Rita Faria’s journal round-up for 4th 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.

Cheap and dirty: the effect of contracting out cleaning on efficiency and effectiveness. Public Administration Review Published 25th February 2019

Before I was a health economist, I used to be a pharmacist and worked for a well-known high street chain for some years. My impression was that the stores with in-house cleaners were cleaner, but I didn’t know if this was a true difference, my leftie bias or my small sample size of 2! This new study by Shimaa Elkomy, Graham Cookson and Simon Jones confirms my suspicions, albeit in the context of NHS hospitals, so I couldn’t resist to select it for my round-up.

They looked at how contracted-out services fare in terms of perceived cleanliness, costs and MRSA rate in NHS hospitals. MRSA is a type of hospital-associated infection that is affected by how clean a hospital is.

They found that contracted-out services are cheaper than in-house cleaning, but that perceived cleanliness is worse. Importantly, contracted-out services increase the MRSA rate. In other words, contracting-out cleaning services could harm patients’ health.

This is a fascinating paper that is well worth a read. One wonders if the cost of managing MRSA is more than offset by the savings of contracting-out services. Going a step further, are in-house services cost-effective given the impact on patients’ health and costs of managing infections?

What’s been the bang for the buck? Cost-effectiveness of health care spending across selected conditions in the US. Health Affairs [PubMed] Published 1st January 2019

Staying on the topic of value for money, this study by David Wamble and colleagues looks at the extent to which the increased spending in health care in the US has translated into better health outcomes over time.

It’s clearly reassuring that, for 6 out of the 7 conditions they looked at, health outcomes have improved in 2015 compared to 1996. After all, that’s the goal of investing in medical R&D, although it remains unclear how much of this difference can be attributed to health care versus other things that have happened at the same time that could have improved health outcomes.

I wasn’t sure about the inflation adjustment for the costs, so I’d be grateful for your thoughts via comments or Twitter. In my view, we would underestimate the costs if we used medical price inflation indices. This is because these indices reflect the specific increase in prices in health care, such as due to new drugs being priced high at launch. So I understand that the main results use the US Consumer Price Index, which means that this reflects the average increase in prices over time rather than the increase in health care.

However, patients may not have seen their income rise with inflation. This means that the cost of health care may represent a disproportionally greater share of people’s income. And that the inflation adjustment may downplay the impact of health care costs on people’s pockets.

This study caught my eye and it is quite thought-provoking. It’s a good addition to the literature on the cost-effectiveness of US health care. But I’d wager that the question remains: to what extent is today’s medical care better value for money that in the past?

The dos and don’ts of influencing policy: a systematic review of advice to academics. Palgrave Communications Published 19th February 2019

We all would like to see our research findings influence policy, but how to do this in practice? Well, look no further, as Kathryn Oliver and Paul Cairney reviewed the literature, summarised it in 8 key tips and thought through their implications.

To sum up, it’s not easy to influence policy; advice about how to influence policy is rarely based on empirical evidence, and there are a few risks to trying to become a mover-and-shaker in policy circles.

They discuss three dilemmas in policy engagement. Should academics try to influence policy? How should academics influence policy? What is the purpose of academics’ engagement in policy making?

I particularly enjoyed reading about the approaches to influence policy. Tools such as evidence synthesis and social media should make evidence more accessible, but their effectiveness is unclear. Another approach is to craft stories to create a compelling case for the policy change, which seems to me to be very close to marketing. The third approach is co-production, which they note can give rise to accusations of bias and can have some practical challenges in terms of intellectual property and keeping one’s independence.

I found this paper quite refreshing. It not only boiled down the advice circulating online about how to influence policy into its key messages but also thought through the practical challenges in its application. The impact agenda seems to be here to stay, at least in the UK. This paper is an excellent source of advice on the risks and benefits of trying to navigate the policy world.

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Meeting round-up: Health Economists’ Study Group (HESG) Winter 2018

Last week’s biannual intellectual knees-up for UK health economists took place at City, University of London. We’ve written before about HESG, but if you need a reminder of the format you can read Lucy Abel’s blog post on the subject. This was the first HESG I’ve been to in a while that took place in an actual university building.

The conference kicked off for me with my colleague Grace Hampson‘s first ever HESG discussion. It was an excellent discussion of Toby Watt‘s paper on the impact of price promotions for cola, in terms of quantities purchased (they increase) and – by extension – sugar consumption. It was a nice paper with a clear theoretical framework and empirical strategy, which generated a busy discussion. Nutrition is a subject that I haven’t seen represented much at past HESG meetings, but there were several on the schedule this time around with other papers by Jonathan James and Ben Gershlick. I expect it’s something we’ll see becoming more prevalent as policymaking becomes more insistent.

The second and third sessions I attended were on the relationship between health and social care, which is a pressing matter in the UK, particular with regard to achieving integrated care. Ben Zaranko‘s paper considered substitution effects arising from changes in the relative budgets of health and social care. Jonathan Stokes and colleagues attempted to identify whether the Better Care Fund has achieved its goal of reducing secondary care use. That paper got a blazing discussion from Andrew Street that triggered an insightful discussion in the room.

A recurring theme in many sessions was the challenge of communicating with local decision-makers, and the apparent difficulty in working without a reference case to fall back on (such as that of NICE). This is something that I have heard regularly discussed at least since the Winter 2016 meeting in Manchester. At City, this was most clearly discussed in Emma Frew‘s paper describing the researchers’ experiences working with local government. Qualitative research has clearly broken through at HESG, including Emma’s paper and a study by Hareth Al-Janabi on the subject of treatment spillovers on family carers.

I also saw a few papers that related primarily to matters of research conduct and publishing. Charitini Stavropoulou‘s paper explored whether highly-cited researchers are more likely to receive public funding, while the paper I chaired by Anum Shaikh explored the potential for recycling cost-effectiveness models. The latter was a joy for me, with much discussion of model registries!

There were plenty of papers that satisfied my own particular research interests. Right up my research street was Mauro Laudicella‘s paper, which used real-world data to assess the cost savings associated with redirecting cancer diagnoses to GP referral rather than emergency presentation. I wasn’t quite as optimistic about the potential savings, with the standard worries about lead time bias and selection effects. But it was a great paper nonetheless. Also using real-world evidence was Ewan Gray‘s study, which supported the provision of adjuvant chemotherapy for early stage breast cancer but delivered some perplexing findings about patient-GP decision-making. Ewan’s paper explored technical methodological challenges, though the prize for the most intellectually challenging paper undoubtedly goes to Manuel Gomes, who continued his crusade to make health economists better at dealing with missing data – this time for the case of quality of life data. Milad Karimi‘s paper asked whether preferences over health states are informed. This is the kind of work I enjoy thinking about – whether measures like the EQ-5D capture what really matters and how we might do better.

As usual, many delegates worked hard and played hard. I took a beating from the schedule at this HESG, with my discussion taking place during the first session after the conference dinner (where we walked in the footsteps of the Spice Girls) and my chairing responsibilities falling on the last session of the last day. But in both cases, the audience was impressive.

I’ll leave the final thought for the blog post with Peter Smith’s plenary, which considered the role of health economists in a post-truth world. Happily, for me, Peter’s ideas chimed with my own view that we ought to be taking our message to the man on the Clapham omnibus and supporting public debate. Perhaps our focus on (national) policymakers is too strong. If not explicit, this was a theme that could be seen throughout the meeting, whether it be around broader engagement with stakeholders, recognising local decision-making processes, or harnessing the value of storytelling through qualitative research. HESG members are STRETCHing the truth.

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Sam Watson’s journal round-up for 9th January 2017

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.

Non-separable time preferences, novelty consumption and body weight: Theory and evidence from the East German transition to capitalism. Journal of Health Economics [PubMed] [RePEc] Published January 2017

Obesity is an ever growing (excuse the pun) problem associated with numerous health risks including diabetes and hypertension. It was recently reported that eight in ten middle-aged Britons are overweight or exercise too little. A strong correlation between economic development and obesity rates has been widely observed both over time within the same countries and between countries across the world. One potential explanation for this correlation is innovation of novel food products that are often energy dense and of little nutritional benefit. However, exploring this hypothesis is difficult as over the long time horizons associated with changing consumer habits and economic development, a multitude of confounding factors also change. This paper attempts to delve into this question making use of the natural experiment of German reunification in 1989. After the fall of the Berlin Wall a wave of products previously available in West Germany became available to East Germans, almost overnight. The paper provides a nice in depth theoretical model, which is then linked to data and an empirical analysis to provide a comprehensive study of the effect of novel food products in both the short and medium terms. At first glance the effect of reunification on diet habits and weight gain appear fairly substantial both in absolute and relative terms, and these results appear robust and well-founded, theoretically speaking. A question that remains in my mind are whether preferences in this case are endogenous or state dependent, a question that has important implications for policy. Similarly, did reunification reveal East German preferences for fast food and the like, or were those preferences changed as a result of the significant cultural shift? Sadly, this last question is unanswerable, but affects whether we can interpret these results as causal – a thought I shall expand upon in an upcoming blog post.

Ontology, methodological individualism, and the foundations of the social sciences. Journal of Economic Literature [RePEc] Published December 2016

It is not often that we feature philosophically themed papers. But, I am a keen proponent of keeping abreast of advances in our understanding of what exactly it is we are doing day to day. Are we actually producing knowledge of the real world? This review essay discusses the book The Ant Trap by Brian Epstein. Epstein argues that social scientists must get the social ontology right in order to generate knowledge of the social world. A view I think it would be hard to disagree with. But, he argues, economists have not got the social ontology right. In particular, economists are of the belief that social facts are built out of individual people, much like an ant colony is built of ants (hence the title), when in fact a less anthropocentric view should be adopted. In this essay, Robert Sugden argues that Epstein’s arguments against ontological individualism – that social facts are reducible to the actions of individuals – are unconvincing, particularly given Epstein’s apparent lack of insight into what social scientists actually do. Epstein also developed an ontological model for social facts on the basis of work by John Searle, a model which Sugden finds to be overly ambitious and ultimately unsuccessful. There is not enough space here to flesh out any of the arguments, needless to say it is an interesting debate, and one which may or may not make a difference to the methods we use, depending on who you agree with.

Heterogeneity in smokers’ responses to tobacco control policies. Health Economics [PubMedPublished 4th January 2016

In an ideal world, public health policy with regards to drugs and alcohol would be designed to minimise harm. However, it is often the case that policy is concerned with reducing the prevalence of use, rather than harm. Prevalence reducing policies, such as a Pigouvian tax, reduce overall use but only among those with the most elastic demand, who are also likely to be those whose use leads to the least harm. In this light, this study assesses the heterogeneity of tobacco users’ responses to tobacco control policies. Using quantile regression techniques, Erik Nesson finds that the effects of tobacco taxes are most pronounced in those who consume lower numbers of cigarettes, as we might expect. This is certainly not the first study to look at this (e.g. here and here), but reproduction of research findings is an essential part of the scientific process, and this study certainly provides further robust evidence to show that taxes alone may not be the optimum harm reduction strategy.

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