Chris Sampson’s journal round-up for 4th June 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.

A qualitative investigation of the health economic impacts of bariatric surgery for obesity and implications for improved practice in health economics. Health Economics [PubMed] Published 1st June 2018

Few would question the ‘economic’ nature of the challenge of obesity. Bariatric surgery is widely recommended for severe cases but, in many countries, the supply is not sufficient to satisfy the demand. In this context, this study explores the value of qualitative research in informing economic evaluation. The authors assert that previous economic evaluations have adopted a relatively narrow focus and thus might underestimate the expected value of bariatric surgery. But rather than going and finding data on what they think might be additional dimensions of value, the authors ask patients. Emotional capital, ‘societal’ (i.e. non-health) impacts, and externalities are identified as theories for the types of value that might be derived from bariatric surgery. These theories were used to guide the development of questions and prompts that were used in a series of 10 semi-structured focus groups. Thematic analysis identified the importance of emotional costs and benefits as part of the ‘socioemotional personal journey’ associated with bariatric surgery. Out-of-pocket costs were also identified as being important, with self-funding being a challenge for some respondents. The information seems useful in a variety of ways. It helps us understand the value of bariatric surgery and how individuals make decisions in this context. This information could be used to determine the structure of economic evaluations or the data that are collected and used. The authors suggest that an EQ-5D bolt-on should be developed for ’emotional capital’ but, given that this ‘theory’ was predefined by the authors and does not arise from the qualitative research as being an important dimension of value alongside the existing EQ-5D dimensions, that’s a stretch.

Developing accessible, pictorial versions of health-related quality-of-life instruments suitable for economic evaluation: a report of preliminary studies conducted in Canada and the United Kingdom. PharmacoEconomics – Open [PubMed] Published 25th May 2018

I’ve been telling people about this study for ages (apologies, authors, if that isn’t something you wanted to read!). In my experience, the need for more (cognitively / communicatively) accessible outcome measures is widely recognised by health researchers working in contexts where this is relevant, such as stroke. If people can’t read or understand the text-based descriptors that make up (for example) the EQ-5D, then we need some alternative format. You could develop an entirely new measure. Or, as the work described in this paper set out to do, you could modify existing measures. There are three descriptive systems described in this study: i) a pictorial EQ-5D-3L by the Canadian team, ii) a pictorial EQ-5D-3L by the UK team, and iii) a pictorial EQ-5D-5L by the UK team. Each uses images to represent the different levels of the different dimensions. For example, the mobility dimension might show somebody walking around unaided, walking with aids, or in bed. I’m not going to try and describe what they all look like, so I’ll just encourage you to take a look at the Supplementary Material (click here to download it). All are described as ‘pilot’ instruments and shouldn’t be picked up and used at this stage. Different approaches were used in the development of the measures, and there are differences between the measures in terms of the images selected and the ways in which they’re presented. But each process referred to conventions in aphasia research, used input from clinicians, and consulted people with aphasia and/or their carers. The authors set out several remaining questions and avenues for future research. The most interesting possibility to most readers will be the notion that we could have a ‘generic’ pictorial format for the EQ-5D, which isn’t aphasia-specific. This will require continued development of the pictorial descriptive systems, and ultimately their validation.

QALYs in 2018—advantages and concerns. JAMA [PubMed] Published 24th May 2018

It’s difficult not to feel sorry for the authors of this article – and indeed all US-based purveyors of economic evaluation in health care. With respect to social judgments about the value of health technologies, the US’s proverbial head remains well and truly buried in the sand. This article serves as a primer and an enticement for the use of QALYs. The ‘concerns’ cited relate almost exclusively to decision rules applied to QALYs, rather than the underlying principles of QALYs, presumably because the authors didn’t feel they could ignore the points made by QALY opponents (even if those arguments are vacuous). What it boils down to is this: trade-offs are necessary, and QALYs can be used to promote value in those trade-offs, so unless you offer some meaningful alternative then QALYs are here to stay. Thankfully, the Institute for Clinical and Economic Review (ICER) has recently added some clout to the undeniable good sense of QALYs, so the future is looking a little brighter. Suck it up, America!

The impact of hospital costing methods on cost-effectiveness analysis: a case study. PharmacoEconomics [PubMed] Published 22nd May 2018

Plugging different cost estimates into your cost-effectiveness model could alter the headline results of your evaluation. That might seems obvious, but there are a variety of ways in which the selection of unit costs might be somewhat arbitrary or taken for granted. This study considers three alternative sources of information for hospital-based unit costs for hip fractures in England: (a) spell-level tariffs, (b) finished consultant episode (FCE) reference costs, and (c) spell-level reference costs. Source (b) provides, in theory, a more granular version of (a), describing individual episodes within a person’s hospital stay. Reference costs are estimated on the basis of hospital activity, while tariffs are prices estimated on the basis of historic reference costs. The authors use a previously reported cohort state transition model to evaluate different models of care for hip fracture and explore how the use of the different cost figures affects their results. FCE-level reference costs produced the highest total first-year hospital care costs (£14,440), and spell-level tariffs the lowest (£10,749). The more FCEs within a spell, the greater the discrepancy. This difference in costs affected ICERs, such that the net-benefit-optimising decision would change. The study makes an important point – that selection of unit costs matters. But it isn’t clear why the difference exists. It could just be due to a lack of precision in reference costs in this context (rather than a lack of accuracy, per se), or it could be that reference costs misestimate the true cost of care across the board. Without clear guidance on how to select the most appropriate source of unit costs, these different costing methodologies represent another source of uncertainty in modelling, which analysts should consider and explore.

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Alastair Canaway’s journal round-up for 28th August 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.

Valuing health-related quality of life: an EQ-5D-5L value set for England. Health Economics [PubMed] Published 22nd August 2017

With much anticipation, the new EQ-5D-5L value set was officially published. For over 18 months we’ve had access to values via the OHE’s discussion paper but the formal peer-reviewed paper has (I imagine) been in publication purgatory. This paper presents the results of the value-set for the new (ish) EQ-5D-5L measure. The study used the internationally agreed hybrid model combining TTO and DCE data to generate the values for the 3125 health states. It’s worth noting that the official values are marginally different to those in the discussion paper, although in practice this is likely to have little impact on results. Important results of the new value set include fewer health states worse than death (5.1% vs over 33%), and a higher minimum value (-0.285 vs -0.594). I’d always been a bit suspect of the values for worse than death states for the 3L measure, so this if anything is encouraging. This does, however, have important implications, primarily for interventions seeking to improve those in the worst health, where potential gains may be reduced. Many of us are actively using the EQ-5D-5L within trials and have been eagerly awaiting this value set. Perhaps naively, I always anticipated that with more levels and an improved algorithm it would naturally supersede the 3L and the outdated 3L value set upon publication. Unfortunately, to mark the release of the new value set, NICE released a ‘position statement’ [PDF] regarding the choice of measure and value sets for the NICE reference case. NICE specifies that i) the 5L value set is not recommended for use, ii) the EQ-5D-3L with the original UK TTO value set is recommended and if both measures are included then the 3L should be preferred, iii) if the 5L measure is included, then scores should be mapped to the EQ-5D-3L using the van Hout et al algorithm, iv) NICE supports the use of the EQ-5D-5L generally to collect data on quality of life, and v) NICE will review this decision in August 2018 in light of future evidence. So, unfortunately, for the next year at least, we will be either sticking to the original 3L measure or mapping from the 5L. I suspect NICE is buying some time as transitioning to the 5L is going to raise lots of interesting issues e.g. if a measure is cost-effective according to the 3L, but not the 5L, or vice-versa, and comparability of 5L results to old 3L results. Interesting times lie ahead. As a final note, it’s worth reading the OHE blog post outlining the position statement and OHE’s plans to satisfy NICE.

Long-term QALY-weights among spouses of dependent and independent midlife stroke survivors. Quality of Life Research [PubMed] Published 29th June 2017

For many years, spillover impacts were largely being ignored within economic evaluation. There is increased interest in capturing wider impacts, indeed, the NICE reference case recommends including carer impacts where relevant, whilst the US Panel on Cost-Effectiveness in Health and Medicine now advocates the inclusion of other affected parties. This study sought to examine whether the dependency of midlife stroke survivors impacted on their spouses’ HRQL as measured using the SF-6D. An OLS approach was used whilst controlling for covariates (age, sex and education, amongst others). Spouses of dependent stroke survivors had a lower utility (0.69) than those whose spouses were independent (0.77). This has interesting implications for economic evaluation. For example, if a treatment were to prevent dependence, then there could potentially be large QALY gains to spouses. Spillover impacts are clearly important. If we are to broaden the evaluative scope as suggested by NICE and the US Panel to include spillover impacts, then work is vital in terms of identifying relevant contexts, measuring spillover impacts, and understanding the implications of spillover impacts within economic evaluation. This remains an important area for future research.

Conducting a discrete choice experiment study following recommendations for good research practices: an application for eliciting patient preferences for diabetes treatments. Value in Health Published 7th August 2017

To finish this week’s round-up I thought it’d be helpful to signpost this article on conducting DCEs, which I feel may be helpful for researchers embarking on their first DCE. The article hasn’t done anything particularly radical or made ground-breaking discoveries. What it does however do is give you a practical guide to walk you through each step of the DCE process following the ISPOR guidelines/checklist. Furthermore, it expands upon the ISPOR checklist to provide researchers with a further resource to consider when conducting DCEs. The case study used relates to measuring patient preferences for type 2 diabetes mellitus medications. For every item on the ISPOR checklist, it explains how they made the choices that they did, and what influenced them. The paper goes through the entire process from identifying the research question all the way through to presenting results and discussion (for those interested in diabetes – it turns out people have a preference for immediate consequences and have a high discount rate for future benefits). For people who are keen to conduct a DCE and find a worked example easier to follow, this paper alongside the ISPOR guidelines is definitely one to add to your reference manager.

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Chris Sampson’s journal round-up for 3rd July 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.

Role of cost on failure to access prescribed pharmaceuticals: the case of statins. Applied Health Economics and Health Policy [PubMed] Published 28th June 2017

Outside work, I find that people often like to tell me how to solve health economics problems. A common one is the idea that the NHS could save a load of money by enforcing prescription charges. It’s a textbook life-ain’t-that-simple situation. One of the reasons it isn’t that simple is that, if you start charging for prescriptions, people will be less likely to take their meds. That’s probably bad news for patients and for doctors. “But it’s only a few quid”. Well… As in many countries, Australians have to cough up a co-payment to fill their prescriptions. The size of the copayment depends on i) whether or not the patient is concessional (e.g. a pensioner) and ii) whether or not a threshold has been reached for total family prescription expenditure in one year. Concessional patients have a lower co-payment, a lower threshold and no co-payment once the threshold is met. This study looks at statin use in this context for 94,000 over-45s in New South Wales from 2005-2011. Separate logistic regressions are run for each of the 4 groups (concessional/non-concessional, pre-threshold/post-threshold) to predict statin adherence, controlling for a good range of sociodemographic and health-related variables. The size of the copayment comes out as the biggest barrier to adherence. More than 75% of people who weren’t adherent before reaching their threshold became so after reaching it – that is, once their co-payment was either much-reduced or zero. Poorest adherence was observed in non-concessional low-income people who hadn’t reached the threshold, who faced the highest co-payment. Income, age group and holding private insurance were also important determinants. In short, charging people for their statins, even if it isn’t much money, reduces the likelihood that they will take them. There is the possibility that adherence is correlated with the likelihood of having reached the threshold, which could undermine these results. I’m not entirely convinced that the analysis cuts the mustard, but I’ll let the more econometrically minded amongst you figure that out.

Conceptualizations of the societal perspective within economic evaluations: a systematic review. International Journal of Technology Assessment in Health Care [PubMed] Published 23rd June 2017

In my last round-up, I included a study looking at resource use measures for intersectoral costs and benefits; costs and benefits that occur outside the health sector. This week we have a study looking at how the inclusion of intersectoral costs and benefits influences results, and how researchers have interpreted the ‘societal perspective’. A systematic review was conducted for economic evaluations purporting to use a societal perspective, published since the CHEERS statement was released, including 107 studies. Only 74 provided a conceptualisation of the societal perspective. Reported conceptualisations of the societal perspective were grouped according to the specificity of their definition – 18 general, 50 specific, 6 both – and assessed using content analysis. Of these, 25 referred to a guideline or other source in their conceptualisation. A total of 10 general and 56 specific clusters of conceptualisations were identified, demonstrating major inconsistency. For some studies – namely trial-based economic evaluations in musculoskeletal or mental disorders – the authors dug deeper and extracted additional information. In both cases, where data were adequately reported, the intersectoral costs tended to make up more than 50% of total costs. But in general the specific intersectoral items were not fully reported and relevant costs (e.g. in education or criminal justice) were not identified. It probably won’t come as a surprise that the general impression is that a lot of researchers interpret the societal perspective – in practice, if not in theory – as health costs plus productivity losses. And usually, that’s not really good enough.

Annual direct medical costs associated with diabetes-related complications in the event year and in subsequent years in Hong Kong. Diabetic Medicine [PubMed] Published 21st June 2017

There are a lot of high-quality decision models built for the evaluation of interventions in diabetes. See Mt Hood. But some are still a bit primitive when it comes to estimating the costs associated with the many clinical pathways and complications associated with diabetes, especially when multimorbidity can be important. So studies like this are very welcome. This study contributes cost estimates for a wide range of complications (13, to be precise) for what should be a representative sample of (Chinese) people with diabetes. It includes public health care expenditure for more than 120,000 people with diabetes in Hong Kong, with 5-year follow-up. For private health care costs, a cross-section of 1275 people was recruited through other studies and provided information about service use by telephone. Fixed effects panel data regressions were used for the public medical costs. During the follow-up, 17% developed at least one complication. The models estimate the impact on total cost of new disease and existing disease separately, in order to identify first-year and subsequent-year cost estimates. Generalised linear models were used for the private health care costs. The base case of a 65-year old with no complications was US$1500/year in costs to the public purse. The biggest effect on costs was a first-year multiplier of 9.38 for lower limb ulcer (1.62 in subsequent years). Other costly complications were stroke, heart failure, end-stage renal disease and acute myocardial infarction. Private costs were much smaller, at $187 for the base case. These figures may prove useful to decision modellers, even outside the Hong Kong setting.

Financing and distribution of pharmaceuticals in the United States. JAMA [PubMed] Published 15th May 2017

The purpose of this article seems to be to demonstrate the complexity of the financing and distribution of pharmaceuticals in the US. It describes distributors, retailers and patients on the distribution side, and pharmacy benefit managers and health insurers on the financing side, with manufacturers in the middle. But the system that is shown in the article’s figure strikes me as surprisingly simple for an industry in which such vast amounts of money are sloshing around. It’s far more straightforward than any diagram you might see relating to the organisation of NHS services. I would imagine that a freer market would be associated with more complexity as upstarts might muscle-in on smaller corners of the market and become new intermediaries. But the article is still enlightening. It outlines some of the features of the market, particularly the high levels of concentration, characteristics of the key players and the staggering sums of money changing hands.

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