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

Return on investment of public health interventions: a systematic review. Journal of Epidemiology & Community Health [PubMed] Published 29th March 2017

Cost-effectiveness analysis in the context of public health is tricky. Often the health benefits are small at the individual level and the returns to investment might be cross-sectoral. Lots of smart people believe that spending on public health is low in proportion to other health spending. Here we have a systematic review of studies reporting cost-benefit ratios (CBR) or return on investment (ROI) estimates for public health interventions. The stated aim of the paper is to demonstrate the false economy associated with cuts to public health spending. 52 titles were included from a search that identified 2957. The inclusion and exclusion criteria are not very clear, with some studies rejected on the basis of ‘poor generalisability to the UK’. There’s a bit too much subjectivity sneaking around in the methods for my liking.  Results for CBR and ROI estimates are presented according to local or national level and grouped by ‘specialism’. From all studies, the median CBR was 8.3 and the median ROI was 14.3. As we might have suspected, public health interventions are cost-saving in a big way. National health protection and legislative interventions offered the greatest return on investment. While there is wide variation in the results, all specialism groupings showed a positive return on average. I don’t doubt the truth of the study’s message – that cuts to public health spending are foolish. But the review doesn’t really demonstrate what the authors want it to demonstrate. We don’t know what (if any) disinvestment is taking place with respect to the interventions identified in the review. The results presented in the study represent a useful reference point for discussion and further analysis, but they aren’t a sufficient basis for supporting general increases in public health spending. That said, the study adds to an already resounding call and may help bring more attention to the issue.

Acceptable health and priority weighting: discussing a reference-level approach using sufficientarian reasoning. Social Science & Medicine Published 27th March 2017

In some ways, the moral principle of sufficiency is very attractive. It acknowledges a desire for redistribution from the haves to the have-nots and may also make for a more manageable goal than all-out maximisation. It may also be particularly useful in specific situations, such as evaluating health care for the elderly, for whom ‘full health’ is never achievable and not a meaningful reference point. This paper presents a discussion of the normative issues at play, drawing insights from the distributive justice literature. We’re reminded of the fair innings argument as a familiar sufficientarian flavoured allocation principle. The sufficientarian approach is outlined in contrast to egalitarianism and prioritarianism. Strict sufficientarian value weighting is not a good idea. If we suppose a socially ‘acceptable’ health state value of 0.7, such an approach would – for example – value an improvement from 0.69 to 0.71 for one person as infinitely more valuable than an improvement from 0.2 to 0.6 for the whole population. The authors go on to outline some more relaxed sufficiency weightings, whereby improvements below the threshold are attributed a value greater than 0 (though still less than those achieving sufficiency). The sufficientarian approach alone is (forgive me) an insufficient framework for the allocation of health care resources and cannot represent the kind of societal preferences that have been observed in the literature. Thus, hybrids are proposed. In particular, a sufficientarian-prioritarian weighting function is presented and the authors suggest that this may be a useful basis for priority setting. One can imagine a very weak form of the sufficientarian approach that corresponds to a prioritarian weighting function that is (perhaps) concave below the threshold and convex above it. Still, we have the major problem of identifying a level of acceptable health that is not arbitrary. The real question you need to ask yourself is this: do you really want health economists to start arguing about another threshold?

Emotions and scope effects in the monetary valuation of health. The European Journal of Health Economics [PubMed] Published 24th March 2017

It seems obvious that emotions could affect the value people attach to goods and services, but little research has been conducted with respect to willingness to pay for health services. This study considers the relationship between a person’s self-reported fear of being operated on and their willingness to pay for risk-reducing drug-eluting stents. A sample of 1479 people in Spain made a series of choices between bare-metal stents at no cost and drug-eluting stents with some out-of-pocket cost, alongside a set of sociodemographic questions and a fear of surgery Likert scale. Each respondent provided 8 responses with 4 different risk reductions and 2 different willingness to pay ‘bids’. The authors outline what they call a ‘cognitive-emotional random utility model’ including an ’emotional shift effect’. Four different models are presented to demonstrate the predictive value of the emotion levels interacting with the risk reduction levels. The sample was split roughly in half according to whether people reported high emotion (8, 9 or 10 on the fear Likert) or low emotion (<8). People who reported more fear of being operated on were willing to pay more for risk reductions, which is the obvious result. More interesting is that the high emotion group exhibited a lower sensitivity to scope – that is, there wasn’t much difference in their valuation of the alternative magnitudes of risk reduction. This constitutes a problem for willingness to pay estimates in this group as it may prevent the elicitation of meaningful values, and it is perhaps another reason why we usually go for collective approaches to health state valuation. The authors conclude that emotional response is a bias that needs to be corrected. I don’t buy this interpretation and would tend to the view that the bias that needs correcting here is that of the economist. Emotions may be a justifiable reflection of personality traits that ought to determine preferences, at least at the individual level. But I do agree with the authors that this is an interesting field for further research if only to understand possible sources of heterogeneity in health state valuation.



Chris Sampson’s journal round-up for 13th March 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 effects of exercise and relaxation on health and wellbeing. Health Economics [PubMedPublished 9th Month 2017

Encouraging self-management of health sounds like a good idea, but the evidence is pretty weak. As economists, we know that something must be displaced in order to do it. This study considers the opportunity cost of time and how it might affect self-management activity and any associated benefits. Employment and education are likely to increase income and thus facilitate more expenditure on exercise. But the time cost of exercise is also likely to increase, meaning that the impact on demand is ambiguous. The study uses data from a trial of self-management support that included people with diabetes, COPD or IBS. EQ-5D, self-assessed health and the amount of time spent ‘being happy’ were all collected. Information was available for 12 different self-management activities, including ‘do exercises’ and ‘rest and relax’, and the extent to which individuals did these. Outcomes for 3,472 people at 12-month follow-up are estimated, controlling for outcomes at baseline and 6 months. The study assumes that employment and education affect health via their influence on exercise and relaxation. That seems a bit questionable and the other 10 self-management indicators could have been looked at to test this. People in full-time employment were 11 percentage points less likely to use relaxation to manage their condition, suggesting that the substitution effect on time dominates as the opportunity cost of self-management increases. Having a degree or professional qualification increased the probability of using exercise by 5 percentage points, suggesting that the income effect dominates. Those who are more likely to use either exercise or relaxation are also more likely to do the other. An interesting suggestion is that time preference might explain things here. Those with more education may prefer to exercise (as an investment) than to get the instant gratification of rest and relaxation. It’s important that policy recommendations take into consideration the fact that different groups will respond differently to incentives for self-management, at least partly due to their differing time constraints. The thing I find most interesting is the analysis of the different outcomes (something I’ve worked on). Exercise is found to improve self-assessed health, while relaxation increases happiness. Neither exercise or relaxation had a (statistically significant) effect on EQ-5D. Depending on your perspective, this either suggests that the EQ-5D is failing to identify important changes in broad health-related domains or it means that self-management does not achieve the goals (QALYs to the max) of the health service.

New findings from the time trade-off for income approach to elicit willingness to pay for a quality adjusted life year. The European Journal of Health Economics [PubMedPublished 8th March 2017

The question ‘what is a QALY worth’ could invoke any number of reactions in a health economist, from chin scratching to eye rolling. The perspective that we’re probably most familiar with in the UK is that the value of a QALY is the value of health foregone in order to achieve it (i.e. opportunity cost within the health care perspective). An alternative perspective is that the value of a QALY is the consumption value of health; how much consumption would individuals be willing to give up in order to obtain an additional QALY? This second perspective facilitates a broader societal perspective. It can tell us whether or not the budget is set at an appropriate level, while the health care perspective can only take the budget as given. This study relates mainly to decisions made with the ‘consumption value’ perspective. One approach that has been proposed is to assess willingness to pay for a QALY using a time trade-off exercise that incorporates trade-offs between length and quality of life and income. This study builds on the original work by using a multiplicative utility function to estimate willingness to pay and also bringing in prospect theory to allow for reference dependence and loss aversion. 550 participants were asked to choose between living 10 years in their current health state with their current salary or to live a reduced number of years in their current health state with a luxury income (pre-specified by the participant). Respondents were also asked to make a similar choice, but framed as a loss of income, between living 10 years at a subsistence income or fewer years with their current income. A quality of life trade-off exercise was also conducted, in which people traded reduced health and a lower income. The findings support the predictions of prospect theory. Loss aversion is found to be stronger for duration than for quality of life. Individuals were more willing to sacrifice life years to move from subsistence income to current income than to move from current income to luxury income. The results imply that quality of life and income are closer substitutes than longevity and income. That makes sense, given the all-or-nothing nature of being alive. Crucially, the findings highlight the need to better understand the shape of the underlying lifetime utility function. In all tasks, more than half of respondents were either non-traders or over-traded, indicating a negative willingness to pay. That should give pause for thought when it comes to any aggregation of the results. Willingness to pay studies often throw up more questions than answers. This one does so more than most, particularly about sources of bias in people’s responses. The authors identify plenty of opportunities for future research.

Beyond QALYs: multi-criteria based estimation of maximum willingness to pay for health technologies. The European Journal of Health Economics [PubMed] Published 3rd March 2017

Life is messy. Evaluating things in terms of a single outcome, whether that be QALYs, £££s or whatever, is necessarily simplifying and restrictive. That’s not necessarily a bad thing, but we’d do well to bear it in mind. In this paper, Erik Nord sets out a kind of cost value analysis that does away with QALYs (gasp!). The author starts by outlining some familiar criticisms of the QALY approach, such as its failure to consider the inherent value of life and people’s differing reference points. Generally, I see these as features rather than bugs, and it isn’t QALYs themselves in the crosshairs here so much as cost-per-QALY analysis. The proposed method flips current practice by putting societal preferences about fair and efficient resource allocation before attaching values to the outcomes. As such, it acknowledges the fact that society’s preferences for gains in quality of life differ from those for gains in length of life. For example, society may prefer treating the more severely ill (independent of age) but also exhibit a ‘fair innings’ preference that is related to age. Thus, quality and quantity of life are disaggregated and the QALY is no more. A set of tables is presented that can be read to assess ‘value’ in alternative scenarios, given the assumptions set out in the paper. There is merit in the approach and a lot that I like about the possibilities of its use. But for me, the whole thing was made less attractive by the way it is presented in the paper. The author touts willingness to pay – for quality of life gains and for longevity gains – as the basis for value. Anything that makes resource allocation more dependent on willingness to pay values for things without a price (health, life) is a big no-no for me. But the method doesn’t depend on that. Furthermore, as is so often the case, most of the criticisms within relate to ways of using QALYs, rather than the fundamental basis for their estimation. This only weakens the argument for an alternative. But I can think of plenty of problems with QALYs, some of which might be addressed by this alternative approach. It’s unfortunate that the paper doesn’t outline how these more fundamental problems might be addressed. There may come a day when we do away with QALYs, and we may end up doing something similar to what’s outlined here, but we need to think harder about how this alternative is really better.


Well-being and gross national happiness for policy

In the early years of the coalition government, David Cameron lauded the measurement of happiness and well-being as an indicator of national performance. Data on life satisfaction have been collected and published by the Office for National Statistics every year since 2012. Despite this, very little is said about well-being. It is not discussed at spending or policy reviews and rarely in the media. Gross domestic product (GDP) continues to dominate the coverage of national performance and the potential impact of policies such as Brexit. Nevertheless, a precursory glance at the data can reveal an interesting picture of national well-being.


Proportion of respondents reporting their life satisfaction to be ‘high’ or ‘very high’. [Data source: ONS; .csv data; R code]

The map above plots the proportion of people reporting their life satisfaction to be ‘high’ or ‘very high’ across England and Wales. This corresponds to a score of seven or more on a ten point scale in response to the question:

Overall, how satisfied are you with your life nowadays? Where 0 is ‘not at all satisfied’ and 10 is ‘completely satisfied’.

There are clearly variations across the country, with the most obvious being the urban/rural divide. The proportion of people reporting ‘high’ or ‘very high’ life satisfaction in the UK has also increased over time, from 76.1% to 81.2% between 2012/3 and 2015/6, corresponding to a mean life satisfaction rating rising from 7.42 to 7.65.

Well-being data can also be used to evaluate the impact of policies or interventions in a cost-benefit analysis. Typically an in-depth analysis may model the impact of a policy on household incomes. But, these changes in income are only valuable insofar as they are instrumental for changes in well-being or welfare. Hence the attraction of well-being data. To derive a monetary valuation of a change in life satisfaction economists consider either compensating surplus or equivalent surplus. The former is the amount of money that someone would need to pay or receive to return them to their initial welfare position following a change in life satisfaction; the latter is the amount they would need to move them to their subsequent welfare position in the absence of a change. For example, to estimate the compensating surplus for a change in life satisfaction, one could estimate the effect of an exogenous change in income on life satisfaction. Such an exogenous change could be a lottery win, which is exactly the approach used in this report valuing the benefits of cultural and sports events like the Olympics.

Health economists have been one of the pioneering groups in the development and valuation of measures of non-monetary benefits. The quality-adjusted life year (QALY) being a prime example. However, a common criticism of these measures is that they only capture health related quality of life, and are fairly insensitive to changes in other areas of well-being. As a result there have been a growing number of broader measures of well-being, such as WEMWBS, that can be used as well as the generic life satisfaction measures discussed above. Broader measures may be able to capture some of the effects of health care policies that QALYs do not. For example, centralisation of healthcare services increases travel time and time away from home for many relatives and carers; reduced staff to patient ratios and consultation time can impact on process of care and staff-patient relationships; or, other barriers to care, such as language difficulties, may cause distress and dissatisfaction.

There are clearly good arguments for the use of broad life satisfaction and well-being instruments and sound methods to value them. One of the major barriers to their adoption is a lack of good data. The other barrier is likely to be the political willingness to accept them as measures of national performance and policy impact.