Alastair Canaway’s journal round-up for 29th 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.

Is “end of life” a special case? Connecting Q with survey methods to measure societal support for views on the value of life-extending treatments. Health Economics [PubMed] Published 19th January 2018

Should end-of-life care be treated differently? A question often asked and previously discussed on this blog: findings to date are equivocal. This question is important given NICE’s End-of-Life Guidance for increased QALY thresholds for life-extending interventions, and additionally the Cancer Drugs Fund (CDF). This week’s round-up sees Helen Mason and colleagues attempt to inform the debate around societal support for views of end-of-life care, by trying to determine the degree of support for different views on the value of life-extending treatment. It’s always a treat to see papers grounded in qualitative research in the big health economics journals and this month saw the use of a particularly novel mixed methods approach adding a quantitative element to their previous qualitative findings. They combined the novel (but increasingly recognisable thanks to the Glasgow team) Q methodology with survey techniques to examine the relative strength of views on end-of-life care that they had formulated in a previous Q methodology study. Their previous research had found that there are three prevalent viewpoints on the value of life-extending treatment: 1. ‘a population perspective: value for money, no special cases’, 2. ‘life is precious: valuing life-extension and patient choice’, 3. ‘valuing wider benefits and opportunity cost: the quality of life and death’. This paper used a large Q-based survey design (n=4902) to identify societal support for the three different viewpoints. Viewpoints 1 and 2 were found to be dominant, whilst there was little support for viewpoint 3. The two supported viewpoints are not complimentary: they represent the ethical divide between the utilitarian with a fixed budget (view 1), and the perspective based on entitlement to healthcare (view 2: which implies an expanding healthcare budget in practice). I suspect most health economists will fall into camp number one. In terms of informing decision making, this is very helpful, yet unhelpful: there is no clear answer. It is, however, useful for decision makers in providing evidence to balance the oft-repeated ‘end of life is special’ argument based solely on conjecture, and not evidence (disclosure: I have almost certainly made this argument before). Neither of the dominant viewpoints supports NICE’s End of Life Guidance nor the CDF. Viewpoint 1 suggests end of life interventions should be treated the same as others, whilst viewpoint 2 suggests that treatments should be provided if the patient chooses them; it does not make end of life a special case as this viewpoint believes all treatments should be available if people wish to have them (and we should expand budgets accordingly). Should end of life care be treated differently? Well, it depends on who you ask.

A systematic review and meta-analysis of childhood health utilities. Medical Decision Making [PubMed] Published 7th October 2017

If you’re working on an economic evaluation of an intervention targeting children then you are going to be thankful for this paper. The purpose of the paper was to create a compendium of utility values for childhood conditions. A systematic review was conducted which identified a whopping 26,634 papers after deduplication – sincere sympathy to those who had to do the abstract screening. Following abstract screening, data were extracted for the remaining 272 papers. In total, 3,414 utility values were included when all subgroups were considered – this covered all ICD-10 chapters relevant to child health. When considering only the ‘main study’ samples, 1,191 utility values were recorded and these are helpfully separated by health condition, and methodological characteristics. In short, the authors have successfully built a vast catalogue of child utility values (and distributions) for use in future economic evaluations. They didn’t, however, stop there, they then built on the systematic review results by conducting a meta-analysis to i) estimate health utility decrements for each condition category compared to general population health, and ii) to examine how methodological factors impact child utility values. Interestingly for those conducting research in children, they found that parental proxy values were associated with an overestimation of values. There is a lot to unpack in this paper and a lot of appendices and supplementary materials are included (including the excel database for all 3,414 subsamples of health utilities). I’m sure this will be a valuable resource in future for health economic researchers working in the childhood context. As far as MSc dissertation projects go, this is a very impressive contribution.

Estimating a cost-effectiveness threshold for the Spanish NHS. Health Economics [PubMed] [RePEc] Published 28th December 2017

In the UK, the cost-per-QALY threshold is long-established, although whether it is the ‘correct’ value is fiercely debated. Likewise in Spain, there is a commonly cited threshold value of €30,000 per QALY with a dearth of empirical justification. This paper sought to identify a cost-per-QALY threshold for the Spanish National Health Service (SNHS) by estimating the marginal cost per QALY at which the SNHS currently operates on average. This was achieved by exploiting data on 17 regional health services between the years 2008-2012 when the health budget experienced considerable cuts due to the global economic crisis. This paper uses econometric models based on the provoking work by Claxton et al in the UK (see the full paper if you’re interested in the model specification) to achieve this. Variations between Spanish regions over time allowed the authors to estimate the impact of health spending on outcomes (measured as quality-adjusted life expectancy); this was then translated into a cost-per-QALY value for the SNHS. The headline figures derived from the analysis give a threshold between €22,000 and €25,000 per QALY. This is substantially below the commonly cited threshold of €30,000 per QALY. There are, however (as to be expected) various limitations acknowledged by the authors, which means we should not take this threshold as set in stone. However, unlike the status quo, there is empirical evidence backing this threshold and it should stimulate further research and discussion about whether such a change should be implemented.


Sam Watson’s journal round-up for October 24th 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.

Mortality decrease according to socioeconomic groups during the economic crisis in Spain: a cohort study of 36 million people. The Lancet [PubMed] Published 13th October 2016

There is no shortage of studies examining the relationship between macroeconomic conditions and population health. Papers have come up on the journal round-up here, here, and here, and we previously discussed economic conditions and baby health. So what does this study add? Using data from the 2011 Spanish census on 36 million individuals, the study compares age-adjusted mortality rates for different socioeconomic groups before and after the economic crisis in Spain. The socioeconomic status of households was classified on the basis of household wealth, household floor space, and number of cars. The study compares the annual change in mortality rates for 2004-7 to the annual percentage change in the post-crisis period 2008-11. In essence the authors are looking for a structural break. The article reports that mortality rates declined faster post-crisis than before and that this effect was more pronounced in low socioeconomic status households. However, this conclusion is based on observed differences in estimated changes of rate: differences between the socioeconomic groups are not directly tested. The authors seem to fall foul of the problem that the difference between “significant” and “not significant” is not itself statistically significant. The plots in the paper illustrate strong differences in age-adjusted mortality rates by socioeconomic status, but a structural break in changes in rates is not so clearly evident. A large econometric literature has arisen around measuring structural breaks in macroeconomic series, many of these methods may have been of use. Indeed, there have been a number of sophisticated and careful analyses of the effect of macroeconomic conditions and health previous published, including the seminal study by Christopher Ruhm. Why this study landed in The Lancet therefore seems somewhat mysterious.

The ambiguous effect of GP competition: the case of hospital admissions. Health Economics [PubMedPublished 14th October 2016

Another mainstay of this blog: competition in healthcare. We’ve covered papers on this topic in previous journal round-ups here and here, and critically discussed a paper on the topic here. It seems to be one of those topics with important implications for healthcare policy but one which becomes less certain the more is known. Indeed, this paper recognises this in its title. The ambiguity to which it refers is the effect of GP competition on hospital admissions: if GPs retain more patients due to increased competition then admissions go down; if they recruit new patients due to increased competition then admissions go up. Typically studies in this area either compare outcomes before and after a pro-competitive policy change, or compare outcomes between areas with different densities (and hence competition) between GPs. This study adopts a variant of the latter approach using the number of open list practices in an area as their proxy for competition. They find that increased competition reduces inpatient attendances and increases outpatient attendances. I’ve often been skeptical of the use of GP density as a proxy for competition. Do people really compare GP practices before choosing them or do they just go to the nearest one? If a person is already registered at one practice, how often do they search around to choose another if care isn’t that bad? An observed effect of a change in GP density could be attributable to entry into or exit from the ‘market’ of differently performing providers, which may have little to do with competition, more the type of GP, GP age, and differences in medical training. Nevertheless, this article does present a well-considered analysis, the difficulty is in the interpretation in light of all the previous studies.

Modeling the economic burden of adult vaccine-preventable diseases in the United States. Health Affairs [PubMed] Published 12th October 2016

Andrew Wakefield, disbarred doctor and disgraced author of the fraudulent Lancet paper on MMR and autism, is currently promoting his new anti-vaccine film. His work and a cabal of conspiracy theorists have led many parents to refuse to get their children vaccinated. All this despite vaccines being one of the safest and most cost-effective of health interventions. This new paper seeks to determine the economic burden of vaccine-preventable diseases is in the US. The diseases considered include hepatitis A and B; measles, mumps, and rubella; and shingles (herpes zoster). Epidemiological models were developed in conjunction with experts; economic costs were assessed using both cost-of-illness and full income methodologies; and, parameters were specified on the basis of a literature review. Taking into account healthcare costs and productivity losses, the burden of the considered diseases was estimated at $9 billion annually. The authors also discuss taking into account social welfare losses using the value of a statistical life, however I think I may be misinterpreting the results when it states

The current-dollar value of statistical life calculated from each source was $5.9 billion from the FDA; $6.3 billion from the NHTSA; and $8.3 billion from the EPA. The full income value of death as a result of vaccine-preventable diseases is estimated to be $176 billion annually (plausibility range: $166 billion–$231 billion).

That seems way too large to me so I’m not sure what to make of that. Nevertheless, the study illustrates the potentially massive burden that vaccine-preventable diseases may present.