: Rebecca Addo

On the third Thursday of every month, we speak to a recent graduate about their thesis and their studies. This month’s guest is Dr Rebecca Addo who has a PhD from the University of Technology Sydney. If you would like to suggest a candidate for an upcoming Thesis Thursday, get in touch.

Title
The feasibility of health technology assessment (HTA) in the Ghanaian health system
Supervisors
Jane Hall, Stephen Goodall, Marion Haas
Repository link
http://hdl.handle.net/10453/133353

Why is now the right time to research the feasibility of HTA in Ghana?

In recent years, Ghana has been struggling to financially sustain the National Health Insurance Scheme (NHIS), through which it aims to attain universal health coverage (UHC). As a result, a number of payment methods have been explored, including capitation, but costs to the NHIS continue to escalate. The search for a more efficient NHIS funding resulted in stakeholders visiting the then NICE International, learnt of HTA, and expressed an interest in pursuing it. This interest was strengthened by the World Health Organization 2014 resolution, which encouraged its member states to adopt health interventions and technology assessments in support of UHC. In 2016, a pilot HTA study was conducted with support from international bodies that demonstrated potential cost savings with HTA. Subsequently, the Ghana National Medicines Policy, 2017, made provisions for the use of HTA in the selection of medicines. What remains uncertain is how the policy will be implemented, considering that the limited use of HTA in developing countries has been attributed to a lack of human capacity to undertake it, quality data, and limited resources to support it. With Ghana making progress towards the formal adoption of HTA for health decision-making, it is important to examine its feasibility considering the available national capacity and the health system’s particular characteristics, and to make recommendations on how Ghana can proceed, so that the anticipated positive changes can be realised.

What determines ‘feasibility’ in this context?

The usefulness of HTA to any health system is highly dependent on its availability, the quality of assessment, and the human capacity to conduct country specific appraisals. Thus ‘feasibility’ in this context is determined by the existing health resources and systems that could support the adoption and use of HTA in Ghana. Health resources include human capacity with the needed technical skills to conduct and contribute to HTA, funding for the HTA processes, and the available data, which is of good quality and easily accessible. In addition, potential users of HTA should have knowledge in HTA and be able to interpret its findings. Without these building blocks, HTA in itself cannot be successfully used in Ghana. The systems to consider are health system characteristics such as existing health decision-making processes, and political and social structures. Knowledge of this would aid with planning, design, and introduction of an HTA process that suits the Ghanaian health system’s decision-making context, which would promote its use.

How is HTA perceived by stakeholders in Ghana?

Whilst the majority of Ghanaian stakeholders who participated in my study understood HTA as a decision making tool, others saw it as using technologies such as telemedicine and mobile phone devices for healthcare delivery. Their prior understanding of HTA and its uses drove these differences. In terms of its potential use in the Ghanaian health system, most stakeholders acknowledged the benefits the health system stood to gain should HTA be adopted. They however perceived some barriers to the successful implementation of HTA and made some recommendations to address them. Perceived barriers included lack of knowledge of HTA by potential users, lack of human resource capacity to conduct it, lack of funds to support the conduct, and existing ways of making decisions. Factors perceived to promote HTA use were allocating funds for HTA activities, educating stakeholders on HTA and involving them in the planning, and introduction of HTA for health decision-making in Ghana. Also, stakeholders recommended that data be collated and managed for HTA, and for local Ghanaians to be trained to conduct HTA but rely on experts from other countries where possible.

Was it especially challenging to conduct an economic evaluation in the Ghanaian context?

Yes. Conducting a Ghanaian specific economic evaluation was very challenging, especially, in getting the appropriate data. There were no country-specific utility and clinical efficacy data, hence, I had to rely on data from elsewhere, which needed to the transformed to be context specific. The most challenging aspect was with getting appropriate clinical data due to the differences between clinical trial settings and the Ghanaian setting. Applicability issues that were addressed included differences in clinical treatment algorithm, alternative treatments, and epidemiology of disease. Cultural acceptance of available treatment for the study population also defined the appropriate comparator for the evaluation and consequently the clinical data that could be considered. This resulted in having to draw on data from two separate arms of two clinical trials for one of the models I built for my economic evaluation. To ensure applicability of data from other countries to Ghana, the data identified were transformed to be context specific with data input from Ghana either not available or not easily accessible. Therefore, clinical experts were relied upon for such inputs, adding to the limitations of the economic evaluation.

Can HTA processes from other countries be applied in Ghana?

Every health system is unique in its entirety, therefore processes used in one cannot be adopted and applied to the other. The same applies to HTA in Ghana. As part of my thesis, I reviewed a number of HTA organisations across the world to assess if one could be adopted in Ghana. The review revealed that HTA processes vary with each health system in terms of the context under which they were established, the scope or focus of HTA, outcomes, and links to funding decisions and their uses. The establishment of most of these HTA organisations was driven by country specific needs such as curbing the rising costs of healthcare and reducing variations in the availability of quality treatment and care. The available resources, such as human and data, and the health systems characteristics also influenced the HTA processes. Therefore it is not advisable for Ghana to simply adopt and use a model of HTA process from other countries. Rather, Ghana must pursue a country specific HTA process that is informed by relevant country data.

What would be your recommended ‘next step’ for HTA in Ghana?

Firstly, to ensure the acceptance, use and diffusion of HTA in Ghana, stakeholders of health should be educated on HTA and a legal framework stipulating its focus and conduct, and mandating its use, to be adopted.

Secondly, in the short-to-medium term, Ghana can leverage on ongoing collaborations with other countries and foreign organisations, such as the International Decision Support initiative (IDSi), to develop local capacity for HTA. In the long-term, it will be necessary for policy makers to explore the human resource capacity available for HTA in Ghana to guide the development of a human resource plan for HTA.

Thirdly, Ghana has to develop a country-specific methodological guideline or adapt an existing one for the conduct and reporting of economic evaluation studies in Ghana. Subsequently, guidelines for conducting HTA should be developed.

Lastly, to support HTA conduct, Ghana must create a national data repository including a manual on health resource use and their corresponding unit prices. The creation of an HTA standing panel of clinical experts and other stakeholders who could be relied upon to supply inputs for HTA when needed is also recommended. This is very important in the Ghanaian setting where availability and access to data is limited.