Rita Faria’s journal round-up for 26th August 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.

Vaccine hesitancy and (fake) news: quasi‐experimental evidence from Italy. Health Economics [PubMed] [RePEc] Published 20th August 2019

Has fake news led to fewer children being vaccinated? At least in Italy, the answer seems to be yes.

It’s shocking to read that the WHO has included the reluctance or refusal to vaccinate as one of the 10 threats to global health today. And many of us are asking: why has this happened and what can we do to address it? Vincenzo Carrieri, Leonardo Madio and Francesco Principe help answer this first question. They looked at how fake news affects the take-up of vaccines, assuming that exposure to fake news is proxied by access to broadband and within a difference-in-differences framework. They found that a 10% increase in broadband coverage is associated with a 1.2-1.6% reduction in vaccination rates.

The differences-in-differences method hinges on a court ruling in 2012 that accepted that the MMR vaccine causes autism. Following the ruling, fake news about vaccines spread across the internet. In parallel, broadband coverage increased over time due to a government programme, but it varied by region, depending on the existing infrastructure and geographical conditions. Broadband coverage, by itself, cannot lead to lower vaccination rates. So it makes sense to assume that broadband coverage leads to greater exposure to fake news about vaccines, which in turn leads to lower vaccination rates.

On the other hand, it may be that greater broadband coverage and lower vaccination rates are both caused by something else. The authors wrote a good introduction to justify the model assumptions and show a few robustness checks. Had they had more space, I would have like to read a bit more about the uncertainties around the model assumptions. This is a fantastic paper and good food for thought on the consequences of fake news. Great read!

The cost-effectiveness of one-time birth cohort screening for hepatitis C as part of the National Health Service Health Check programme in England. Value in Health Published 19th August 2019

Jack Williams and colleagues looked at the cost-effectiveness of one-time birth cohort screening for hepatitis C. As hepatitis C is usually asymptomatic before reaching its more advanced stages, people may not be aware that they are infected. Therefore, they may not get tested and treated, even though treatment is effective and cost-effective.

At the level of the individual eligible for testing, the ICERs were between £8k-£31k/QALY, with lower ICERs for younger birth cohorts. The ICERs also depended on the transition probabilities for the progression of the disease, with lower ICERs if progression is faster. Extensive sensitivity and value of information analyses indicate that the key cost-effectiveness drivers are the transition probabilities, probabilities of referral and of treatment post-referral, and the quality of life benefits of being cured.

This is a great example of a good quality applied cost-effectiveness analysis. The model is well justified, the results are thoroughly tested, and the discussion is meticulous. Well done!

NICE, in confidence: an assessment of redaction to obscure confidential information in Single Technology Appraisals by the National Institute for Health and Care Excellence. PharmacoEconomics [PubMed] Published 27th June 2019

NICE walks a fine line between making decisions transparent and protecting confidential information. Confidential information includes commercially sensitive information (e.g. discounts to the price paid by the NHS) and academic-in-confidence information, such as unpublished results of clinical trials. The problem is that the redacted information may preclude readers from understanding NICE decisions.

Ash Bullement and colleagues reviewed NICE appraisals of technologies with an approved price discount. Their goal was to understand the extent of redactions and their consequences on the transparency of NICE decisions. Of the 171 NICE appraisals, 118 had an approved commercial arrangement and 110 had a simple price discount. The type of redacted information varied. Some did not present the ICER, others presented ICERs but not the components of the ICERs, and others did not even present the estimates of life expectancy from the model. Remarkably, the confidential discount could be back-calculated in seven NICE appraisals! The authors also looked at the academic-in-confidence redactions. They found that 68 out of 86 appraisals published before 2018 still had academic-in-confidence information redacted. This made me wonder if NICE has a process to review these redactions and disclose them once the information is in the public domain.

As Ash and colleagues rightly conclude, this review shows that there does not seem to be a consistent process for redaction and disclosure. This is a compelling paper on the practicalities of the NICE process, and with useful reflections for HTA agencies around the world. The message for NICE is that it may be time to review the process to handle sensitive information.

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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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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.

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