Chris Sampson’s journal round-up for 3rd October 2016

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.

Using discrete choice experiments with duration to model EQ-5D-5L health state preferences: testing experimental design strategies. Medical Decision Making [PubMedPublished 28th September 2016

DCEs are a bit in vogue for the purpose of health state valuation, so it was natural that EuroQol turned to it for valuation of the EQ-5D-5L. But previous valuation studies have highlighted challenges  associated with this approach, some of which this paper now investigates. Central to the use of DCE in this way is the inclusion of a duration attribute to facilitate anchoring from 1 to dead. This study looks at the effect of increasing the options when it comes to duration, as previous studies were limited in this regard. In this study, possible durations were 6 months or 1, 2, 4, 7 or 10 years. 802 online survey respondents we presented with 10 DCE choice sets, and the resulting model had generally logically ordered coefficients. So the approach looks feasible, but it isn’t clear whether or not there are any real advantages to including more durations. Another issue is that the efficiency of the DCE design might be improved by introducing prior information from previous studies to inform the selection of health profiles – that is, by introducing non-zero prior values. With 800 respondents, this design resulted in more disordering with – for example – a positive coefficient on level 2 for the pain/discomfort dimension. This was not the expected result. However, the design included a far greater proportion of more difficult choices, which the authors suggest may have resulted in inconsistencies. An alternative way of increasing efficiency might be to use a 2-stage approach, whereby health profiles are selected and then durations are selected based on information from previous studies. Using the same number of pairs but a sample half the size (400), the 2-stage design seemed to work a treat. It’s a promising design that will no doubt see further research in this context.

Is the distribution of care quality provided under pay-for-performance equitable? Evidence from the Advancing Quality programme in England. International Journal for Equity in Health [PubMedPublished 23rd September 2016

Suppose a regional health care quality improvement initiative worked, but only for the well-off. Would we still support it? Maybe not, so it’s important to uncover for whom the policy is working. QOF is the most-studied pay-for-performance programme in England and it does not seem to have reduced health inequalities in the context of primary care. There is less evidence regarding P4P in hospital care, which is where this study comes in by looking at the Advancing Quality initiative across five different health conditions. Using individual-level data for 73,002 people, the authors model the probability of receiving a quality indicator according to income deprivation in their local area. There were 23 indicators altogether, across which the results were not consistent. Poorer patients were more likely to receive pre-surgical interventions for hip and knee replacements and for coronary artery bypass grafting (CABG). And poorer people were less likely to receive advice at discharge. On the other hand, for hip and knee replacement and CABG, richer people were more likely to receive diagnostic tests. The main finding is that there is no obvious systematic pro-poor or pro-rich bias in the effects of this pay-for-performance initiative in secondary care. This may not be a big surprise due to the limited amount of self-selection and self-direction for patients in secondary care, compared with primary care.

The impact of social security income on cognitive function at older ages. American Journal of Health Economics [RePEc] Published 19th September 2016

Income correlates with health, as we know. But it’s useful to be more specific – as this article is – in order to inform policy. So does more social security income improve cognitive function at older ages? The short answer is yes. And that wasn’t a foregone conclusion as there is some evidence that higher income leads to earlier retirement, which in turn can be detrimental to cognitive function. In this study the authors use changes in the Social Security Act in the US in the 1970s. Between 1972 and 1977, Congress messed up a bit and temporarily introduced a policy that made payments increase at a rate faster than inflation, which was therefore enjoyed by people born between 1910 and 1916, with a 5 year gradual transition until 1922. Unsurprisingly, this study follows many others that have made the most of this policy quirk. Data are taken from a longitudinal survey of older people, which includes a set of scores relating to cognition, with a sample of 4139 people. Using an OLS model, the authors estimate the association between Social Security income and cognition. Cognition is measured using a previously developed composite score with 3 levels: ‘normal’, ‘cognitively impaired’ and ‘demented’. To handle the endogeneity of income, an instrumental variable is constructed on the basis of year of birth to tie-in with the peak in benefit from the policy (n=673). In today’s money the beneficiary cohort received around $2000 extra. It’s also good to see the analysis extended to a quantile regression to see whereabouts in the cognition score distribution effects accrue. The additional income resulted in improvements in working memory, knowledge, languages and orientation and overall cognition. The effects are strong and clinically meaningful. A $1000 (in 1993 prices) increase in annual income lead to a 1.9 percentage point reduction in the likelihood of being classified as cognitively impaired. The effect is strongest for those with higher levels of cognition. The key take-home message here is that even in older populations, policy changes can be beneficial to health. It’s never too late.


Health and retirement policy

Last week a significant chunk of the UK public sector went on strike. It was over pensions. This isn’t the first of its kind, and it certainly won’t be the last. As the government tries to deal with an ageing population (and imaginary deficit-reduction responsibilities), it is set on a policy of reducing pensions and increasing the retirement age. Clearly this is not a sustainable policy. It seems to me time for health economists to weigh in on this issue and inform a much needed revolution in retirement policy. From a health perspective there are a number of things to consider here; these can be broadly divided in to considerations of efficiency and equity.

Efficiency of retirement policy

There are societal costs (and benefits) relating to retirement, as well as potential health implications for the individual. Two papers were published recently on the issue of whether retirement is beneficial or detrimental to an individual’s health. One of the papers demonstrated that retirement makes people less likely to report bad health, while the other showed that retirement can induce ill-health. If we believe the former then it might be more efficient to offer people earlier retirement, while if we believe the latter there would be efficiency arguments to the contrary. Unfortunately the papers don’t use comparable outcomes; neither using a generic measure of health to capture the health effect of retirement. A second limitation is that neither take in to account the societal costs (or benefits) of retirement. To my knowledge no study exists that fills these gaps.

An ideal analysis might investigate the health impact of retirement alongside the health-related costs and wider societal impacts. If it were the case, for example, that effectively forcing people to remain in work was damaging to their health, it may be more cost-effective to allow them to retire earlier. This seems quite feasible. Clearly, capturing these figures could be difficult, but hope may lie in large studies such as The Health and Retirement Study, which holds many data on the health of people over 50; particularly useful are those relating to their use of health care services and their previous employment. If we were to find that retirement leads to better health and a reduced usage of health care services then current government policies to increase the retirement age may be a very bad idea.

Equitability of retirement policy

There are also some equity concerns when it comes to retirement, as highlighted in a recent editorial news article. The key problem here is that poorer people die younger. As health economists it is also relevant to us that poorer people also tend to be less healthy. The implication of this is that a richer person’s retirement would be longer, and characterised by better health, than a poorer person’s. As such an increase in the retirement age may be disproportionately detrimental to the poor.

I am not suggesting that health economics should dominate this policy area, clearly health is only one aspect of interest. But as we know, health is an important one. There seems to be an assumption amongst decision makers that as people are getting older, people need to work longer. However, it seems safe to assume that when there is a step increase in the retirement age there is not an equivalent increase in the number of jobs available. Here the government’s logic falls down. It seems to me that the health impact of retirement is a reasonable starting point in the evaluation of such policies and the development of new (evidence-based) ones.

Do you believe retirement really can have a definitive impact on health? Should health economists play a part in the formation of policy in this area? Please comment below.