2019

Publication details

Journal Social Science & Medicine
Date Accepted/In press - 22 Feb 2019
Date E-pub ahead of print (current) - 1 Mar 2019
Date Published - May 2019
Volume 228
Number of pages 8
Pages (from-to) 1 - 8
Early online date 1/03/19
Original language English

Abstract

The paper develops and illustrates a new multivariate approach to analysing inequity in health care. We measure multiple inequity in health care relating to multiple equity-relevant variables – including income, gender, ethnicity, rurality, insurance status and others – and decompose the contribution of each variable to multiple inequity. Our approach encompasses the standard bivariate approach as a special case in which there is only one equity-relevant variable, such as income. We illustrate through an application to physician visits in Brazil, using data from the Health and Health Care Supplement of the Brazilian National Household Sample Survey, comprising 391,868 individuals in the year 2008. We find that health insurance coverage and urban location both contribute more to multiple inequity than income. We hope this approach will help researchers and analysts shed light on the comparative size and importance of the many different inequities in health care of interest to decision makers, rather than focus narrowly on income-related inequity.

Bibliographical note

© 2019 The Authors. Published by Elsevier Ltd.

2018

General Practitioners and Emergency Departments (GPED): Efficient Models of Care. A mixed-methods study protocol

Morton, K., Voss, S., Adamson, J., Baxter, H., Bloor, K. E., Brandling, J., Cowlishaw, S., Doran, T., Gibson, A., Gutacker, N., Liu, D., Purdy, S., Roy, P., Salisbury, C., Scantlebury, A. L., Vaittinen, A., Watson, R. M. & Benger, J., 5 Oct 2018

Article in BMJ Open

Publication details

Journal BMJ Open
Date Accepted/In press - 16 Jul 2018
Date Published (current) - 5 Oct 2018
Volume 8
Number of pages 8
Original language English

Bibliographical note

© Author(s). This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy. Further copying may not be permitted; contact the publisher for details

Publication details

Journal International journal of STD & AIDS
Date Accepted/In press - 23 Jul 2018
Date E-pub ahead of print (current) - 19 Sep 2018
Number of pages 7
Early online date 19/09/18
Original language English

Bibliographical note

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Publication details

Journal BMC Medicine
Date Accepted/In press - 12 Jul 2018
Date Published (current) - 29 Aug 2018
Number of pages 13
Original language English

Bibliographical note

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The association between a primary care pay-for performance scheme and suicide in England: a spatial cohort study

Grigoroglou, C., Munford, L., Webb, R. T., Kapur, N., Doran, T., Ashcroft, D. M. & Kontopantelis, E., 30 Jul 2018

Article in British Journal of Psychiatry

Publication details

Journal British Journal of Psychiatry
Date Accepted/In press - 16 Jun 2018
Date E-pub ahead of print (current) - 30 Jul 2018
Issue number 4
Volume 213
Number of pages 9
Pages (from-to) 600-608
Early online date 30/07/18
Original language English

Bibliographical note

© The Royal College of Psychiatrists 2018. This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy. Further copying may not be permitted; contact the publisher for details.

Publication details

Journal Health Economics
Date Accepted/In press - 12 Jun 2018
Date E-pub ahead of print (current) - 22 Jul 2018
Number of pages 18
Early online date 22/07/18
Original language English

Abstract

In principle, questionnaire data on public views about hypothetical trade-offs between improving total health and reducing health inequality can provide useful normative health inequality aversion parameter benchmarks for policymakers faced with real trade-offs of this kind. However, trade-off questions can be hard to understand, and one standard type of question finds that a high proportion of respondents-sometimes a majority-appear to give exclusive priority to reducing health inequality. We developed and tested two e-learning interventions designed to help respondents understand this question more completely. The interventions were a video animation, exposing respondents to rival points of view, and a spreadsheet-based questionnaire that provided feedback on implied trade-offs. We found large effects of both interventions in reducing the proportion of respondents giving exclusive priority to reducing health inequality, though the median responses still implied a high degree of health inequality aversion and-unlike the video-the spreadsheet-based intervention introduced a substantial new minority of non-egalitarian responses. E-learning may introduce as well as avoid biases but merits further research and may be useful in other questionnaire studies involving trade-offs between conflicting values.

Bibliographical note

© 2018 The Authors.

Publication details

Journal Public Health Ethics
Date Accepted/In press - 17 May 2017
Date E-pub ahead of print - 17 May 2017
Date Published (current) - 1 Apr 2018
Issue number 1
Volume 11
Pages (from-to) 90-102
Early online date 17/05/17
Original language English

Abstract

The main aim of this paper is to investigate the views of healthcare professionals in Portugal about healthcare rationing, and compare them with the views of college students. A self-administered questionnaire was used to collect data from a sample of 60 healthcare professionals and 180 college students. Respondents faced a hypothetical rationing dilemma where they had to order four patients (differentiated by personal characteristics and health conditions) and justify their choices. Multinomial logistic regressions were used to test for differences in orderings, and content analysis to categorize the written justifications. The findings suggest that both groups appeared to support three main rationing principles: (i) health maximization, (ii) priority to the severely ill and (iii) priority to the young. However, professionals seemed to give less weight to the latter principle. In conclusion, professionals have similar views to students about healthcare rationing, though may be slightly less inclined to give priority to the young.

Bibliographical note

© The Author 2017. This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy. Further copying may not be permitted; contact the publisher for details

Publication details

Journal Journal of epidemiology and community health
Date Accepted/In press - 1 Mar 2018
Date E-pub ahead of print (current) - 19 Mar 2018
Early online date 19/03/18
Original language English

Bibliographical note

This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy. Further copying may not be permitted; contact the publisher for details

Publication details

Journal Journal of epidemiology and community health
Date Accepted/In press - 31 Jan 2018
Date E-pub ahead of print (current) - 15 Feb 2018
Early online date 15/02/18
Original language English

Bibliographical note

© 2018 Article author(s). This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy. Further copying may not be permitted; contact the publisher for details

Chronic morbidity, deprivation and primary medical care spending in England in 2015-16: a cross-sectional spatial analysis

Kontopantelis, E., Mamas, M. A., van Marwijk, H., Ryan, A. M., Bower, P., Guthrie, B. & Doran, T., 14 Feb 2018

Article in BMC Medicine

Publication details

Journal BMC Medicine
Date Accepted/In press - 15 Dec 2017
Date Published (current) - 14 Feb 2018
Issue number 19
Volume 16
Number of pages 13
Original language English

Bibliographical note

© The Author(s). 2018

Publication details

Journal Social science and medicine
Date Accepted/In press - 4 Jan 2018
Date E-pub ahead of print (current) - 6 Jan 2018
Number of pages 36
Pages (from-to) 1-36
Early online date 6/01/18
Original language English

Bibliographical note

© 2018 Published by Elsevier Ltd. This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy.

Publication details

Journal Social science and medicine
Date Accepted/In press - 4 Jan 2018
Date E-pub ahead of print (current) - 6 Jan 2018
Number of pages 36
Pages (from-to) 1-36
Early online date 6/01/18
Original language English

Bibliographical note

© 2018 Published by Elsevier Ltd. This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy.

Publication details

Journal Health Policy and Planning
Date Accepted/In press - 13 Nov 2017
Date E-pub ahead of print - 3 Jan 2018
Date Published (current) - 3 Jan 2018
Number of pages 35
Pages (from-to) 1-35
Early online date 3/01/18
Original language English

Abstract

Reducing health inequality is a major policy concern for low- and middle-income countries (LMICs) on the path to universal health coverage. However, health inequality impacts are rarely quantified in cost-effectiveness analyses of health programmes. Distributional cost-effectiveness analysis (DCEA) is a method developed to analyse the expected social distributions of costs and health benefits, and the potential trade-offs that may exist between maximising total health and reducing health inequality. This is the first paper to show how DCEA can be applied in LMICs. Using the introduction of rotavirus vaccination in Ethiopia as an illustrative example, we analyse a hypothetical re-designed vaccination programme, which invests additional resources into vaccine delivery in rural areas, and compare this with the standard programme currently implemented in Ethiopia. We show that the re-designed programme has an incremental cost-effectiveness ratio of US$69 per health-adjusted life year (HALY) compared with the standard programme. This is potentially cost-ineffective when compared with current estimates of health opportunity cost in Ethiopia. However, rural populations are typically less wealthy than urban populations and experience poorer lifetime health. Prioritising such populations can thus be seen as being equitable. We analyse the trade-off between cost-effectiveness and equity using the Atkinson inequality aversion parameter, ε, representing the decision maker's strength of concern for reducing health inequality. We find that the more equitable programme would be considered worthwhile by a decision maker whose inequality concern is greater than ε = 5.66, which at current levels of health inequality in Ethiopia implies that health gains are weighted at least 3.86 times more highly in the poorest compared with the richest wealth quintile group. We explore the sensitivity of this conclusion to a range of assumptions and cost-per-HALY threshold values, to illustrate how DCEA can inform the thinking of decision makers and stakeholders about health equity trade-offs.

Bibliographical note

© The Author(s) 2018. This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy. Further copying may not be permitted; contact the publisher for details.

2017

Publication details

Journal Journal of epidemiology and community health
Date Accepted/In press - 21 Nov 2017
Date E-pub ahead of print (current) - 20 Dec 2017
Number of pages 8
Early online date 20/12/17
Original language English

Bibliographical note

This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy. Further copying may not be permitted; contact the publisher for details

Primary care and health inequality: Difference-in-difference study comparing England and Ontario

Cookson, R., Mondor, L., Asaria, M., Kringos, D. S., Klazinga, N. S. & Wodchis, W. P., 28 Nov 2017

Article in PLoS ONE

Publication details

Journal PLoS ONE
Date Accepted/In press - 9 Nov 2017
Date Published (current) - 28 Nov 2017
Issue number 11
Volume 12
Number of pages 15
Original language English

Abstract

BACKGROUND: It is not known whether equity-oriented primary care investment that seeks to scale up the delivery of effective care in disadvantaged communities can reduce health inequality within high-income settings that have pre-existing universal primary care systems. We provide some non-randomised controlled evidence by comparing health inequality trends between two similar jurisdictions-one of which implemented equity-oriented primary care investment in the mid-to-late 2000s as part of a cross-government strategy for reducing health inequality (England), and one which invested in primary care without any explicit equity objective (Ontario, Canada).

METHODS: We analysed whole-population data on 32,482 neighbourhoods (with mean population size of approximately 1,500 people) in England, and 18,961 neighbourhoods (with mean population size of approximately 700 people) in Ontario. We examined trends in mortality amenable to healthcare by decile groups of neighbourhood deprivation within each jurisdiction. We used linear models to estimate absolute and relative gaps in amenable mortality between most and least deprived groups, considering the gradient between these extremes, and evaluated difference-in-difference comparisons between the two jurisdictions.

RESULTS: Inequality trends were comparable in both jurisdictions from 2004-6 but diverged from 2007-11. Compared with Ontario, the absolute gap in amenable mortality in England fell between 2004-6 and 2007-11 by 19.8 per 100,000 population (95% CI: 4.8 to 34.9); and the relative gap in amenable mortality fell by 10 percentage points (95% CI: 1 to 19). The biggest divergence occurred in the most deprived decile group of neighbourhoods.

DISCUSSION: In comparison to Ontario, England succeeded in reducing absolute socioeconomic gaps in mortality amenable to healthcare from 2007 to 2011, and preventing them from growing in relative terms. Equity-oriented primary care reform in England in the mid-to-late 2000s may have helped to reduce socioeconomic inequality in health, though other explanations for this divergence are possible and further research is needed on the specific causal mechanisms.

Bibliographical note

© 2017 Cookson et al.

Publication details

Journal Health Services and Delivery Research
Date Accepted/In press - 1 Apr 2017
Date Published (current) - 22 Nov 2017
Issue number 30
Volume 5
Number of pages 114
Original language English

Bibliographical note

© Queen’s Printer and Controller of HMSO 2017.

Publication details

Journal Health Economics
Date Accepted/In press - 30 Aug 2016
Date E-pub ahead of print - 20 Sep 2016
Date Published (current) - Oct 2017
Issue number 10
Volume 26
Number of pages 7
Early online date 20/09/16
Original language English

Abstract

Health inequality aversion parameters can be used to represent alternative value judgements about policy concern for reducing health inequality versus improving total health. In this study, we use data from an online survey of the general public in England (n = 244) to elicit health inequality aversion parameters for both Atkinson and Kolm social welfare functions. We find median inequality aversion parameters of 10.95 for Atkinson and 0.15 for Kolm. These values suggest substantial concern for health inequality among the English general public which, at current levels of quality adjusted life expectancy, implies weighting health gains to the poorest fifth of people in society six to seven times as highly as health gains to the richest fifth. Copyright © 2016 John Wiley & Sons, Ltd.

Publication details

Journal BMJ Quality & Safety
Date Accepted/In press - 17 Aug 2017
Date E-pub ahead of print (current) - 29 Sep 2017
Number of pages 11
Pages (from-to) 1-11
Early online date 29/09/17
Original language English

Abstract

Background
Emergency hospital admission at weekends is associated with an increased risk of mortality. Previous studies have been limited to examining single years and assessing day – not time – of admission. We used an enhanced longitudinal dataset to estimate the ‘weekend effect’ over time and the effect of night-time admission on the mortality rate.

Method
We examined 246,350 emergency spells from a large teaching hospital in England between April 2004 and March 2014. Outcomes included 7-day, 30-day and in-hospital mortality rates. We conducted probit regressions to estimate the impact of two key predictors on mortality: i) admission at weekends (7.00 pm Friday to 6.59 am Monday); ii) night-time admission (7.00 pm to 6.59 am). Logistic regressions were estimated to produce odds ratios.

Results
Crude 30-day mortality rate decreased from 6.6% in 2004/05 to 5.2% in 2013/14. Adjusted mortality risk was elevated for all out-of-hours periods. The highest risk was associated with admission at weekend night-times: 30-day mortality increased by 0.6 percentage points (adjusted OR: 1.168), 7-day mortality by 0.4 percentage points (adjusted OR: 1.225), and in-hospital mortality by 0.5 percentage points (adjusted OR: 1.140) compared with admission on weekday day-times. Weekend night-time admission was associated with increased mortality risk in 9 out of 10 years, but this was only statistically significant (P≤ 0.05) in 5 out of 10 years.

Conclusions
There is an increased risk of mortality for patients admitted as emergencies both at weekends and during the night-time. These effects are additive, so that the greatest risk of mortality occurs in patients admitted during the night at weekends. This increased risk appears to be consistent over time, but the effects are small and are not statistically significant in individual hospitals in every year.

Bibliographical note

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017.

Publication details

Journal British Journal of General Practice
Date Accepted/In press - 12 May 2017
Date E-pub ahead of print (current) - 25 Sep 2017
Number of pages 10
Early online date 25/09/17
Original language English

Bibliographical note

© British Journal of General Practice 2017

When is a randomised controlled trial health equity relevant? Development and validation of a conceptual framework

Jull, J., Whitehead, M., Petticrew, M., Kristjansson, E., Gough, D., Petkovic, J., Volmink, J., Weijer, C., Taljaard, M., Edwards, S., Mbuagbaw, L., Cookson, R., McGowan, J., Lyddiatt, A., Boyer, Y., Cuervo, L. G., Armstrong, R., White, H., Yoganathan, M., Pantoja, T. & 10 othersShea, B., Pottie, K., Norheim, O., Baird, S., Robberstad, B., Sommerfelt, H., Asada, Y., Wells, G., Tugwell, P. & Welch, V., 25 Sep 2017

Article in BMJ Open

Publication details

Journal BMJ Open
Date Accepted/In press - 31 Jul 2017
Date Published (current) - 25 Sep 2017
Issue number 9
Volume 7
Number of pages 9
Pages (from-to) 1-9
Original language English

Abstract

Background Randomised controlled trials can provide evidence relevant to assessing the equity impact of an intervention, but such information is often poorly reported. We describe a conceptual framework to identify health equity-relevant randomised trials with the aim of improving the design and reporting of such trials.Methods An interdisciplinary and international research team engaged in an iterative consensus building process to develop and refine the conceptual framework via face-to-face meetings, teleconferences and email correspondence, including findings from a validation exercise whereby two independent reviewers used the emerging framework to classify a sample of randomised trials.Results A randomised trial can usefully be classified as 'health equity relevant' if it assesses the effects of an intervention on the health or its determinants of either individuals or a population who experience ill health due to disadvantage defined across one or more social determinants of health. Health equity-relevant randomised trials can either exclusively focus on a single population or collect data potentially useful for assessing differential effects of the intervention across multiple populations experiencing different levels or types of social disadvantage. Trials that are not classified as 'health equity relevant' may nevertheless provide information that is indirectly relevant to assessing equity impact, including information about individual level variation unrelated to social disadvantage and potentially useful in secondary modelling studies.Conclusion The conceptual framework may be used to design and report randomised trials. The framework could also be used for other study designs to contribute to the evidence base for improved health equity.

Bibliographical note

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Publication details

Journal British Journal of Psychiatry
Date Accepted/In press - 14 Jul 2017
Date Published (current) - 1 Sep 2017
Issue number 3
Volume 211
Number of pages 2
Pages (from-to) 130-131
Original language English

Abstract

In this editorial, we discuss a UK-based cohort study examining the mortality gap for people with schizophrenia and bipolar disorder from 2000 to 2014. There have been concerted efforts to improve physical and mental healthcare for this population in recent decades. Have these initiatives reduced mortality and ‘closed the gap’?

Bibliographical note

© The Royal College of Psychiatrists. This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy. Further copying may not be permitted; contact the publisher for details

Publication details

Journal Israel Journal of Health Policy Research
Date Accepted/In press - 23 Jun 2017
Date Published (current) - 10 Jul 2017
Issue number 38
Volume 6
Original language English

Abstract

When making recommendations about the public funding of new health
technologies, policy makers typically pay close attention to quantitative
evidence about the comparative effectiveness, cost effectiveness and budget
impact of those technologies – what we might call “efficiency” criteria. Less
attention is paid, however, to quantitative evidence about who gains and who
loses from these public expenditure decisions, and whether those who gain are
better or worse off than the rest of the population in terms of their health –
what we might call “equity” criteria. Two studies recently published in this
journal by Shmueli and colleagues suggest that this efficiency-oriented
imbalance in the use of quantitative evidence may have unfortunate
consequences – as the old adage goes: “what gets measured, gets done”. The first study, by Shmueli, Golan, Paolucci and Mentzakis, found that health
policy makers in Israel think equity considerations are just as important as
efficiency considerations – at least when it comes to making hypothetical
technology funding decisions in a survey. By contrast, the second study – by
Shmueli alone – found that efficiency rules the roost when it comes to making
real decisions about health technology funding in Israel. Both studies have
limitations and potential biases, and more research is needed using qualitative
methods and more nuanced survey designs to determine precisely which kinds
of equity consideration decision makers think are most important and why
these considerations do not appear to be given much weight in decision
making. However, the basic overall finding from the two studies seems
plausible and important. It suggests that health technology funding bodies
need to pay closer attention to equity considerations, and to start making
equity a quantitative endpoint of health technology assessment using the
methods of equity-informative economic evaluation that are now available.

Bibliographical note

© The Author(s). 2017

Publication details

Journal Journal of epidemiology and community health
Date Accepted/In press - 20 May 2017
Date E-pub ahead of print (current) - 5 Jul 2017
Number of pages 7
Pages (from-to) 1-7
Early online date 5/07/17
Original language English

Bibliographical note

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017.

Publication details

Journal British Journal of General Practice
Date Accepted/In press - 8 Mar 2017
Date E-pub ahead of print (current) - 5 Jul 2017
Early online date 5/07/17
Original language English

Abstract

Background – Serious mental illness (SMI) – which comprises long term conditions such as schizophrenia, bipolar disorder and other psychoses – has enormous costs for both patients and society. In many countries, people with SMI are treated solely in primary care, and have particular needs for physical care. Aim - The objective of this study was to review systematically the literature to create a list of quality indicators relevant to patients with SMI which could be captured using routine data, and which could be used to monitor or incentivise better quality primary care. Design and setting – A systematic literature review, combined with a search of quality indicator databases and guidelines. Methods – We assessed whether indicators could be measured from routine data and the quality of the evidence. Results – 1,847 papers and quality indicator databases were identified, 27 were included, from which 59 quality indicators were identified, covering six domains. Of the 59 indicators, 52 could be assessed using routine data. The evidence base underpinning these indicators was relatively weak, and was primarily based on expert opinion rather than trial evidence. Conclusions – With appropriate adaptation for different contexts, and in line with relative responsibilities of primary and secondary care, use of the quality indicators has the potential to improve care and to improve the physical and mental health of people with SMI. However, before the indicators can be used to monitor or incentivise primary care quality, more robust links need to be established with improved patient outcomes.

Bibliographical note

© British Journal of General Practice. This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy. Further copying may not be permitted; contact the publisher for details

Publication details

Journal Journal of Social Policy
Date Accepted/In press - 28 Nov 2016
Date E-pub ahead of print - 19 Jan 2017
Date Published (current) - Jul 2017
Issue number 3
Volume 46
Number of pages 23
Pages (from-to) 423-445
Early online date 19/01/17
Original language English

Abstract

Long-range temporal choices are built into contemporary policy-making, with policy decisions having consequences that play out across generations. Decisions are made on behalf of the public who are assumed to give much greater weight to their welfare than to the welfare of future generations. The paper investigates this assumption. It briefly discusses evidence from sociological and economic studies before reporting the findings of a British survey of people's intergenerational time preferences based on a representative sample of nearly 10,000 respondents. Questions focused on two sets of policies: (i) health policies to save lives and (ii) environmental policies to protect against floods that would severely damage homes, businesses and other infrastructure. For both sets of policies, participants were offered a choice of three policy options, each bringing greater or lesser benefits to their, their children's and their grandchildren's generations. For both saving lives and protecting against floods, only a minority selected the policy that most benefited their generation; the majority selected policies bringing equal or greater benefits to future generations. Our study raises questions about a core assumption of standard economic evaluation, pointing instead to concern for future generations as a value that many people hold in common.

Bibliographical note

© Cambridge University Press 2017.
nominated for the Cambridge University Press Awards for Excellence in Social Policy

Publication details

Journal Journal of Health Economics
Date Accepted/In press - 11 Jun 2017
Date E-pub ahead of print (current) - 23 Jun 2017
Early online date 23/06/17
Original language English

Abstract

Equity of access is a key policy objective in publicly-funded healthcare systems. However, observed inequalities of access by socioeconomic status may result from differences in patients’ choices. Using data on non-emergency coronary revascularisation procedures in the English National Health Service, we found substantive differences in waiting times within public hospitals between patients with different socioeconomic status: up to 35% difference, or 43 days, between the most and least deprived population quintile groups. Using selection models with differential distances as identification variables, we estimated that only up to 12% of these waiting time inequalities can be attributed to patients’ choices of hospital and type of treatment (heart bypass versus stent). Residual inequality, after allowing for choice, was economically significant: patients in the least deprived quintile group benefited from shorter waiting times and the associated health benefits were worth up to £850 per person.

Bibliographical note

© 2017, The Authors.

Publication details

Journal Medical Decision Making
Date Accepted/In press - 4 Jan 2017
Date E-pub ahead of print (current) - 25 Apr 2017
Number of pages 12
Early online date 25/04/17
Original language English

Abstract

Background:
Empirical studies have found that members of the public are inequality averse and value health gains for disadvantaged groups with poor health many times more highly than gains for better off groups. However, these studies typically use abstract scenarios that involve unrealistically large reductions in health inequality and face-to-face survey administration. It is not known how robust these findings are to more realistic scenarios or anonymous online survey administration.
Methods:
This study aimed to test the robustness of questionnaire estimates of inequality aversion by comparing the following: 1) small versus unrealistically large health inequality reductions, 2) population-level versus individual-level descriptions of health inequality reductions, 3) concrete versus abstract intervention scenarios,
and 4) online versus face-to-face mode of administration. Fifty-two members of the public participated in face-to-face discussion groups, while 83 members of the public completed an online survey. Participants were given a questionnaire instrument with different scenario descriptions for eliciting aversion to social inequality in health.
Results:
The median respondent was inequality averse under all scenarios. Scenarios involving small rather than unrealistically large health gains made little difference in terms of inequality aversion, as did population level rather than individual-level scenarios. However, the proportion expressing extreme inequality aversion fell 19 percentage points when considering a specific health
intervention scenario rather than an abstract scenario and was 11 to 21 percentage points lower among online public respondents compared with the discussion group.
Conclusions:
Our study suggests that both concrete scenarios and online administration reduce the proportion expressing extreme inequality aversion but still yield median responses implying substantial health inequality aversion.

Bibliographical note

© The Author(s) 2017. This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy. Further copying may not be permitted; contact the publisher for details

Publication details

Journal Health services research
Date In preparation - 2016
Date Accepted/In press - 18 Jan 2016
Date E-pub ahead of print - 16 May 2016
Date Published (current) - 3 Apr 2017
Issue number 2
Volume 52
Number of pages 16
Pages (from-to) 863-878
Early online date 16/05/16
Original language English

Abstract

Objective: To estimate a safe minimum hospital volume for hospitals performing
coronary artery bypass graft (CABG) surgery.

Data source: Hospital data on all publicly funded CABG in five European countries, 2007-2009 (106,149 patients).

Design: Hierarchical logistic regression models to estimate the relationship between hospital volume and mortality, allowing for case-mix. Segmented regression analysis to estimate a threshold.

Findings: The 30-day in-hospital mortality rate was 3.0% overall, 5.2% (95% CI 4.0-6.4) in low volume hospitals and 2.1% (95% CI 1.8-2.3) in high volume hospitals. There is a significant curvilinear relationship between volume and mortality, flatter above 415 cases per hospital per year.

Conclusions: There is a clear relationship between hospital CABG volume and
mortality in Europe, implying a ‘safe’ threshold volume of 415 cases per year.

Bibliographical note

© Health Research and Educational Trust. This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy. Further copying may not be permitted; contact the publisher for details

Publication details

Journal Journal of Health Services Research & Policy
Date E-pub ahead of print - 15 Nov 2016
Date Published (current) - 1 Apr 2017
Issue number 2
Volume 22
Number of pages 8
Pages (from-to) 83-90
Early online date 15/11/16
Original language English

Abstract

Objectives Reducing health inequalities is an explicit goal of England's health system. Our aim was to compare the performance of English local administrative areas in reducing socioeconomic inequality in emergency hospital admissions for ambulatory care sensitive chronic conditions. Methods We used local authority area as a stable proxy for health and long-term care administrative geography between 2004/5 and 2011/12. We linked inpatient hospital activity, deprivation, primary care, and population data to small area neighbourhoods (typical population 1500) within administrative areas (typical population 250,000). We measured absolute inequality gradients nationally and within each administrative area using neighbourhood-level linear models of the relationship between national deprivation and age-sex-adjusted emergency admission rates. We assessed local equity performance by comparing local inequality against national inequality to identify areas significantly more or less equal than expected; evaluated stability over time; and identified where equity performance was steadily improving or worsening. We then examined associations between change in socioeconomic inequalities and change in within-area deprivation (gentrification). Finally, we used administrative area-level random and fixed effects models to examine the contribution of primary care to inequalities in admissions. Results Data on 316 administrative areas were included in the analysis. Local inequalities were fairly stable between consecutive years, but 32 areas (10%) showed steadily improving or worsening equity. In the 21 improving areas, the gap between most and least deprived fell by 3.9 admissions per 1000 (six times the fall nationally) between 2004/5 and 2011/12, while in the 11 areas worsening, the gap widened by 2.4. There was no indication that measured improvements in local equity were an artefact of gentrification or that changes in primary care supply or quality contributed to changes in inequality. Conclusions Local equity performance in reducing inequality in emergency admissions varies both geographically and over time. Identifying this variation could provide insights into which local delivery strategies are most effective in reducing such inequalities.

Bibliographical note

© The Author(s) 2016

Publication details

Journal Journal of epidemiology and community health
Date Accepted/In press - 3 Feb 2017
Date E-pub ahead of print (current) - 29 Mar 2017
Number of pages 9
Pages (from-to) 1-9
Early online date 29/03/17
Original language English

Abstract

BACKGROUND: Public sector austerity measures in many high-income countries mean that public health budgets are reducing year on year. To help inform the potential impact of these proposed disinvestments in public health, we set out to determine the return on investment (ROI) from a range of existing public health interventions.

METHODS: We conducted systematic searches on all relevant databases (including MEDLINE; EMBASE; CINAHL; AMED; PubMed, Cochrane and Scopus) to identify studies that calculated a ROI or cost-benefit ratio (CBR) for public health interventions in high-income countries.

RESULTS: We identified 2957 titles, and included 52 studies. The median ROI for public health interventions was 14.3 to 1, and median CBR was 8.3. The median ROI for all 29 local public health interventions was 4.1 to 1, and median CBR was 10.3. Even larger benefits were reported in 28 studies analysing nationwide public health interventions; the median ROI was 27.2, and median CBR was 17.5.

CONCLUSIONS: This systematic review suggests that local and national public health interventions are highly cost-saving. Cuts to public health budgets in high income countries therefore represent a false economy, and are likely to generate billions of pounds of additional costs to health services and the wider economy.

Bibliographical note

© 2017 The Author(s).

Publication details

Journal Annual Review of Public Health
Date Accepted/In press - 29 Sep 2016
Date E-pub ahead of print (current) - 20 Mar 2017
Issue number 7
Volume 38
Number of pages 17
Early online date 20/03/17
Original language English

Abstract

The use of financial incentives to improve quality in health care has become widespread. Yet evidence on the effectiveness of incentives suggests that they have generally had limited impact on the value of care and have not led to better patient outcomes. Lessons from social psychology and behavioral economics indicate that incentive programs in health care have not been effectively designed to achieve their intended impact. In the United States, Medicare's Hospital Readmission Reduction Program and Hospital Value- Based Purchasing Program, created under the Affordable Care Act (ACA), provide evidence on how variations in the design of incentive programs correspond with differences in effect. As financial incentives continue to be used as a tool to increase the value and quality of health care, improving the design of programs will be crucial to ensure their success. Expected final online publication date for the Annual Review of Public Health Volume 38 is March 20, 2017. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Bibliographical note

© 2017 by Annual Reviews.

Publication details

Journal Social science and medicine
Date Accepted/In press - 3 Nov 2016
Date E-pub ahead of print - 4 Nov 2016
Date Published (current) - Mar 2017
Volume 177
Number of pages 14
Pages (from-to) 127-140
Early online date 4/11/16
Original language English

Abstract

Health Insurance (HI) programmes in low-income countries aim to reduce the burden of individual out-of-pocket (OOP) health care expenditure. However, if the decisions to purchase insurance and to seek care when ill are correlated with the expected healthcare expenditure, the use of naïve models may produce biased estimates of the impact of insurance membership on OOP expenditure. Whilst many studies in the literature have accounted for the endogeneity of the insurance decision, the potential selection bias due to the care-seeking decision has not been taken into account. We extend the Heckman selection model to account simultaneously for both care-seeking and insurance-seeking selection biases in the healthcare expenditure regression model. The proposed model is illustrated in the context of a Vietnamese HI programme using data from a household survey of 1192 individuals conducted in 1999. Results were compared with those of alternative econometric models making no or partial allowance for selection bias. In this illustrative example, the impact of insurance membership on reducing OOP expenditures was underestimated by 21 percentage points when selection biases were not taken into account. We believe this is an important methodological contribution that will be relevant to future empirical work.

Bibliographical note

© 2016 Elsevier Ltd. This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy

Publication details

Journal Value in Health
Date Accepted/In press - 23 Nov 2016
Date E-pub ahead of print (current) - 24 Feb 2017
Issue number 2
Volume 20
Number of pages 7
Pages (from-to) 206-212
Early online date 24/02/17
Original language English

Abstract

This articles serves as a guide to using cost-effectiveness analysis (CEA) to address health equity concerns. We first introduce the "equity impact plane," a tool for considering trade-offs between improving total health-the objective underpinning conventional CEA-and equity objectives, such as reducing social inequality in health or prioritizing the severely ill. Improving total health may clash with reducing social inequality in health, for example, when effective delivery of services to disadvantaged communities requires additional costs. Who gains and who loses from a cost-increasing health program depends on differences among people in terms of health risks, uptake, quality, adherence, capacity to benefit, and-crucially-who bears the opportunity costs of diverting scarce resources from other uses. We describe two main ways of using CEA to address health equity concerns: 1) equity impact analysis, which quantifies the distribution of costs and effects by equity-relevant variables, such as socioeconomic status, location, ethnicity, sex, and severity of illness; and 2) equity trade-off analysis, which quantifies trade-offs between improving total health and other equity objectives. One way to analyze equity trade-offs is to count the cost of fairer but less cost-effective options in terms of health forgone. Another method is to explore how much concern for equity is required to choose fairer but less cost-effective options using equity weights or parameters. We hope this article will help the health technology assessment community navigate the practical options now available for conducting equity-informative CEA that gives policymakers a better understanding of equity impacts and trade-offs.

Bibliographical note

© 2017, International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc.

2016

Publication details

Journal British Journal of General Practice
Date Accepted/In press - 26 Aug 2016
Date Published (current) - 29 Dec 2016
Issue number 654
Volume 67
Number of pages 9
Original language English

Abstract

Background Outcomes of diabetes care are unequal and the NHS has a duty to consider reducing inequality in healthcare outcomes.

Aim To quantify trends in socioeconomic inequality and diabetes outcomes.

Design and setting Whole-population longitudinal study of 32 482 neighbourhoods (Lower Layer Super Output Areas [LSOAs]) in England between 2004/2005 and 2011/2012.

Method Slope indices of inequality (SIIs) between neighbourhoods of great and little deprivation were measured annually for: glycated haemoglobin control in people with diabetes; emergency hospitalisation for diabetes; and amenable mortality from diabetes.

Results From 2004/2005 to 2011/2012 glycaemic control improved in all social groups, regardless of deprivation level, although inequality was unchanged as measured by the SII (0.04, 95% confidence interval [CI] = −0.43 to 0.52). Diabetes-related amenable mortality improved in all social groups, but decreased at a faster rate in neighbourhoods of greater deprivation. Inequality in diabetes-related amenable mortality improved, with the SII falling by 2.68 (95% CI = 1.93 to 3.43), resulting in 594 (95% CI = 420 to 767) fewer deaths. In contrast, emergency hospitalisations for diabetes increased in all social groups, with faster growth in neighbourhoods of greater deprivation. The socioeconomic gradient increased with the SII widening by 19.59 admissions for diabetes per 100 000 (95% CI = 16.00 to 23.17), resulting in an increase of 5991 (95% CI = 5084 to 6899) excess admissions associated with socioeconomic inequality during the study period.

Conclusion In diabetes, mortality declined faster, but emergency hospitalisation grew faster in more deprived neighbourhoods. Unequal growth in emergency hospitalisation for diabetes is likely to be partly due to increased diabetes prevalence and patients living longer, but may also be due to overuse of glycaemic control medication.

Bibliographical note

©British Journal of General Practice. This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy. Further copying may not be permitted; contact the publisher for details

Publication details

Journal Social science and medicine
Date Accepted/In press - 19 Oct 2016
Date E-pub ahead of print - 24 Oct 2016
Date Published (current) - 1 Dec 2016
Volume 170
Number of pages 2
Pages (from-to) 218-219
Early online date 24/10/16
Original language English

Bibliographical note

© Elsevier Ltd, 2016. This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy. Further copying may not be permitted; contact the publisher for details

Publication details

Journal Fiscal Studies
Date Published - 21 Nov 2016
Issue number 3-4
Volume 37
Number of pages 33
Pages (from-to) 371–403
Original language English

Abstract

This paper reviews what is known about socio-economic inequalities in health care in England, with particular attention to inequalities relative to need that may be considered unfair (‘inequities’). We call inequalities of 5 per cent or less between the most and least deprived socio-economic quintile groups ‘slight’, inequalities of 5–15 per cent ‘moderate’ and inequalities of more than 15 per cent ‘substantial’. Overall public health care expenditure is substantially concentrated on poorer people. At any given age, poorer people are more likely to see their family doctor, have a public outpatient appointment, visit accident and emergency, and stay in hospital for publicly-funded inpatient treatment. After allowing for current self-assessed health and morbidity, there is slight pro-rich inequity in combined public and private medical specialist visits but not in family doctor visits. There are also slight pro-rich inequities in overall indicators of clinical process quality and patient experience from public health care, substantial pro-rich inequalities in bereaved people’s experiences of health and social care for recently deceased relatives, and mostly slight but occasionally substantial pro-rich inequities in the use of preventive care (for example, dental check-ups, eye tests, screening and vaccination) and a few specific treatments (for example, hip and knee replacement). Studies of population health care outcomes (for example, avoidable emergency hospitalisation) find substantial pro-rich inequality after adjusting for age and sex only. These findings are all consistent with a broad economic framework that sees health care as just one input into the production of health over the life course, alongside many other socio-economically patterned inputs including environmental factors (for example, living and working conditions), consumption (for example, diet and smoking), self-care (for example, seeking medical information) and informal care (for example, support from family and friends).

Bibliographical note

© 2016 The Authors

Publication details

Journal BMJ Quality & Safety
Date Accepted/In press - 3 Sep 2016
Date Published (current) - 18 Oct 2016
Number of pages 9
Original language English

Abstract

BACKGROUND: Studies finding higher mortality rates for patients admitted to hospital at weekends rely on routine administrative data to adjust for risk of death, but these data may not adequately capture severity of illness. We examined how rates of patient arrival at accident and emergency (A&E) departments by ambulance-a marker of illness severity-were associated with in-hospital mortality by day and time of attendance.

METHODS: Retrospective observational study of 3 027 946 admissions to 140 non-specialist hospital trusts in England between April 2013 and February 2014. Patient admissions were linked with A&E records containing mode of arrival and date and time of attendance. We classified arrival times by day of the week and daytime (07:00 to 18:59) versus night (19:00 to 06:59 the following day). We examined the association with in-hospital mortality within 30 days using multivariate logistic regression.

RESULTS: Over the week, 20.9% of daytime arrivals were in the highest risk quintile compared with 18.5% for night arrivals. Daytime arrivals on Sundays contained the highest proportion of patients in the highest risk quintile at 21.6%. Proportions of admitted patients brought in by ambulance were substantially higher at night and higher on Saturday (61.1%) and Sunday (60.1%) daytimes compared with other daytimes in the week (57.0%). Without adjusting for arrival by ambulance, risk-adjusted mortality for patients arriving at night was higher than for daytime attendances on Wednesday (0.16 percentage points). Compared with Wednesday daytime, risk-adjusted mortality was also higher on Thursday night (0.15 percentage points) and increased throughout the weekend from Saturday daytime (0.16 percentage points) to Sunday night (0.26 percentage points). After adjusting for arrival by ambulance, the raised mortality only reached statistical significance for patients arriving at A&E on Sunday daytime (0.17 percentage points).

CONCLUSION: Using conventional risk-adjustment methods, there appears to be a higher risk of mortality following emergency admission to hospital at nights and at weekends. After accounting for mode of arrival at hospital, this pattern changes substantially, with no increased risk of mortality following admission at night or for any period of the weekend apart from Sunday daytime. This suggests that risk-adjustment based on inpatient administrative data does not adequately account for illness severity and that elevated mortality at weekends and at night reflects a higher proportion of more severely ill patients arriving by ambulance at these times.

Bibliographical note

Copyright Article author (or their employer) 2016.

Publication details

Journal Health Services and Delivery Research
Date Published - Sep 2016
Issue number 26
Volume 4
Original language English

Bibliographical note

© Queen’s Printer and Controller of HMSO 2016.

Fairer decisions, better health for all: Health equity and cost-effectiveness analysis

Cookson, R. A., Mirelman, A., Asaria, M., Dawkins, B. & Griffin, S., Sep 2016, Centre for Health Economics, University of York, p. 1-43, 43 p. (CHE Research Paper; no. 135).

Research output: Working paperDiscussion paper

Publication details

Date Published - Sep 2016
Publisher Centre for Health Economics, University of York
Number of pages 43
Original language English

Publication series

Name CHE Research Paper
Publisher Centre for Health Economics, University of York
No. 135

Abstract

This report provides a non-technical introduction to practical methods for using cost-effectiveness analysis to address health equity concerns, with applications to low-, middle- and high-income countries. These methods can provide information about the likely impacts of alternative health policy decisions on inequalities in health, financial risk protection and other health-related outcomes that may be considered unfair, allowing for the distribution of costs as well as benefits. They can also provide information about the trade-offs that sometimes arise between improving total health and reducing health inequalities of different kinds. We distinguish three general ways of using cost-effectiveness analysis to address health equity concerns: (1) equity impact analysis, which quantifies the distribution of costs and effects across a population by equity-relevant variables such as socioeconomic status, ethnicity, location, gender, age and severity of illness; (2) equity constraint analysis, which counts the cost of choosing fairer but less cost-effective options; and (3) equity weighting analysis, which uses equity weights or parameters to explore how much concern for equity is required to choose fairer but less cost-effective options. We hope this report will raise awareness of the practical tools of cost-effectiveness analysis that are now available to help give health care and public health policy makers a better understanding of who gains and who loses from their priority setting decisions.

Associations between exemption and survival outcomes in the UK's primary care pay-for-performance programme: a retrospective cohort study

Kontopantelis, E., Springate, D. A., Ashcroft, D. M., Valderas, J. M., van der Veer, S. N., Reeves, D., Guthrie, B. & Doran, T., 17 Aug 2016

Article in BMJ Quality & Safety

Publication details

Journal BMJ Quality & Safety
Date Accepted/In press - 1 Nov 2015
Date E-pub ahead of print (current) - 17 Aug 2016
Issue number 9
Volume 25
Number of pages 14
Pages (from-to) 657-70
Early online date 17/08/16
Original language English

Abstract

OBJECTIVES: The UK's Quality and Outcomes Framework permits practices to exempt patients from financially-incentivised performance targets. To better understand the determinants and consequences of being exempted from the framework, we investigated the associations between exception reporting, patient characteristics and mortality. We also quantified the proportion of exempted patients that met quality targets for a tracer condition (diabetes).

DESIGN: Retrospective longitudinal study, using individual patient data from the Clinical Practice Research Datalink.

SETTING: 644 general practices, 2006/7 to 2011/12.

PARTICIPANTS: Patients registered with study practices for at least one year over the study period, with at least one condition of interest (2 460 341 in total).

MAIN OUTCOME MEASURES: Exception reporting rates by reason (clinical contraindication, patient dissent); all-cause mortality in year following exemption. Analyses with logistic and Cox proportional-hazards regressions, respectively.

RESULTS: The odds of being exempted increased with age, deprivation and multimorbidity. Men were more likely to be exempted but this was largely attributable to higher prevalence of conditions with high exemption rates. Modest associations remained, with women more likely to be exempted due to clinical contraindication (OR 0.90, 99% CI 0.88 to 0.92) and men more likely to be exempted due to informed dissent (OR 1.08, 99% CI 1.06 to 1.10). More deprived areas (both for practice location and patient residence) were non-linearly associated with higher exception rates, after controlling for comorbidities and other covariates, with stronger associations for clinical contraindication. Compared with patients with a single condition, odds ratios for patients with two, three, or four or more conditions were respectively 4.28 (99% CI 4.18 to 4.38), 16.32 (99% CI 15.82 to 16.83) and 68.69 (99% CI 66.12 to 71.37) for contraindication, and 2.68 (99% CI 2.63 to 2.74), 4.02 (99% CI 3.91 to 4.13) and 5.17 (99% CI 5.00 to 5.35) for informed dissent. Exempted patients had a higher adjusted risk of death in the following year than non-exempted patients, regardless of whether this exemption was for contraindication (hazard ratio 1.37, 99% CI 1.33 to 1.40) or for informed dissent (1.20, 99% CI 1.17 to 1.24). On average, quality standards were met for 48% of exempted patients in the diabetes domain, but there was wide variation across indicators (ranging from 8 to 80%).

CONCLUSIONS: Older, multimorbid and more deprived patients are more likely to be exempted from the scheme. Exception reported patients are more likely to die in the following year, whether they are exempted by the practice for a contraindication or by themselves through informed dissent. Further research is needed to understand the relationship between exception reporting and patient outcomes.

Bibliographical note

© 2017, The Author(s).

Years of good life based on income and health: re-engineering cost-benefit analysis to examine policy impacts on wellbeing and distributive justice

Cookson, R. A., Cotton-Barrett, O., Adler, M., Asaria, M. & Ord, T., Jul 2016, York UK: Centre for Health Economics, University of York, p. 1-25, 25 p. (CHE Research Paper; no. 132).

Research output: Working paperDiscussion paper

Publication details

Date Published - Jul 2016
Publisher Centre for Health Economics, University of York
Place of Publication York UK
Number of pages 25
Original language English

Publication series

Name CHE Research Paper
Publisher Centre for Health Economics, University of York
No. 132

Abstract

In this paper, we propose a practical measure of individual wellbeing to facilitate the economic evaluation of public policies. We propose to evaluate policies in terms of years of good life gained, in a way that complements and generalises conventional cost-benefit analysis in terms of money. We aim to show how years of good life could be measured in practice by harnessing readily available data on three important elements of individual wellbeing: income, health-related quality of life, and longevity. We also aim to identify the main ethical assumptions needed to use this measure.

Publication details

Journal Social Science & Medicine
Date Accepted/In press - 5 May 2016
Date E-pub ahead of print - 6 May 2016
Date Published (current) - 1 Jun 2016
Volume 159
Number of pages 12
Pages (from-to) 140-151
Early online date 6/05/16
Original language English

Abstract

A number of OECD countries have introduced waiting time prioritisation policies which give explicit priority to severely ill patients with high marginal disutility of waiting. There is however little empirical evidence on how patients are actually prioritised. We exploit a unique opportunity to investigate this issue using a large national dataset with accurate measures of severity on nearly 400,000 patients. We link data from a national patient-reported outcome measures survey to administrative data on all patients waiting for a publicly funded hip and knee replacement in England during the years 2009-14. We find that patients suffering the most severe pain and immobility have shorter waits than those suffering the least, by about 24% for hip replacement and 11% for knee replacement, and that the association is approximately linear. These differentials are more closely associated with pain than immobility, and are larger in hospitals with longer average waiting times. These result suggests that doctors prioritise patients according to severity even when no formal prioritisation policy is in place and average waiting times are short.

Bibliographical note

©2016 Elsevier Ltd. All rights reserved. This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy.

Publication details

Journal Journal of epidemiology and community health
Date Accepted/In press - 19 Apr 2016
Date E-pub ahead of print (current) - 17 May 2016
Number of pages 7
Early online date 17/05/16
Original language English

Abstract

BACKGROUND: There are substantial socioeconomic inequalities in both life expectancy and healthcare use in England. In this study, we describe how these two sets of inequalities interact by estimating the social gradient in hospital costs across the life course.

METHODS: Hospital episode statistics, population and index of multiple deprivation data were combined at lower-layer super output area level to estimate inpatient hospital costs for 2011/2012 by age, sex and deprivation quintile. Survival curves were estimated for each of the deprivation groups and used to estimate expected annual costs and cumulative lifetime costs.

RESULTS: A steep social gradient was observed in overall inpatient hospital admissions, with rates ranging from 31 298/100 000 population in the most affluent fifth of areas to 43 385 in the most deprived fifth. This gradient was steeper for emergency than for elective admissions. The total cost associated with this inequality in 2011/2012 was £4.8 billion. A social gradient was also observed in the modelled lifetime costs where the lower life expectancy was not sufficient to outweigh the higher average costs in the more deprived populations. Lifetime costs for women were 14% greater than for men, due to higher costs in the reproductive years and greater life expectancy.

CONCLUSIONS: Socioeconomic inequalities result in increased morbidity and decreased life expectancy. Interventions to reduce inequality and improve health in more deprived neighbourhoods have the potential to save money for health systems not only within years but across peoples' entire lifetimes, despite increased costs due to longer life expectancies.

Bibliographical note

© Authors 2016

Publication details

Journal Journal of epidemiology and community health
Date Accepted/In press - 19 Apr 2016
Date E-pub ahead of print (current) - 17 May 2016
Number of pages 7
Early online date 17/05/16
Original language English

Abstract

BACKGROUND: There are substantial socioeconomic inequalities in both life expectancy and healthcare use in England. In this study, we describe how these two sets of inequalities interact by estimating the social gradient in hospital costs across the life course.

METHODS: Hospital episode statistics, population and index of multiple deprivation data were combined at lower-layer super output area level to estimate inpatient hospital costs for 2011/2012 by age, sex and deprivation quintile. Survival curves were estimated for each of the deprivation groups and used to estimate expected annual costs and cumulative lifetime costs.

RESULTS: A steep social gradient was observed in overall inpatient hospital admissions, with rates ranging from 31 298/100 000 population in the most affluent fifth of areas to 43 385 in the most deprived fifth. This gradient was steeper for emergency than for elective admissions. The total cost associated with this inequality in 2011/2012 was £4.8 billion. A social gradient was also observed in the modelled lifetime costs where the lower life expectancy was not sufficient to outweigh the higher average costs in the more deprived populations. Lifetime costs for women were 14% greater than for men, due to higher costs in the reproductive years and greater life expectancy.

CONCLUSIONS: Socioeconomic inequalities result in increased morbidity and decreased life expectancy. Interventions to reduce inequality and improve health in more deprived neighbourhoods have the potential to save money for health systems not only within years but across peoples' entire lifetimes, despite increased costs due to longer life expectancies.

Bibliographical note

© Authors 2016

Publication details

Journal Lancet.
Date Accepted/In press - 13 May 2016
Date E-pub ahead of print (current) - 17 May 2016
Number of pages 8
Early online date 17/05/16
Original language English

Bibliographical note

© 2016, Elsevier Ltd. This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy. Further copying may not be permitted; contact the publisher for details

Publication details

Journal Journal of Health Services Research & Policy
Date E-pub ahead of print - 6 May 2016
Number of pages 8
Original language English

Abstract

Objective: Patients admitted as emergencies to hospitals at the weekend have higher death rates than patients admitted on weekdays. This may be because the restricted service availability at weekends leads to selection of patients with
greater average severity of illness. We examined volumes and rates of hospital admissions and deaths across the week for patients presenting to emergency services through two routes: (a) hospital Accident and Emergency departments, which are open throughout the week; and (b) services in the community, for which availability is more restricted at weekends.

Method: Retrospective observational study of all 140 non-specialist acute hospital Trusts in England analysing 12,670,788 Accident and Emergency attendances and 4,656,586 emergency admissions (940,859 direct admissions
from primary care and 3,715,727 admissions through Accident and Emergency) between April 2013 and February 2014.Emergency attendances and admissions to hospital and deaths in any hospital within 30 days of attendance or admission were compared for weekdays and weekends.

Results: Similar numbers of patients attended Accident and Emergency on weekends and weekdays. There were similar numbers of deaths amongst patients attending Accident and Emergency on weekend days compared with weekdays (378.0 vs. 388.3). Attending Accident and Emergency at the weekend was not associated with a significantly higher probability of death (risk-adjusted OR: 1.010). Proportionately fewer patients who attended Accident and Emergency at weekend were admitted to hospital (27.5% vs. 30.0%) and it is only amongst the subset of patients attending Accident and Emergency who were selected for admission to hospital that the probability of dying was significantly higher at the weekend (risk-adjusted OR: 1.054). The average volume of direct admissions from services in the community was 61% lower on weekend days compared to weekdays (1317 vs. 3404). There were fewer deaths following direct admission on weekend days than weekdays (35.9 vs. 80.8). The mortality rate was significantly higher at weekends amongst direct admissions (risk-adjusted OR: 1.212) due to the proportionately greater reduction in admissions relative to deaths.

Conclusions: There are fewer deaths following hospital admission at weekends. Higher mortality rates at weekends are found only amongst the subset of patients who are admitted. The reduced availability of primary care services and the higher Accident and Emergency admission threshold at weekends mean fewer and sicker patients are admitted at weekends than during the week. Extending services in hospitals and in the community at weekends may increase the number of emergency admissions and therefore lower mortality, but may not reduce the absolute number of deaths.

Bibliographical note

© 2016, The authors.

Socioeconomic inequalities in health care in England

Cookson, R. A., Propper, C., Asaria, M. & Raine, R., Apr 2016, York, UK: Centre for Health Economics, University of York, p. 1-34, 34 p. (CHE Research Paper; no. 129).

Research output: Working paperDiscussion paper

Publication details

Date Published - Apr 2016
Publisher Centre for Health Economics, University of York
Place of Publication York, UK
Number of pages 34
Original language English

Publication series

Name CHE Research Paper
Publisher Centre for Health Economics, University of York
No. 129

Abstract

This paper reviews what is known about socioeconomic inequalities in health care in England, with particular attention to inequalities relative to need that may be considered unfair (‘inequities’). We call inequalities of 5% or less between most and least deprived socioeconomic quintile groups ‘slight’; inequalities of 6-15% ‘moderate’, and inequalities of > 15% ‘substantial’. Overall public health care expenditure is substantially concentrated on poorer people. At any given age, poorer people are more likely to see their family doctor, have a public outpatient appointment, visit accident and emergency, and stay in hospital for publicly funded inpatient treatment. After allowing for current self-assessed health and morbidity, there is slight pro-rich inequity in combined public and private medical specialist visits but not family doctor visits. There are also slight pro-rich inequities in overall indicators of clinical process quality and patient experience from public health care, substantial pro-rich inequalities in bereaved people’s experiences of health and social care for recently deceased relatives, and mostly slight but occasionally substantial pro-rich inequities in the use of preventive care (e.g. dental checkups, eye tests, screening and vaccination) and a few specific treatments (e.g. hip and knee replacement). Studies of population health care outcomes (e.g. avoidable emergency hospitalisation) find substantial pro-rich inequality after adjusting for age and sex only. These findings are all consistent with a broad economic framework that sees health care as just one input into the production of health, alongside many other socioeconomically patterned inputs including environmental factors (e.g. living and working conditions), consumption (e.g. diet, smoking), self care (e.g. seeking medical information) and informal care (e.g. support from family and friends).

Modelling Conditions and Health Care Processes in Electronic Health Records: An Application to Severe Mental Illness with the Clinical Practice Research Datalink

Olier, I., Springate, D. A., Ashcroft, D. M., Doran, T., Reeves, D., Planner, C., Reilly, S. & Kontopantelis, E., 26 Feb 2016

Article in PLoS ONE

Publication details

Journal PLoS ONE
Date Published - 26 Feb 2016
Issue number 2
Volume 11
Number of pages 13
Original language English

Abstract

BACKGROUND: The use of Electronic Health Records databases for medical research has become mainstream. In the UK, increasing use of Primary Care Databases is largely driven by almost complete computerisation and uniform standards within the National Health Service. Electronic Health Records research often begins with the development of a list of clinical codes with which to identify cases with a specific condition. We present a methodology and accompanying Stata and R commands (pcdsearch/Rpcdsearch) to help researchers in this task. We present severe mental illness as an example.

METHODS: We used the Clinical Practice Research Datalink, a UK Primary Care Database in which clinical information is largely organised using Read codes, a hierarchical clinical coding system. Pcdsearch is used to identify potentially relevant clinical codes and/or product codes from word-stubs and code-stubs suggested by clinicians. The returned code-lists are reviewed and codes relevant to the condition of interest are selected. The final code-list is then used to identify patients.

RESULTS: We identified 270 Read codes linked to SMI and used them to identify cases in the database. We observed that our approach identified cases that would have been missed with a simpler approach using SMI registers defined within the UK Quality and Outcomes Framework.

CONCLUSION: We described a framework for researchers of Electronic Health Records databases, for identifying patients with a particular condition or matching certain clinical criteria. The method is invariant to coding system or database and can be used with SNOMED CT, ICD or other medical classification code-lists.

Bibliographical note

© 2016, The authors.

Patient and hospital determinants of primary percutaneous coronary intervention in England, 2003-2013

Hall, M., Laut, K., Dondo, T. B., Alabas, O. A., Brogan, R. A., Gutacker, N., Cookson, R., Norman, P., Timmis, A., De Belder, M., Ludman, P. F. & Gale, C. P., 1 Feb 2016

Article in Heart

Publication details

Journal Heart
Date Accepted/In press - 27 Nov 2015
Date E-pub ahead of print - 6 Jan 2016
Date Published (current) - 1 Feb 2016
Issue number 4
Volume 102
Number of pages 7
Pages (from-to) 313-319
Early online date 6/01/16
Original language English

Abstract

Objective Primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI) is insufficiently implemented in many countries. We investigated patient and hospital characteristics associated with PPCI utilisation. Methods Whole country registry data (MINAP, Myocardial Ischaemia National Audit Project) comprising PPCI-capable National Health Service trusts in England (84 hospital trusts; 92 350 hospitalisations; 90 489 patients), 2003-2013. Multilevel Poisson regression modelled the relationship between incidence rate ratios (IRR) of PPCI and patient and trust-level factors. Results Overall, standardised rates of PPCI increased from 0.01% to 86.3% (2003-2013). While, on average, there was a yearly increase in PPCI utilisation of 30% (adjusted IRR 1.30, 95% CI 1.23 to 1.36), it varied substantially between trusts. PPCI rates were lower for patients with previous myocardial infarction (0.95, 0.93 to 0.98), heart failure (0.86, 0.81 to 0.92), angina (0.96, 0.94 to 0.98), diabetes (0.97, 0.95 to 0.99), chronic renal failure (0.89, 0.85 to 0.90), cerebrovascular disease (0.96, 0.93 to 0.99), age >80 years (0.87, 0.85 to 0.90), and travel distances >30 km (0.95, 0.93 to 0.98). PPCI rates were higher for patients with previous percutaneous coronary intervention (1.09, 1.05 to 1.12) and among trusts with >5 interventional cardiologists (1.30, 1.25 to 1.34), more visiting interventional cardiologists (1-5: 1.31, 1.26 to 1.36; ≥6: 1.42, 1.35 to 1.49), and a 24 h, 7-days-a-week PPCI service (2.69, 2.58 to 2.81). Half of the unexplained variation in PPCI rates was due to between-trust differences. Conclusions Following an 8 year implementation phase, PPCI utilisation rates stabilised at 85%. However, older and sicker patients were less likely to receive PPCI and there remained between-trust variation in PPCI rates not attributable to differences in staffing levels. Compliance with clinical pathways for STEMI is needed to ensure more equitable quality of care.

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How a universal health system reduces inequalities: lessons from England

Asaria, M., Ali, S., Doran, T., Ferguson, B., Fleetcroft, R., Goddard, M., Goldblatt, P., Laudicella, M., Raine, R. & Cookson, R., 19 Jan 2016

Article in Journal of epidemiology and community health

Publication details

Journal Journal of epidemiology and community health
Date Published - 19 Jan 2016
Original language English

Abstract

Background Provision of universal coverage is essential for achieving equity in healthcare, but inequalities still exist in universal healthcare systems. Between 2004/2005 and 2011/2012, the National Health Service (NHS) in England, which has provided universal coverage since 1948, made sustained efforts to reduce health inequalities by strengthening primary care. We provide the first comprehensive assessment of trends in socioeconomic inequalities of primary care access, quality and outcomes during this period. Methods Whole-population small area longitudinal study based on 32 482 neighbourhoods of approximately 1500 people in England from 2004/2005 to 2011/2012. We measured slope indices of inequality in four indicators: (1) patients per family doctor, (2) primary care quality, (3) preventable emergency hospital admissions and (4) mortality from conditions considered amenable to healthcare. Results Between 2004/2005 and 2011/2012, there were larger absolute improvements on all indicators in more-deprived neighbourhoods. The modelled gap between the most-deprived and least-deprived neighbourhoods in England decreased by: 193 patients per family doctor (95% CI 173 to 213), 3.29 percentage points of primary care quality (3.13 to 3.45), 0.42 preventable hospitalisations per 1000 people (0.29 to 0.55) and 0.23 amenable deaths per 1000 people (0.15 to 0.31). By 2011/2012, inequalities in primary care supply and quality were almost eliminated, but socioeconomic inequality was still associated with 158 396 preventable hospitalisations and 37 983 deaths amenable to healthcare. Conclusions Between 2004/2005 and 2011/2012, the NHS succeeded in substantially reducing socioeconomic inequalities in primary care access and quality, but made only modest reductions in healthcare outcome inequalities.

Bibliographical note

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Health equity indicators for the English NHS

Cookson, R. A., Asaria, M., Ali, S., Ferguson, B., Fleetcroft, R., Goddard, M. K., Goldblatt, P., Laudicella, M. & Raine, R., Jan 2016, York: Centre for Health Economics, University of York, 265 p. (CHE Research Paper; no. 124).

Research output: Working paper

Publication details

Date Published - Jan 2016
Publisher Centre for Health Economics, University of York
Place of Publication York
Number of pages 265
Volume CHE Research Paper 124
Original language English

Publication series

Name CHE Research Paper
No. 124

Abstract

Background:
There are inequalities in healthcare access and outcomes in the English NHS which raise concerns about both quality of care and justice. In 2012, the NHS was given a statutory duty to consider reducing these inequalities

Objectives:
To develop indicators of socioeconomic inequality in healthcare access and outcomes at different stages of the patient pathway
To develop methods for monitoring local NHS equity performance in tackling socioeconomic healthcare inequalities
To produce prototype equity indicators at national and local (clinical commissioning group) level, with appropriate adjustment for need and risk
To develop “equity dashboards” for communicating equity indicator findings to decision makers in a clear and concise format

Design:
Longitudinal whole-population study at small area level

Setting:
England from 2001/2 to 2011/12

Participants:
32,482 small area neighbourhoods (lower super output areas) of approximately 1,500 people

Main outcome measures:
Slope index of inequality gaps between the most and least deprived neighbourhoods in England, adjusted for need or risk, for: (1) patients per family doctor, (2) primary care quality, (3) inpatient hospital waiting time, (4) emergency hospitalisation for chronic ambulatory care sensitive conditions, (5) repeat emergency hospitalisation in the same year, (6) dying in hospital, (7) mortality amenable to healthcare and (8) overall mortality

Data sources:
Practice level workforce data from the general practice census (Indicator 1), practice level quality and outcomes framework data (Indicator 2), inpatient hospital data from hospital episode statistics (Indicators 3-6), mortality data from ONS (Indicators 6-8)

Results:
Between 2004/5 and 2011/12, primary care was strengthened and more deprived neighbourhoods gained larger absolute improvements on all indicators except waiting time and repeat hospitalisation. Inequality gaps decreased by: 193 patients per family doctor (95% confidence interval 173 to 213), 0.42 preventable hospitalisations per 1,000 people (0.29 to 0.55) and 0.23 amenable deaths per 1,000 people (0.15 to 0.31). In 2011/12, there was little measurable inequality in primary care supply and quality but inequality was associated with 171,119 preventable hospitalisations and 41,123 deaths amenable to healthcare. Indicators (1) through (5) above found that more than twenty percent of CCGs performed statistically significantly better or worse on equity than the England average in 2011/12

Conclusions:
NHS actions can have a measurable impact on socioeconomic inequality in both healthcare access and outcomes. Reducing inequality in healthcare outcomes is more challenging than reducing inequality of access to healthcare. Monitoring of local NHS equity against a national benchmark can now be performed using any administrative geography comprising 100,000 or more people, both to help managers learn quality improvement lessons and to improve public accountability

Future work:
Exploration of quality improvement lessons from local NHS areas doing better and worse than the national equity benchmark, development of better measures of need and risk and other methodological refinements, and monitoring of other dimensions of equity. Research using these indicators is also needed to evaluate the healthcare equity impacts of interventions and to make international healthcare equity comparisons

Funding:
The National Institute for Health Research Health Services and Delivery Research Programme

Eliciting the level of health inequality aversion in England

Robson, M., Asaria, M., Tsuchiya, A., Ali, S. & Cookson, R. A., Jan 2016, York, UK: Centre for Health Economics, University of York, p. 1-19, 19 p. (CHE Research Paper; no. 125).

Research output: Working paperDiscussion paper

Publication details

Date Published - Jan 2016
Publisher Centre for Health Economics, University of York
Place of Publication York, UK
Number of pages 19
Original language English

Publication series

Name CHE Research Paper
Publisher Centre for Health Economics, University of York
No. 125

Abstract

Policy makers faced with equality-efficiency trade-offs can articulate the nature and extent of their health inequality aversion using social welfare functions. In this study we use data from an online survey of the general public in England (n=246) to elicit health inequality aversion parameters by numerically solving Atkinson and Kolm social welfare functions. We elicit median inequality aversion parameters of 10.95 for Atkinson and 0.15 for Kolm. These values suggest substantial concern for health inequality among the English general public which, at current levels of quality adjusted life expectancy, implies weighting health gains to the poorest fifth of people in society six to seven times as highly as health gains to the richest fifth.

Publication details

Journal BMJ Open
Date Published - 2016
Issue number 1
Volume 6
Pages (from-to) e008783
Original language English

Abstract

OBJECTIVE: To measure changes in socioeconomic inequality in the distribution of family physicians (general practitioners (GPs)) relative to need in England from 2004/2005 to 2013/2014.

DESIGN: Whole-population small area longitudinal data linkage study.

SETTING: England from 2004/2005 to 2013/2014.

PARTICIPANTS: 32 482 lower layer super output areas (neighbourhoods of 1500 people on average).

MAIN OUTCOME MEASURES: Slope index of inequality (SII) between the most and least deprived small areas in annual full-time equivalent GPs (FTE GPs) per 100 000 need adjusted population.

RESULTS: In 2004/2005, inequality in primary care supply as measured by the SII in FTE GPs was 4.2 (95% CI 3.1 to 5.3) GPs per 100 000. By 2013/2014, this SII had fallen to -0.7 (95% CI -2.5 to 1.1) GPs per 100 000. The number of FTE GPs per 100 000 serving the most deprived fifth of small areas increased over this period from 54.0 to 60.5, while increasing from 57.2 to 59.9 in the least deprived fifth, so that by the end of the study period there were more GPs per 100 000 need adjusted population in the most deprived areas than in the least deprived. The increase in GP supply in the most deprived fifth of neighbourhoods was larger in areas that received targeted investment for establishing new practices under the 'Equitable Access to Primary Medical Care'.

CONCLUSIONS: There was a substantial reduction in socioeconomic inequality in family physician supply associated with national policy. This policy may not have completely eliminated socioeconomic inequality in family physician supply since existing need adjustment formulae do not fully capture the additional burden of multimorbidity in deprived neighbourhoods. The small area approach introduced in this study can be used routinely to monitor socioeconomic inequality of access to primary care and to indicate workforce shortages in particular neighbourhoods. http://creativecommons.org/licenses/by/4.0.

Bibliographical note

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Publication details

Journal Medical Decision Making
Date Accepted/In press - 11 Mar 2015
Date E-pub ahead of print - 23 Apr 2015
Date Published (current) - 1 Jan 2016
Issue number 1
Volume 36
Number of pages 12
Pages (from-to) 8-19
Early online date 23/04/15
Original language English

Abstract

Distributional cost-effectiveness analysis (DCEA) is a framework for incorporating health inequality concerns into the economic evaluation of health sector interventions. In this tutorial, we describe the technical details of how to conduct DCEA, using an illustrative example comparing alternative ways of implementing the National Health Service (NHS) Bowel Cancer Screening Programme (BCSP). The 2 key stages in DCEA are 1) modeling social distributions of health associated with different interventions, and 2) evaluating social distributions of health with respect to the dual objectives of improving total population health and reducing unfair health inequality. As well as describing the technical methods used, we also identify the data requirements and the social value judgments that have to be made. Finally, we demonstrate the use of sensitivity analyses to explore the impacts of alternative modeling assumptions and social value judgments.

Bibliographical note

© The Author(s) 2015. This is an author-produced version of the published paper. Uploaded in accordance with the publisher’s self-archiving policy. Further copying may not be permitted; contact the publisher for details

2015

Primary care consultation rates among people with and without severe mental illness: a UK cohort study using the Clinical Practice Research Datalink

Kontopantelis, E., Olier, I., Planner, C., Reeves, D., Ashcroft, D. M., Gask, L., Doran, T. & Reilly, S., 16 Dec 2015

Article in BMJ Open

Publication details

Journal BMJ Open
Date Published - 16 Dec 2015
Volume 5
Number of pages 11
Pages (from-to) e008650
Original language English

Abstract

OBJECTIVES: Little is known about service utilisation by patients with severe mental illness (SMI) in UK primary care. We examined their consultation rate patterns and whether they were impacted by the introduction of the Quality and Outcomes Framework (QOF), in 2004.

DESIGN: Retrospective cohort study using individual patient data collected from 2000 to 2012.

SETTING: 627 general practices contributing to the Clinical Practice Research Datalink, a large UK primary care database.

PARTICIPANTS: SMI cases (346,551) matched to 5 individuals without SMI (1,732,755) on age, gender and general practice.

OUTCOME MEASURES: Consultation rates were calculated for both groups, across 3 types: face-to-face (primary outcome), telephone and other (not only consultations but including administrative tasks). Poisson regression analyses were used to identify predictors of consultation rates and calculate adjusted consultation rates. Interrupted time-series analysis was used to quantify the effect of the QOF.

RESULTS: Over the study period, face-to-face consultations in primary care remained relatively stable in the matched control group (between 4.5 and 4.9 per annum) but increased for people with SMI (8.8-10.9). Women and older patients consulted more frequently in the SMI and the matched control groups, across all 3 consultation types. Following the introduction of the QOF, there was an increase in the annual trend of face-to-face consultation for people with SMI (average increase of 0.19 consultations per patient per year, 95% CI 0.02 to 0.36), which was not observed for the control group (estimates across groups statistically different, p=0.022).

CONCLUSIONS: The introduction of the QOF was associated with increases in the frequency of monitoring and in the average number of reported comorbidities for patients with SMI. This suggests that the QOF scheme successfully incentivised practices to improve their monitoring of the mental and physical health of this group of patients.

Inequalities in physical comorbidity: a longitudinal comparative cohort study of people with severe mental illness in the UK

Reilly, S., Olier, I., Planner, C., Doran, T., Reeves, D., Ashcroft, D. M., Gask, L. & Kontopantelis, E., 15 Dec 2015

Article in BMJ Open

Publication details

Journal BMJ Open
Date Published - 15 Dec 2015
Issue number 12
Volume 5
Number of pages 14
Original language English

Abstract

OBJECTIVES: Little is known about the prevalence of comorbidity rates in people with severe mental illness (SMI) in UK primary care. We calculated the prevalence of SMI by UK country, English region and deprivation quintile, antipsychotic and antidepressant medication prescription rates for people with SMI, and prevalence rates of common comorbidities in people with SMI compared with people without SMI.

DESIGN: Retrospective cohort study from 2000 to 2012.

SETTING: 627 general practices contributing to the Clinical Practice Research Datalink, a UK primary care database.

PARTICIPANTS: Each identified case (346,551) was matched for age, sex and general practice with 5 randomly selected control cases (1,732,755) with no diagnosis of SMI in each yearly time point.

OUTCOME MEASURES: Prevalence rates were calculated for 16 conditions.

RESULTS: SMI rates were highest in Scotland and in more deprived areas. Rates increased in England, Wales and Northern Ireland over time, with the largest increase in Northern Ireland (0.48% in 2000/2001 to 0.69% in 2011/2012). Annual prevalence rates of all conditions were higher in people with SMI compared with those without SMI. The discrepancy between the prevalence of those with and without SMI increased over time for most conditions. A greater increase in the mean number of additional conditions was observed in the SMI population over the study period (0.6 in 2000/2001 to 1.0 in 2011/2012) compared with those without SMI (0.5 in 2000/2001 to 0.6 in 2011/2012). For both groups, most conditions were more prevalent in more deprived areas, whereas for the SMI group conditions such as hypothyroidism, chronic kidney disease and cancer were more prevalent in more affluent areas.

CONCLUSIONS: Our findings highlight the health inequalities faced by people with SMI. The provision of appropriate timely health prevention, promotion and monitoring activities to reduce these health inequalities are needed, especially in deprived areas.

Impact of the Prevalence of Concordant and Discordant Conditions on the Quality of Diabetes Care in Family Practices in England

Ricci-Cabello, I., Stevens, S., Kontopantelis, E., Dalton, A. R. H., Griffiths, R. I., Campbell, J. L., Doran, T. & Valderas, J. M., Nov 2015

Article in Annals of Family Medicine

Publication details

Journal Annals of Family Medicine
Date Published - Nov 2015
Issue number 6
Volume 13
Number of pages 9
Pages (from-to) 514-22
Original language English

Abstract

PURPOSE: The purpose of this study was to examine the association between the prevalence of both diabetes-concordant and diabetes-discordant conditions and the quality of diabetes care at the family practice level in England. We hypothesized that the prevalence of concordant (or discordant) conditions would be associated with better (or worse) quality of diabetes care.

METHODS: We conducted a cross-sectional study using practice-level data (7,884 practices). We estimated the practice-level prevalence of diabetes and 15 other chronic conditions, which were classified as diabetes concordant (ie, with the same pathophysiologic risk profile and therefore more likely to be part of the same management plan) or diabetes discordant (ie, not directly related in either their pathogenesis or management). We measured quality of diabetes care with diabetes-specific indicators (8 processes and 3 intermediate outcomes of care). We used linear regression models to quantify the effect of the prevalence of the conditions on aggregate achievement rate for quality of diabetes care.

RESULTS: Consistent with the proposed model, the prevalence rates of 4 of 7 concordant conditions (obesity, chronic kidney disease, atrial fibrillation, heart failure) were positively associated with quality of diabetes care. Similarly, negative associations were observed as predicted for 2 of the 8 discordant conditions (epilepsy, mental health). Observations for other concordant and discordant conditions did not match predictions in the hypothesized model.

CONCLUSIONS: The quality of diabetes care provided in English family practices is associated with the prevalence of other major chronic conditions at the practice level. The nature and direction of the observed associations cannot be fully explained by the concordant-discordant model.

Publication details

Journal PLoS ONE
Date Published - 29 Sep 2015
Issue number 9
Volume 10
Original language English

Abstract

Objective Chile, a South American country recently defined as a high-income nation, carried out a major healthcare system reform from 2005 onwards that aimed at reducing socioeconomic inequality in health. This study aimed to estimate income-related inequality in self-reported health status (SRHS) in 2000 and 2013, before and after the reform, for the entire adult Chilean population. Methods Using data on equivalized household income and adult SRHS from the 2000 and 2013 CASEN surveys (independent samples of 101 046 and 172 330 adult participants, respectively) we estimated Erreygers concentration indices (CIs) for above average SRHS for both years. We also decomposed the contribution of both "legitimate" standardizing variables (age and sex) and "illegitimate" variables (income, education, occupation, ethnicity, urban/rural, marital status, number of people living in the household, and healthcare entitlement). Results There was a significant concentration of above average SRHS favoring richer people in Chile in both years, which was less pronounced in 2013 than 2000 (Erreygers corrected CI 0.165 [Standard Error, SE 0.007] in 2000 and 0.047 [SE 0.008] in 2013). To help interpret the magnitude of this decline, adults in the richest fifth of households were 33% more likely than those in the poorest fifth to report above-average health in 2000, falling to 11% in 2013. In 2013, the contribution of illegitimate factors to income-related inequality in SRHS remained higher than the contribution of legitimate factors. Conclusions Income-related inequality in SRHS in Chile has fallen after the equity-based healthcare reform. Further research is needed to ascertain how far this fall in health inequality can be attributed to the 2005 healthcare reform as opposed to economic growth and other determinants of health that changed during the period.

Waiting time prioritisation: evidence from England

Cookson, R. A., Gutacker, N. & Siciliani, L., Sep 2015, York, UK: Centre for Health Economics, University of York, p. 1-26, 26 p. (CHE Research Paper; no. 114).

Research output: Working paperDiscussion paper

Publication details

Date Published - Sep 2015
Publisher Centre for Health Economics, University of York
Place of Publication York, UK
Number of pages 26
Original language English

Publication series

Name CHE Research Paper
Publisher Centre for Health Economics
No. 114

Abstract

A number of OECD countries have introduced waiting time prioritisation policies which give explicit priority to severely ill patients with high marginal disutility of waiting. There is however little empirical evidence on how patients are actually prioritised. We exploit a unique opportunity to investigate this issue using a large national dataset with accurate measures of severity on over 200,000 patients. We link data from a national patient-reported outcome measures survey to administrative data on all patients waiting for a publicly funded hip and knee replacement in England during the years 2009-12. We find that patients suffering the most severe pain and immobility have shorter waits than those suffering the least, by about 29% for hip replacement and 9% for knee replacement, and that the association is approximately linear. These differentials are more closely associated with pain than immobility, and are larger in hospitals with longer average waiting times.

Publication details

Journal Health Economics
Date Accepted/In press - 30 Apr 2015
Date E-pub ahead of print - 22 May 2015
Date Published (current) - Aug 2015
Issue number 8
Volume 24
Number of pages 6
Pages (from-to) 907-912
Early online date 22/05/15
Original language English

Abstract

The English National Health Service is moving towards providing comprehensive 7-day hospital services in response to higher death rates for emergency weekend admissions. Using Hospital Episode Statistics between 1st April 2010 and 31st March 2011 linked to all-cause mortality within 30 days of admission, we estimate the number of excess deaths and the loss in quality-adjusted life years associated with emergency weekend admissions. The crude 30-day mortality rate was 3.70% for weekday admissions and 4.05% for weekend admissions. The excess weekend death rate equates to 4355 (risk adjusted 5353) additional deaths each year. The health gain of avoiding these deaths would be 29 727-36 539 quality-adjusted life years per year. The estimated cost of implementing 7-day services is £1.07-£1.43 bn, which exceeds by £339-£831 m the maximum spend based on the National Institute for Health and Care Excellence threshold of £595 m-£731 m. There is as yet no clear evidence that 7-day services will reduce weekend deaths or can be achieved without increasing weekday deaths. The planned cost of implementing 7-day services greatly exceeds the maximum amount that the National Health Service should spend on eradicating the weekend effect based on current evidence. Policy makers and service providers should focus on identifying specific service extensions for which cost-effectiveness can be demonstrated. Copyright © 2015 John Wiley & Sons, Ltd.

Bibliographical note

Copyright © 2015 John Wiley & Sons, Ltd.

Publication details

Journal Economics and Philosophy
Date Published - 1 Jul 2015
Issue number 2
Volume 31
Number of pages 9
Pages (from-to) 312-320
Original language English

Abstract

What happens when you ask a bunch of philosophers for advice about
a policy problem? They will start by asking you to imagine all sorts
of absurdly unrealistic hypothetical dilemmas, and conclude by telling
you: ‘its all very, very complicated!’ That is why philosophers are rarely
asked for advice about policy problems. Sometimes, however, policy
problems really are more complicated than policy makers and their
advisers realize, in important ways they need to understand. This edited
collection convincingly demonstrates that health inequality is a case in
point. My review starts with a chapter-by-chapter summary, and then
picks out three cross-cutting issues that I believe will repay careful
consideration by anyone involved in studying health inequality or
advising policy makers.

Publication details

Journal Value in Health
Date E-pub ahead of print - 18 Apr 2015
Date Published (current) - Jul 2015
Issue number 5
Volume 18
Number of pages 8
Pages (from-to) 655-662
Early online date 18/04/15
Original language English

Abstract

OBJECTIVE: To model the social distribution of quality-adjusted life expectancy (QALE) in England by combining survey data on health-related quality of life with administrative data on mortality.

METHODS: Health Survey for England data sets for 2010, 2011, and 2012 were pooled (n = 35,062) and used to model health-related quality of life as a function of sex, age, and socioeconomic status (SES). Office for National Statistics mortality rates were used to construct life tables for age-sex-SES groups. These quality-of-life and length-of-life estimates were then combined to predict QALE as a function of these characteristics. Missing data were imputed, and Monte-Carlo simulation was used to estimate standard errors. Sensitivity analysis was conducted to explore alternative regression models and measures of SES.

RESULTS: Socioeconomic inequality in QALE at birth was estimated at 11.87 quality-adjusted life-years (QALYs), with a sex difference of 1 QALY. When the socioeconomic-sex subgroups are ranked by QALE, a differential of 10.97 QALYs is found between the most and least healthy quintile groups. This differential can be broken down into a life expectancy difference of 7.28 years and a quality-of-life adjustment of 3.69 years.

CONCLUSIONS: The methods proposed in this article refine simple binary quality-adjustment measures such as the widely used disability-free life expectancy, providing a more accurate picture of overall health inequality in society than has hitherto been available. The predictions also lend themselves well to the task of evaluating the health inequality impact of interventions in the context of cost-effectiveness analysis.

Bibliographical note

Copyright © 2015 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

Socioeconomic inequality of access to healthcare: Does patients’ choice explain the gradient?Evidence from the English NHS

Moscelli, G., Siciliani, L., Gutacker, N. & Cookson, R. A., Jun 2015, York, UK: Centre for Health Economics, University of York, p. 1-43, 43 p. (CHE Research Paper; no. 112).

Research output: Working paperDiscussion paper

Publication details

Date Published - Jun 2015
Publisher Centre for Health Economics, University of York
Place of Publication York, UK
Number of pages 43
Original language English

Publication series

Name CHE Research Paper
Publisher Centre for Health Economics, University of York
No. 112

Abstract

Equity of access is a key policy objective in publicly-funded healthcare systems. Using data on patients undergoing non-emergency heart revascularization procedures in the English National Health Service, we find evidence of significant differences in waiting times within public hospitals between patients with different socioeconomic status (up to 35% difference between the most and least deprived population quintiles). We employ selection models to test whether such differences are explained by patients exercising choice over hospital or type of treatment. Selection bias due to choice has a limited effect on the gradient suggesting the presence of substantial inequities within the public system.

Publication details

Journal Health Economics
Date E-pub ahead of print - 2 May 2014
Date Published (current) - Jun 2015
Issue number 6
Volume 24
Number of pages 13
Pages (from-to) 742-754
Early online date 2/05/14
Original language English

Abstract

This paper presents an application of a new methodological framework for undertaking distributional cost-effectiveness analysis to combine the objectives of maximising health and minimising unfair variation in health when evaluating population health interventions. The National Health Service bowel cancer screening programme introduced in 2006 is expected to improve population health on average and to worsen population health inequalities associated with deprivation and ethnicity - a classic case of 'intervention-generated inequality'. We demonstrate the distributional cost-effectiveness analysis framework by examining two redesign options for the bowel cancer screening programme: (i) the introduction of an enhanced targeted reminder aimed at increasing screening uptake in deprived and ethnically diverse neighbourhoods and (ii) the introduction of a basic universal reminder aimed at increasing screening uptake across the whole population. Our analysis indicates that the universal reminder is the strategy that maximises population health, while the targeted reminder is the screening strategy that minimises unfair variation in health. The framework is used to demonstrate how these two objectives can be traded off against each other, and how alternative social value judgements influence the assessment of which strategy is best, including judgements about which dimensions of health variation are considered unfair and judgements about societal levels of inequality aversion.

Bibliographical note

© 2014 The Authors. Health Economics published by John Wiley & Sons Ltd.

Publication details

Journal BMC Family Practice
Date Accepted/In press - 7 May 2015
Date Published (current) - 14 May 2015
Issue number 61
Volume 16
Number of pages 13
Original language English

Abstract

BACKGROUND: Socioeconomic deprivation is associated with inequalities in health care and outcomes. Despite concerns that the Quality and Outcomes Framework pay-for-performance scheme in the UK would exacerbate inequalities in primary care delivery, gaps closed over time. Local schemes were promoted as a means of improving clinical engagement by addressing local health priorities. We evaluated equity in achievement of target indicators and practice income for one local scheme.

METHODS: We undertook a longitudinal survey over four years of routinely recorded clinical data for all 83 primary care practices. Sixteen indicators were developed that covered five local clinical and public health priorities: weight management; alcohol consumption; learning disabilities; osteoporosis; and chlamydia screening. Clinical indicators were logit transformed from a percentage achievement scale and modelled allowing for clustering of repeated measures within practices. This enabled our study of target achievements over time with respect to deprivation. Practice income was also explored.

RESULTS: Higher practice deprivation was associated with poorer performance for five indicators: alcohol use registration (OR 0.97; 95 % confidence interval 0.96,0.99); recorded chlamydia test result (OR 0.97; 0.94,0.99); osteoporosis registration (OR 0.98; 0.97,0.99); registration of repeat prednisolone prescription (OR 0.98; 0.96,0.99); and prednisolone registration with record of dual energy X-ray absorptiometry (DEXA) scan/referral (OR 0.92; 0.86,0.97); practices in deprived areas performed better for one indicator (registration of osteoporotic fragility fracture (OR 1.26; 1.04,1.51). The deprivation-achievement gap widened for one indicator (registered females aged 65-74 with a fracture referred for a DEXA scan; OR 0.97; 0.95,0.99). Two other indicators indicated a similar trend over two years before being withdrawn (registration of fragility fracture and over-75 s with a fragility fracture assessed and treated for osteoporosis risk). For one indicator the deprivation-achievement gap reduced over time (repeat prednisolone prescription (OR 1.01; 1.01,1.01). Larger practices and those serving more affluent areas earned more income per patient than smaller practices and those serving more deprived areas (t = -3.99; p =0.0001).

CONCLUSIONS: Any gaps in achievement between practices were modest but mostly sustained or widened over the duration of the scheme. Given that financial rewards may not reflect the amount of work undertaken by practices serving more deprived patients, future pay-for-performance schemes also need to address fairness of rewards in relation to workload.

The appraisal of public health interventions: the use of theory

Threlfall, A. G., Meah, S., Fischer, A. J., Cookson, R., Rutter, H. & Kelly, M. P., 1 Mar 2015

Article in Journal of public health (Oxford, England)

Publication details

Journal Journal of public health (Oxford, England)
Date Published - 1 Mar 2015
Issue number 1
Volume 37
Number of pages 6
Pages (from-to) 166-171
Original language English

Abstract

BACKGROUND: Public health decision-making is hampered by inappropriate adherence to underpowered randomized controlled trials (RCTs) which give inconclusive results and lead to decision-makers being loath to recommend interventions with strong theoretical and observational support.

METHODS: We outline situations in which robust decisions about health interventions can be made without trial evidence. We present a new approach in which theory, causal models and past observations are given proper regard in the decision-making process.

RESULTS: Using our approach, we provide examples where the use of causal theories and observations in areas, such as salt reduction, smoking cessation and gardening to improve mental health, is sufficient for deciding that such interventions are effective for improving health without needing the support of underpowered RCTs. Particularly where RCT evidence is inconclusive, our approach may provide similar aggregate health outcomes for society for vastly lower cost.

CONCLUSIONS: When knowledge and theoretical understanding are unable sufficiently to reduce doubt about the direction of effect from an intervention, decisions should be made using evidence-based medicine approaches. There are, however, many cases where the combination of robust theory, causal understanding and observation are able to provide sufficient evidence of the direction of effect from an intervention that current practice should be altered.

Glucose, blood pressure and cholesterol levels and their relationships to clinical outcomes in type 2 diabetes: a retrospective cohort study

Kontopantelis, E., Springate, D. A., Reeves, D., Ashcroft, D. M., Rutter, M., Buchan, I. & Doran, T., Mar 2015

Article in DIABETOLOGIA

Publication details

Journal DIABETOLOGIA
Date Accepted/In press - 25 Nov 2014
Date Published (current) - Mar 2015
Issue number 3
Volume 58
Number of pages 14
Pages (from-to) 505-518
Original language English

Abstract

AIMS/HYPOTHESIS: We aimed to describe the shape of observed relationships between risk factor levels and clinically important outcomes in type 2 diabetes after adjusting for multiple confounders.

METHODS: We used retrospective longitudinal data on 246,544 adults with type 2 diabetes from 600 practices in the Clinical Practice Research Datalink, 2006-2012. Proportional hazards regression models quantified the risks of mortality and microvascular or macrovascular events associated with four modifiable biological variables (HbA1c, systolic BP, diastolic BP and total cholesterol), while controlling for important patient and practice covariates.

RESULTS: U-shaped relationships were observed between all-cause mortality and levels of the four biometric risk factors. Lowest risks were associated with HbA1c 7.25-7.75% (56-61 mmol/mol), total cholesterol 3.5-4.5 mmol/l, systolic BP 135-145 mmHg and diastolic BP 82.5-87.5 mmHg. Coronary and stroke mortality related to the four risk factors in a positive, curvilinear way, with the exception of systolic BP, which related to deaths in a U-shape. Macrovascular events showed a positive and curvilinear relationship with HbA1c but a U-shaped relationship with total cholesterol and systolic BP. Microvascular events related to the four risk factors in a curvilinear way: positive for HbA1c and systolic BP but negative for cholesterol and diastolic BP.

CONCLUSIONS/INTERPRETATION: We identified several relationships that support a call for major changes to clinical practice. Most importantly, our results support trial data indicating that normalisation of glucose and BP can lead to poorer outcomes. This makes a strong case for target ranges for these risk factors rather than target levels.

Publication details

Journal Health Economics, Policy and Law
Date Published - 9 Feb 2015
Issue number 3
Volume 10
Number of pages 7
Pages (from-to) 351-356
Original language English

Abstract

Financial and reputational incentives are increasingly common components in strategies to performance manage the medical profession. Judging the impacts of incentives is challenging, however, and the science of framework design remains in its infancy. Oliver's taxonomy therefore offers a useful and timely guide to the approaches that are most likely to be successful (and unsuccessful) in the field of health care. The use of incentives to date has focused on process measures and a narrow range of outcomes, a pragmatic approach that has produced some substantial quality gains within the constraints of existing health care systems. Improvement of specific technical aspects of quality may, however, have been achieved at the expense of trust, cooperation and benevolence. Deficits in these indispensible virtues will undermine any attempt to performance manage the medical and allied professions.

Publication details

Journal European Journal of Public Health
Date Published - 1 Feb 2015
Issue number Suppl 1
Volume 25
Number of pages 7
Pages (from-to) 21-27
Original language English

Abstract

BACKGROUND: Cross-country comparisons of socioeconomic equity in health care typically use sample survey data on general services such as physician visits. This study uses comprehensive administrative data on a specific service: hip replacement.

METHODS: We analyse 651 652 publicly funded hip replacements, excluding fractures and accidents, in adults over 35 in Denmark, England, Portugal and Spain from 2002 to 2009. Sub-national administrative areas are split into socioeconomic quintile groups comprising approximately one-fifth of the national population. Area-level Poisson regression with Huber-White standard errors is used to calculate age-sex standardised hip replacement rates by quintile group, together with gaps and ratios between richest and poorest groups (Q5 and Q1) and the middle group (Q3).

RESULTS: We find pro-rich-area inequality in England (2009 Q5/Q1 ratio 1.35 [CI 1.25-1.45]) and Spain (2009 Q5/Q1 ratio 1.43 [CI 1.17-1.70]), pro-poor-area inequality in Portugal (2009 Q5/Q1 ratio 0.67 [CI 0.50-0.83]) and no significant inequality in Denmark. Pro-rich-area inequality increased over time in England and Spain but not significantly. Within-country differences between socioeconomic quintile groups are smaller than between-country differences in general population averages: hip replacement rates are substantially lower in Portugal and Spain (8.6 and 7.4 per 10 000 in 2009) than England and Denmark (20.2 and 27.8 per 10 000 in 2009).

CONCLUSION: Despite limitations regarding individual-level inequality and area heterogeneity, analysis of area-level data on publicly funded hospital activity can provide useful cross-country comparisons and longitudinal monitoring of socioeconomic inequality in specific health services. Although this kind of analysis cannot provide definitive answers, it can raise important questions for decision makers.

Bibliographical note

© The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

Publication details

Journal European Journal of Public Health
Date Published - Feb 2015
Issue number Suppl 1
Volume 25
Number of pages 6
Pages (from-to) 15-20
Original language English

Abstract

BACKGROUND: The Charlson and Elixhauser comorbidity measures are commonly used methods to account for patient comorbidities in hospital-level comparisons of clinical quality using administrative data. Both have been validated in North America, but there is less evidence of their performance in Europe and in pooled cross-country data, which are features of the European Collaboration for Healthcare Optimization (ECHO) project. This study compares the performance of the Charlson/Deyo and Elixhauser comorbidity measures in predicting in-hospital mortality using data from five European countries in three inpatient groups.

METHODS: Administrative data is used from five countries in 2008-2009 for three indicators commonly used in hospital quality comparisons: mortality rates following acute myocardial infarction, coronary artery bypass graft surgery and stroke. Logistic regression models are constructed to predict mortality controlling for age, gender and the relevant comorbidity measure. Model discrimination is evaluated using c-statistics. Model calibration is evaluated using calibration slopes. Overall goodness-of-fit is evaluated using Nagelkerke's R(2) and the Akaike information criterion. All models are validated internally by using bootstrapping and externally by using the 2009 model parameters to predict mortality in 2008.

RESULTS: The Elixhauser measure has better overall predictive ability in terms of discrimination and goodness-of-fit than the Charlson/Deyo measure or the age-sex only model. There is no clear difference in model calibration. These findings are robust to the choice of country, to pooling all five countries and to internal and external validation.

CONCLUSIONS: The Elixhauser list contains more comorbidities, which may enable it to achieve better discrimination than the Charlson measure. Both measures achieve similar calibration, so for the purpose of ECHO we judged the Elixhauser measure to be preferable.

Bibliographical note

© The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

Publication details

Journal European Journal of Public Health
Date Published - Feb 2015
Volume 25 Suppl 1
Number of pages 7
Pages (from-to) 28-34
Original language English

Abstract

OBJECTIVE: To assess the feasibility, strengths and weaknesses of using administrative data to compare hospital performance across countries, using mortality after coronary artery bypass graft (CABG) surgery as an illustrative example.

METHODS: Country specific and pooled models using individual-level data and logistic regression methods assess individual hospital performance using funnel plots accounting for multiple testing. Outcomes are adjusted for age, sex, comorbidities and indicators of patient severity. Data includes patients from all publicly funded hospitals delivering CABG surgery in England and Spain. Inpatient hospital-level standardized mortality rates within 30 days of CABG surgery are calculated for 83 999 CABG patients between 2007 and 2009.

RESULTS: Unadjusted national mortality rates are 5% in Spain and 2.3% in England. Country-specific models identified similar patterns of excess mortality 'alerts' and 'alarms' in hospitals in Spain or England. Pooling data from both countries identifies larger numbers of alerts and alarms in Spanish hospitals, and risk-adjustment increased the already large national mortality difference. This was reduced but not eliminated by accounting for lower volume in Spanish hospitals.

CONCLUSION: Cross-national comparisons potentially add value by providing international performance benchmarks. Hospital-level analysis across countries can illuminate differences in hospital performance, which might not be identified using country-specific data or incomplete registry data, and can test hypotheses that may explain national differences. Difficulties of making data comparable between countries, however, compound the usual within-country measurement problems.

Bibliographical note

© The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

Cost analysis of the legal declaratory relief requirement for withdrawing Clinically Assisted Nutrition and Hydration (CANH) from patients in the Permanent Vegetative State (PVS) in England and Wales

Formby, A. P., Cookson, R. A. & Halliday, S., Feb 2015, York, UK: Centre for Health Economics, University of York, 15 p. (CHE Research Paper; no. 108).

Research output: Working paperDiscussion paper

Publication details

Date Published - Feb 2015
Publisher Centre for Health Economics, University of York
Place of Publication York, UK
Number of pages 15
Original language English

Publication series

Name CHE Research Paper
Publisher Centre for Health Economics, University of York
No. 108

Abstract

This paper estimates the NHS cost per case of the legal declaratory relief process in relation to withdrawal of clinically assisted nutrition and hydration (CANH) from patients diagnosed as being in a permanent vegetative state (PVS), in relatively ‘straightforward’ cases where family and clinicians agree this is in the best interests of the patient. The PVS declaratory relief process lasts, on average, nine months and costs the NHS about £122,000 per case. This comprises about £53,000 in legal costs and about £69,000 in on-going care costs which we estimate cost just over £7,500 per month.

Bibliographical note

© Adam Formby, Richard Cookson, Simon Halliday

Publication details

Journal Medical Law Review
Date E-pub ahead of print - 6 Jul 2015
Date Published (current) - 2015
Number of pages 32
Early online date 6/07/15
Original language English

Abstract

In this article we reassess the court’s role in the withdrawal of clinically assisted nutrition and hydration from patients in the permanent vegetative state, focusing on cases where health care teams and families agree that such in the patient’s best interest. As well as including a doctrinal analysis, the reassessment draws on empirical data from the families of patients with prolonged disorders of consciousness, on economic data about the costs of the declaratory relief process to the NHS, and on comparative legal data about the comparable procedural requirements in other jurisdictions. We show that, following the decision in the Bland case, the role of the Court of Protection is now restricted to the direct supervision of the PVS diagnosis as a matter of proof. We argue that this is an inappropriate role for the court, and one that sits in some tension with the best interests of patients. The blanket requirement of declaratory relief for all cases is economically expensive for the NHS and thus deprives other NHS patients from health care. We demonstrate that many of the ancillary benefits currently offered by declaratory relief could be achieved by other means. Ultimately, we suggest that reform to the declaratory relief requirement is called for.

Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study

Kontopantelis, E., Springate, D. A., Ashworth, M., Webb, R. T., Buchan, I. E. & Doran, T., 2015

Article in BMJ

Publication details

Journal BMJ
Date Accepted/In press - 13 Jan 2015
Date Published (current) - 2015
Volume 350
Number of pages 19
Original language English

Abstract

OBJECTIVES: To quantify the relationship between a national primary care pay-for-performance programme, the UK's Quality and Outcomes Framework (QOF), and all-cause and cause-specific premature mortality linked closely with conditions included in the framework.

DESIGN: Longitudinal spatial study, at the level of the "lower layer super output area" (LSOA).

SETTING: 32482 LSOAs (neighbourhoods of 1500 people on average), covering the whole population of England (approximately 53.5 million), from 2007 to 2012.

PARTICIPANTS: 8647 English general practices participating in the QOF for at least one year of the study period, including over 99% of patients registered with primary care.

INTERVENTION: National pay-for-performance programme incentivising performance on over 100 quality-of-care indicators.

MAIN OUTCOME MEASURES: All-cause and cause-specific mortality rates for six chronic conditions: diabetes, heart failure, hypertension, ischaemic heart disease, stroke, and chronic kidney disease. We used multiple linear regressions to investigate the relationship between spatially estimated recorded quality of care and mortality.

RESULTS: All-cause and cause-specific mortality rates declined over the study period. Higher mortality was associated with greater area deprivation, urban location, and higher proportion of a non-white population. In general, there was no significant relationship between practice performance on quality indicators included in the QOF and all-cause or cause-specific mortality rates in the practice locality.

CONCLUSIONS: Higher reported achievement of activities incentivised under a major, nationwide pay-for-performance programme did not seem to result in reduced incidence of premature death in the population.

Bibliographical note

© Kontopantelis et al 2015.

Publication details

Journal Journal of Medical Ethics
Date Published - 2015
Issue number 1
Volume 41
Number of pages 4
Pages (from-to) 99-102
Original language English

Abstract

When thinking about population level healthcare priority setting decisions, such as those made by the National Institute for Health and Care Excellence, good medical ethics requires attention to three main principles of health justice: (1) cost-effectiveness, an aspect of beneficence, (2) non-discrimination, and (3) priority to the worse off in terms of both current severity of illness and lifetime health. Applying these principles requires consideration of the identified patients who benefit from decisions and the unidentified patients who bear the opportunity costs.

Publication details

Journal BMJ Open
Date Accepted/In press - 2015
Date Published (current) - 2015
Issue number 4
Volume 5
Original language English

Abstract

OBJECTIVES: To conduct a fully independent, external validation of a research study based on one electronic health record database using a different database sampling from the same population.

DESIGN: Retrospective cohort analysis of β-blocker therapy and all-cause mortality in patients with cancer.

SETTING: Two UK national primary care databases (PCDs): the Clinical Practice Research Datalink (CPRD) and Doctors' Independent Network (DIN).

PARTICIPANTS: CPRD data for 11,302 patients with cancer compared with published results from DIN for 3462 patients; study period January 1997 to December 2006.

PRIMARY AND SECONDARY OUTCOME MEASURES: All-cause mortality: overall; by treatment subgroup (β-blockers only, β-blockers plus other blood pressure lowering medicines (BPLM), other BPLMs only); and by cancer site.

RESULTS: Using CPRD, β-blocker use was not associated with mortality (HR=1.03, 95% CI 0.93 to 1.14, vs patients prescribed other BPLMs only), but DIN β-blocker users had significantly higher mortality (HR=1.18, 95% CI 1.04 to 1.33). However, these HRs were not statistically different (p=0.063), but did differ for patients on β-blockers alone (CPRD=0.94, 95% CI 0.82 to 1.07; DIN=1.37, 95% CI 1.16 to 1.61; p<0.001). Results for individual cancer sites differed by study, but only significantly for prostate and pancreas cancers. Results were robust under sensitivity analyses, but we could not be certain that mortality was identically defined in both databases.

CONCLUSIONS: We found a complex pattern of similarities and differences between databases. Overall treatment effect estimates were not statistically different, adding to a growing body of evidence that different UK PCDs produce comparable effect estimates. However, individually the two studies lead to different conclusions regarding the safety of β-blockers and some subgroup effects differed significantly. Single studies using even internally well-validated databases do not guarantee generalisable results, especially for subgroups, and confirmatory studies using at least one other independent data source are strongly recommended.

Bibliographical note

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

2014

Publication details

Journal British medical journal
Date Published - 11 Nov 2014
Volume 349
Number of pages 8
Original language English

Abstract

Objective: To estimate the impact of a national primary care pay for performance scheme, the Quality and Outcomes Framework in England, on emergency hospital admissions for ambulatory care sensitive conditions (ACSCs).
Design: Controlled longitudinal study.
Setting: English National Health Service between 1998/99 and 2010/11.
Participants: Populations registered with each of 6975 family practices in England.
Main outcome measures: Year specific differences between trend adjusted emergency hospital admission rates for incentivised ACSCs before and after the introduction of the Quality and Outcomes Framework scheme and two comparators: non-incentivised ACSCs and non-ACSCs.
Results: Incentivised ACSC admissions showed a relative reduction of 2.7% (95% confidence interval 1.6% to 3.8%) in the first year of the Quality and Outcomes Framework compared with ACSCs that were not incentivised. This increased to a relative reduction of 8.0% (6.9% to 9.1%) in 2010/11. Compared with conditions that are not regarded as being influenced by the quality of ambulatory care (non-ACSCs), incentivised ACSCs also showed a relative reduction in rates of emergency admissions of 2.8% (2.0% to 3.6%) in the first year increasing to 10.9% (10.1% to 11.7%) by 2010/11.
Conclusions: The introduction of a major national pay for performance scheme for primary care in England was associated with a decrease in emergency admissions for incentivised conditions compared with conditions that were not incentivised. Contemporaneous health service changes seem unlikely to have caused the sharp change in the trajectory of incentivised ACSC admissions immediately after the introduction of the Quality and Outcomes Framework. The decrease seems larger than would be expected from the changes in the process measures that were incentivised, suggesting that the pay for performance scheme may have had impacts on quality of care beyond the directly incentivised activities.

Bibliographical note

© Harrison et al 2014.

Publication details

Journal BMC Family Practice
Date Published - 25 Oct 2014
Issue number 168
Volume 15
Number of pages 11
Original language English

Abstract

BACKGROUND: A range of policy initiatives have addressed inequalities in healthcare and health outcomes. Local pay-for-performance schemes for primary care have been advocated as means of enhancing clinical ownership of the quality agenda and better targeting local need compared with national schemes such as the UK Quality and Outcomes Framework (QOF). We investigated whether professionals' experience of a local scheme in one English National Health Service (NHS) former primary care trust (PCT) differed from that of the national QOF in relation to the goal of reducing inequalities.

METHODS: We conducted retrospective semi-structured interviews with primary care professionals implementing the scheme and those involved in its development. We purposively sampled practices with varying levels of population socio-economic deprivation and achievement. Interviews explored perceptions of the scheme and indicators, likely mechanisms of influence on practice, perceived benefits and harms, and how future schemes could be improved. We used a framework approach to analysis.

RESULTS: Thirty-eight professionals from 16 general practices and six professionals involved in developing local indicators participated. Our findings cover four themes: ownership, credibility of the indicators, influences on behaviour, and exacerbated tensions. We found little evidence that the scheme engendered any distinctive sense of ownership or experiences different from the national scheme. Although the indicators and their evidence base were seldom actively questioned, doubts were expressed about their focus on health promotion given that eventual benefits relied upon patient action and availability of local resources. Whilst practices serving more affluent populations reported status and patient benefit as motivators for participating in the scheme, those serving more deprived populations highlighted financial reward. The scheme exacerbated tensions between patient and professional consultation agendas, general practitioners benefitting directly from incentives and nurses who did much of the work, and practices serving more and less affluent populations which faced different challenges in achieving targets.

CONCLUSIONS: The contentious nature of pay-for-performance was not necessarily reduced by local adaptation. Those developing future schemes should consider differential rewards and supportive resources for practices serving more deprived populations, and employing a wider range of levers to promote professional understanding and ownership of indicators.

Guidance on priority setting in health care (GPS-Health): The inclusion of equity criteria not captured by cost-effectiveness analysis

Norheim, O. F., Baltussen, R., Johri, M., Chisholm, D., Nord, E., Brock, D. W., Carlsson, P., Cookson, R., Daniels, N., Danis, M., Fleurbaey, M., Johansson, K. A., Kapiriri, L., Littlejohns, P., Mbeeli, T., Rao, K. D., Edejer, T. T. & Wikler, D., 29 Aug 2014

Article in Cost Effectiveness and Resource Allocation

Publication details

Journal Cost Effectiveness and Resource Allocation
Date Published - 29 Aug 2014
Issue number 1
Volume 12
Original language English

Abstract

This Guidance for Priority Setting in Health Care (GPS-Health), initiated by the World Health Organization, offers a comprehensive map of equity criteria that are relevant to health care priority setting and should be considered in addition to cost-effectiveness analysis. The guidance, in the form of a checklist, is especially targeted at decision makers who set priorities at national and sub-national levels, and those who interpret findings from cost-effectiveness analysis. It is also targeted at researchers conducting cost-effectiveness analysis to improve reporting of their results in the light of these other criteria. The guidance was develop through a series of expert consultation meetings and involved three steps: i) methods and normative concepts were identified through a systematic review; ii) the review findings were critically assessed in the expert consultation meetings which resulted in a draft checklist of normative criteria; iii) the checklist was validated though an extensive hearing process with input from a range of relevant stakeholders. The GPS-Health incorporates criteria related to the disease an intervention targets (severity of disease, capacity to benefit, and past health loss); characteristics of social groups an intervention targets (socioeconomic status, area of living, gender; race, ethnicity, religion and sexual orientation); and non-health consequences of an intervention (financial protection, economic productivity, and care for others).

Bibliographical note

© Authors 2015

Incorporating Health Inequality Impacts into Cost-Effectiveness Analysis

Asaria, M., Cookson, R. A. & Griffin, S., 28 Apr 2014, Encyclopedia of Health Economics. Culyer, A. (ed.). 1 ed. San Diego: Elsevier, Vol. 2. p. 22-26

Research output: Chapter in Book/Report/Conference proceedingChapter

Publication details

Title of host publication Encyclopedia of Health Economics
Date Published - 28 Apr 2014
Pages 22-26
Publisher Elsevier
Place of Publication San Diego
Editors Anthony Culyer
Volume 2
Edition 1
Original language English
ISBN (Electronic) 978-0-12-375679-4
ISBN (Print) 978-0123756787

Economic evaluation of public health interventions: methodological challenges

Weatherly, H. L. A., Cookson, R. A. & Drummond, M. F., Mar 2014, Encyclopedia of Health Economics. Culyer, A. J. (ed.). San Diego: Elsevier, Vol. 1. p. 217-223 7 p.

Research output: Chapter in Book/Report/Conference proceedingChapter

Publication details

Title of host publication Encyclopedia of Health Economics
Date Published - Mar 2014
Pages 217-223
Number of pages 7
Publisher Elsevier
Place of Publication San Diego
Editors A. J. Culyer
Volume 1
Original language English
ISBN (Electronic) 9780123756794
ISBN (Print) 9780123756787

Social status and living with a chronic illness: An exploration of assessment and meaning attributed to work and employment

Vassilev, I., Rogers, A., Sanders, C., Cheraghi-Sohi, S., Blickem, C., Brooks, H., Kapadia, D., Reeves, D., Doran, T. & Kennedy, A., 6 Feb 2014

Article in Chronic illness

Publication details

Journal Chronic illness
Date Published - 6 Feb 2014
Issue number 4
Volume 10
Number of pages 18
Pages (from-to) 273-290
Original language English

Abstract

BACKGROUNDTraditional measures of social status are predicated on position in the labour market. There has been less attention directed to the meanings of social position for people with a long-term condition whose relationship to employment is precarious. Previous research has demonstrated that the MacArthur scale is capable of capturing contextualised aspects of social status, which makes it a useful tool for exploring changes in meaning.AimsThe paper explores the meanings and experiences of social status of people living with a long-term condition with particular reference to employment status. METHODSA sample of 300 participants was drawn from diabetes and chronic heart disease registers of General Practices in North West England. A cross-sectional survey with nested qualitative interviews was used in collecting and analysing the data.FindingsHaving financial independence and participating in valued activities are more important for people with chronic illness than power and status mediated through the labour market. Income and the lack and loss of employment were given a central role in respondents' narratives reflecting the absence of acceptable alternative routes through which social status for those with a long-term condition can realistically be rebuilt outside of participation in the labour market. CONCLUSIONSocial participation, where people with chronic illness feel valued and of tangible utility to other people, might offer some opportunities for rebuilding social status outside the labour market. Chronic illness management interventions need to focus on improving people's engagement with such activities.

Publication details

Journal BMJ (Clinical research ed.)
Date Published - 27 Jan 2014
Volume 348
Original language English

Abstract

To investigate the effect of withdrawing incentives on recorded quality of care, in the context of the UK Quality and Outcomes Framework pay for performance scheme.

Public Health: Overview

Cookson, R. & Suhrcke, M., 2014, Encyclopedia of Health Economics. Elsevier, p. 210-217 8 p.

Research output: Chapter in Book/Report/Conference proceedingChapter

Publication details

Title of host publication Encyclopedia of Health Economics
Date Published - 2014
Pages 210-217
Number of pages 8
Publisher Elsevier
Original language English
ISBN (Electronic) 9780123756787
ISBN (Print) 9780123756794

Abstract

This article is a short introduction to the economics of public health. It starts by describing some of the contributions that economists have made to research on the measurement and determinants of population health. It then provides a brief overview of the nature and scope of public health, broadly understood as public policy intervention to prevent ill health. It then reviews normative economic arguments about market failure in public health and discusses the role of economic evaluation in public health. It concludes by noting three important areas for future research: public choice analysis of government failure in public health, the application of behavioral economic insights to the design of public health interventions, and methods for the economic evaluation of intersectoral public health interventions.

Eliciting value judgements about health inequality aversion: testing for framing effects

Ali, S., Cookson, R. A., Tsuchiya, A. & Asaria, M., 2014, p. 1. 20 p.

Research output: Contribution to conferencePaper

Conference

Conference HESG meeting
Country United Kingdom
City Sheffield
Conference date(s) 8/01/1410/01/14

Publication details

Date Published - 2014
Number of pages 20
Original language English

Abstract

Questionnaire-based estimates of health inequality aversion are potentially vulnerable to framing effects. This study tests for four framing effects and a sample selection effect related to framing in the broad sense of cognition and information processing: (1) small versus unrealistically large health inequality reductions; (2) population-level versus individual-level descriptions of inequality reductions; (3) concrete versus abstract scenarios; (4) online versus discussion mode of administration; and (5) “academic versus non-academic” sample. Twenty nine respondents participated in a discussion group meeting, and a separate convenience sample of 156 respondents completed an online questionnaire. In line with previous studies we found that between 20% and 61% of respondents in different conditions expressed extreme inequality aversion that violates monotonicity, and between 3% and 20% expressed zero inequality aversion. We found small but non-significant effects of (1), (2) and (4), and substantial and significant effects of (3) and (5): a higher proportion of respondents expressed zero health inequality aversion in the concrete scenario, and a lower proportion expressed extreme health inequality aversion in the academic sample despite expressing similar or more egalitarian social attitudes to the welfare state and income redistribution.

Publication details

Journal BMJ Open
Date E-pub ahead of print - 23 Apr 2014
Date Published (current) - 2014
Issue number 4
Volume 4
Early online date 23/04/14
Original language English

Abstract

To conduct a fully independent and external validation of a research study based on one electronic health record database, using a different electronic database sampling the same population.

2013

Publication details

Journal Journal of health politics policy and law
Date Published - Dec 2013
Issue number 6
Volume 38
Number of pages 20
Pages (from-to) 1129-48
Original language English

Abstract

In 2009 the UK National Institute for Health and Clinical Excellence (NICE) announced that its health technology appraisal committees would henceforth give special additional weight to health gains from life-extending end-of-life treatments. This was a response to mounting concern from NICE's stakeholders that effective new drugs for end-stage cancer often fail NICE's standard test of cost effectiveness. This change of policy may be justifiable on procedural grounds as the result of a democratic political process responding to stakeholder concerns. However, according to the "accountability for reasonableness" framework proposed by the philosopher Norman Daniels and endorsed by NICE, there also needs to be transparency about the substantive ethical grounds for public health care resource allocation decisions. In that spirit, I analyze eleven potentially relevant justifications for the NICE "end-of-life premium," drawn from the economics and philosophy literature: (1) rule of rescue, (2) fair chances, (3) ex post willingness to pay, (4) caring externality, (5) financial protection, (6) symbolic value, (7) diminishing marginal value of future life years, (8) concentration of benefits, (9) dread, (10) time to set your affairs in order, and (11) severity of illness. I conclude that none of them yields a coherent ethical justification for the NICE end-of-life premium.

Distributional cost-effectiveness analysis: a tutorial

Asaria, M., Griffin, S. & Cookson, R. A., Nov 2013, York, UK: Centre for Health Economics, University of York, 24 p. (CHE Research Paper; no. 92).

Research output: Working paperDiscussion paper

Publication details

Date Published - Nov 2013
Publisher Centre for Health Economics, University of York
Place of Publication York, UK
Number of pages 24
Original language English

Publication series

Name CHE Research Paper
Publisher Centre for Health Economics, University of York
No. 92

Abstract

Distributional cost-effectiveness analysis (DCEA) is a framework for incorporating health inequality concerns into the economic evaluation of health sector interventions. In this tutorial we describe the technical details of how to conduct DCEA, using an illustrative example comparing alternative ways of implementing the NHS Bowel Cancer Screening Programme (BCSP). The two key stages in DCEA are (A) modelling social distributions of health associated with different interventions and (B) evaluating social distributions of health with respect to the dual objectives of improving total population health and reducing unfair health inequality. As well as describing the technical methods used, we also identify the data requirements and the social value judgements that have to be made. Finally, we demonstrate the use of sensitivity analyses to explore the impacts of alternative modelling assumptions and social value judgements.

Distributional cost-effectiveness analysis of health care programmes

Asaria, M., Griffin, S., Cookson, R. A., Whyte, S. & Tappenden, P., Nov 2013, York, UK: Centre for Health Economics, University of York, 20 p. (CHE Research Paper; no. 91).

Research output: Working paperDiscussion paper

Publication details

Date Published - Nov 2013
Publisher Centre for Health Economics, University of York
Place of Publication York, UK
Number of pages 20
Original language English

Publication series

Name CHE Research Paper
Publisher Centre for Health Economics, University of York
No. 91

Abstract

This paper presents a case study application of a new methodological framework for undertaking distributional cost-effectiveness analysis (DCEA) to combine the objectives of maximising health and minimising unfair variation in health when evaluating population health interventions. The NHS Bowel Cancer Screening Programme (BCSP) introduced in 2006 is expected to improve population health on average but also to worsen population health inequalities associated with deprivation and ethnicity – a classic case of “intervention generated inequality”. We demonstrate the DCEA framework by examining two redesign options for the BCSP: (1) the introduction of an enhanced targeted reminder aimed at increasing screening uptake in deprived and ethnically diverse neighbourhoods and (2) the
introduction of a basic universal reminder aimed at increasing screening uptake across the whole population. Our analysis indicates that the universal reminder is the strategy that maximises population health while the targeted reminder is the screening strategy that minimises unfair variation in health. The framework is used to demonstrate how these two objectives can be traded off against
each other, and how alternative social value judgements influence the assessment of which strategy is best, including judgements about which dimensions of health variation are considered unfair and judgements about societal levels of inequality aversion.

Publication details

Journal BMJ Quality & Safety
Date Published - 22 Aug 2013
Issue number 1
Volume 22
Number of pages 12
Pages (from-to) 53-64
Original language English

Abstract

The UK's Quality and Outcomes Framework (QOF) was introduced in 2004/5, linking remuneration for general practices to recorded quality of care for chronic conditions, including diabetes mellitus. We assessed the effect of the incentives on recorded quality of care for diabetes patients and its variation by patient and practice characteristics.

Publication details

Journal Health services research
Date Published - 1 Aug 2013
Issue number 2
Volume 49
Pages (from-to) 568-587
Original language English

Abstract

To test whether receiving a financial bonus for quality in the Premier Hospital Quality Incentive Demonstration (HQID) stimulated subsequent quality improvement.

Bibliographical note

© Health Research and Educational Trust.

Publication details

Journal The British journal of general practice : the journal of the Royal College of General Practitioners
Date Published - Apr 2013
Issue number 609
Volume 63
Number of pages 9
Pages (from-to) 291-299
Original language English

Publication details

Journal The British journal of general practice : the journal of the Royal College of General Practitioners
Date Published - Apr 2013
Issue number 609
Volume 63
Number of pages 9
Pages (from-to) 291-299
Original language English

Publication details

Journal Current diabetes reports
Date Published - Apr 2013
Issue number 2
Volume 13
Number of pages 9
Pages (from-to) 196-204
Original language English

Abstract

Pay-for-performance schemes explicitly link provider remuneration to the quality of care provided, with the aims of modifying provider behavior and improving patient outcomes. If successful, pay-for-performance schemes could drive improvements in quality and efficiency of care. However, financial incentives could also erode providers' intrinsic motivation, narrow their focus, promote unethical behavior, and ultimately increase health care inequalities. Evidence from schemes implemented to date suggests that carefully designed pay-for-performance schemes that align sufficient rewards with clinical priorities can produce modest but significant improvements in processes of diabetic care and intermediate outcomes. There is limited evidence, however, on whether improvements in processes of care result in improved outcomes, in terms of patient satisfaction, reduced complications, and greater longevity. The lack of adequate control groups has limited research findings to date, and more robust studies are needed to explore both the potential long-term benefits of pay-for-performance schemes and their unintended consequences.

Measuring health inequality in the context of cost-effectiveness analysis

Asaria, M., Griffin, S. & Cookson, R., 1 Jan 2013, Research on Economic Inequality. Bishop, J. (ed.). JAI Press, Vol. 21. p. 491-507 (Research on Economic Inequality; vol. 21).

Research output: Chapter in Book/Report/Conference proceedingChapter

Publication details

Title of host publication Research on Economic Inequality
Date Published - 1 Jan 2013
Pages 491-507
Publisher JAI Press
Editors John Bishop
Volume 21
Original language English
ISBN (Print) 9781781905531

Publication series

Name Research on Economic Inequality
Volume 21
ISSN (Print) 10492585

Abstract

In this chapter we discuss the cost-effectiveness analysis (CEA) of public health interventions where there are combined, and potentially conflicting, objectives of increasing total population health and reducing unfair health inequalities in the population. Our focus is on identifying appropriate health inequality measures in this context to quantify the impacts of interventions on unfair health inequality and, where necessary, analyse equity-efficiency trade-offs between improving total population health and reducing unfair health inequality. We recognise that this requires a number of important social value judgements to be made, and so prefer measures that facilitate transparency about these social value judgements. We briefly summarise the literature on health inequality and health-related social welfare functions, and conclude that while valuable it is not entirely suitable for our purpose. We borrow instead from the wider literature on economic inequality, highlighting how this translates to a health setting, and identify appropriate measures for CEA. We conclude with a stylised example illustrating how we would apply a battery of dominance rules and social welfare indices to evaluate the health distributions associated with two hypothetical health interventions.

Publication details

Date Published - 2013
Number of pages 345
Publisher University of York
Place of Publication York
Original language English
ISBN (Print) 978-1-907265-22-8

Abstract

Jonathan Bradshaw has been a leading social policy scholar for over 40 years. He has made seminal contributions to the comparative study of child well-being, poverty and the adequacy of benefits, as well as writing on a range of important social policy issues. He founded the Social Policy Research Unit at the University of York, contributed to numerous landmark studies of poverty and minimum income standards in Britain for the Joseph Rowntree Foundation, and issued a wake-up call to policy makers worldwide by producing the first international 'league table' of child well-being. This volume brings together Bradshaw's best writings and demonstrates his clear, humane thinking based on systematic evidence and analysis. It will interest social policy students, practitioners and policy makers and is required reading for anyone who wants to understand how and why poverty and low child well-being persist in the twenty-first century. The book was produced to mark Jonathan Bradshaw's retirement and to introduce future generations of social policy students and scholars to his work. It was sponsored by the Joseph Rowntree Foundation, the Social Policy Research Unit and the Foundation for International Studies on Social Security.

Publication details

Journal Journal of Health Services Research & Policy
Date Published - Jan 2013
Issue number 1
Volume 18
Number of pages 6
Pages (from-to) 34-39
Original language English

Abstract

We summarise and evaluate Harris' criticisms of cost-effectiveness analysis (CEA) and the alternative processes he commends to health care decision makers. In contrast to CEA, Harris' asserts that individuals have a right to life-saving treatment that cannot be denied on the basis of their capacity to benefit. We conclude that, whilst Harris' work has challenged the proponents of CEA and quality-adjusted life years to be explicit about the method's indirect discriminatory characteristics, his arguments ignore important questions about what 'lives saved' mean. Harris also attempts to avoid opportunity cost by advocating the same chance of treatment for every person desiring treatment. Using a simple example, we illustrate that an 'equal chances' lottery is not in the interest of any patient, as it reduces the chance of treatment for all patients by leaving some of the health budget unspent.

Publication details

Journal BMJ Open
Date Published - 2013
Issue number 8
Volume 3
Original language English

Abstract

To investigate the relationship between performance on the UK Quality and Outcomes Framework pay-for-performance scheme and choice of clinical computer system.

Research shapes policy: but the dynamics are subtle

Foy, R., Locock, L., Purdy, S., O'Donnell, C., Gray, N., Doran, T. & Davies, H., Jan 2013

Article in Public Money and Management

Publication details

Journal Public Money and Management
Date Published - Jan 2013
Issue number 1
Volume 33
Pages (from-to) 9-14
Original language English

Abstract

Major policy initiatives such as the Quality and Outcomes Framework (QOF) in the national contract for UK general practitioners might variably be informed by evidence at their inception, implementation and subsequent evolution. But what evidence gets admitted into these policy debates—and what is left out? Using QOF as an example, this article demonstrates what an analysis of the relationship between policy and the associated research can tell us about the underlying policy assumptions and about the role of evidence in policy debates.

2012

The Humble Economist: Tony Culyer on Health, Health Care and Social Decision Making

Cookson, R. A. (ed.), Claxton, K. P. (ed.) & Culyer, T., 26 Nov 2012, York and London: University of York and Office of Health Economics. 382 p.

Research output: Book/ReportBook

Publication details

Date Published - 26 Nov 2012
Number of pages 382
Publisher University of York and Office of Health Economics
Place of Publication York and London
Original language English
ISBN (Electronic) ISBN 978-0-9525601-6-6
ISBN (Print) ISBN 978-0-9525601-5-9

Abstract

The Humble Economist will change the way you think about health, health care and social decision making. These short, enjoyable essays by Tony Culyer distil a powerful set of ideas that have profoundly influenced health policy and decision making. Tony Culyer is a founding father of health economics who helped set up the renowned UK National Institute for Health and Clinical Excellence. His insights into how to improve health sector institutions and decision making processes will interest anyone working in the health field. The humble economist shows how reason and evidence can be used to improve decision making in any area of social policy.

Bibliographical note

Tony Culyer has worked at the University of York since 1969, and has played leading roles in administration – as a Head of Department, Pro-Vice-Chancellor and Deputy Vice-Chancellor, and in developing the health research infrastructure at York – as well as research and teaching. Tony Culyer’s connection with the Office of Health Economics has also been long and invaluable. He generously has given of his time and talent as chairman of both the Editorial Board, which oversees OHE’s publications programme, and the Policy Board, which sets the general substantive direction of OHE’s research programme.

Publication details

Journal Health services research
Date Published - Aug 2012
Issue number 4
Volume 47
Number of pages 19
Pages (from-to) 1418-1436
Original language English

Abstract

The Medicare and Premier Inc. Hospital Quality Incentive Demonstration (HQID), a hospital-based pay-for-performance program, changed its incentive design from one rewarding only high performance (Phase 1) to another rewarding high performance, moderate performance, and improvement (Phase 2). We tested whether this design change reduced the gap in incentive payments among hospitals treating patients across the gradient of socioeconomic disadvantage.

Bibliographical note

© Health Research and Educational Trust.

Risk of self-harm in physically ill patients in UK primary care

Webb, R. T., Kontopantelis, E., Doran, T., Qin, P., Creed, F. & Kapur, N., Aug 2012

Article in Journal of Psychosomatic Research

Publication details

Journal Journal of Psychosomatic Research
Date Published - Aug 2012
Issue number 2
Volume 73
Number of pages 6
Pages (from-to) 92-7
Original language English

Abstract

To examine self-harm risk across the adult age range in patients diagnosed with various physical illnesses using the General Practice Research Database - a broadly representative sample of all people registered with a family practice in the United Kingdom.

Bibliographical note

Copyright © 2012 Elsevier Inc. All rights reserved.

Publication details

Journal Health services research
Date Published - Jun 2012
Issue number 3 part 1
Volume 47
Number of pages 19
Pages (from-to) 1117-1136
Original language English

Abstract

OBJECTIVE: To analyze the effect of setting higher targets, in a primary care pay-for-performance scheme, on rates of influenza immunization and exception reporting. STUDY SETTING: The U.K. Quality and Outcomes Framework links financial rewards for family practices to four separate influenza immunization rates for patients with coronary heart disease (CHD), chronic obstructive pulmonary disease, diabetes, and stroke. There is no additional payment for immunization rates above an upper threshold. Patients for whom immunization would be inappropriate can be excepted from the practice for the calculation of the practice immunization rate. DATA: Practice-level information on immunizations and exceptions extracted from electronic records of all practices in England 2004/05 to 2009/10 (n = 8,212-8,403). STUDY DESIGN: Longitudinal random effect multilevel linear regressions comparing changes in practice immunization and exception rates for the four chronic conditions before and after the increase in the upper threshold immunization rate for CHD patients in 2006/07. PRINCIPAL FINDINGS: The 5 percent increase in the upper payment threshold for CHD was associated with increases in the proportion of immunized CHD patients (0.41 percent, CI: 0.25-0.56 percent), and exception was reported (0.26 percent, CI: 0.12-0.40 percent). CONCLUSIONS: Making quality targets more demanding can not only lead to improvement in quality of care but can also have other consequences.

Publication details

Journal Social Science & Medicine
Date Published - May 2012
Issue number 9
Volume 74
Number of pages 11
Pages (from-to) 1331-1341
Original language English

Abstract

Waiting times for elective surgery, like hip replacement, are often referred to as an equitable rationing mechanism in publicly-funded healthcare systems because access to care is not based on socioeconomic status. Previous work has established that that this may not be the case and there is evidence of inequality in NHS waiting times favouring patients living in the least deprived neighbourhoods in England. We advance the literature by explaining variations of inequalities in waiting times in England in four different ways. First, we ask whether inequalities are driven by education rather than income. Our analysis shows that education and income deprivation have distinct effects on waiting time. Patients in the first quintile with least deprivation in education wait 9% less than patients in the second quintile and 14% less than patients in the third-to-fifth quintile. Patients in the fourth and fifth most income-deprived quintile wait about 7% longer than patients in the least deprived quintile. Second, we investigate whether inequalities arise "across" hospitals or "within" the hospital. The analysis provides evidence that most inequalities occur within hospitals rather than across hospitals. Moreover, failure to control for hospital fixed effects results in underestimation of the income gradient. Third, we explore whether inequalities arise across the entire waiting time distribution. Inequalities between better educated patients and other patients occur over large part of the waiting time distribution. Moreover we find that the education gradient becomes smaller for very long waiting. Fourth, we investigate whether the gradient may reflect the fact that patients with higher socioeconomic status have a different severity as proxied through a range of types and the number of diagnoses (in addition to age and gender) compared to those with lower socioeconomic status. We find no evidence that differences in severity explain the social gradient in waiting times. (C) 2012 Elsevier Ltd. All rights reserved.

Publication details

Journal BMC Health Services Research
Date Published - 16 Apr 2012
Issue number 1
Volume 12
Number of pages 9
Pages (from-to) -
Original language English

Abstract

Background: The General Medical Services primary care contract for the United Kingdom financially rewards performance in 19 clinical areas, through the Quality and Outcomes Framework. Little is known about how best to determine the size of financial incentives in pay for performance schemes. Our aim was to test the hypothesis that performance indicators with larger population health benefits receive larger financial incentives.

Methods: We performed cross sectional analyses to quantify associations between the size of financial incentives and expected health gain in the 2004 and 2006 versions of the Quality and Outcomes Framework. We used non-parametric two-sided Spearman rank correlation tests. Health gain was measured in expected lives saved in one year and in quality adjusted life years. For each quality indicator in an average sized general practice we tested for associations first, between the marginal increase in payment and the health gain resulting from a one percent point improvement in performance and second, between total payment and the health gain at the performance threshold for maximum payment.

Results: Evidence for lives saved or quality adjusted life years gained was found for 28 indicators accounting for 41% of the total incentive payments. No statistically significant associations were found between the expected health gain and incentive gained from a marginal 1% increase in performance in either the 2004 or 2006 version of the Quality and Outcomes Framework. In addition no associations were found between the size of financial payment for achievement of an indicator and the expected health gain at the performance threshold for maximum payment measured in lives saved or quality adjusted life years.

Conclusions: In this subgroup of indicators the financial incentives were not aligned to maximise health gain. This disconnection between incentive and expected health gain risks supporting clinical activities that are only marginally effective, at the expense of more effective activities receiving lower incentives. When designing pay for performance programmes decisions about the size of the financial incentive attached to an indicator should be informed by information on the health gain to be expected from that indicator.

Publication details

Journal Medical Care
Date Published - Mar 2012
Issue number 3
Volume 50
Number of pages 9
Pages (from-to) 191-199
Original language English

Abstract

Despite the extensive use of process of care measures in pay-for-performance programs, little is known about the effect of improving process performance on patient outcomes.

Publication details

Journal BMJ (Clinical research ed.)
Date Published - 2012
Volume 344
Pages (from-to) e2405
Original language English

Abstract

To examine the reasons why practices exempt patients from the UK Quality and Outcomes Framework pay for performance scheme (exception reporting) and to identify the characteristics of general practices associated with informed dissent.

Publication details

Journal Journal of Health Services Research & Policy
Date Published - Jan 2012
Issue number SUPPL. 1
Volume 17
Number of pages 9
Pages (from-to) 55-63
Original language English

Abstract

The central objectives of the 'Blair/Brown' reforms of the English NHS in the 2000s were to reduce hospital waiting times and improve the quality of care. However, critics raised concerns that the choice and competition elements of reform might undermine socioeconomic equity in health care. By contrast, the architects of reform predicted that accelerated growth in NHS spending combined with increased patient choice of hospital would enhance equity for poorer patients. This paper draws together and discusses the findings of three large-scale national studies designed to shed empirical light on this issue. Study one developed methods for monitoring change in neighbourhood level socioeconomic equity in the utilization of health care, and found no substantial change in equity between 2001-02 and 2008-09 for non-emergency hospital admissions, outpatient admissions (from 2004-05) and a basket of specific hospital procedures (hip replacement, senile cataract, gastroscopy and coronary revascularization). Study two found that increased competition between 2003-04 and 2008-09 had no substantial effect on socioeconomic equity in health care. Study three found that potential incentives for public hospitals to select against socioeconomically-disadvantaged hip replacement patients were small, compared with incentives to select against elderly and co-morbid patients. Taken together, these findings suggest that the Blair/Brown reforms had little effect on socioeconomic equity in health care. This may be because the 'dose' of competition was small and most hospital services continued to be provided by public hospitals which did not face strong incentives to select against socioeconomically-disadvantaged patients. Journal of Health Services Research & Policy Vol 17 Suppl 1, 2012: 55-63 (C) The Royal Society of Medicine Press Ltd 2012

2011

NICE’s social value judgements about equity in health and health care

Shah, K., Cookson, R. A., Culyer, A. J. & Littlejohns, P., Nov 2011, York, UK: Centre for Health Economics, University of York, 20 p. (CHE Research Paper; no. 70).

Research output: Working paperDiscussion paper

Publication details

Date Published - Nov 2011
Publisher Centre for Health Economics, University of York
Place of Publication York, UK
Number of pages 20
Original language English

Publication series

Name CHE Research Paper
Publisher Centre for Health Economics, University of York
No. 70

Abstract

The National Institute for Health and Clinical Excellence (NICE) routinely publishes details of the evidence and reasoning underpinning its recommendations, including its social value judgements. To date, however, NICE‟s social value judgements relating to equity in the distribution of health and health care have been less specific and systematic than those relating to cost-effectiveness in the pursuit of improved sum total population health. NICE takes a pragmatic, case-based approach to developing its principles of social value judgement, drawing on the cumulative experience of its advisory bodies in making decisions that command respect among its broad range of stakeholders. This paper aims to describe the social value judgements about equity in health and health care that NICE has hitherto used to guide its decision making. To do this, we review both the general social value judgements reported in NICE guidance on methodology and the case-specific social value judgements reported in NICE guidance about particular health care technologies and public health interventions.

Measuring Change in Health Care Equity Using Small Area Administrative Data: Evidence from the English NHS 2001-8

Cookson, R. A., Laudicella, M. & Li Donni, P., Oct 2011, York, UK: Centre for Health Economics, University of York, 25 p. (CHE Research Paper; no. 67).

Research output: Working paperDiscussion paper

Publication details

Date Published - Oct 2011
Publisher Centre for Health Economics, University of York
Place of Publication York, UK
Number of pages 25
Original language English

Publication series

Name CHE Research Paper
Publisher Centre for Health Economics, University of York
No. 67

Abstract

This study developed a method for measuring change in socio-economic equity in health care utilisation using small area level administrative data. Our method provides more detailed information on utilisation than survey data but only examines socio-economic differences between neighbourhoods rather than individuals. The context was the English NHS from 2001 to 2008, a period of accelerated expenditure growth and pro-competition reform. Hospital records for all adults receiving non-emergency hospital care in the English NHS from 2001 to 2008 were aggregated to 32,482 English small areas with mean population about 1,500 and combined with other small area administrative data. Regression models of utilisation were used to examine year-on-year change in
the small area association between deprivation and utilisation, allowing for population size, age-sex composition and disease prevalence including (from 2003-8) cancer, chronic kidney disease, coronary heart disease, diabetes, epilepsy, hypertension, hypothyroidism, stroke, transient ischaemic attack and (from 2006-8) atrial fibrillation, chronic obstructive pulmonary disease, obesity and heart failure. There was no substantial change in small area associations between deprivation and utilisation for outpatient visits, hip replacement, senile cataract, gastroscopy or coronary revascularisation, though overall non-emergency inpatient admissions rose slightly faster in more deprived areas than elsewhere. Associations between deprivation and disease prevalence changed
little during the period, indicating that observed need did not grow faster in more deprived areas than elsewhere. We conclude that there was no substantial deterioration in socio-economic equity in health care utilisation in the English NHS from 2001 to 2008, and if anything, there may have been a slight improvement.

Does hospital competition harm equity? Evidence from the English National Health Service

Cookson, R. A., Laudicella, M. & Li Donni, P., Oct 2011, York, UK: Centre for Health Economics, University of York, 30 p. (CHE Research Paper; no. 66).

Research output: Working paperDiscussion paper

Publication details

Date Published - Oct 2011
Publisher Centre for Health Economics, University of York
Place of Publication York, UK
Number of pages 30
Original language English

Publication series

Name CHE Research Paper
Publisher Centre for Health Economics, University of York
No. 66

Abstract

Increasing evidence shows that hospital competition under fixed prices can improve quality and reduce cost. Concerns remain, however, that competition may undermine socio-economic equity in the utilisation of care. We test this hypothesis in the context of the pro-competition reforms of the English National Health Service progressively introduced from 2004 to 2006. We use a panel of 32,482 English small areas followed from 2003 to 2008 and a difference in differences approach. The effect of competition on equity is identified by the interaction between market structure, small area income deprivation and year. We find a negative association between market dispersion and elective admissions in deprived areas. The effect of pro-competition reform was to reduce this negative association slightly, suggesting that competition did not undermine equity.

Publication details

Journal BMJ (Clinical research ed.)
Date Published - 9 Jul 2011
Issue number 7814
Volume 342
Original language English

Abstract

To investigate whether the incentive scheme for UK general practitioners led them to neglect activities not included in the scheme.

Publication details

Journal Health affairs (Project Hope)
Date Published - Jun 2011
Issue number 6
Volume 30
Number of pages 11
Pages (from-to) 1165-75
Original language English

Abstract

In 2006 Massachusetts took the novel approach of using pay-for-performance--a payment mechanism typically used to improve the quality of care--to specifically target racial and ethnic disparities in hospital care for Medicaid patients. We describe the challenges of implementing such an ambitious effort in a short time frame, with limited resources. The early years of the program have yielded little evidence of racial or ethnic disparity in hospital care in Massachusetts, and raise questions about whether pay-for-performance as it is now practiced is a suitable tool for addressing disparities in hospital care.

Publication details

Journal Health services research
Date Published - Feb 2011
Issue number 1 Pt 1
Volume 46
Number of pages 20
Pages (from-to) 27-46
Original language English

Abstract

To investigate the association between indicators of quality of diabetic management in English family practices and emergency hospital admissions for short-term complications of diabetes.

Publication details

Journal Social Science & Medicine
Date Published - Jan 2011
Issue number 2
Volume 72
Number of pages 12
Pages (from-to) 173-184
Original language English

Abstract

The Blair/Brown reforms of the English NHS in the early to mid 2000s gave hospitals strong new incentives to reduce waiting times and length of stay for elective surgery. One concern was that these efficiency-oriented reforms might harm equity, by giving hospitals new incentives to select against socio-economically disadvantaged patients who stay longer and cost more to treat. This paper aims to assess the magnitude of these new selection incentives in the test case of hip replacement. Anonymous hospital records are extracted on 274,679 patients admitted to English NHS Hospital Trusts for elective total hip replacement from 2001/2 through 2007/8. The relationship between length of stay and small area income deprivation is modelled allowing for other patient characteristics (age, sex, number and type of diagnoses, procedure type) and hospital effects. After adjusting for these factors, we find that patients from the most deprived tenth of areas stayed just 6% longer than others in 2001/2, falling to 2% by 2007/8. By comparison, patients aged 85 or over stayed 57% longer than others in 2001/2, rising to 71% by 2007/8, and patients with seven or more diagnoses stayed 58% longer than others in 2001/2, rising to 73% by 2007/8. We conclude that the Blair/Brown reforms did not give NHS hospitals strong new incentives to select against socio-economically deprived hip replacement patients. (C) 2010 Elsevier Ltd. All rights reserved.

2010

Publication details

Journal British Journal of General Practice
Date Published - Sep 2010
Issue number 578
Volume 60
Number of pages 6
Pages (from-to) 649-654
Original language English

Abstract

Background

General practices in the UK contract with the government to receive additional payments for high-quality primary care. Little is known about the resulting impact on population health.

Aim

To estimate the potential reduction in population mortality from implementation of the pay-for-performance contract in England.

Design of study

Cross-sectional and modelling study.

Setting

Primary care in England.

Method

Twenty-five clinical quality indicators in the contract had controlled trial evidence of mortality benefit. This was combined with condition prevalence, and the differences in performance before and after contract implementation, to estimate the potential mortality reduction per indicator. Improvement was adjusted pre-existing trends where data were available.

Results

The 2004 contract potentially reduced mortality by 11 lives per 100 000 people (lower upper estimates 7-16) over 1 year, as performance improved from baseline to the target for full incentive payment. If all eligible patients were treated; over and above the target, 56 (29-81) lives per 100 000 might have been saved. For the 2006 contract, mortality reduction was effectively zero, because new baseline performance for a typical practice had already exceeded the target performance for full payment.

Conclusion

The contract may have delivered substantial health gain, but potential health gain was limited by performance targets for full payment being set lower than typical baseline performance. Information on both baseline performance and population health gain should inform decisions about future selection of indicators for pay-for-performance schemes, and the level of performance at which full payment is triggered.

Publication details

Journal JOURNAL OF PUBLIC ADMINISTRATION RESEARCH AND THEORY
Date Published - Jul 2010
Issue number supplement 2
Volume 20
Number of pages 25
Pages (from-to) I181-I205
Original language English

Abstract

Competition is often prescribed as an efficiency-enhancing tonic for ailing health systems. However, critics claim that competition exacerbates socioeconomic inequality in health care. This claim is tested in relation to the "internal market" reforms of the English National Health Service (NHS) from 1991 to 97, which injected a small dose of hospital competition into a state-funded, state-owned health system responsible for more than 90% of national health expenditure. Our dependent variables are NHS hospital utilization rates for hip replacement and heart revascularization in 8,500 English small areas from 1991 to 2001. We estimate small area level associations between deprivation and hospital utilization, allowing for need and supply variables. We then compare year-by-year inequality differences between areas with "potentially competitive" and "noncompetitive" local hospital markets, as competition was phased in and out. No evidence is found that competition had any effect on socioeconomic health care inequality.

Bibliographical note

© The Author 2010. Published by Oxford University Press on behalf of the Journal of Public Administration Research and Theory, Inc. All rights reserved.

Publication details

Journal Health Economics
Date Published - Jun 2010
Issue number 6
Volume 19
Number of pages 12
Pages (from-to) 644-655
Original language English

Abstract

The assumption of risk neutrality over discounted life years underlies the standard QALY model of individual preferences over health outcomes, and is thus implicitly assumed by NICE and other health technology advisory bodies worldwide. The primary objective of this article is to report a study to test the assumption in a convenience sample of 30 respondents with use of the probability equivalence version of the standard gamble. The results indicate considerable risk aversion over life years, and therefore call into question the standard assumption of risk neutrality in practical cost-utility analyses (CUA). A secondary objective is to observe whether risk aversion can be reduced through the use of the lottery equivalents method, under the hypothesis that the gambling effect can be lessened with this instrument. In a separate convenience sample of 40 respondents, however, the observed level of risk aversion was at least that seen in the standard gamble. Further research is warranted to ascertain whether risk aversion over discounted life years is a generalisable concern. Copyright (C) 2009 John Wiley & Sons, Ltd.

Publication details

Journal British Journal of General Practice
Date Published - May 2010
Issue number 574
Volume 60
Number of pages 8
Pages (from-to) e213-e220
Original language English

Abstract

Background

The Quality and Outcomes Framework (QOF) is a pioneering attempt to improve the quality of primary care in the UK through the use of financial rewards. Despite its achievements, there are concerns that the QOF rimy offer poor value for money.

Aim

To assess the Cost-effectiveness of QOF payments.

Design of study

Economic analysis.

Setting

England, UK.

Method

Cost-effectiveness evidence was identified for a subset of nine QOF indicators with a direct therapeutic impact. These data were then applied to an analytic framework to determine the conditions under which QOF payments would be cost-effective. This framework was constructed to assess the cost-effectiveness of QOF payments by modelling the incentive structure using cost-effectiveness thresholds of 20 000 and 30 000 per quality-adjusted life year (QALY) gained, to represent good value to the NHS. It used 2004/2005 data on the QOF performance of all English primary care practices.

Results

Average indicator payments ranged from 0.63 to 40.61 per patient, and the percentage of eligible patients treated ranged from 63% to 90%. The proportional changes required for QOF payments to be cost-effective varied widely between the indicators. Although most indicators required only a fraction of a 1% change to be cost-effective, for some indicators improvements in performance of around 20% were needed.

Conclusion

For most indicators that can be assessed, QOF incentive payments are likely to be a cost-effective use of resources for a high proportion of primary care. practices, even if the QOF achieves only modest improvements.in care. However, only a small subset of the indicators has been considered, and no account has been taken of the costs of administering the QOF scheme.

Publication details

Journal Health affairs (Project Hope)
Date Published - May 2010
Issue number 5
Volume 29
Number of pages 7
Pages (from-to) 1023-9
Original language English

Abstract

Primary care in the United Kingdom faced a crisis in 2000. General practitioners (GPs) complained of low morale, long hours, and low pay. The quality of care delivered to patients, meanwhile, was highly variable. The U.K. government responded with a program of quality improvement initiatives, a substantial increase in funding, and an ambitious pay-for-performance scheme that introduced publicly reported quality-of-care targets. Following these reforms, GPs' income and morale increased, the number of working hours declined, and the quality of care improved. The reforms, however, presented a serious challenge to medical professionalism, and the long-term effects on patient outcomes remain uncertain.

2009

Publication details

Journal Health policy (Amsterdam, Netherlands)
Date Published - Dec 2009
Issue number 2-3
Volume 93
Number of pages 8
Pages (from-to) 85-92
Original language English

Abstract

RATIONALE: Increasing attention is being given to the evaluation of public health interventions. Methods for the economic evaluation of clinical interventions are well established. In contrast, the economic evaluation of public health interventions raises additional methodological challenges. The paper identifies these challenges and provides suggestions for overcoming them.

METHODS: To identify the methodological challenges, five reviews that explored the economics of public health were consulted. From these, four main methodological challenges for the economic evaluation of public health interventions were identified. A review of empirical studies was conducted to explore how the methodological challenges had been approached in practice and an expert workshop convened to discuss how they could be tackled in the future.

RESULTS: The empirical review confirmed that the four methodological challenges were important. In all, 154 empirical studies were identified, covering areas as diverse as alcohol, drug use, obesity and physical activity, and smoking. However, the four methodological challenges were handled badly, or ignored in most of the studies reviewed.

DISCUSSION: The empirical review offered few insights into ways of addressing the methodological challenges. The expert workshop suggested a number of ways forward for overcoming the methodological challenges.

CONCLUSION: Although the existing empirical literature offers few insights on how to respond to these challenges, expert opinion suggests a number of ways forward. Much of what is suggested here has not yet been applied in practice, and there is an urgent need both for pilot studies and more methodological research.

Publication details

Journal Journal of health economics
Date Published - Dec 2009
Issue number 6
Volume 28
Number of pages 14
Pages (from-to) 1048-1061
Original language English

Abstract

This paper proposes a new approach to the measurement of inequality and inequity in the delivery of health care based on contributions from the literature on poverty and deprivation. This approach has some appealing characteristics: (I) inequity is additively decomposable by population subgroups; (2) the approach does not rely on socio-economic ranks; (3) it provides a graphical representation of the distribution of inequity; (4) it offers a range of indices consistent with dominance. An empirical application is provided investigating the effect of the GP fundholding reform on equity in English NHS. The results show that the most equitable GP practices self-selected into the scheme in 1991; evidence of an inequity-reducing treatment effect as well as a self-selection effect are found in 1992 and 1993; the self-selection process reduces and no evidence of a treatment effect is present thereafter. (C) 2009 Elsevier B.V. All rights reserved.

Measuring overall population health - the use and abuse of QALYs

Cookson, R. & Culyer, T., 2009, Evidence Based Public Health: Effectiveness and Efficiency. Killoran, A. & Kelly, M. (eds.). Oxford: Oxford University Press, p. 148-168 21 p.

Research output: Chapter in Book/Report/Conference proceedingChapter

Publication details

Title of host publication Evidence Based Public Health
Date Published - 2009
Pages 148-168
Number of pages 21
Publisher Oxford University Press
Place of Publication Oxford
Editors A. Killoran, M. Kelly
Original language English
ISBN (Print) 978-0-19-956362-3

2008

Publication details

Journal New England Journal of Medicine
Date Published - 17 Jul 2008
Issue number 3
Volume 359
Number of pages 11
Pages (from-to) 274-284
Original language English

Abstract

Background: In the English pay-for-performance program, physicians use a range of criteria to exclude individual patients from the quality calculations that determine their pay. This process, which is called exception reporting, is intended to safeguard patients against inappropriate treatment by physicians seeking to maximize their income. However, exception reporting may allow physicians to inappropriately exclude patients for whom targets have been missed (a practice known as gaming).

Methods: We analyzed data extracted automatically from clinical computing systems for 8105 family practices in England (96% of all practices), data from the U.K. Census, and data on practice characteristics from the U.K. Department of Health. We determined the rate of exception reporting for 65 clinical activities and the association between this rate and the characteristics of patients and medical practices.

Results: From April 2005 through March 2006, physicians excluded a median of 5.3% of patients (interquartile range, 4.0 to 6.9) from the quality calculations. Physicians were most likely to exclude patients from indicators that were related to providing treatments and achieving target levels of intermediate outcomes; they were least likely to exclude patients from indicators that were related to routine checks and measurements and to offers of treatment. The characteristics of patients and practices explained only 2.7% of the variance in exception reporting. We estimate that exception reporting accounted for approximately 1.5% of the cost of the pay-for-performance program.

Conclusions: Exception reporting brings substantial benefits to pay-for-performance programs, providing that the process is used appropriately. In England, rates of exception reporting have generally been low, with little evidence of widespread gaming.

Bibliographical note

2008 Massachusetts Medical Society

Publication details

Journal Journal of Medical Ethics
Date Published - 1 Jul 2008
Issue number 7
Volume 34
Number of pages 5
Pages (from-to) -
Original language English

Abstract

In healthcare, a tension sometimes arises between the injunction to do as much good as possible with scarce resources and the injunction to rescue identifiable individuals in immediate peril, regardless of cost (the '' Rule of Rescue''). This tension can generate serious ethical and political difficulties for public policy makers faced with making explicit decisions about the public funding of controversial health technologies, such as costly new cancer drugs. In this paper we explore the appropriate role of the Rule of Rescue in public resource allocation decisions by health technology funding advisory bodies such as the National Institute for Health and Clinical Excellence. We consider practical approaches to operationalising the Rule of Rescue from Australia and the UK before examining the relevance of individual moral imperatives to public policy making. We conclude that that whilst public policy makers in a humane society should facilitate exceptional departures from a cost effectiveness norm in clinical decisions about identified individuals, it is not so obvious that they should, as a matter of national public policy, exempt any one group of unidentified individuals within society from the rules of opportunity cost at the expense of all others.

Publication details

Journal BMC Health Services Research
Date Published - 17 Jun 2008
Issue number n/a
Volume 8
Number of pages 8
Original language English

Abstract

Background: The 2003 revision of the UK GMS contract rewards general practices for performance against clinical quality indicators. Practices can exempt patients from treatment, and can receive maximum payment for less than full coverage of eligible patients. This paper aims to estimate the gap between the percentage of maximum incentive gained and the percentage of patients receiving indicated care (the pay-performance gap), and to estimate how much of the gap is attributable respectively to thresholds and to exception reporting.

Methods: Analysis of Quality Outcomes Framework data in the National Primary Care Database and exception reporting data from the Information Centre from 8407 practices in England in 2005 -6. The main outcome measures were the gap between the percentage of maximum incentive gained and the percentage of patients receiving indicated care at the practice level, both for individual indicators and a combined composite score. An additional outcome was the percentage of that gap attributable respectively to exception reporting and maximum threshold targets set at less than 100%.

Results: The mean pay-performance gap for the 65 aggregated clinical indicators was 13.3% ( range 2.9% to 48%). 52% of this gap (6.9% of eligible patients) is attributable to thresholds being set at less than 100%, and 48% to patients being exception reported. The gap was greater than 25% in 9 indicators: beta blockers and cholesterol control in heart disease; cholesterol control in stroke; influenza immunization in asthma; blood pressure, sugar and cholesterol control in diabetes; seizures in epilepsy and treatment of hypertension.

Conclusion: Threshold targets and exception reporting introduce an incentive ceiling, which substantially reduces the percentage of eligible patients that UK practices need to treat in order to receive maximum incentive payments for delivering that care. There are good clinical reasons for exception reporting, but after unsuitable patients have been exempted from treatment, there is no reason why all maximum thresholds should not be 100%.

Publication details

Journal The Lancet
Date Published - 2008
Issue number 9640
Volume 372
Number of pages 9
Pages (from-to) 728-736
Original language English

Abstract

The quality and outcomes framework is a financial incentive scheme that remunerates general practices in the UK for their performance against a set of quality indicators. Incentive schemes can increase inequalities in the delivery of care if practices in affluent areas are more able to respond to the incentives than are those in deprived areas. We examined the relation between socioeconomic inequalities and delivered quality of clinical care in the first 3 years of this scheme.

Public health care resource allocation and the rule of rescue

Cookson, R., Tsuchiya, A. & McCabe, C., 2008, Journal of Medical Ethics.

Research output: Working paperDiscussion paper

Publication details

Date Published - 2008
Publisher Journal of Medical Ethics
Original language English

Abstract

In health care, a tension sometimes arises between the injunction to do as much good as possible with scarce resources and the injunction to rescue identifiable individuals in immediate peril, regardless of cost (the "Rule of Rescue". This tension can generate serious ethical and political difficulties for public policy makers faced with making explicit decisions about the public funding of controversial health technologies, such as costly new cancer drugs. In this paper we explore the appropriate role of the Rule of Rescue in public resource allocation decisions. We consider practical approaches to operationalising the Rule of Rescue from Australia and the UK before examining the relevance of individual moral imperatives to public policy making. We conclude that, whilst public policy makers in a humane society should facilitate exceptional departures from a cost effectiveness norm in clinical decisions about identified individuals, it is not so obvious that they should, as a matter of national public policy, except any one group of unidentified individuals within society from the rules of opportunity cost at the expense of all others.

2007

Publication details

Journal Journal of Health Services Research and Policy
Date Published - 1 Apr 2007
Issue number 1
Volume 12
Number of pages 8
Pages (from-to) 10-17
Original language English

Abstract

Objectives: To compare socioeconomic inequality in small area use of elective total hip replacement in the English National Health Service (NHS) in 1991 and 2001. Methods: Hospital Episode Statistics and Census data were aggregated to a common geography of 'frozen' 1991 English electoral wards. The Townsend deprivation score was used as the primary indicator of socioeconomic status for each ward, and the sensitivity analysis used other Census indicators. Two main measures of inequality were examined: the indirectly age–sex standardized utilization rate ratio between most and least deprived quintile groups, and the concentration index of deprivation-related inequality in age–sex standardized utilization ratios between small areas. Each standardized utilization ratio is the observed use divided by the expected use, if each age and sex group in the study population had the same use rate as the national population. Results: In both years, observed use was below expected use for the bottom third of areas by socioeconomic status. The standardized utilization rate ratio between top and bottom Townsend quintiles fell from 1.41 (95% confidence interval [CI] 1.36–1.47) in 1991 to 1.27 (95% CI 1.23–1.32) in 2001. The proportionate increase in use required to bring the bottom quintile to the level of top thus fell significantly from 41% to 27%. The Town-send-based concentration index also fell from 0.069 (95% CI 0.059–0.079) in 1991 to 0.060 (95% CI 0.050–0.071) in 2001, although this fall was not statistically significant (P = 0.085). Other socioeconomic indicators yielded a similar pattern. Conclusions: Socioeconomic small area inequality in use of total hip replacement appears to have fallen between 1991 and 2001. One possible explanation is that increased hip replacement rates in the 1990s may have lowered barriers to access, thus allowing this health technology to diffuse further among lower socioeconomic groups.

Publication details

Journal Current hypertension reports
Date Published - 2007
Issue number 5
Volume 9
Number of pages 8
Pages (from-to) 360-7
Original language English

Abstract

Pay-for-performance schemes provide financial incentives to health care providers for achieving specified performance targets, and therefore seek to explicitly link physician pay to the quality of care provided for patients. This article provides an overview of the essential elements of pay-for-performance schemes and how these relate to the treatment of hypertension. It also reviews the evidence for the effectiveness of pay-for-performance schemes and analyzes new data from a program in the United Kingdom that provides financial incentives for family practitioners caring for 6 million hypertensive patients. Although several pay-for-performance schemes have proved effective at improving quality of care, few to date have addressed patients with hypertension. Findings from the UK pay-for-performance scheme suggest that generous financial incentives are associated with high levels of achievement for aspects of care for hypertensive patients, but much of this achievement may be attributable to other quality improvement initiatives.

Publication details

Journal Medical Education
Date Published - 2007
Issue number 5
Volume 41
Number of pages 8
Pages (from-to) 487-94
Original language English

Abstract

Workload pressures may lead pre-registration house officers (PRHOs) to undervalue critical appraisal and thinking skills. This study aimed to explore Mersey Deanery PRHOs' attitudes, experiences and perceived readiness for practising evidence-based medicine with critical appraisal skills.

2006

Publication details

Journal British Journal of General Practice
Date Published - Aug 2006
Issue number 529
Volume 56
Number of pages 7
Pages (from-to) 613-9
Original language English

Abstract

BACKGROUND: If all GPs target their prescribing appropriately, then a positive relationship may be expected between targeting quality indicators and associated prescribing expenditure. Little is known about this relationship.

AIM: To explore the relationship between prescribing quality indicators and associated prescribing expenditures.

DESIGN: Observational study of prescribing expenditure and quality indicators.

SETTING: Seventy-one of the 121 practices in the Norfolk and Waveney area of East Anglia in England.

METHOD: Data were collected on quality indicators for 2002-2003 in seven areas likely to produce the greatest number of lives saved over a period of 1 year. This was linked to routine data on associated pharmaceutical expenditure.

RESULTS: There was considerable variation in quality in all areas apart from influenza immunisation. Significant correlations between prescribing quality and expenditure were found in only two of the seven areas. When quality scores were combined into a composite quality index weighted by health gain, a small positive association was found, but this association is lost if all indicators are weighted equally.

CONCLUSIONS: There appeared to be no relationship between quality indicators and prescribing expenditure at the practice level for most of the therapeutic areas studied. This suggests the possibility that there may be scope for some GPs to target prescribing more appropriately towards high risk patients -- and thus save more lives -- without increasing prescribing expenditure.

Publication details

Journal British Journal of General Practice
Date Published - Aug 2006
Issue number 56
Volume 56
Number of pages 6
Pages (from-to) 613-619
Original language English

Abstract

Background: If all GPs target their prescribing appropriately, then a positive relationship may be expected between targeting quality indicators and associated prescribing expenditure. Little is known about this relationship. Aim: To explore the relationship between prescribing quality indicators and associated prescribing expenditures. Design: Observational study of prescribing expenditure and quality indicators. Setting: Seventy-one of the 121 practices in the Norfolk and Waveney area of East Anglia in England. Method: Data were collected on quality indicators for 2002-2003 in seven areas likely to produce the greatest number of lives saved over a period of 1 year. This was linked to routine data on associated pharmaceutical expenditure. Results: There was considerable variation in quality in all areas apart from influenza immunisation. Significant correlations between prescribing quality and expenditure were found in only two of the seven areas. When quality scores were combined into a composite quality index weighted by health gain, a small positive association was found, but this association is lost if all indicators are weighted equally. Conclusions: There appeared to be no relationship between quality indicators and prescribing expenditure at the practice level for most of the therapeutic areas studied. This suggests the possibility that there may be scope for some GPs to target prescribing more appropriately towards high risk patients — and thus save more lives — without increasing prescribing expenditure.

Socio-economic inequality in small area use of elective total hip replacement in the English NHS in 1991 and 2001

Cookson, R., Dusheiko, M. & Hardman, G., May 2006, York, UK: Centre for Health Economics. 17 p. (CHE Research Paper)

Research output: Book/ReportCommissioned report

Publication details

Date Published - May 2006
Number of pages 17
Publisher Centre for Health Economics
Place of Publication York, UK
Original language English

Publication series

Name CHE Research Paper
Publisher Centre for Health Economics

Abstract

Introduction International evidence suggests that there are substantial socio-economic inequalities in the delivery of specialist health services, even in the UK and other high-income countries with publicly funded health systems (Goddard and Smith 2001, Dixon et al. 2003, Van Doorslaer, Koolman and Jones 2004, Van Doorslaer et al. 2000). Studies of total hip replacement in the English NHS have yielded particularly striking examples, given that hip replacement is such a common, effective and longestablished health technology. Administrative data show that people living in deprived areas are less likely to receive hip replacement (Chaturvedi and Ben-Shlomo 1995, Dixon et al. 2004) while survey data suggest they may be more likely to need it (Milner et al. 2004). However, previous studies have not examined change in inequality over time. This paper presents evidence on the change in socio-economic inequality in small area use of elective total hip replacement in the English NHS, comparing 1991 with 2001. This was a period of important large-scale health care reform in England, involving at least two significant reforms that might potentially have influenced socio-economic inequality in health care delivery: (1) the introduction and subsequent abolition of the Conservative “internal market” 1991-7, and (2) the introduction in 1995 of a revised NHS resource allocation formula designed to reduce geographical inequalities in health care delivery. Two datasets, for 1991 and 2001, were assembled from routine NHS data sources: Hospital Episode Statistics (HES) on hospital utilisation in England and the corresponding decennial National Censuses in 1991 and 2001. Both datasets contain information on over 8,000 electoral wards in England (over 95% of the total). To improve comparability, a common geography of frozen 1991 wards was adopted. The Townsend deprivation score was employed as an indicator of socio-economic status. Inequality was analysed in two ways. First, for comparability with previous small area studies of hip replacement, by using simple range measures based on indirectly age-sex standardised utilisation ratios (SURs) by deprivation quintile groups. Second, using concentration indices of deprivationrelated inequality in use based on indirectly age-sex standardised utilisation ratios for each individual small area. Each SUR is the observed use divided by the expected use, if each age and sex group in the study population had the same rates of use as the national population.

Bibliographical note

© 2006 the authors. The full text of this report can be viewed free of charge from the Centre for Health Economics web site at: http://www.york.ac.uk/inst/che/pdf/rp15.pdf

Publication details

Journal Journal of epidemiology and community health
Date Published - 2006
Issue number 8
Volume 60
Number of pages 8
Pages (from-to) 686-93
Original language English

Abstract

To identify English local authorities that "overachieve" and "underachieve" in health terms, given their level of deprivation, sociodemographic context, and region.

Competition and choice in publicly funded health care

Cookson, R., Dawson, D. & Jones, A. (ed.), 2006, The Elgar Companion to Health Economics. Edward Elgar

Research output: Chapter in Book/Report/Conference proceedingChapter

Publication details

Title of host publication The Elgar Companion to Health Economics
Date Published - 2006
Publisher Edward Elgar
Original language English

Hospital Competition and Patient Choice in Publically Funded Health Care

Cookson, R. & Dawson, D., 2006, The Elgar Companion to Health Economics. Part IV, Chapter 20. Jones, A. M. (ed.). Cheltenham: Edward Elgar

Research output: Chapter in Book/Report/Conference proceedingChapter

Publication details

Title of host publication The Elgar Companion to Health Economics. Part IV, Chapter 20
Date Published - 2006
Publisher Edward Elgar
Place of Publication Cheltenham
Editors Andrew. M. Jones
Original language English

Publication details

Journal International Journal of Technology Assessment in Health Care
Date Published - 2006
Issue number 1
Volume 22
Number of pages 9
Pages (from-to) 1-9
Original language English

Abstract

Health technology assessment (HTA) currently focuses on efficiency, rather than equity, on the basis that its primary objective is to maximize population health. Yet a strict cost-effectiveness approach sometimes conflicts with important equity concerns, such as the reduction of socioeconomic health inequalities. Managing such equity-efficiency trade-offs on the basis of intuition is unsatisfactory in a democracy, as it arouses suspicions of special pleading and favoritism toward vested interests. Over the next few decades, therefore, decision making may progress through up to three further stages of development observed historically in other areas of resource allocation. Stage two involves case law, limited to principles distilled from precedent. Stage three involves codification, seeking to generalize these principles without specifying their relative weights. Finally, at stage four, quantitative trade-offs are incorporated into a formula. At stage four, deliberation centers on adjustments to the formula, which would then be applied impartially, transparently, and fair-mindedly to all future decisions. Methods already exist for valuing equity-efficiency trade-offs, based on established methodological principles for valuing trade-offs between different dimensions of health. Early findings indicate that the general public thinks that social class inequalities are more inequitable than those by smoking status, with inequalities between the sexes somewhere in between. Relative weights can be calculated from these data, although the data are not yet comprehensive enough to do this credibly for current policy purposes. In the mean time, the equity-efficiency trade-offs suggested by current decisions can be estimated using standard cost-effectiveness analysis. This is because every departure from a strict cost-effectiveness approach has an opportunity cost. The size of that opportunity cost is a test of how much weight a particular equity concern is deemed to merit.

Publication details

Journal Journal of Health Services Research & Policy
Date Published - 2006
Issue number 1
Volume 11
Number of pages 4
Pages (from-to) 27-31
Original language English

Abstract

Objective: The new contract for primary care in the UK offers fee-for-service (FFS) payments for a wide range of activities in a quality outcomes framework (QOF), with payments designed to reflect likely workload. This study aims to explore the link between these financial incentives and the likely population health gains. Methods: The study examines a subset of eight preventive interventions covering 38 of the 81 clinical indicators in the quality framework. The maximum payment for each service was calculated and compared with the likely population health gain in terms of lives saved per 100,000 population based on evidence from McColl et al. (1998). Results: Maximum payments for the eight interventions examined make up 57% of the total maximum payment for all clinical interventions in the (QOF). There appears to be no relationship between pay and health gain across these eight interventions. Two of the eight interventions (warfarin in atrial fibrillation and statins in primary prevention) receive no incentive. Conclusions: Payments in the new contract do not reflect likely population health gain. There is a danger that clinical activity may be skewed towards high-workload activities that are only marginally effective, to the detriment of more cost-effective activities. If improving population health is the primary goal of the NHS, then FFS incentives should be designed to reflect likely health gain rather than likely workload.

2005

Publication details

Journal Health Economics
Date Published - Aug 2005
Issue number 8
Volume 14
Number of pages 13
Pages (from-to) 817-829
Original language English

Abstract

This explores the applicability of Sen's capability approach to the economic evaluation of health care programmes. An individual's 'capability set' describes his freedom to choose valuable activities and states of being ('functionings'). Direct estimation and valuation of capability sets is not feasible at present. Standard preference-based methods such as willingness to pay are feasible, but problematic due to the adaptive and constructed nature of individual preferences over time and under uncertainty. An alternative is to re-interpret the QALY as a cardinal and interpersonally comparable index of the value of the individual's capability set. This approach has limitations, since the link between QALYs and capabilities is not straightforward. Nevertheless, the QALY approach is recognisable as an application of the capability approach since it pays close attention to functionings, through the use of survey-based multi-attribute health state valuation instruments, and permits conceptions of value other than the traditional utilitarian ones of choice, desire-fulfilment and happiness. Furthermore, suitably re-interpreted, it can account for (i) non-separability between health and non-health components of value; and suitably modified it can also account for (ii) process attributes of care, which may have a direct effect on non-health functionings such as comfort and dignity, and (iii) sub-group diversity in the value of the same health functionings. Copyright (c) 2005 John Wiley & Sons, Ltd.

Publication details

Journal British Journal of Surgery
Date Published - Jun 2005
Issue number 6
Volume 92
Number of pages 7
Pages (from-to) 700-706
Original language English

Abstract

Background: This study examined the short-term cost-effectiveness and long-term cost of laparoscopic Nissen fundoplication (LNF) versus maintenance proton-pump inhibitor (PPI) medication for severe gastro-oesophageal reflux disease (GORD) based on a randomized clinical trial.

Methods: Costs and outcomes for 12 months were obtained from the first 100 patients in the trial. Detailed costing was performed using resource use data from hospital records and general practitioners' notes. Short-term incremental cost-effectiveness ratios, calculated as the cost difference divided by the effectiveness difference between LNF and PPI therapy, were analysed using net benefit and bootstrap approaches. Long-term cost was examined using sensitivity analyses incorporating published data from other large series.

Results: The incremental cost of LNF compared with PPI therapy per additional patient returned to a physiologically normal acid score (less than 13.9) at 3 months was 5515 pound (95 per cent confidence interval (c.i.) 3655 pound to 13 pound 400) and the incremental cost per point improvement in combined Gastro-Intestinal and Psychological Well-being score at 12 months was 293 pound (90 per cent c.i. 149 pound to 5250) pound. On average, LNF cost 2247 pound (95 per cent c.i. 2020 pound to 2473) pound more than PPI therapy in year 1 and broke even in year 8. Break-even was highly sensitive to hospital unit costs but less sensitive to PPI ingestion rate after LNF, LNF reoperation rate, PPI relapse rate, future PPI price, PPI dose escalation and discount rate.

Conclusion: From a National Health Service perspective, LNF may be cost-saving after 8 years compared with maintenance PPI therapy for the treatment of GORD.

Do the incentive payments in the new NHS contract for primary care reflect likely population health gains?

Cookson, R. & Fleetcroft, R., May 2005, York, UK: Centre for Health Economics. 13 p. (CHE Research Paper)

Research output: Book/ReportCommissioned report

Publication details

Date Published - May 2005
Number of pages 13
Publisher Centre for Health Economics
Place of Publication York, UK
Original language English

Publication series

Name CHE Research Paper
Publisher Centre for Health Economics

Abstract

Objective: The new contract for primary care in the UK offers fee-for-service payments for a wide range of activities in a quality outcomes framework, with payments designed to reflect likely workload. This study aims to explore the link between these financial incentives and the likely population health gains. Methods: The study examines a subset of eight preventive interventions covering 38 of the 81 clinical indicators in the quality framework. The maximum payment for each service was calculated and compared with the likely population health gain in terms of lives saved per 100,000 population based on evidence from McColl et al. (1998). Results: Maximum payments for the eight interventions examined make up 57% of the sum total maximum payment for all clinical interventions in the quality outcomes framework. There appears to be no relationship between pay and health gain across these eight interventions. Two of the eight interventions (warfarin in atrial fibrillation and statins in primary prevention) receive no incentive. Conclusions: Payments in the new contract do not reflect likely population health gain. There is a danger that clinical activity may be skewed towards high-workload activities that are only marginally effective, to the detriment of more cost effective activities. If improving population health is the primary goal of the NHS, then fee-for-service incentives should be designed to reflect likely health gain rather than likely workload.

Bibliographical note

© 2005 R. Fleetcroft, R. Cookson. The full text of this report can be viewed free of charge from the Centre for Health Economics web site at: http://www.york.ac.uk/inst/che/pdf/rp3.pdf

Regulating health care markets

Cookson, R., Goddard, M., Gravelle, H., Smith, P. C. (ed.), Ginnelly, L. (ed.) & Sculpher, M. (ed.), 2005, Health policy and economics: opportunities and challenges. Maidenhead: Open University Press, p. 121-147 27 p.

Research output: Chapter in Book/Report/Conference proceedingChapter

Publication details

Title of host publication Health policy and economics: opportunities and challenges
Date Published - 2005
Pages 121-147
Number of pages 27
Publisher Maidenhead: Open University Press
Original language English

Publication details

Journal Health statistics quarterly / Office for National Statistics
Date Published - 2005
Issue number 25
Number of pages 6
Pages (from-to) 12-7
Original language English

Abstract

Data on 25.6 million adults from the UK 2001 Census were analysed to compare the regional pattern of self-rated health of the long-term unemployed to that of people from different social classes and of those who have never worked. The results show that the health of the long-term unemployed was better in high unemployment regions, and conversely, worse where the local labour market was traditionally stronger. This is the reverse of the regional pattern found-for different social classes and for those who have never worked.

2004

Publication details

Journal Journal of epidemiology and community health
Date Published - 2004
Issue number 7
Volume 58
Number of pages 7
Pages (from-to) 590-6
Original language English

Abstract

To examine the relation between class, gender, and self rated health in adults in Great Britain.

Publication details

Journal BMJ (Clinical research ed.)
Date Published - 2004
Issue number 7447
Volume 328
Number of pages 3
Pages (from-to) 1043-5
Original language English

Abstract

To examine individual social class inequalities in self rated general health within and between the constituent countries of Great Britain and the regions of England.

2003

Publication details

Journal Health Policy
Date Published - Feb 2003
Issue number 2
Volume 63
Number of pages 7
Pages (from-to) 133-9
Original language English

Abstract

This paper examines the current state of evaluations of health care interventions in the European Union, from the identification and commissioning of research through to its impact on policy and practice. Material is drawn from a survey conducted for the ASTEC project as well as a review of literature. Although the use of evaluative research has increased substantially in the last decade, both the pace of change and preferred research methodologies employed differ markedly. Much research still concentrates on issues of safety, efficacy and effectiveness, although there is evidence of an increasing emphasis on cost-effectiveness. Many countries are beginning to introduce systems linking economic evaluation to the decision-making process, while networks for the exchange of information continue to evolve. Research capacity in the public sector, although improving, is uneven, in part due to the uncertainty over long term career prospects and competition from industry. Capacity building measures should in particular ensure that dissemination expertise is strengthened, and that more emphasis is placed on developing receptor capacity within different stakeholder groups. Linking knowledge production to changes in practice remains a key challenge. Further research on implementation and impact assessment is required, to help demonstrate the value of evaluations on both policy and practice.

Publication details

Journal Health Policy
Date Published - Feb 2003
Issue number 2
Volume 63
Number of pages 12
Pages (from-to) 167-78
Original language English

Abstract

Throughout the developed world, economic evaluation of costly new pharmaceuticals and medical devices became increasingly widespread and systematic during the 1990s. However, serious concerns remain about the validity and relevance of this economic evidence, and about the transparency and accountability of its use in public sector reimbursement decisions. In this article, we summarise current concerns in Europe, based on interviews with European health economists from industry, universities, research institutes and consulting firms. We identify five challenges for European policy-makers, and conclude that there is considerable scope for improving decision-making without damaging incentives to innovate. The challenges are: (1). full publication of the economic evidence used in reimbursement decisions; (2). the redesign of licensing laws to improve the relevance of economic data available at product launch; (3). harmonisation of economic evaluation methodologies; (4). development of methodologies for evaluation of health inequality impacts; and (5). negotiation of price-performance deals to facilitate the use of economic evidence in post-launch pricing review decisions, as information is gathered from studies of product performance in routine use.

Publication details

Journal International journal of health services : planning, administration, evaluation
Date Published - 2003
Issue number 3
Volume 33
Number of pages 28
Pages (from-to) 495-522
Original language English

Abstract

This U.K. case study combines lessons from historical assessments with new empirical analyses of trends over the last decade to inform an appraisal of the impact of social actions on health. The empirical analyses examine life expectancy in the 354 local government councils in England by first identifying those that have better or worse health than expected fromtheir socioeconomic profile, and then selecting paired sets of "overachievers" and "underachievers" for more in-depth analysis. The findings taken as a whole provide evidence that social policies and political context do indeed matter for health. The historical material from the first industrial revolution, in particular, provides some of the most compelling evidence for this proposition. The empirical analyses over the last decade found a very powerful inverse association: the more deprived the local council, the lower the life expectancy of the population within that locality. However, even for the same level of deprivation and socioeconomic characteristics, some councils were doing much better than others in terms of health: for example, more than three years difference in life expectancy for carefully matched "urban fringe" councils. The article then examines the councils' political makeup and hence their likely policy perspective.

2001

Publication details

Journal British medical journal
Date Published - 29 Sep 2001
Issue number 7315
Volume 323
Number of pages 3
Pages (from-to) 743-745
Original language English

Abstract

The Scottish Intercollegiate Guidelines Network, a precursor to the National Institute for Clinical Excellence (NICE) in England and Wales, has not yet started to consider cost effectiveness. NICE considers cost effectiveness but has been reluctant to advise against funding many costly new pharmaceuticals in the NHS in England and Wales. NICE must devise politically acceptable ways of refusing to spend taxpayers' money on costly new drugs and devices that lack demonstrable incremental cost effectiveness. Otherwise, new and often inefficient technologies will continue to fuel the widening gap between public expectations and public willingness to pay for the NHS. NICE should prioritise new national guidance within a fixed growth budget for the net cost of new technologies and in relation to incremental cost effectiveness. If reducing postcode rationing would compromise more important goals of equity or efficiency, NICE should sometimes refuse to issue definite national guidance.

Bibliographical note

© 2001 BMJ Publishing Group Ltd

Measurement issues concerning equity in health

Carr-Hill, R., Williams, A. H., Oliver, A. (ed.), Cookson, R. (ed.) & McDaid, D. (ed.), 2001, Issues panel on Equity in Health: the discussion papers. London: Nuffield Trust, p. 27-30 4 p.

Research output: Chapter in Book/Report/Conference proceedingChapter

Publication details

Title of host publication Issues panel on Equity in Health
Date Published - 2001
Pages 27-30
Number of pages 4
Publisher Nuffield Trust,
Place of Publication London
Original language English

Equity in health: a note on resource allocation

Carr-Hill, R., Oliver, A. (ed.), Cookson, R. (ed.) & McDaid, D. (ed.), 2001, Issues panel on Equity in Health: the discussion papers. London: Nuffield Trust,

Research output: Chapter in Book/Report/Conference proceedingChapter

Publication details

Title of host publication Issues panel on Equity in Health
Date Published - 2001
Publisher Nuffield Trust,
Place of Publication London
Original language English

Publication details

Journal Journal of Public Health Medicine
Date Published - 2001
Issue number 4
Volume 23
Number of pages 6
Pages (from-to) 329-34
Original language English

Abstract

General practices undertake annual immunization campaigns to protect susceptible patients against influenza. Many practices, however, do not adopt effective approaches and there is great variation in the immunization rates achieved. This study aimed to assess the attitudes of primary care staff to the annual immunization programme, the obstacles they face, and possible reasons for the wide variation in immunization rates.

2000

Equity in Health

Williams, A., Cookson, R. & Newhouse, J. P. (ed.), 2000, Handbook of Health Economics. 1B: Elsevier Science B.V.

Research output: Chapter in Book/Report/Conference proceedingEntry for encyclopedia/dictionary

Publication details

Title of host publication Handbook of Health Economics
Date Published - 2000
Publisher 1B: Elsevier Science B.V.
Original language English

Publication details

Journal International Journal of Technology Assessment in Health Care
Date Published - 2000
Issue number 2
Volume 16
Number of pages 12
Pages (from-to) 639-650
Original language English

Abstract

This paper discusses the challenges facing health technology assessment (HTA) in Europe, based on an explicit analysis of the characteristics of an "optimal" HTA system. It has three objectives: a) to elaborate an explicit system of policy goals and the characteristics of an optimal HTA system that facilitates the achievement of these goals; b) to identify the general institutional incentive barriers (government and market failures) that prevent the attainment of an optimal HTA system in Europe; and c) to argue that evaluation of the implications of health technologies for equity and inequality in health is an essential part of this optimal system and a considerable challenge for HTA decision makers. especially as national governments realign policy toward equity goals.

1999

Publication details

Journal British medical journal
Date Published - 3 Apr 1999
Issue number 7188
Volume 318
Number of pages 4
Pages (from-to) 916-919
Original language English

Abstract

Objective To investigate the extent to which people change their views about priority setting in health care as a result of discussion and deliberation.

Design A random sample of patients from two urban general practices was invited to attend two focus group meetings, a fortnight apart.

Setting North Yorkshire Health Authority.

Subjects 60 randomly chosen patients meeting in 10 groups of five to seven people.

Main outcome measures Differences between people's views at the start of the first meeting and at the end of the second meeting, after they have had an opportunity for discussion and deliberation, measured by questionnaires at the start of the first meeting and the end of the second meeting.

Results Respondents became more reticent about the role that their views should play in determining priorities and more sympathetic to the role that healthcare managers play. About a half of respondents initially wanted to give lower priority to smokers, heavy drinkers, and illegal drug users, but after discussion many no longer wished to discriminate against these people.

Conclusion The public's views about setting priorities in health care are systematically different when they have been given an opportunity to discuss the issues. If the considered opinions of the general public are required, surveys that do not allow respondents time or opportunity for reflection may be of doubtful value.

1996

Publication details

Journal Environmental values
Date Published - Feb 1996
Issue number 1
Volume 5
Number of pages 16
Pages (from-to) 59-74
Original language English

Abstract

This article examines Sagoff's criticisms of 'Four Dogmas of Environmental Economics' (Environmental Values, Winter 1994) and argues that none of them are fatal. Many of the criticisms appear to rest on general misunderstandings about welfare economics. One misunderstanding is that transaction costs are theoretically indistinguishable from regular production costs. The theoretical distinction is that transaction costs vary under alternative policies and institutions whereas production costs are fixed by tastes, technology and endowments. Another misunderstanding is that market failure concerns only Pareto efficiency. Market failure also concerns social efficiency with respect to the 'social welfare function', a device for making explicit ethical judgments about the interpersonal distribution of welfare. A third misunderstanding is that the 'rationality assumption' drives economic theory. In fact, the explanatory power of economic models comes mainly from explicit assumptions about the constraints facing economic agents. A fourth misunderstanding is that welfare economics is used as a mechanism for making legal and political decisions. Rather, welfare economics is used as a method for informing legal and political decisions by evaluating their outcomes on the basis of individual welfare. Used properly, it can improve the democratic process by bringing hidden costs and difficult issues to the attention of both policy-makers and the wider public.