Chris Sampson’s journal round-up for 29th April 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.

Here comes the SUN: self‐assessed unmet need, worsening health outcomes, and health care inequity. Health Economics [PubMed] Published 24th April 2019

How should we measure inequity in health care? Often, it is measured on the basis of health care use, and the extent to which people with different socioeconomic circumstances – conditional on their level of need – access services. One problem with this approach is that differences might not only reflect barriers to access but also heterogeneity in preferences. If people of lower socioeconomic status prefer to access services less (conditional on need), then this is arguably an artificial signal of inequities in the system. Instead, we could just ask people. But can self-assessed unmet need provide a valid and meaningful measure of inequity?

In this study, the researchers looked at whether self-reported unmet need can predict deterioration in health. The idea here is that we would expect there to be negative health consequences if people genuinely need health care but cannot access it. The Canadian National Population Health Survey asks whether, during the preceding 12 months, the individual needed health care but did not receive it, with around 10% reporting unmet need. General health outcomes are captured by self-assessed health and by the HUI3, and there are also variables for specific chronic conditions. A few model specifications, controlling for a variety of health-related and demographic variables, are implemented. For the continuous variables, the authors use a fixed effects model with lagged health, and for the categorical outcomes they used a random effects probit.

The findings are consistent across models and outcomes. People who report self-assessed unmet need are more likely to have poorer health outcomes in subsequent periods, in terms of both general health and the number of self-reported chronic conditions. This suggests that self-assessed unmet need is probably a meaningful indicator of barriers to access in health care. I’m not aware of any UK-based surveys that include self-assessed unmet need, but this study provides some reason to think that they should.

Cost effectiveness of treatments for diabetic retinopathy: a systematic literature review. PharmacoEconomics [PubMed] Published 22nd April 2019

I’ve spent a good chunk of the last 8 years doing research in the context of diabetic eye disease. Over that time, treatment has changed, and there have been some interesting controversies relating to the costs of new treatments. So this review is timely.

There are four groups of treatments that the authors consider – laser, anti-VEGF eye injections, corticosteroids, and surgery. The usual databases were searched, turning up 1915 abstracts, and 17 articles were included in the review. That’s not a lot of studies, which is why I’d like to call the authors out for excluding one HTA report, which I assume was Royle et al 2015 and which probably should have been included. The results are summarised according to whether the evaluations were of treatments for diabetic macular oedema (DMO) or proliferative diabetic retinopathy (PDR), which are the two main forms of sight-threatening diabetic eye disease. The majority of studies focussed on DMO. As ever, in reviews of this sort, the studies and their findings are difficult to compare. Different methods were employed, for different purposes. The reason that there are so few economic evaluations in the context of PDR is probably that treatments have been so decisively shown to be effective. Yet there is evidence to suggest that, for PDR, the additional benefits of injections do not justify the much higher cost compared with laser. However, this depends on the choice of drug that is being injected, because prices vary dramaticly. For DMO, injections are cost-effective whether combined with laser or not. The evidence on corticosteroids is mixed and limited, but there is promise in recently-developed fluocinolone implants.

Laser might still be king in PDR, and early surgical intervention is also still cost-effective where indicated. For DMO, the strongest evidence is in favour of using an injection (bevacizumab) that can only be used off-label. You can blame Novartis for that, or you can blame UK regulators. Either way, there’s good reason to be angry about it. The authors of this paper clearly have a good understanding of the available treatments, which is not always the case for reviews of economic evaluations. The main value of this study is as a reference point for people developing research in this area, to identify the remaining gaps in the evidence and appropriately align (or not) with prevailing methods.

Exploring the impacts of the 2012 Health and Social Care Act reforms to commissioning on clinical activity in the English NHS: a mixed methods study of cervical screening. BMJ Open [PubMed] Published 14th April 2019

Not everybody loves the Health and Social Care Act of 2012. But both praise and criticism of far-reaching policies like this are usually confined to political arguments. It’s nice to see – and not too long after the fact – some evidence of its impact. In this paper, we learn about the impact of the Act on cervical screening activity.

The researchers used both qualitative and quantitative methods in their study in an attempt to identify whether the introduction of the Act influenced rates of screening coverage. With the arrival of the Act, responsibility for commissioning screening services shifted from primary care trusts to regional NHS England teams, while sexual health services were picked up by local authorities. The researchers conducted 143 (!) interviews with commissioners, clinicians, managers, and administrators from various organisations. Of these, 93 related to the commissioning of sexual health services, with questions regarding the commissioning system before and after the introduction of the Act. How did participants characterise the impact of the Act? Confusion, complexity, variability, uncertainty, and the idea that these characteristics could result in a drop in screening rates.

The quantitative research plan, and in particular the focus on cervical screening, arose from the qualitative findings. The quantitative analysis sought to validate the qualitative findings. But everyone had the Act dropped on them at the same time (those wily politicians know how to evade blame), so the challenge for the researchers was to identify some source of variation that could represent exposure to the effects of the Act. Informed by the interviewees, the authors differentiated between areas based on the number of local authorities that the clinical commissioning group (CCG) had to work with. Boundaries don’t align, so while some CCGs only have to engage with one local authority, some have to do so with as many as three, increasing the complexity created by the Act. As a kind of control, the researchers looked at the rate of unassisted births, which we wouldn’t expect to have been affected by the introduction of the Act. From this, they estimated the triple difference in cervical screening rates before and after the introduction of the Act, between CCGs with one or more than one local authority, minus the difference in the unassisted birth rate. Screening rates (and unassisted delivery rates) were both declining before the introduction of the Act. Without any adjustment, screening rates before and after the introduction of the act decreased by 0.39% more for GP practices in those CCGs that had to work with multiple local authorities. Conversely, unassisted delivery rates actually increased by a similar amount. The adjusted impact of the Act on screening rates was a drop of around 0.62%.

Clearly, there are big disclaimers attached to findings from a study of this sort, though the main finding seems to be robust to a variety of specifications. Any number of other things could explain the change in screening rates over the period, which the researchers couldn’t capture. But the quantitative findings are backed-up by the qualitative reports, making this a far more convincing piece of work. There’s little doubt that NHS redisorganisations of this kind create challenges in the short term, and we can now see the impact that this has on the provision of care.

Public involvement in health outcomes research: lessons learnt from the development of the recovering quality of life (ReQoL) measures. Health and Quality of Life Outcomes [PubMed] Published 11th April 2019

We’ve featured a few papers from the ReQoL project on this blog. The researchers developed several outcome measures to be used in the context of mental health. A couple of weeks ago, we also featured a paper turning a sceptical eye to the idea of co-production, whereby service users or members of the public are not simply research participants but research partners. This paper describes the experience of coproduction in the context of the ReQoL study. The authors are decidedly positive about co-production.

The logic behind the involvement of service users in the development of patient-reported outcome measures is obvious; measures need to be meaningful and understandable to patients, and enabling service users to inform research decisions could facilitate that. But there is little guidance on co-production in the context of developing patient-reported outcomes. Key decisions in the development of ReQoL were made by a ‘scientific group’, which included academics, clinicians, and seven expert service users. An overlapping ‘expert service user group’ also supported the study. In these roles, service users contributed to all stages of the research, confirming themes and items, supporting recruitment, collecting and analysing data, agreeing the final items for the measures, and engaging in dissemination activities. It seems that the involvement was in large part attendance at meetings, discussing data and findings to achieve an interpretation that includes the perspectives of services users. This resulted in decisions – about which items to take forward – that probably would not have been made if the academics and clinicians were left to their own devices. Service users were also involved in the development of research materials, such as the interview topic guide. In some examples, however, it seems like the line between research partner and research participant was blurred. If an expert service user group is voting on candidate items and editing them according to their experience, this is surely a data collection process and the services users become research subjects.

The authors describe the benefits as they saw them, in terms of the expert service users’ positive influence on the research. The costs and challenges are also outlined, including the need to manage disagreements and make additional preparations for meetings. We’re even provided with the resource implications in terms of the additional days of work. The comprehensive description of the researchers’ experiences in this context and the recommendations that they provide make this paper an important companion for anybody designing a research study to develop a new patient-reported outcome measure.

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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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