Chris Sampson’s journal round-up for 17th December 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.

Health related quality of life aspects not captured by EQ-5D-5L: results from an international survey of patients. Health Policy Published 14th December 2018

Generic preference-based measures, such as the EQ-5D, cannot capture all aspects of health-related quality of life. They’re not meant to. Rather, their purpose is to capture just enough information to be able to adequately distinguish between health states with respect to the domains deemed normatively relavent to decisionmakers. The stated aim of this paper is to determine whether people with a variety of chronic conditions believe that their experiences can be adequately represented by the EQ-5D-5L.

The authors conducted an online survey, identifying participants through 320 patient associations across 47 countries. Participants were asked to complete the EQ-5D-5L and then asked if any aspects of their illness, which had a “big impact” on their health, were not captured by the EQ-5D-5L. 1,031 people started the survey and 767 completed it. More than half were from the UK. 51% of respondents said that there was some aspect of health not captured by the EQ-5D-5L. Of them, 19% mentioned fatigue, 12% mentioned medication side effects, 9.5% mentioned co-morbid conditions, and then a bunch of others in smaller proportions.

It’s nice to know what people think, but I have a few concerns about the usefulness of this study. One of the main problems is that it doesn’t seem safe to assume that respondents interpret “big impact” as meaning “an impact that is independently important in determining your overall level of quality of life”. So, even if we accept that people judging something to be important makes it important (which I’m not sure it does), then we still can’t be sure whether what they are identifying is within the scope of what we’re trying to measure. For starters, I can see no justification for including a ‘medication side effects’ domain. There’s also some concern about selection and attrition. I’d guess that people with more complicated or less common health concerns would be more likely to start and finish a survey about more complicated or less common health concerns.

The main thing I took from this study is that half of respondents with chronic diseases thought that the EQ-5D-5L captured every single aspect of health that had a “big impact”, and that there wasn’t broad support for any other specific dimension.

Reducing drug wastage in pharmaceuticals dosed by weight or body surface areas by optimising vial sizes. Applied Health Economics and Health Policy [PubMed] Published 5th December 2018

It’s common for pharmaceuticals to be wasted. Not just those out-of-date painkillers you threw in the bin, but also the expensive stuff being used in hospitals. One of the main reasons that waste occurs is that vials are made to specific sizes and, often, dosage varies from patient to patient – according to weight, for example – and doesn’t match the vial size. Suppose that vials are available as 50mg and 80mg and that an individual requires a 60mg dose. One way to address this might be to allow for vial sharing, whereby the leftovers are given to the next patient. But that isn’t always possible. So, we might like to consider what the best combination of available vial sizes should be, given the characteristics of the population.

In this paper, the authors set out the problem mathematically. Essentially, the optimisation problem is to minimise cost across the population subject to the vial sizes. An example is presented for two drugs (pembrolizumab and cabazitaxel), simulating patients based on samples drawn from the Health Survey for England. Simplifications are applied to the examples, such as setting a constraint of 8 vials per patient and assuming that prices are linear (i.e. fixed per milligram).

Pembrolizumab is currently available in 50mg and 100mg vials, and the authors estimate current wastage to be 13.2%. The simulations show that switching the 50mg to a 70mg would cut wastage to 8.6%. Cabazitaxel is available in 60mg vials, resulting in 19.4% wastage. Introducing a 12.5mg vial would cut wastage by around two thirds. An important general finding, which should be self-evident, is that vial sizes should not be divisible by each other, as this limits the number of possible combinations.

Depending on when vial sizes are determined (e.g. pre- or post-authorisation), pharmaceutical companies might use it to increase profit margins, or health systems might use it to save costs. Regardless, wastage isn’t useful. Evidence-based manufacture is an example of one of those best ideas; the sort that is simple and seems obvious once it’s spelt out. It’s a rare opportunity to benefit patients, health care providers, and manufacturers, with no significant burden on policymakers.

Death or debt? National estimates of financial toxicity in persons with newly-diagnosed cancer. The American Journal of Medicine [PubMed] Published October 2018

If you’re British, what’s the scariest thing about an ‘Americanised’ (/Americanized) health care system? Expensive inhalers? A shortened life expectancy? My guess is that the prospect of having to add financial ruin to terminal illness looms pretty large. You should make sure your fear is evidence-based. Here’s a paper to shake in the face of anyone who doesn’t support universal health care.

The authors use data from the Health and Retirement Study from 1998-2014, which includes people over 50 years of age and includes new (self-reported) diagnoses of cancer. This was the basis for inclusion in the study, with over 9.5 million new diagnoses of cancer. Up to two years pre-diagnosis was taken as a baseline. The data set also includes information on participants’ assets and debts, allowing the authors to use change in net worth as the primary outcome. Generalised linear models were used to assess various indicators of financial toxicity, including change or incurrence of consumer debt, mortgage debt, and home equity debt at two- and four-year follow-up. In addition to cancer diagnosis, various chronic comorbidities and socio-demographic variables were included in the models.

Shockingly, after two years following diagnosis, 42.4% of people had depleted their entire life’s assets. Average net worth had dropped $92,000. After four years, 38.2% were still insolvent. Women, older people, people who weren’t White, people with Medicaid, and those with worsening cancer status were among those more likely to have completely depleted their assets within two years. Having private insurance and being married had protective effects, as we might expect. There were some interesting findings associated with the 2008 financial crisis, which also seemed to be protective. And a protective effect associated with psychiatric comorbidity deserves more thought.

It’s difficult to explain away any (let alone all) of the magnitude of these findings. The analysis seems robust. But, given all other evidence available about out-of-pocket costs for cancer patients in the US, it should be shocking but not unexpected. The authors describe financial toxicity as ‘unintended’. There’s nothing unintended about this. Policymakers in the US keep deciding that they’d prefer to destroy the lives of sick people than allow for the spreading of that financial risk.

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Sam Watson’s journal round-up for 26th March 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.

Affordability and availability of off-patent drugs in the United States—the case for importing from abroad: observational study. BMJ [PubMedPublished 19th March 2018

Martin Shkreli has been frequently called “the most hated man in America“. Aside from defrauding investors and being the envied owner of a one-of-a-kind Wu-Tang Clan album, the company of which he was chief executive, Turing Pharmaceuticals, purchased the sole US approved manufacturer of a toxoplasmosis treatment, pyrimethamine, and hiked its price from $13 to $750 per tablet. Price gouging is nothing new in the pharmaceutical sector. An episode of the recent Netflix documentary series Dirty Money covers the story of Valeant Pharmaceuticals whose entire business was structured around the purchase of drug companies, laying off any research staff, and then hiking the price as high as the market could bear (even if this included running their own pharmacies to buy products at these inflated prices). The structure of the US drug market often allows the formation of monopolies on off-patent, or generic, medication, since the process for regulatory approval for a new manufacturer can be long and expensive. There have been proposals though that this could be ameliorated by allowing manufacturers approved by other trusted agencies (such as the European Medicines Agencies) to sell generics in the US while the FDA approvals process takes place. The aim of this paper is to determine how many more manufacturers this would allow into the US drugs market. The authors identify all the off-patent drugs that have been approved by the FDA since 1939 and all the manufacturers of those drugs that were approved by the FDA and by other trusted agencies. No analysis is given of how this might affect drug prices, though there is a pretty obvious correlation between the number of manufacturers and drug prices shown elsewhere. The results show that the proposed policy would increase the number of manufacturers for a sizeable proportion of generics: for example, 39% of generic medications could reach four or more manufacturers when including those approved by non-FDA bodies.

Why internists might want single-payer health care. Annals of Internal Medicine [PubMedPublished 20th March 2018

The US healthcare system has long been an object of fascination for many health economists. It spends far more than any other nation on healthcare (approximately $9,000 per capita compared to, say, $4,000 for the UK) and yet population health ranks alongside middle-income countries like Cuba and Ecuador. Garber and Skinner wondered whether it was uniquely inefficient and identified or questioned a number of issues that may or may not explain the efficiency or lack thereof. One of these was the administrative burden of multiple insurance companies, which evidence suggests does not actually account for much of the total expenditure on health care. However, Garber and Skinner say this does not take into account time spent by clinical and non-clinical staff on administration within hospitals. In this opinion piece, Paul Sorum argues that internists should support a move to a single-payer system in the US. One of his four points is the administrative burden of dealing with insurance companies, which he cites as an astonishing 61 hours per week per physician (presumably spread across a number of staff). Certainly, this seems to be a key issue. But Sorum’s other three points don’t necessarily support a single-payer system. He also argues that the insurance system is leading to increasing deductibles and co-payments placed on patients, limiting access to medications, as drug prices rise. Indeed, Garber and Skinner note also that high deductibles limit the use of highly cost-effective measures and actually have the opposite effect of reducing productive efficiency. A single payer system per se would not solve this, it would need significant subsidies and regulation as well, and as our previous paper shows, other measures can be used to bring down drug prices. Sorum also argues that the US insurance system places an unnecessary burden from quality measures and assessment as well as electronic medical records used to collect information for billing purposes. But these issues of quality and electronic medical records have been discussed in the context of many health care systems, not least the NHS, as the political and regulatory framework still requires this. So a single-payer system is not a solution here. A key difference between the US and elsewhere that Garber and Skinner identify is that the US permits much more heterogeneity in access to and use of health care (e.g. overuse by the wealthy and underuse by the poor). Significant political barriers stand in the way of a single payer system, and since other means can be used to achieve universal coverage, such as the provisions in the Affordable Care Act, maybe internists would be better directing their energy at more achievable goals.

Social ties in academia: a friend is a treasure. Review of Economics and Statistics [RePEcPublished 2nd March 2018

If you ever wondered whether the reason you didn’t get published in that top economics journal was that you didn’t know the right people, you may well be right! This article examines the social ties between authors and editors of the top four economics journals. Almost half of the papers published in these journals had at least one author with a connection to an editor, either through working in the same department, co-authoring a paper, or PhD supervision. The QJE appears to be the worst offender with (if I’ve read this correctly) all authors between 2000 and 2006 getting their PhD in either Harvard or MIT. So don’t bother trying to get published there! This article also shows that you’re more likely to get a paper into the journals when your former PhD supervisor is editing it. Given how much sway a paper published in these journals has on the future careers of young economists, it is disheartening to see the extent of nepotism in the publication process. Of course, one may argue that it just so happens that those that work at the top journals associate most frequently with those who write the best papers. But given even a little understanding of human nature, one would be inclined to discount this explanation. We have all previously asked ourselves, especially when writing a journal round-up, how this or that paper got into a particularly highly regarded journal, now we know…

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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%.

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