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.

Credits

Sam Watson’s journal round-up for 30th October 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.

Conditional cash transfers: the case of Progresa/OportunidadesJournal of Economic Literature [RePEc] Published September 2017

The Progresa/Oportunidades programme was instigated in Mexico in 1995. The main innovation of the programme was a series of cash payments conditional on various human capital investments in children, such as regular school attendance and health check-ups. Beginning principally in rural areas, it expanded to urban areas in 2000-1. Excitingly for researchers, randomised implementation of the programme was built into its rollout, permitting evaluation of its effectiveness. Given it was the first such programme in a low- or middle-income country to do this, there has been a considerable amount of analysis and literature published on the topic. This article provides an in-depth review of this literature – incorporating over one hundred articles from economics and health journals. I’ll just focus on the health-related aspects of the review rather than education, labour market, or nutrition outcomes, but they’re also worth a look. The article provides a simple theoretical model about the effects of conditional cash transfers to start with and suggests that they have both a price effect, through reducing the shadow wage of time in activities other than those to which the payment is targeted, and an income effect, by increasing total income. The latter effect is ambiguous in its direction. For health, a large number of outcomes including child mortality and height, behavioural problems, obesity, and depression have all been assessed. For the most part  this has been through health modules applied to a subsample of people in surveys, which may limit the conclusions one can make for reasons such as attrition in the samples of treated and control households. Generally, the programme has demonstrated positive health effects (of varying magnitudes) in both the short and medium terms. Health care utilisation increased and with it there was a reduction in self-reported illness, behavioural problems, and obesity. However, positive effects are not reported universally. For example, one study reported an increase in child height in the short term, but in the medium term little change was reported in height-for-age z-scores in another study, which may suggest children catch-up in their growth. Nevertheless, it seems as though the programme succeeded in its aims, although there remains the question of its cost-benefit ratio and whether these ends could have been achieved more cost-effectively by other means. There is also the political question about the paternalism of the programme. While some political issues are covered, such as the perception of the programme as a vehicle for buying votes, and strategies for mitigating these issues, the issue of its acceptability to poor Mexicans is not well covered.

Health‐care quality and information failure: evidence from Nigeria. Health Economics [PubMedPublished 23rd October 2017

When we conceive of health care quality we often think of preventable harm to patients. Higher quality institutions make fewer errors such as incorrect diagnoses, mistakes with medication, or surgical gaffes. However, determining when an error has been made is difficult and quality is often poorly correlated with typical measures of performance like standardised mortality ratios. Evaluating quality is harder still in resource-poor settings where there are no routine data for evaluation and often an absence of patient records. Patients may also have less knowledge about what constitutes quality care. This may provide an environment for low-quality providers to remain in business as patients do not discriminate on the basis of quality. Patient satisfaction is another important aspect of quality, but not necessarily related to more ‘technical’ aspects of quality. For example, a patient may feel that they’ve not had to wait long and been treated respectfully even if they have been, unbeknownst to them, misdiagnosed and given the wrong medication. This article looks at data from Nigeria to examine whether measures of patient satisfaction are correlated with technical quality such as diagnostic accuracy and medicines availability. In brief, they report that there is little variation in patient satisfaction reports, which may be due to some reporting bias, and that diagnostic accuracy was correlated with satisfaction but other markers of quality were not. Importantly though, the measures of technical quality did little to explain the overall variation in patient satisfaction.

State intimate partner violence-related firearm laws and intimate partner homicide rates in the United States, 1991 to 2015. Annals of Internal Medicine [PubMedPublished 17th October 2017

Gun violence in the United States is a major health issue. Other major causes of death and injury attract significant financial investment and policy responses. However, the political nature of firearms in the US limit any such response. Indeed, a 1996 law passed by Congress forbade the CDC “to advocate or promote gun control”, which a succession of CDC directors has interpreted as meaning no federally funded research into gun violence at all. As such, for such a serious cause of death and disability, there is disproportionately little research. This article (not federally funded, of course) examines the impact of gun control legislation on inter-partner violence (IPV). Given the large proportion of inter-partner homicides (IPH) carried out with a gun, persons convicted of IPV felonies and, since 1996, misdemeanours are prohibited from possessing a firearm. However, there is variation in states about whether those convicted of an IPV crime have to surrender a weapon already in their possession. This article examines whether states that enacted ‘relinquishment’ laws that force IPV criminals to surrender their weapons reduced the rate of IPHs. They use state-level panel data and a negative binomial fixed effects model and find that relinquishment laws reduced the risk of IPHs by around 10% and firearm-related IPH by around 15%.

Credits

Sam Watson’s journal round-up for 2nd October 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 path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan Africa. The Lancet [PubMedPublished 13th September 2017

The African continent has the highest rates of economic growth, the fastest growing populations and rates of urbanisation, but also the highest burden of disease. The challenges for public health and health care provision are great. It is no surprise then that this Lancet commission on the future of health in Sub-Saharan Africa runs to 57 pages yet still has some notable absences. In the space of a few hundred words, it would be impossible to fully discuss the topics in this tome, these will appear in future blog posts. For now, I want to briefly discuss a lack of consideration of the importance of political economy in the Commission’s report. For example, the report notes the damaging effects of IMF and World Bank structural adjustment programs in the 70s and 80s. These led to a dismantling of much of the public sector in indebted African nations in order for them to qualify for further loans. However, these issues have not gone away. Despite strongly emphasizing that countries in Africa must increase their health spending, it does not mention that many countries spend much more servicing debt than on public health and health care. Kenya, for example, will soon no longer qualify for aid as it becomes a middle-income country, and yet it spends almost double (around $6 billion) servicing its debt than it does on health care (around $3 billion). Debt reform and relief may be a major step towards increasing health expenditure. The inequalities in access to basic health services reflect the disparities in income and wealth both between and within countries. The growth of slums across the continent is stark evidence of this. Residents of these communities, despite often facing the worst exposure to major disease risk factors, are often not recognised by authorities and cannot access health services. Even where health services are available there are still difficulties with access. A lack of regulation and oversight can lead the growth of a rentier class within slums as those with access to small amounts of capital, land, or property act as petty landlords. So while some in slum areas can afford the fees for basic health services, the poorest still face a barrier even when services are available. These people are also those who have little access to decent water and sanitation or education and have the highest risk of disease. Finally, the lack of incentives for trained doctors and medical staff to work in poor or rural areas is also identified as a key problem. Many doctors either leave for wealthier countries or work in urban areas. Doctors are often a powerful interest group and can influence macro health policy, distorting it to favour richer urban areas. Political solutions are required, as well as the public health interventions more widely discussed. The Commission’s report is extensive and worth the time to read for anyone with an interest in the subject matter. What also becomes clear upon reading it is the lack of solid evidence on health systems and what works and does not work. From an economic perspective, much of the evidence pertaining to health system functioning and efficiency is still just the results from country-level panel data regressions, which tell us very little about what is actually happening. This results in us being able to identify areas needed for reform with very little idea of how.

The relationship of health insurance and mortality: is lack of insurance deadly? Annals of Internal Medicine [PubMedPublished 19th September 2017

One sure-fire way of increasing your chances of publishing in a top-ranked journal is to do something on a hot political topic. In the UK this has been seven-day services, as well as other issues relating to deficiencies of supply. In the US, health insurance is right up there with the Republicans trying to repeal the Affordable Care Act, a.k.a. Obamacare. This paper systematically reviews the literature on the relationship between health insurance coverage and the risk of mortality. The theory being that health insurance permits access to medical services and therefore treatment and prevention measures that reduce the risk of death. Many readers will be familiar with the Oregon Health Insurance Experiment, in which the US state of Oregon distributed access to increased Medicaid expansion by lottery, therein creating an RCT. This experiment, which takes a top spot in the review, estimated that those who had ‘won’ the lottery had a mortality rate 0.032 percentage points lower than the ‘losers’, whose mortality rate was 0.8%; a relative reduction of around 4%. Similar results were found for the quasi-experimental studies included, and slightly larger effects were found in cohort follow-up studies. These effects are small. But then so is the baseline. Most of these studies only examined non-elderly, non-disabled people, who would otherwise not qualify for any other public health insurance. For people under 45 in the US, the leading cause of death is unintentional injury, and its only above this age that cancer becomes the leading cause of death. If you suffer major trauma in the US you will (for the most part) be treated in an ER insured or uninsured, even if you end up with a large bill afterwards. So it’s no surprise that the effects of insurance coverage on mortality are very small for these people. This is probably the inappropriate endpoint to be looking at for this study. Indeed, the Oregon experiment found that the biggest differences were in reduced out-of-pocket expenses and medical debt, and improved self-reported health. The review’s conclusion that, “The odds of dying among the insured relative to the uninsured is 0.71 to 0.97,” is seemingly unwarranted. If they want to make a political point about the need for insurance, they’re looking in the wrong place.

Smoking, expectations, and health: a dynamic stochastic model of lifetime smoking behavior. Journal of Political Economy [RePEcPublished 24th August 2017

I’ve long been sceptical of mathematical models of complex health behaviours. The most egregious of which is often the ‘rational addiction’ literature. Originating with the late Gary Becker, the rational addiction model, in essence, assumes that addiction is a rational choice made by utility maximising individuals, whose preferences alter with use of a particular drug. The biggest problem I find with this approach is that it is completely out of touch with the reality of addiction and drug dependence, and makes absurd assumptions about the preferences of addicts. Nevertheless, it has spawned a sizable literature. And, one may argue that the model is useful if it makes accurate predictions, regardless of the assumptions underlying it. On this front, I have yet to be convinced. This paper builds a rational addiction-type model for smoking to examine whether learning of one’s health risks reduces smoking. As an illustration of why I dislike this method of understanding addictive behaviours, the authors note that “…the model cannot explain why individuals start smoking. […] The estimated preference parameters in the absence of a chronic illness suggest that, for a never smoker under the age of 25, there is no incentive to begin smoking because the marginal utility of smoking is negative.” But for many, social and cultural factors simply explain why young people start smoking. The weakness of the deductive approach to social science seems to rear its head, but like I said, the aim here may be the development of good predictive models. And, the model does appear to predict smoking behaviour well. However, it is all in-sample prediction, and with the number of parameters it is not surprising it predicts well. This discussion is not meant to be completely excoriating. What is interesting is the discussion and attempt to deal with the endogeneity of smoking – people in poor health may be more likely to smoke and so the estimated effects of smoking on longevity may be overestimated. As a final point of contention though, I’m still trying to work out what the “addictive stock of smoking capital” is.

Credits