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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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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Paul Mitchell’s journal round-up for 1st January 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.

Does the approach to economic evaluation in health care depend on culture, values and institutional context? European Journal of Health Economics [PubMedPublished 5th December 2017

In last week’s round-up we looked at a paper that attempted to develop guidance for costing across European economic evaluations, even when the guidelines across countries vary as to what should and should not be included in an economic evaluation. Why is it that there is such variation in health economic evaluation methods across countries? Why are economic outcomes like quality-adjusted life years (QALYs) standard practice in some countries yet frowned upon in others? This editorial argues that cultures, values and institutional context play a role in the economic evaluation methodologies applied across countries. It does so by comparing five large European countries in terms of 1. the organisation and governance of the agencies undertaking health technology assessments (HTAs) and economic evaluation, 2. the methods used for economic evaluation, and 3. the use of HTA and economic evaluation in decision making. The authors argue that due to differences in these areas across countries, it is difficult to see how a “one size fits all” economic evaluation framework can be implemented, when health care systems, their regulations and social values towards health care differ. An argument is presented that where greater social value is placed on horizontal equity (equal treatment of equals) over vertical equity (unequal treatment of unequals), the QALY outcome is more likely to be applied in such countries. They argue that of the five largest European countries, the German efficiency frontier model of economic analysis may offer the best off-the-shelf option for countries like the United States who also have similar qualms about the use of QALYs in decision making. However, it may be the case that current economic evaluations lack international application due to other reasons beyond those notable considerations raised in this paper.

Reconciling ethical and economic conceptions of value in health policy using the capabilities approach: a qualitative investigation of Non-Invasive Prenatal Testing. Social Science & Medicine [PubMed] [RePEcPublished 16th November 2017

The capability approach, initially developed by economist and philosopher Amartya Sen, provides an alternative evaluative framework to welfare economics, shifting the focus on individual welfare away from utility and preferences, towards a person’s freedom to do and be valuable things to their life. It has more recently been used as a critique of the current approach to health economic evaluations, specifically what aspects of quality of life are included in the economic outcome, where the current measurement tools used in the generation of QALYs have been argued to have too narrow a focus on health outcomes, with a number of capability measures now developed as alternatives. This study, on the other hand, applies the capability approach to tackle health technologies that pose difficult ethical challenges where standard clinical and economic outcomes used in cost-effectiveness analysis may be in conflict with social values. The authors propose why they think the evaluative framework of the capability approach may be advantageous in such areas, using non-invasive prenatal testing (NIPT), a screening test that analyses cell-free fetal DNA circulating in maternal blood in order to gain information about the fetal genotype, as a case study. The authors propose that adopting a capability evaluative framework in NIPT may account for the enhancement of valuable options available to prospective parents and families, as well as capabilities that may be diminished if NIPT was made routinely available, such as the option of refusing a test as an informed choice. A secondary analysis of qualitative data was conducted on women with experience of NIPT in Canada. Using a constructivist orientation to directed qualitative content analysis, interviews were analysed to see how NIPT related to a pre-existing list of ten Central Human Capabilities developed by philosopher Martha Nussbaum. From the analysis, they found eight of the ten Nussbaum capabilities emerge from the interviewees who were not directly asked to consider capability in the interview. As well as these eight (life; bodily health; bodily integrity; senses, imagination and thought; emotions; practical reason; affiliation; control over one’s environment), a new capability emerged related to care-taking as a result of NIPT, both for potential children and also the impact on existing children. The next challenge for the authors will be trying to formulate their findings into a usable outcome measure for decision-making. However, the analysis undertaken here is a good example of how economists can attempt to tackle the assessment of ethically challenging technologies as a way of dealing with standard economic outcomes that might be considered counter-productive in such evaluations.

Quality of life in a broader perspective: does ASCOT reflect the capability approach? Quality of Life Research [PubMedPublished 14th December 2017

The Adult Social Care Outcomes Toolkit (ASCOT) is a measure developed specifically for the economic assessment of social care interventions in the UK. Although a number of versions of ASCOT have been developed, the most recent version of ASCOT has been argued to be a measure influenced by the capability approach, even though previous versions of the measure were not justified similarly, so it remains to be seen how influential the capability approach is in the composition of this outcome measure. This study attempts to add justification of linking the capability approach with the ASCOT by conducting a literature review on the capability approach to identify key issues of quality of life measurement and how ASCOT deals with these issues. The methods for conducting the literature review are not described in detail in this paper, but the authors state that three primary issues with quality of life measurement in the capability approach literature that emerge from their review are concerned with 1. the measurement of capability, 2. non-reliance on adaptive preferences, and 3. focus on a multidimensional evaluative space. The authors argue that capability measurement is tackled by ASCOT, through the use of “as I want” phraseology at the top level on the ASCOT dimensions. Adaptive preferences are argued to be tackled by the use of general population preferences of different states on ASCOT and the outcome addresses several dimensions of quality of life. I would argue that there is much more to measuring capability beyond these three areas identified by the authors. Although the authors rightly question if the “as I want” phraseology is adequate to measure capability in their conclusion, the other two criteria could equally justify most measures for generating QALYs, so the criteria they use to be a capability measure is set at a very low benchmark. I remain unconvinced about how much of a capability measure ASCOT actually is in practice.

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