Academic Unit of
Health Economics
LEEDS INSTITUTE OF HEALTH SCIENCES
Health Economists' Study Group Conference
HESG Leeds 2015
7th - 9th January 2015, Leeds
Abstract booklet
Organising Committee
John Buckell
John O’ Dwyer
Sophie Guthmuller
Sandy Tubeuf
Roberta Longo
Thomas Veale
Silviya Nikolova
Denise Womersley
Scientific Committee
John Buckell
Paul Kind
Eirini-Christina Saloniki
Carolyn Czoski-Murray
Joachim Marti
Alison Smith
Sophie Guthmuller
Silviya Nikolova
Sandy Tubeuf
Peter Hall
John O’ Dwyer
Ge Yu
with the Health Economics At Lancaster research group (HEAL), Lancaster University
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A004
3 December 2014
Exploratory analysis of the main variables driving the Drug Reimbursement Decisions in 15 EU countries
Authors: Laia Maynou and John Cairns
Submitting author's institution: London School of Hygiene & Tropical Medicine, UK
Keywords: HTA, reimbursement, ICER
Drug reimbursement decisions are one of the foremost uses of Health Technology Assessment. Depending on the drug
and the country assessing it, the decision can be favourable, favourable with restrictions or non-favourable. The
differences in the final decision among the European Union countries are the driving force behind this paper. Our main
objective is to determine the factors that drive this decision making process. In an attempt to understand how the drug
reimbursement system works in the European Union (EU) countries, we have conducted a detailed analysis of the HTA
systems in 15 EU countries. Out of this study, we have designed a classification taking into account the particularities of
each country, going from system-level to product-specific variables. For instance, this taxonomy encompasses variables
that define the role played by economic evaluation in each decision, the initiator of the process, the level of stakeholders’
involvement and other variables showing the main characteristics of the procedure. We present an empirical analysis of
decisions for 10 EU countries with respect to a number of anti-cancer drugs to demonstrate the utility of the approach.
The results of the multi-level econometric model show that a drug-indication with a NICE non-favourable decision reduces
the probability of being accepted in another country. However, the types of cancer with lower incidence rate are more
probable to be accepted. The main conclusion is the country characteristics are significant enough to explain the decision
outcome.
A005
The Impact of Active Transportation on Health
Authors: Mark Foley and Stephanie Schauder
Submitting author's institution: Davidson College, USA
Keywords: active transportation, bicycling, walking, health, BMI, cholesterol
Active Transportation (bicycling and walking for transportation) has attracted attention for its environmental and health
benefits. In this paper, we use survey data on over 14,000 individuals from the National Health and Nutrition Examination
Survey (NHANES III). We investigate the extent to which the number of minutes spent bicycling and walking for
transportation affect ten health outcomes. We use instrumental variables to address the endogeneity caused by the
complex relationship between exercise and health. The ability to causally ascertain the impact of active transportation on
health could greatly improve cost benefit analyses on this subject. We find mixed results suggesting that active
transportation may affect some health outcomes such as weight and cholesterol, but not others such as blood pressure
and glycohemoglobin.
A006
Disability discrimination as exploitation using a simple model of monopsony in the pre- and post-DDA
period
Authors: Eirini-Christina Saloniki
Submitting author's institution: University of Leeds, UK
Keywords: monopsony, disability, discrimination, DDA, wages
The paper explains the differences in wages between the disabled and non-disabled in a monopsonistic framework.
Employers can exploit the disabled workers and potential workers by offering them lower wages to increase profits,
knowing that they face high search costs. This describes the pre-period. In the post-period, legislation (Disability
Discrimination Act in the UK, 1995) prohibits discrimination in employment and related areas hence, firms are not allowed
to treat disabled and non-disabled differently. We model these mechanisms using the simple Burdett-Mortensen (1998)
model and we propose an extension of this model to account for the non-discriminatory case. The models’ predictions
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show that non-discrimination improves the wage distribution for the disabled workers but worsens it for the non-disabled.
Data from the British Household Panel Survey between 1991 and 2009 show these predictions to have been verified.
A009
What is the effect of a wage increase on mental health? Evidence from the UK minimum wage
Authors: Christoph Kronenberg, Rowena Jacobs, Eugenio Zucchelli
Submitting author's institution: University of York, UK
Keywords: Minimum Wage, Mental Health, GHQ
Previous literature, mostly exploiting lottery winnings, has established a positive causal effect of income on mental health.
We exploit the wage increase caused by the introduction of the UK minimum wage in April 1999 to identify the impact of a
wage increase on mental health for low-wage earners. Mental Health is measured using the 12-item version of the
General Health Questionnaire. We use two treatment groups to identify individuals affected by the national minimum
wage legislation. The first treatment group includes workers whose wage in 1998 was below the minimum wage. The
second treatment group covers workers reporting to have had a wage increase due to the minimum wage legislation. By
means of difference-in-differences estimation we find that the minimum wage had no effect on the mental health of those
affected by the introduction of the minimum wage. This result does not lend support to earlier findings that an income
increase improves mental health. Several robustness checks tackling measurement error and anticipation effects are
employed confirming the main result.
A010
The value of implementation: how to invest in getting cost-effective technologies into practice.
Framework and application to novel oral anticoagulants in the prevention of stroke and systemic embolism
Authors: Rita Faria, Simon Walker, Sophie Whyte, Simon Dixon, Stephen Palmer, Mark Sculpher
Submitting author's institution: University of York, UK
Keywords: cost-effectiveness, implementation, novel oral anticoagulants
The value of implementation activities requiring funding by publicly-funded healthcare services should be assessed in a
manner consistent to that of other interventions that compete for funding from the same constrained budget. This study
proposes a framework for the evaluation of the value of implementation and applies it to the case study of novel oral
anticoagulants (NOACs) for the prevention of stroke and systemic embolism in patients with atrial fibrillation in the
National Health Service (NHS) in England and Wales. It explores the potential of value of implementation in informing
decisions on how much to invest to increase utilisation, how best to target implementation efforts and explores the impact
of uncertainties in the evidence-base. The results suggest that there is value in additional implementation activities,
particularly in targeting patients with average or poor warfarin control. At a cost-effectiveness threshold of £20,000 per
QALY gained, additional investment in an educational activity that increases utilisation by 5% in the entire population
currently on warfarin generates additional 254 QALYs vs 973 QALYs in the subgroup with average to poor warfarin
control. Most importantly, greater value to the NHS could be achieved with higher uptake of anticoagulation more
generally: switching 5% of patients potentially eligible for anticoagulation but currently on no treatment or on aspirin
would generate an additional 4,990 QALYs. This work has implications to how the technology appraisal process used for
the NHS could be improved to better help commissioners and clinicians implement guidance.
A013
Do Financial Incentives trump Clinical Guidance? Hip Replacement in England and Scotland
Authors: Irene Papanicolas and Alistair McGuire
Submitting author's institution: London School of Economics and Political Science, UK
Keywords: Financial Incentives; Hip Replacement; Activity based payment
Following devolution in 1999 England and Scotland’s National Health Systems (NHS’) diverged, resulting in major
differences in hospital payment policies. England introduced a case based payment mechanism from 2003/4, while
Scotland continued to pay through global hospital budgets. We investigate the impact this change has had on activity for
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Hip Replacement. In particular, we examine the differential financial reimbursement attached to reimbursement for
uncemented Hip Replacement in England, which has been more generous than for its cemented counterpart, although
clinical guidance from the National Institute for Clinical Excellence recommends the later. In Scotland, where providers
are not reimbursed for cases treated, this financial incentive does not exist. We use a difference-in-difference estimator,
with a number of robustness checks, to test whether the change in reimbursement across the two countries had an
influence on treatment. Our results indicate that financial incentives are directly linked to the faster uptake of the more
expensive, uncemented Hip Replacement in England, contrary to the NICE clinical guidance that advocates use of
cemented hip replacements.
A014
The Cost of Safe Sex: Evidence from an Indian natural experiment
Authors: Matthew Quaife, Aurélia Lépine, Shajy Isac, Parinita Bhattacharjee, HL Mohan, Stephen Moses, BM Ramesh,
Fern Terris-Prestholt, Peter Vickerman
Submitting author's institution: London School of Hygiene & Tropical Medicine, UK
Keywords: HIV prevention, condom use, instrumental variables, endogeneity, sex work, India
Background: Studies have shown that despite facing a substantial risk of STI and HIV acquisition, male clients are willing
to pay a premium for unprotected intercourse with female sex-workers (FSWs). Where sex is a commodity, FSWs may
face substantial high-powered incentives to provide unprotected intercourse and the higher price becomes a powerful
barrier to using condoms. The literature estimates the premium for condom use to be anywhere between 7% and 80%.
Data and Methods: We analysed condom use and pricing data from 4099 sex-workers in 5 Indian states gathered
between 2008 and 2009 as part of the Avahan HIV prevention programme. Depending on unobservable characteristics
such as productive capital or persuasion skills, some FSWs may be able to negotiate both higher prices and condom use,
biasing ordinary least-squares (OLS) estimates. To account for this endogeneity we used instrumental variables in twostage least-squares regressions.
Results and Conclusions: OLS estimation suggests condom use has a non-significant positive effect on price, although
this is likely to be biased. Using an instrumental variable (IV), we find FSWs who report consistent condom use face
income losses of 60%. A subgroup analysis reinforces the intuition of the premium, which increases in women who are
STI free and those who are sterilised. In order to effectively control the epidemic amongst FSWs it is important for HIV
prevention interventions to consider the unique incentives FSWs face, demand from clients for unprotected sex acts, and
how these hinder the effectiveness of FSW targeted interventions.
A018
The impact of long-term care on primary care doctor consultations for older people
Authors: Julien Forder, Katerina Gousia, Eirini-Christina Saloniki
Submitting author's institution: University of Leeds, UK
Keywords: substitution, social care, doctor, primary care, older people
In this paper we study the interdependency between the use of long-term care services and consultations with a primary
care doctor. Using a model of individual demand for doctor consultations we derive the hypothesis that the use of home
care by older people will reduce the number of consultations, other things equal. We test this hypothesis estimating a
series of pseudo-continuous panel models with data from the BHPS for years 1991-2009. To address potential concerns
about endogeneity we use a set of instrumental variables for home care motivated by institutional features of the social
care system. We find that there is a statistically significant substitution effect between home care and doctor visits, which
is robust across a range of specifications. This result has implications for policies that consider increased coordination
between health care and social care systems.
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A022
3 December 2014
Generic preference-based measures: Are they appropriate for use with people with Multiple Sclerosis?
Authors: Hawton, A, Green C.
Submitting author's institution: University of Exeter, UK
Keywords: Generic preference-based measures – Multiple Sclerosis – psychometrics
Aims: Condition-specific (CS) preference-based measures (PBMs) are increasing, yet the rationale for their use versus
generic (G)PBMs is debated. GPBMs, the EQ-5D and SF-6D, are commonly used in healthcare policy decision-making
regarding interventions for Multiple Sclerosis (MS), but there has been little investigation of the appropriateness of either
instrument for this condition. This research assessed the psychometric properties of these GPBMs in the context of MS.
Methods: Psychometric assessments included: i) content validity of the measures’ descriptive systems; ii) construct
(convergent and discriminative) validity of the descriptive systems and health state utility values; and iii) responsiveness.
Analyses utilised data from a UK prospective, longitudinal, cohort study of people with MS (SWIMS) (n=1,441).
Results: Specific content domains relevant to people with MS are not included in these measures, particularly the EQ-5D.
Convergent validity was high for both. Correlations with Multiple Sclerosis Impact Scale-29 scores showed the SF-6D
performed marginally better (‘Vitality’, 0.34[p<0.001] to ‘Physical functioning’, 0.78[p<0.001]) than the EQ-5D
(‘Anxiety/depression’, 0.34[p<0.001] to ‘Usual activities’, 0.66[p<0.001]). Discriminative validity (according to clinical
subgroups), was good for both measures, until the most severe health states where the EQ-5D performed better (EQ-5D,
F=60.15, p<0.001; SF-6D, F=23.85,p<0.01). Potential ceiling and floor effects on the EQ-5D and SF-6D, respectively,
were identified.
Conclusions: These findings imply the appropriateness of the EQ-5D and SF-6D for use in funding decisions relating to
people with severe and mild MS, respectively. However, limited content validity indicates the role of MS CSPBMs. This
work has also highlighted shortcomings with conventional psychometric criteria when assessing PBMs.
A024
Operationalising equivalent consumption: an informal pilot study
Authors: Ignacio Abásolo, Erik Schokkaert, Aki Tsuchiya
Submitting author's institution: The University of Sheffield, UK
Keywords: preference-based measure of wellbeing; health; online DCE
Equivalent Consumption” is a preference-based measure of individual wellbeing (some have also used the term
equivalent “income”). To illustrate with just two dimensions – “health” (h) and “material consumption” (c) – assume an
individual with a combination of health and consumption (h,c), and an associated level of wellbeing. Let h* denote full
health, and imagine another combination (h*,c’) that is equally good, to the individual, as the current combination. If we
assume that “full health” is the same across everybody, then the level of consumption c’ alone represents the level of
wellbeing that is equivalent to the individual’s current level of wellbeing. This c’ is equivalent consumption, an
interpersonally comparable uni-dimensional measure of wellbeing which collapses health and consumption based on
each individual’s own preferences. This paper reports on an informal pilot study that explored how equivalent
consumption can be measured. Measuring this using a personal perspective will allow the estimation of the respondent’s
own preferences, and of the equivalent consumption for their current situation. Alternatively, using a societal perspective
will generate the social welfare function, and thus identify their inequality aversion. A discrete choice experiment was
designed, involving three indicators of health (physical functioning, pain and depression), alongside personal relationships
and consumption, covering the immediate 12 months. The tasks were carried out in the form of sequential best worst
scaling (i.e. a series of ranking exercises) using four scenarios at a time. Paper and online versions were used with
convenience samples in Leuven and Sheffield. Data are currently being analysed.
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A027
3 December 2014
Socioeconomic inequalities in informal payments for healthcare in sub-Saharan Africa: Is the system
redistributive?
Authors: Hyacinthe Kankeu Tchewonpi
Submitting author's institution: Aix-Marseille School of Economics, France
Keywords: Socioeconomic inequalities; Informal payments; sub-Saharan Africa
In sub-Saharan African countries, informal payments are frequently made to access healthcare. Some literature
suggested that the informal payment system could lead to quasi-redistribution among patients, with physicians playing a
‘Robin Hood’ role, subsidizing the poor at the expense of the rich. We empirically tested this assumption with data from
the Afrobarometer round 3 surveys conducted in 18 sub-Saharan African countries from 2005 to 2006 and using the
‘normalized’ concentration index. We obtained that: i) the socioeconomic gradient in informal payments is in favor of the
rich in almost all countries, indicating a rather regressive system; ii) the stratification according to the gender and the
place of residence highlights some specificities in certain countries, but overall, informal payments remain highly
regressive. Although essentially empirical, the paper tries to make concluding remarks about the mechanisms that could
underline the observed inequities and makes some policy recommendations.
A034
Income-related inequality in hospital waiting times for heart revascularization: allowing for selection bias
due to alternative treatments and hospitals choice
Authors: Giuseppe Moscelli, Luigi Sicilian, Nils Gutacker, Richard Cookson
Submitting author's institution: University of York, UK
Keywords: waiting times inequalities, socioeconomic status, selection bias
Background: Equity is a key policy objective in publicly-funded health systems. In many health systems, waiting times are
the main rationing mechanism for matching healthcare demand and supply. An emerging empirical literature has
examined whether, controlling for need, individuals with different socioeconomic status (SES) face different waiting times
in publicly funded hospitals. We extend this literature by addressing two selection biases that can be seen as sources of
“fair” inequality in waiting time individual choice of (i) treatment modality and ii) hospital provider.
Data: All NHS patients undergoing non-emergency heart revascularisation through either coronary artery bypass surgery
(CABG) or percutaneous coronary intervention (PCI) in England from 2002/3 to 2010/11. SES measured by economic
deprivation at English small area neighbourhood level.
Methods: Patient and provider level panel data models with provider fixed effects and patient covariates; switching
regression models with provider fixed effects to account for selection bias.
Results: We find evidence of a significant SES gradient in both procedures analysed, showing waiting time inequality
favouring patients living in less economically deprived neighbourhoods. Pro-rich inequalities have reduced over time, but
remain significant. We find significant but small selection biases due to choice of both procedure and hospital.
Conclusion: There are socioeconomic inequalities in waiting time for heart revascularisation in the English NHS, which
cannot be fully explained by choice of treatment or hospital and which reduced but did not disappear during a period of
sustained expenditure growth and waiting time reduction in the 2000s.
A036
Loss aversion and altruism in repeated blood donation”
Authors: Sara Ribeirinho Machado
Submitting author's institution: Boston University, USA
Keywords: blood donation, financial incentives, natural experiment
Policy makers have long been concerned about the effects of economic incentives on blood donations. The goal of this
paper is to use a natural experiment to study the short¬ and long¬ run effects of the introduction and posterior removal of
a specific monetary incentive for regular blood donors. Between 2004 and 2011, donors who had donated twice within the
past 365 days would be waived user charges in using the Portuguese National Health System (NHS). I use a unique
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panel to analyze pattern of donation of all potential donors enrolled in the Lisbon center of the Portuguese Blood Institute,
between January 2003 and December 2012 (N=241,605 donors and 906,139 donations). The dataset includes detailed
information regarding health and each attempted donation, as well as sociodemographic variables. This dataset is quite
unique in its ability to identify donors throughout the period, its large sample size and its health data. New donors have
higher intervals between donations with the incentives, compared to new donors before the incentives were in place.
Regular donors (two or more donations per year) also have larger intervals between donations in this period, conditional
on fulfilling the eligibility requirements. Regular donors are very sensitive to the removal of monetary benefits, as shown
by the decrease in the frequency of donation to levels lower than the eligibility requirements. However, new donors that
join the registry after the removal of the benefit donate more frequently and helped to mitigate the effects of a short-run
blood shortage due to the negative impact on regular donations.
A038
How Does Expanded Public Health Insurance Coverage Impact Health Care Use of Students? Evidence
from a Natural Experiment in France
Authors: Sophie Guthmuller and Florence Jusot
Submitting author's institution: University of Leeds, UK
Keywords: Public health insurance, difference-in-differences, France
This study aims at evaluating the effect of a more generous public health insurance coverage on health care utilization in
France within a student population. Using two specific features of the public health insurance system in France, we run a
difference-in-differences analysis: (1) A ‘local’ public health insurance system exists in two local authorities that were
under German occupation between 1871 and 1918. This local system called “Alsace-Moselle scheme” is a health
insurance plan that offers employees in the Alsace region and the Moselle department a lower copayment than the
‘national’ public health insurance scheme in the rest of France, in return to increased employees’ contributions. (2) Under
the age of 20, students are covered by the same health insurance policy as their parents. Over 20, all students are
covered by the national health insurance policy. Students whose parents are covered by the Alsace-Moselle scheme
benefit from this local plan until the age of 20 and are covered by the national scheme afterwards. We then use the loss
of the local insurance benefit that occurs by law for students over the age of 20 to identify the causal effect of the more
generous plan on health care utilization. We evaluate the impact of the more generous plan on ambulatory health care
expenses using data from a health insurance provider in Eastern France. This provider offers compulsory and
complementary coverage and has the originality of covering enrolled students in the local “Alsace-Moselle” scheme and
students enrolled in the national scheme.
A040
Value judging, fast and slow: an experimental study of the effects of slow thinking interventions on
expressed health inequality aversion
Authors: Richard Cookson, Shehzad Ali, Aki Tsuchiya, Miqdad Asaria
Submitting author's institution: University of York, UK
Keywords: Health inequality, slow thinking, value elicitation
Background: Value judgements are vulnerable to “fast thinking” cognitive biases, yet public opinion surveys rarely offer
opportunities for “slow thinking” or careful deliberation. We investigate this issue in the context of cognitively demanding
trade-offs between improving total health versus reducing socioeconomic health inequality. Many previous studies have
found a high proportion of respondents appearing to express infinite inequality aversion.
Aim: To test the effects of two slow thinking interventions on expressed aversion to socioeconomic health inequality.
Methods: Sixty members of the public were randomised to complete either a standard paper questionnaire, or a
computer-based interactive questionnaire providing feedback on the implications of alternative choices (intervention 1).
Both groups were then exposed to a video animation debate between characters arguing for different choices based on
different ethical principles (intervention 2), and asked to complete the questionnaire again. We conducted between- and
within-subject tests by modelling the level of inequality aversion using ordered probit regressions.
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Preliminary Results: Compared with the paper questionnaire, the computer-based interactive questionnaire resulted in
fewer respondents supporting infinite inequality aversion and more supporting zero inequality aversion. Furthermore,
exposure to the animated debate reduced the proportion of both such responses across the groups.
Conclusion: Slow thinking interventions can help value elicitation questionnaires to better capture the diversity of public
opinion about cognitively demanding value trade-offs, and to reduce the risk of attributing “polar extreme” views to people
with nuanced opinions.
A042
Exploring the evaluative framework within economic evaluation: the case of social and behaviour
network therapy (SBNT) for heroin users
Authors: Ilias Goranitis, Joanna Coast, Emma Frew
Submitting author's institution: University of Birmingham, UK
Keywords: Evaluative framework; ICECAP; Drug misuse
Background: Economic evaluation is conducted from a conventional NHS/PSS perspective whereby costs and outcomes
relevant to health care and personal social services are included. Proponents for broadening this evaluative space argue
that these methods are too narrow and fail to reach benefits that go beyond the dimensions of health, or go beyond
patients. This is particularly important within the context of drug misuse as interventions are aimed at improving wider
wellbeing and can generate positive externalities that would, under this conventional approach, be ignored.
Aim: This study reports on a pilot trial designed to measure the cost-effectiveness of social behavioural network therapy
(SBNT) for heroin users and explores the impact of broadening the evaluative space within economic evaluation.
Methods and Results: Cost data were collected using the ‘Client Service Receipt Inventory’ which measures health care,
productivity, criminal justice service and community-related costs. Outcomes were measured using the EQ-5D and the
ICECAP. Both costs and outcomes for the clients and network members were measured. The economic evaluation will
be conducted from 3 perspectives: 1. Conventional: NHS/PSS costs and outcomes included; 2. Wider (clients only):
Costs and outcomes from wider perspective for clients included. 3. Wider (clients and network members): Costs and
outcomes from wider perspective for clients and network members included. The results will highlight the impact of
broadening the evaluative space with respect to the cost-effectiveness of SBNT. The discussion will focus on the
implications of this result with respect to the methodological lessons and treatment policy for drug misuse.
A044
Cognitive Impairment and Healthcare Utilisation Amongst the Ageing Population: An analysis of SHARE
data
Authors: Brenda Gannon, James Banks, James Nazroo, Luke Munford
Submitting author's institution: University of Manchester, UK
Keywords: Healthcare utilisation; Ageing Population; Cognitive Impairment
Background: The ageing population is a major area for policy concern, with the ever increasing strains placed on health
budgets. One overlooked area of research is the impact that cognitive impairment (an early marker of potential dementia
onset) has on the healthcare utilisation of an ageing population, conditional on other health conditions.
Aims: Based on the theoretical foundations of health care demand (Grossman), we study the relationship between
cognitive impairment, measured by word recall, and healthcare utilisation among over 50s in nine European countries.
Due to observable difference in healthcare systems across Europe, we provide separate analyses based on: (i) GPGatekeeping (GP-GK); (ii) funding – taxation vs. Supplementary Health Insurance (SHI); (iii) the level of informal care
provision.
Data/Methodology: Using data from Waves 1, 2, and 4 of the Survey of Health, Ageing and Retirement in Europe
(SHARE), healthcare utilisation is modelled as a count variable, in pooled cross-sectional and fixed and random effects
linear and count data regressions.
Results: Recalling one additional word leads to a reduction in visits to a medical doctor of 0.5, per year (p<0.01). Living in
a GP-GK country reduces visits, as does living in a country with SHI funding. Formal and informal care may be
compliments, as those who live in countries with high informal care provision also make more visits to medical doctors
(p<0.01).
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Conclusions: Changes in cognitive impairment lead to an increase in the number of visits to a doctor. This negative
relationship is consistent when we group countries by different characteristics.
A045
Methodological Evaluation of the Impact of Survival Costs in Oncology Modelling
Authors: Taylor M, Filby A, Proudfoot C
Submitting author's institution: University of York, UK
Keywords: Modelling, oncology, cost-effectiveness
Economic evaluations typically include all costs relevant to a disease. This is particularly relevant to oncology modelling,
as costs are assigned to each health state in the model, and, therefore, extending survival also increases costs. Because
patients often incur higher healthcare costs in the post-progressed state of disease where costs of disease management
are high, extending survival and increasing a patient’s time in the post-progressed stage can be particularly costly. The
objective of this research was to investigate the methodology used in oncology modelling, and to determine the effect that
this has on predicted cost-effectiveness.
Methods: We developed a flexible three-state economic model with ten key parameters to calculate the ICERs associated
with various combinations of inputs. Extensive scenario and multiway sensitivity analyses were carried out to document
informative patterns and relationships between parameters that affected the results.
Results: Results showed that in some cases with higher post-progression costs, the likelihood of a treatment being costeffective decreased as the effectiveness of the treatment improved. The results demonstrate circumstances in which no
matter how effective a treatment is and how low the price is, it will not be cost-effective.
A046
Social Health Insurance and Health Care Utilization: Evidence from New Rural Cooperative Medical
Scheme in China
Authors: Miaoqing Yang
Submitting author's institution: Lancaster University, UK
Keywords: health insurance; propensity score matching; difference-in-difference
Aim: In 2003, China introduced a heavily subsidized voluntary health insurance program, the New Rural Cooperative
Medical Scheme (NRCMS). The program aimed to increase access to health care and reduce the financial burden of
health expenditure faced by rural residents. This paper evaluates the effectiveness of the NRCMS by assessing its impact
on health care utilization and people’s treatment-seeking behavior.
Methods: As the program is a non-random policy initiative rolled out nationally, propensity score matching (PSM) with
difference-in-difference and flexible difference-in-difference methods are employed based on data from the China Health
and Nutrition Survey (CHNS) from 1991 to 2006.
Results: No evidence is found for the utilization of formal medical care, preventive services or folk doctor utilization. There
are some substitution effects across different levels of health providers: A large, negative effect on the utilization of
village clinics is observed, as well as large, positive effects in town hospitals and county hospitals.
Conclusion: The results indicate that the NRCMS does not increase the overall utilization but directs people away from
primary care towards secondary- and tertiary-level medical facilities. The substitution effects may indicate that the
NRCMS alleviates financial barriers to accessing higher levels of medical care and help patients to access better quality
care.
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A049
3 December 2014
Care home placement following hospital admission: does the quality primary care for people with
dementia matter?
Authors: Panos Kasteridis, Anne Mason, Maria Goddard, Rowena Jacobs, Rita Santos, Beatriz Rodriguez
Submitting author's institution: University of York, UK
Keywords: Dementia, Primary Health Care, Patient Discharge, Nursing Homes
Aims: GPs are paid to identify and review patients with dementia as part of the Quality and Outcomes Framework (QOF).
The reviews are intended to address the patient’s and carer’s support needs, the patient’s physical and mental health,
and to assess communication and coordination arrangements across care boundaries. Patients on an acute hospital ward
should not be transferred directly to long-term residential care unless there are exceptional circumstances. Support
provided though the QOF review may help prevent placements, but this has not previously been tested.
Methods: We ran multilevel logit models to test the impact of practice performance on the dementia QOF indicator on the
risk of discharge to nursing home following acute hospital admission. Our response variable was nursing home placement
following emergency admission for people with a primary diagnosis of dementia. As people with dementia often have
complex health and social care needs, we adjusted for an array of potential confounders.
Data: 37,783 individuals for the years 2006/7 to 2010/11. We merged admissions data from Hospital Episode Statistics,
neighbourhood statistics, and QOF practice data.
Results: Risk factors for discharge to nursing home following admission were age, female gender, incontinence, falls,
senility, and number of comorbidities. When assessed as a practice-level indicator of quality, the QOF dementia review
was not associated with risk of nursing home placement.
Conclusions: The QOF review does not appear to influence risk of discharge to nursing home for this patient group. We
plan to extend the analysis to admissions for ambulatory care sensitive conditions.
A051
Do practices with more GPs have fewer emergency hospital admissions for ambulatory care sensitive
conditions?
Authors: Hugh Gravelle, Steve Martin, Rita Santos
Submitting author's institution: University of York, UK
Keywords: primary care, ACSCs, GP practice resources
Aims: Ambulatory Care Sensitive Conditions (ACSCs) are conditions which, if managed appropriately in primary care
should not result in emergency admissions. We examine (a) whether practice characteristics (number of GPs and
measures of practice quality) affect ACSC admissions and (b) whether the number of GPs affects practice quality.
Data: Panel (2006/7-2011/12) of 7000+ English practices with data from Hospital Episode Statistics, Attribution Data Set,
Quality and Outcomes Framework, General Practice Patient Survey, Neighbourhood Statistics. Quality is measured by
QOF clinical performance, and the proportions of patients able to make urgent appointments, to make advance
appointments, and to see their preferred GP.
Methods: Negative binomial models of ACSC emergency admissions (overall, incentivised, unincentivised, and for
specific conditions). Linear models of the four quality measures.
Results: ACSC admissions are lower in practices with higher scores on the four quality measures and with more GPs.
Practices with more GPs have higher proportions of patients able to make urgent and to make advance appointments and
a smaller proportion of patients able to see their preferred GP. There is no association between the number of GPs and
QOF clinical performance.
Conclusions: The number of GPs in a practice has both direct and indirect effects on ACSC emergency admissions.
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A056
3 December 2014
Waiting Time Targets and Health Care Quality: Empirical Investigation of the English Acute Trusts
Authors: Shimaa Elkomy
Submitting author’s institution: University of Surrey
Keywords: waiting time, quality outcome, dynamic panel analysis
The difficulty of measuring public services outcome results in governments adopting some quality performance
measurements to oversee the standards and characteristics of the presented services. This paper examines the
effectiveness of the waiting time target set by the English National Health Care Service which is used as a benchmark for
assessing the performance of the hospital. The empirical investigation assesses the quality performance of the hospitals
with relevance to their average waiting times and the patients waiting more than the target of 13 weeks in 146 acute trusts
in England from 2009 to 2013. The study examines to which extent the waiting time policy would result in higher quality
service and better health outcomes. The empirical analysis uses four sets of quality indicators including overall patient
experience score, health gain scores in four operations as reported by patients (PROM), the percentage of cancelled
operations and number of patients not treated within 28 days of last minute cancellation. The basic results show that
waiting times could reflect some dimensions of the quality of the health care unit but this association is not systemic and
does not always hold
A057
Estimating the demand for endocrinologist visits in diabetics
Authors: Andrade LF, Rapp T, Sevilla-Dedieu C
Submitting author's institution: MGEN Foundation for Public Health, Paris, France
Keywords: diabetes management, health costs, count data
Diabetes is today a major public health concern as regarding its financial and social burden. The motivation of this paper
is due to previous estimations revealing that specialist care amongst diabetics leads to more positive outcomes compared
to GP only follow-up. Hence, the aim of this research is to estimate the demand function for endocrinologist visits
amongst diabetics. We used a two part model to estimate both the decision and frequency of care. We used claim data
collected for 66,508 affiliates of a major French social security provider. Patients were aged over 18 and treated for
diabetes (types I and II). We controlled for patients’ socioeconomic characteristics, type of diabetes treatment, medical
care, and health status. We also controlled for macro-level variables, such as the cost for a visit, the distance to the
nearest endocrinologist’s office and the medical density. Results show that parameters driving the probability of speciality
care amongst diabetics are considerable different from factors associated to the frequency of visits. Besides age,
socioeconomic determinants follow the predictions of theory. A large income effect was found for the decision to consult
only, whereas opportunity costs of travel to the office have a negative impact on both decisions. The price of the
consultation is a barrier to seeing an endocrinologist, but is positively correlated with the frequency of visits, which may
indicate that the price is perceived as a measure of quality of care provided to patients.
A061
On the estimation of the monetary value of a QALY: is the dilemma really over?
Authors: Laura Vallejo-Torres, Borja García-Lorenzo, Iván Castilla, Lidia García-Pérez, Renata Linertová, Cristina
Valcárcel-Nazco
Submitting author's institution: Universidad de la Laguna and Servicio de Evaluación y Planificación, Spain
Keywords: Quality-Adjusted Life Year (QALY), willingness to pay, threshold
Many health care systems claim to incorporate the cost-effectiveness criterion in their investment decisions. However,
information on the system’s willingness to pay per effectiveness unit, normally measured as Quality-Adjusted Life Years
(QALY), is not available in many contexts. Different perspectives and methodologies have been proposed in the literature
to arrive at such a threshold value. The aim of this work is to identify and critically appraise the methodologies used to
date to estimate the monetary value of a QALY (MVQALY) in the empirical international literature, and ultimately to
investigate how such a value can be obtained for the Spanish context. We undertook a systematic review of empirical
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analyses on the MVQALY, and constituted an expert panel to conduct a discussion process on methodological issues.
Identified studies were categorised as taking a demand perspective, i.e., articles estimating the value that society places
on a QALY; and as taking a supply perspective, i.e., those estimating the incremental cost per QALY gained that a
system can afford given their budget constraints. These studies show different underpinning assumptions, strengths and
limitations that are highlighted and discussed. The discussion process is currently ongoing to inform the design of the
next stage of this project that aims to generate the most appropriate evidence for decision makers to set a costeffectiveness threshold in Spain. We hope this discussion will be enhanced by a participative debate by HESG audience.
A063 Understanding how to estimate the cost of long term conditions in children: the example of juvenile
idiopathic arthritis
Authors: Wendy Gidman, Ian Jacob, Linda Davies, Julie Ratcliffe, Roberto Carrasco, Kimme Hyrich, Deborah Symmons
Submitting author's institution: University of Manchester
Keywords: economic evaluation, productivity loss, indirect costs
Background The National Institute for Health and Care Excellence (NICE) apply cost-effectiveness analyses (CEA) to
inform priority setting. Approaches to estimate costs employ diverse methodologies and perspectives. Ideally a societal
perspective is needed, to capture the costs of all the associated consequences of treatments, regardless of who bears
them. Juvenile idiopathic arthritis (JIA) is a complex condition requiring multiple medical appointments. Some treatments
are only available in specialist centres increasing travel and lost productivity costs. Including travel and productivity loss
costs in CEA is problematic because methods of estimating these costs vary and are ill-defined for carers and
children. This paper examines estimation methods for these costs in JIA.
Methods The Childhood Arthritis Prospective Study was used to estimate direct costs. Travel distances for appointments
were explored using ggmap. Other carer and child costs are multifaceted and include:



Time to attend hospital clinic
Time off work/school as an input to care production or consequence of illness
Long-term impact on child and carer productivity
Results and implications Preliminary analysis suggests a high number of hospital appointments were recorded in 3 years
(median 18; range 1-107). Data were positively skewed with some patients likely to incur considerable costs associated
with travel and reduced parent’s and children’s productivity. The long-term implications of lost productivity for parents, and
in childhood, could be far reaching. NICE does not consider these costs currently. Our finding has broader implications for
treatment costs in the UK, as health policy is centralising care in specialist centres, potentially increasing productivity
losses.
A066
Estimating the Level of Health Inequality Aversion in England
Authors: Matthew Robson, Miqdad Asaria, Richard Cookson and Shehzad Ali
Submitting author's institution: University of York, UK
Keywords: Inequality, Aversion, Health
Objective: To elicit a specific inequality aversion parameter, in the domain of health, from the general public; by analysing
questionnaire-based survey data and extending the existing Social Welfare Function literature.
Introduction: A Social Welfare Function is a way of explicitly articulating a coherent set of social value judgements with
respect to the trade-off between equity and efficiency that society is willing to make. In order to establish a level of Social
Welfare for the existing, and potential, distributions within society a specific inequality aversion parameter is required.
Methods: Analysis of questionnaire-based survey data from the English public (n = 933) was conducted. The existing
literature was built upon to enable the elicitation of these parameter values for the Atkinson, Kolm, Extended Gini,
HRSWF and Hyperbolic Indices.
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Results: The amount of total health willing to be sacrificed in order to marginally increase the health of the worst-off is
4.46. The specific inequality aversion parameters are as follows; Atkinson: 10.5894, Kolm: 0.1474, HRSWF: 9.5894,
Hyperbolic: 12.6260, Extended Gini: 1.9125.
Conclusion: Society is willing to make a trade-off between maximising total health and reducing the inequality gap, where
societal preference reflects the philosophical standpoint of a "Weighted Prioritarian". The parameters elicited could be
utilised as benchmark values in Distributional Cost-Effectiveness Analysis, enabling societal aversion to inequality to be
incorporated in policy decisions regarding health care in England.
A070
The impact of the French Law 1987 on the employment of disabled people: an evaluation by the triple
difference methodology
Authors: Thomas Barnay, Emmanuel Duguet, Christine Le Clainche, Mathieu Narcy, Yann Videau
Submitting author's institution: Université Paris-Est Créteil, France
Keywords: Difference in difference methodology, durable disability, career paths, French handicap legislation
In France, the 1987 Law set up a legal quota of disabled workers in more than 20 employees companies. In order to
encourage employers to better integrate disabled workers into the labour market, this law decreed financial penalties for
non-compliance. The goal of this paper is to evaluate the impact of this Law on the employment of disabled people by
using a triple difference method, in order to disentangle the specific effect of the legislation.
On the basis of a panel data built from the “Santé et itinéraire professionnel” (“Health and Labor Market Histories”) survey
conducted in France in 2006-2007, we investigate whether handicaps have a significant impact on individuals’
performance in the labour market depending on the sector of employment (private and public), distinguishing the
handicap status (permanent or compensated).
At first, we use the difference in differences methodology with exact dynamic matching in order to control for both
observable and unobservable correlated heterogeneity and lagged endogenous variables. Then we compare the labor
position of disabled people with the labor position relative to individuals without disabilities before and after the setting up
of the law.
Our findings highlight the counterproductive impact of the law on the employment of people with disabilities. Indeed, it
seems that the implementation of this law has led employers to hire fewer workers with disabilities directly, as if they
would prefer to pay a penalty, whatever the definition of the handicap is. Nevertheless, only the handicapped people
working in the public sector undergo a negative shock on career.
A071
Choice of hospital for hip replacement: Do patient-reported outcome measures (PROMs) matter?
Authors: Nils Gutacker, Luigi Siciliani, Giuseppe Moscelli, Hugh Gravelle
Submitting author's institution: University of York, UK
Keywords: PROMs, hospital choice, conditional logit, quality of care
Background: Patient-reported outcome measures (PROMs) have been collected in the NHS since April 2009. One of the
stated objectives of this initiative is that patients can use this information to decide where to seek care. This implies that
demand responds to quality as measured by PROMs. However, whether this is the case has not been explored
empirically.
Aims: a) To estimate the elasticity of hospital demand for hip replacement surgery to changes in hospital PROM scores
and b) to explore whether this elasticity is a function of patients’ pre-treatment health and other characteristics.
Data: Hospital Episode Statistics linked to published hospital PROM scores and the PROM survey for the years 20092011. All NHS-funded patients undergoing unilateral elective and emergency hip replacement in public and private
providers, excluding patients undergoing revision surgery.
Methods: We estimate conditional and random coefficient logit models. We address endogeneity in waiting time and
quality using lagged variables and compare choices made by elective and emergency patients. We discuss the conditions
under which this comparison can be interpreted as an estimate of the causal effect of quality on demand.
Results: We find a statistically significant positive association between PROM scores and demand, independent of the
choice of PROM or modelling strategy. Patients in better pre-operative health tend to travel farther and are less
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responsive to quality differences. Emergency patients are also responsive to quality but less compared to elective
patients.
A074
Substitutes or Complements? Formal and co-residential informal care amongst individuals whose daily
activities are limited
Authors: Sean Urwin, Thomas Mason, Yiu-Shing Lau, Matthew Sutton
Submitting author's institution: University of Manchester, UK
Keywords: health care substitution; formal and informal care; panel data models
The UK population is projected to increase from mid-2012 to mid-2037 by 9.6 million. 13% of the population is expected
to be aged 75 and over in mid-2037 compared with 8% in mid-2012, an increase of over 50%. An ageing population will
not only increase the demand for formal care but also reduce the supply of formal care through more people taking
retirement. This study aims to analyse whether formal care and co-residential informal care are substitutes or
complements amongst those whose health affects daily activities. This captures a sample of individuals with the capacity
to benefit from informal care. We use 18 years of the British Household Panel Survey (BHPS) data (1991-2008) and
employ a range of panel data econometric methods. We also account for the potential endogeneity of informal care, by
using IV estimation. Formal care is separated into several categories including GP visits and hospital inpatient days. This
is the first study, to our knowledge, to analyse this relationship in the UK setting using a broad spectrum of formal care
measures for primary, secondary and community care. Preliminary results provide evidence that formal and co-residential
informal care are substitutes, with an extra hour of co-residential informal care per week reducing the number of GP visits
by 0.008 per year. This may suggest that increasing provision of informal care can reduce the demand for formal care,
which could allow policymakers to divert resources to other priorities.
A076
Evaluating end of life care: how close are we to getting it right?
Authors: Philip Kinghorn, Joanna Coast
Submitting author's institution: University of Birmingham, UK
Keywords: End of life care; QALYs; Capability
Background: End of life (EoL) care is characterised as care from the point at which there is no longer a curative intent.
End of life care can be thought of as the final element/phase of palliative care, which overall is broader in scope. Care at
the EoL is provided by a complex mix of healthcare professionals and non-health professionals, NHS, charity, private and
local authority providers. Care at the EoL therefore blurs the boundaries between health and social care, and private and
public providers, as well as being extreme/unique in other respects. Typically in the UK, quality adjusted life years
(QALYs) are used when evaluating healthcare interventions, but recently issued NICE guidance recommends capability
measures as a way of assessing non-health outcomes in the context of social care.
Methods: Qualitative interviews with 20 stakeholders from a range of academic and clinical disciplines (Nursing & allied
health; Palliative care and general practice; Health psychology; Health Economics; Ethics & Philosophy). Stakeholders
were asked about the purpose, nature and provision of EoL care, outcomes and economic frameworks. Audio recordings
were transcribed and analysed using constant comparison.
Results: Three viewpoints emerged relating to QALYs/CUA: (i) QALYs are appropriate conceptually and, to a large
extent, methodologically. (ii) Cost-utility analysis is appropriate conceptually, but the way it is applied in practice is too
restrictive. (iii) Serious weaknesses with the QALY are more apparent in the context of EoL care. We also explore, from
the qualitative data, the characteristics of an ‘ideal’ evaluative framework for EoL Care.
A077
Vertical Transmission of Overweight: Evidence from English Adoptees
Authors: Joan Costa-Font, Mireia Jofre-Bonet, and Julian LeGrand
Submitting author's institution: City University London, UK
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Keywords: vertical transmission, cultural transmission, obesity, overweight, children, natural parents, Body Mass Index,
sample selection.
We estimate the vertical transmission of overweight (and obesity) drawing upon a sample English children both adopted
and non-adopted and their families. Findings suggest strong evidence of an intergenerational association of overweight
among adoptees. When both adoptive parents are overweight the likelihood of an adopted child being overweight is
between 10% and 30% higher than when they are not. In contrast, our estimates for the cultural transmission of obesity
are much weaker. Overall, our findings are robust to robustness checks, specification and sample selection corrections
and do not confirm the existence of a female labour market participation penalty on child obesity among adoptees.
A078
Valuing the health and wellbeing aspects of Community Empowerment in Urban Regeneration
programmes using economic evaluation techniques; a discrete choice experiment
Authors: Camilla Baba, Dr. Emma McIntosh, Prof. Carol Tannahill
Submitting author's institution: University of Glasgow, UK
Keywords: DCE, PHIs, equity
Introduction: Economic evaluations of population health interventions (PHIs) raise numerous methodological challenges.
PHIs' unstandardised, multifaceted approach to tackling health inequalities differ greatly from the traditional clinical
interventions to which economic evaluation techniques are commonly applied. A key challenge is the evaluation of equity
impacts from PHIs. Outcome measures such as QALYs are typically weighted equally regardless of the recipient. Using
aggregated individual values and utilities to create overall societal preference has received criticism from critics
suggesting that individuals are social beings and as communities, can look beyond their own wellbeing to that of others.
Gavin Mooney discussed 'vertical equity' and 'communitarian claims' as possible means for fairer allocation of resources.
He argued that looking beyond the individual and considering the society or community would ensure more equitable
priority setting. However, methods for applying such concepts are still developing.
Aims: Examining notions of 'vertical equity' and 'communitarian claims' the aim is to explore the use of discrete choice
experiments (DCE) as a means to assist economic justification of community-based programmes.
Methods: A DCE conducted with a representative UK general population sample to elicit population preferences for the
delivery of Community Empowerment (CE) as part of an Urban Regeneration programme. The survey captures sociodemographic data and incorporates the Short-form Warwick Edinburgh Mental Well-Being Scale (SWEMWBS) to explore
features influencing choices. CE attributes were identified following a literature search and analysis of cross-sectional
data (GoWell survey).
Results: Currently piloting, analysis of main study in November 2014.
A080
The Cost of Binge Drinking
Authors: Jonathan James, Marco Francesconi
Submitting author's institution: University of Bath, UK
Keywords: Alcohol, crime, accidents
We estimate the effect of binge drinking on accident and emergency attendances, road accidents, arrests, and the
number of police officers on duty using a variety of unique data from Britain and a novel two-sample minimum distance
estimation. Our structural estimates, which reveal sizeable effects of bingeing on all outcomes, are then used to monetize
the short-term externalities of binge drinking. We find that these externalities are on average £4.37 billion per year ($6.26
billion) or £69 for each man, woman, and child living in the UK. The price that internalizes this externality would be
equivalent to 5p per alcoholic unit, implying a 13% increase with respect to the current average price.
A084
Patent Purchase as a Policy for Pharmaceuticals
Authors: Barend A van Hout; Jolian McHardy; Aki Tsuchiya
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Submitting author's institution: University of Sheffield, UK
Keywords: Patent Policy; Pharmaceuticals; Welfare
We consider a novel proposal for patenting policy for pharmaceuticals: namely, for society to purchase the patent of the
drug, instead of purchasing the drug. For example, PCSK9 is an enzyme which, if blocked, may reduce cholesterol, and
within 5 to 10 years there may be three PCSK9 blockers on the market. The first of these may show an unprecedented
decrease in cholesterol, and be priced at a premium, say £3 a day per patient. The second and third products will have
similar efficacy, and price, to the first. At this price, only the highest risk patients will be treated, because it would not be
cost effective for those with lower risk. This is a pattern observed across numerous classes of drugs. The price may be
much higher than the production costs, and if so, by buying the first patent, producing the drug, and refusing further
patents, society could offer it at or nearer the marginal cost of production. This would benefit more patients and produce
larger health gains. Under this policy social welfare is increased, the winner is fully compensated, while the runner-up firm
incurs possible losses – but there are viable conditions under which firms would not lose on average. The result is
generated based upon a number of stylised facts regarding R&D in the pharmaceutical industry. The paper is entirely
theoretical, with no data.
A085
Cost-effectiveness thresholds for application in low and middle-income countries (an exploratory study)
Authors: Karl Claxton, Beth Woods, Paul Revill, Mark Sculpher
Submitting author's institution: University of York, UK
Keywords: decision-rules, cost-effectiveness thresholds, global health
Healthcare systems in low- and middle-income countries (LMICs) face considerable population healthcare needs with
markedly fewer resources than those in developed countries. The way in which available resources are allocated across
competing priorities is crucial in affecting how much health is generated overall, who receives healthcare interventions
and who goes without. Cost-effectiveness analysis (CEA) is one tool that can assist policy-makers in resource allocation.
The central concern in CEA is whether the health gains offered by an intervention are large enough relative to it costs to
warrant adoption. This requires some notion of the value that must be realized by an intervention, which is most
frequently represented using a cost-effectiveness threshold (CET). CETs should be based on estimates of the forgone
benefit associated with alternative priorities which consequently cannot be implemented as a result of the commitment of
resources to an alternative. However, most CEAs to inform decisions in LMICs have used World Health Organization
(WHO) recommended CETs (of 1-3 times GDP per capita in a country) which are not based upon this kind of
assessment. In contrast, we estimate CETs for a number of countries based upon a robust empirical estimate of foregone
benefit (from the UK NHS) and international income elasticities of the value of health. The resulting CETs are much lower
than those previously applied. The study is intended to provoke further research in this area of crucial policy importance
and outlines how more robust estimates of CETs could be generated.
A089
The wider effects of cancer screening programmes on healthcare utilization and health behaviours
Authors: Jack Higgins, Rachel Meacock, Matt Sutton
Submitting author's institution: University of Manchester, UK
Keywords: Cancer screening, difference-in-differences, regression discontinuity.
Background: Decisions over the eligibility rules for invitation to screening programmes tend to focus only on effects in
terms of the management of the targeted health condition. Invitation to screening may, however, have wider
consequences for individuals’ health awareness and use of other healthcare services. Aim: To examine whether invitation
to cancer screening has wider implications for the use of general health services, healthy behaviours, and self-assessed
health.
Method: We exploit two natural experiments created by changes to the eligibility rules for invitation to cervical and breast
cancer screening in England. Age of first invitation to cervical screening increased from 20 to 25 years in October 2003,
and from 64 to 70 for breast screening in 2004, whilst remaining 20 and 64 respectively in Scotland and Wales. We
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evaluate the effect of these policy changes on screening attendance, GP visits, smoking, and self-assessed general
health using regression discontinuity and difference-in-differences (DiD) methods.
Data: Cervical (N=1165) and breast (N=1258) screening attendance in women aged 20 and 65 respectively from waves
1999-2008 of the British Household Panel Survey.
Results: Preliminary DiD results show that cervical screening attendance amongst 20 year olds decreased by 21.6
percentage points (from 31.3%; p<0.01) after the age of first invitation was increased. There were no associated changes
in the probability of seeing a GP in the last year, smoking behaviour, or self-assessed health. Further analysis will
consider breast cancer screening and regression discontinuity techniques.
Implications: Changing the eligibility rules for cancer screening did not appear to impact use of general health services,
health behaviours or the self-assessed health of the affected population.
A091
How best to deal with Protest responses in Contingent Valuation studies
Authors: Mark Pennington, Manuel Gomes
Submitting author's institution: London School of Hygiene & Tropical Medicine, UK
Keywords: Contingent Valuation, Multiple Imputation, Willingness-to-Pay
Introduction: Protest responses, whereby respondents refuse to reveal a value, are commonly encountered in Contingent
Valuation studies. Ignoring protest responses will bias estimates of Willingness-to-pay values. Previous literature has
corrected for protest responses using Heckman models. This approach imposes distributional assumptions on the
logarithm of Willingness-to-pay responses. This paper presents Multiple Imputation (MI) approaches to appropriately
address protest and missing responses and compares them with a Heckman approach. The methods are contrasted
using a survey of 17,657 respondents across nine European countries who valued different types of health gain
(EuroVaQ).
Methods: Alternative MI approaches such as Predictive Mean Matching and two part models were assessed by
comparing predictions with observed responses. The optimal MI technique was then applied to impute protest and
missing responses. Heckman models were fitted to predict protest and missing data. Means and medians were estimated
for protest responses, missing responses and the entire sample using both MI and Heckman models.
Results: Imputed responses using Predictive Mean Matching closely matched the distribution of observed data. After
imputation mean willingness-to-pay values for protest responses were lower than means for observed data. Mean
Willingness-to-pay values rose after adjustment for protest responses using a Heckman model. Comparison of
observations for respondents who sometimes protested accorded with results from MI.
Conclusions: Heckman models impose stringent distributional assumptions that may lead to incorrect inference. Multiple
Imputation can circumvent these assumptions, and supports inference around Median and Arithmetic Means. Ongoing
work is examining the impact of assuming the data is missing at Random.
A092
Non-payment for Performance: Financial Penalties for Readmissions in England
Authors: Søren Rud Kristensen, Matt Sutton
Submitting author's institution: University of Manchester, UK
Keywords: Non-pay for performance, Quality, Provider incentives
Background: Recent reimbursement reforms implemented in the English National Health Service and as part of the
Affordable Care Act in the USA, rely on financial penalties rather than bonuses to incentivise reductions in hospital
readmission rates. Individuals are known to respond stronger to incentives framed as penalties rather than bonuses, but
the effect of such schemes on organisations (termed non-payment for performance (NP4P)) is hitherto unknown.
Aim: We analyse the effect of the English NP4P policy for readmissions on three outcomes: 1) The readmission rate (to
assess the effect of the policy), 2) Length of stay of the index admission (as a potential policy response variable), 3) the
same-provider readmission rate (to test for gaming).
Methods: Difference-in-differences analysis of our three outcome variables between conditions included and not included
in the policy before and after the policy was introduced, controlling for admission and patient characteristics.
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Data: a 25% random sample of patients having a hospital admission between April 2008 and January 2012 (will be
updated to include 2013 data when these are received).
Results: Readmission rates continued to rise for conditions excluded from the policy, but there was no or little increase in
readmissions targeted by the policy. An increase in the length of stay of index admissions for elective conditions targeted
by the policy coincided with a decrease in readmissions for these conditions, although these were in line with the previous
trends. We find some evidence that hospitals responded strategically to the design of the new policy.
A095
Predicting emergency readmissions and bed-days among heart failure patients: can outcomes other than
30-day readmissions help us better understand re-hospitalisation burden?
Authors: Rosalind Goudie, Paul Aylin, Alex Bottle
Submitting author's institution: Imperial College London, UK
Keywords: Heart failure, readmissions, prediction
Heart failure (HF) is a common cause of emergency admission to English National Health Service (NHS) hospitals and
worldwide. Unplanned hospital readmission rates among HF patients are also high, placing a considerable cost on the
NHS. Despite a growing number of studies exploring readmissions and hospitals facing financial incentives to do so,
reducing the burden of readmissions remains a challenge. Published risk models typically do not perform very well at
identifying HF patients at high risk of readmission and the predictors of rehospitalisation vary significantly between
models. To assess whether prediction models for rehospitalisation outcomes besides the prevailing 30-day readmission
metric can facilitate better understanding of readmissions, Hospital Episode Statistics (HES) data were used to compare a
range of readmission models for HF patients in England. We examined whether the predictors of different all-cause
readmissions outcomes are the same and considered the potential value of alternative readmission metrics, for example
measures based on total hospital stay in the post-discharge year, to risk-stratify patients, better target disease
management programs and inform hospital reimbursement schemes. Patterns of re-hospitalisation varied between
patients and some patients had multiple unplanned readmissions. Count data models for total bed-days in the year after
discharge from an index emergency HF admission, allowed us to identify for different sub-groups the differing drivers of
high resource-use: repeat readmissions and length of stay on readmission. Concentrating on binary readmission
outcomes, such as 30-day readmissions, neglects the contribution the number and duration of unplanned readmissions
make to total HF burden.
A097
How should we allocate budgets for public health to local areas?
Authors: Mason, T. Sutton, M., Whittaker, W.
Submitting author's institution: University of Manchester, UK
Keywords: resource allocation; public health; health production
Background: Many of the responsibilities for improving the public's health and reducing health inequalities were
transferred from the NHS to Local Authorities under the Health & Social Care Act 2012. Local Authorities have a duty to
improve the health and wellbeing of local populations, reduce health inequalities across the life course, and provide
population health and healthcare advice. Local authorities have been given ring-fenced grants since April 2013 to fund
these new public health responsibilities but formula used for these allocations are made is regarded as provisional.
Aim: To describe work we are undertaking for the Advisory Committee on Resource Allocation on methods for allocating
public health funds to Local authorities.
Methods: We will review methodologies and approaches that have been used previously in England and in other
centrally-financed health systems, and available data sources. Particular emphasis will be given to: (i) how the utilisation
approach can be developed in the future to prevent ossification of the existing pattern of provision and the hindrance of
innovation; (ii) a bottom-up costing approach based on the prevalence of lifestyles, the cost-effectiveness of different
interventions and research on the social determinants of illness incidence and recovery; and (iii) the feasibility of basing
allocations on health production functions.
Implications: The work will benefit greatly from discussion at HESG, as we have been asked by the Department of Health
to review options for how they can develop a long-term strategy for the national public health formula.
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A099
3 December 2014
Children health and domestic violence
Authors: Mireia Jofre-Bonet, Victoria Serra-Sastre, Melcior Rosselló-Roig
Submitting author's institution: City University London, UK
Keywords: children health production, domestic violence, cultural transmission, sample selection, endogeneity
This article unravels the effect of the domestic violence into the children health production function. Drawing results from
the Millenium Cohort Study, our findings highlight the negative externality effect of violence on Health outcomes. We also
provide evidence of the transmission mechanism in terms of school performance. We shed light into the effects of living in
a violent environment by exploiting the variation of family composition and sexual assaults in UK recorded by the Police.
Our paper contributes to the literature of estimating the effect of a non-marketable good into the health production
function.
A103
The impact of culture on lifestyle choices: regression discontinuity evidence from Switzerland
Authors: Joachim Marti, Sophie Guthmuller, Stefan Boes
Submitting author's institution: University of Leeds, UK
Keywords: lifestyles, culture, spatial econometrics, regression discontinuity, Switzerland
Unhealthy lifestyle choices are important risk factors for a wide range of chronic conditions such as cancers and
cardiovascular diseases and are therefore among the main drivers of morbidity and mortality in western countries. An
important economic literature has investigated the determinants of risky health behaviours with a particular focus on the
role of time and risk preferences and, more recently, by incorporating insights from behavioural economics. A dimension
that has less been explored is the potential role of culture in individual health decision making. Switzerland offers an
interesting opportunity to study the impact of culture and language on lifestyle choices because of its important cultural
diversity that is well defined geographically. Language groups are located in specific regions that are close to each other
and the dominant language (i.e. French, German, or Italian) changes sharply at the language borders. In this paper, we
exploit this characteristic by using a spatial regression discontinuity design (RDD). Intuitively, we compare lifestyle
choices of individuals who live on both sides of the linguistic borders, i.e. who share a similar institutional and social
environment but who speak different languages. We use a rich dataset that contains information on smoking, physical
activity and health care utilisation as well as the exact geographical location of 5,000 Swiss households. We are now
finalising the construction of the geospatial dataset and will start analysing the data to uncover whether people who share
similar institutional environments but have a different cultural background make different decisions about their health.
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