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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James Lomas’s journal round-up for 21st 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.

Decision making for healthcare resource allocation: joint v. separate decisions on interacting interventions. Medical Decision Making [PubMed] Published 23rd April 2018

While it may be uncontroversial that including all of the relevant comparators in an economic evaluation is crucial, a careful examination of this statement raises some interesting questions. Which comparators are relevant? For those that are relevant, how crucial is it that they are not excluded? The answer to the first of these questions may seem obvious, that all feasible mutually exclusive interventions should be compared, but this is in fact deceptive. Dakin and Gray highlight inconsistency between guidelines as to what constitutes interventions that are ‘mutually exclusive’ and so try to re-frame the distinction according to whether interventions are ‘incompatible’ – when it is physically impossible to implement both interventions simultaneously – and, if not, whether interventions are ‘interacting’ – where the costs and effects of the simultaneous implementation of A and B do not equal the sum of these parts. What I really like about this paper is that it has a very pragmatic focus. Inspired by policy arrangements, for example single technology appraisals, and the difficulty in capturing all interactions, Dakin and Gray provide a reader-friendly flow diagram to illustrate cases where excluding interacting interventions from a joint evaluation is likely to have a big impact, and furthermore propose a sequencing approach that avoids the major problems in evaluating separately what should be considered jointly. Essentially when we have interacting interventions at different points of the disease pathway, evaluating separately may not be problematic if we start at the end of the pathway and move backwards, similar to the method of backward induction used in sequence problems in game theory. There are additional related questions that I’d like to see these authors turn to next, such as how to include interaction effects between interventions and, in particular, how to evaluate system-wide policies that may interact with a very large number of interventions. This paper makes a great contribution to answering all of these questions by establishing a framework that clearly distinguishes concepts that had previously been subject to muddied thinking.

When cost-effective interventions are unaffordable: integrating cost-effectiveness and budget impact in priority setting for global health programs. PLoS Medicine [PubMed] Published 2nd October 2017

In my opinion, there are many things that health economists shouldn’t try to include when they conduct cost-effectiveness analysis. Affordability is not one of these. This paper is great, because Bilinski et al shine a light on the worldwide phenomenon of interventions being found to be ‘cost-effective’ but not affordable. A particular quote – that it would be financially impossible to implement all interventions that are found to be ‘very cost-effective’ in many low- and middle-income countries – is quite shocking. Bilinski et al compare and contrast cost-effectiveness analysis and budget impact analysis, and argue that there are four key reasons why something could be ‘cost-effective’ but not affordable: 1) judging cost-effectiveness with reference to an inappropriate cost-effectiveness ‘threshold’, 2) adoption of a societal perspective that includes costs not falling upon the payer’s budget, 3) failing to make explicit consideration of the distribution of costs over time and 4) the use of an inappropriate discount rate that may not accurately reflect the borrowing and investment opportunities facing the payer. They then argue that, because of this, cost-effectiveness analysis should be presented along with budget impact analysis so that the decision-maker can base a decision on both analyses. I don’t disagree with this as a pragmatic interim solution, but – by highlighting these four reasons for divergence of results with such important economic consequences – I think that there will be further reaching implications of this paper. To my mind, Bilinski et al essentially serves as a call to arms for researchers to try to come up with frameworks and estimates so that the conduct of cost-effectiveness analysis can be improved in order that paradoxical results are no longer produced, decisions are more usefully informed by cost-effectiveness analysis, and the opportunity costs of large budget impacts are properly evaluated – especially in the context of low- and middle-income countries where the foregone health from poor decisions can be so significant.

Patient cost-sharing, socioeconomic status, and children’s health care utilization. Journal of Health Economics [PubMed] Published 16th April 2018

This paper evaluates a policy using a combination of regression discontinuity design and difference-in-difference methods. Not only does it do that, but it tackles an important policy question using a detailed population-wide dataset (a set of linked datasets, more accurately). As if that weren’t enough, one of the policy reforms was actually implemented as a result of a vote where two politicians ‘accidentally pressed the wrong button’, reducing concerns that the policy may have in some way not been exogenous. Needless to say I found the method employed in this paper to be a pretty convincing identification strategy. The policy question at hand is about whether demand for GP visits for children in the Swedish county of Scania (Skåne) is affected by cost-sharing. Cost-sharing for GP visits has occurred for different age groups over different periods of time, providing the basis for regression discontinuities around the age threshold and treated and control groups over time. Nilsson and Paul find results suggesting that when health care is free of charge doctor visits by children increase by 5-10%. In this context, doctor visits happened subject to telephone triage by a nurse and so in this sense it can be argued that all of these visits would be ‘needed’. Further, Nilsson and Paul find that the sensitivity to price is concentrated in low-income households, and is greater among sickly children. The authors contextualise their results very well and, in addition to that context, I can’t deny that it also particularly resonated with me to read this approaching the 70th birthday of the NHS – a system where cost-sharing has never been implemented for GP visits by children. This paper is clearly also highly relevant to that debate that has surfaced again and again in the UK.

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Lazaros Andronis’s journal round-up for 4th September 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.

The effect of spending cuts on teen pregnancy. Journal of Health Economics [PubMed] Published July 2017

High teenage pregnancy rates are an important concern that features high in many countries’ social policy agendas. In the UK, a country which has one of the highest teen pregnancy rates in the world, efforts to tackle the issue have been spearheaded by the Teenage Pregnancy Strategy, an initiative aiming to halve under-18 pregnancy rates by offering access to sex education and contraception. However, the recent spending cuts have led to reductions in grants to local authorities, many of which have, in turn, limited or cut a number of teenage pregnancy-related programmes. This has led to vocal opposition by politicians and organisations, who argue that cuts jeopardise the reductions in teenage pregnancy rates seen in previous years. In this paper, Paton and Wright set out to examine whether this is the case; that is, whether cuts to Teenage Pregnancy Strategy-related services have had an impact on teenage pregnancy rates. To do so, the authors used panel data from 149 local authorities in England collected between 2009 and 2014. To capture changes in teenage pregnancy rates across local authorities over the specified period, the authors used a fixed effects model which assumed that under-18 conception rates are a function of annual expenditure on teenage pregnancy services per 13-17 year female in the local authority, and a set of other socioeconomic variables acting as controls. Area and year dummies were also included in the model to account for unobservable effects that relate to particular years and localities and a number of additional analysis were run to get around spurious correlations between expenditure and pregnancy rates. Overall, findings showed that areas which implemented bigger cuts to teenage pregnancy-targeting programmes have, on average, seen larger drops in teenage pregnancy rates. However, these drops are, in absolute terms, small (e.g. a 10% reduction in expenditure is associated with a 0.25% decrease in teenage conception rates). Various explanations can be put forward to interpret these findings, one of which is that cuts might have trimmed off superfluous or underperforming elements of the programme. If this is the case, Paton and Wright’s findings offer some support to arguments that spending cuts may not always be bad for the public.

Young adults’ experiences of neighbourhood smoking-related norms and practices: a qualitative study exploring place-based social inequalities in smoking. Social Science & Medicine [PubMed] Published September 2017

Smoking is a universal problem affecting millions of people around the world and Canada’s young adults are no exception. As in most countries, smoking prevalence and initiation is highest amongst young groups, which is bad news, as many people who start smoking at a young age continue to smoke throughout adulthood. Evidence suggests that there is a strong socioeconomic gradient in smoking, which can be seen in the fact that smoking prevalence is unequally distributed according to education and neighbourhood-level deprivation, being a greater problem in more deprived areas. This offers an opportunity for local-level interventions that may be more effective than national strategies. Though, to come up with such interventions, policy makers need to understand how neighbourhoods might shape, encourage or tolerate certain attitudes towards smoking. To understand this, Glenn and colleagues saw smoking as a practice that is closely related to local smoking norms and social structures, and sought to get young adult smokers’ views on how their neighbourhood affects their attitudes towards smoking. Within this context, the authors carried out a number of focus groups with young adult smokers who lived in four different neighbourhoods, during which they asked questions such as “do you think your neighbourhood might be encouraging or discouraging people to smoke?” Findings showed that some social norms, attitudes and practices were common among neighbourhoods of the same SES. Participants from low-SES neighbourhoods reported more tolerant and permissive local smoking norms, whereas in more affluent neighbourhoods, participants felt that smoking was more contained and regulated. While young smokers from high SES neighbourhoods expressed some degree of alignment and agency with local smoking norms and practices, smokers in low SES described smoking as inevitable in their neighbourhood. Of interest is how individuals living in different SES areas saw anti-smoking regulations: while young smokers in affluent areas advocate social responsibility (and downplay the role of regulations), their counterparts in poorer areas called for more protection and spoke in favour of greater government intervention and smoking restrictions. Glenn and colleagues’ findings serve to highlight the importance of context in designing public health measures, especially when such measures affect different groups in entirely different ways.

Cigarette taxes, smoking—and exercise? Health Economics [PubMed] Published August 2017

Evidence suggests that rises in cigarette taxes have a positive effect on smoking reduction and/or cessation. However, it is also plausible that the effect of tax hikes extends beyond smoking, to decisions about exercise. To explore whether this proposition is supported by empirical evidence, Conway and Niles put together a simple conceptual framework, which assumes that individuals aim to maximise the utility they get from exercise, smoking, health (or weight management) and other goods subject to market inputs (e.g. medical care, diet aids) and time and budget constraints. Much of the data for this analysis came from the Behavioral Risk Factor Surveillance System (BRFSS) in the US, which includes survey participants’ demographic characteristics (age, gender), as well as answers to questions about physical activities and exercise (e.g. intensity and time per week spent on activities) and smoking behaviour (e.g. current smoking status, number of cigarettes smoked per day). Survey data were subsequently combined with changes in cigarette taxes and other state-level variables. Conway and Niles’s results suggest that increased cigarette costs reduce both smoking and exercise, with the decline in exercise being more pronounced among heavy and regular smokers. However, the direction of the effect varied according to one’s age and smoking experience (e.g. higher cigarette cost increased physical activity among recent quitters), which highlights the need for caution in drawing conclusions about the exact mechanism that underpins this relationship. Encouraging smoking cessation and promoting physical exercise are important and desirable public health objectives, but, as Conway and Niles’s findings suggest, pursuing both of them at the same time may not always be plausible.

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