Examining the hospital costs of children born into relative deprivation in England.

OBJECTIVE: To examine the association between being born into relative deprivation and hospital costs during childhood. DESIGN: Retrospective cohort study. METHODS: We created a birth cohort using Hospital Episode Statistics for children born in NHS hospitals in 2003/2004. The Index of Multiple Deprivation (IMD) rank at birth was missing from 75% of the baby records, so we linked mother and baby records to obtain the IMD decile from the mother's record. We aggregated and costed each child's hospital inpatient admissions, and outpatient and emergency department (ED) attendances up to 15 years of age. We used 2019/2020 NHS tariffs to assign costs. We constructed an additional cohort, all children born in 2013/2014, to explore any changes over time, comparing the utilisation and costs up to 5 years of age. RESULTS: Our main cohort comprised 567 347 babies born in 2003/2004, of which we could include 91%. Up to the age of 15 years, children born into the most deprived areas used more hospital services than those born in the least deprived, reflected in higher costs of inpatient, outpatient and ED care. The highest costs and greatest differences are in the year following birth. Comparing this with the later cohort (up to age 5 years), the average cost per child increased across all deprivation deciles, but differences between the most and least deprived deciles appeared to narrow slightly. CONCLUSIONS: Healthcare utilisation and costs are consistently higher for children who are born into the most deprived areas compared with the least.

Financial incentives and prescribing behavior in primary care.

Many healthcare systems prohibit primary care physicians from dispensing the drugs they prescribe due to concerns that this encourages excessive, ineffective or unnecessarily costly prescribing. Using data from the English National Health Service for 2011-2018, we estimate the impact of physician dispensing rights on prescribing behavior at the extensive margin (comparing practices that dispense and those that do not) and the intensive margin (comparing practices with different proportions of patients to whom they dispense). We control for practices selecting into dispensing based on observable (OLS, entropy balancing) and unobservable practice characteristics (2SLS). We find that physician dispensing increases drug costs per patient by 3.1%, due to more, and more expensive, drugs being prescribed. Reimbursement is partly based on a fixed fee per package dispensed and we find that dispensing practices prescribe smaller packages. As the proportion of the practice population for whom they can dispense increases, dispensing practices behave more like non-dispensing practices.

Decomposition of Quality-Adjusted Life Expectancy Inequalities by Mortality and Health-Related Quality of Life Dimensions.

BACKGROUND: Quality-adjusted life expectancy (QALE) combines mortality risk and multidimensional health-related quality of life (HRQoL) information to measure healthy life expectancy in terms of quality-adjusted life years (QALYs). This paper estimates the relative importance of individual quality of life dimensions in explaining inequalities in QALE. METHODS: We combined EQ-5D-5L data from the Health Survey for England for 2017 and 2018 (N = 14,412) with full population mortality data from the Office for National Statistics to calculate QALE by age, sex and deprivation quintile. The effect of HRQoL dimensions on the socioeconomic gradient in QALE was decomposed using an iterative imputation approach, in which inequalities associated with socioeconomic status in each domain were removed by imputing the response distribution of the richest quintile for all participants. Sampling uncertainty in the HRQoL data was evaluated using bootstrapping. RESULTS: People in the least deprived fifth of neighbourhoods in England can expect to live 7.0 years longer and experience 11.1 more QALYs than those in the most deprived fifth. Inequalities in HRQoL accounted for 28.0% and 45.7% of QALE inequalities for males and females, respectively. Pain/discomfort, anxiety/depression and mobility were the most influential HRQoL domains. DISCUSSION: Our results identify the extent of inequalities associated with socioeconomic status in lifetime health and the relative importance of inequalities by mortality and HRQoL. The contributions of the individual dimensions of HRQoL towards lifetime inequalities vary substantially by sex. Our findings can help to identify the types of interventions most likely to alleviate health inequalities, which may be different for males and females.

Inequality in quality-adjusted life expectancy by educational attainment in Norway: an observational study.

BACKGROUND: Health inequalities are often assessed in terms of life expectancy or health-related quality of life (HRQoL). Few studies combine both aspects into quality-adjusted life expectancy (QALE) to derive comprehensive estimates of lifetime health inequality. Furthermore, little is known about the sensitivity of estimated inequalities in QALE to different sources of HRQoL information. This study assesses inequalities in QALE by educational attainment in Norway using two different measures of HRQoL. METHODS: We combine full population life tables from Statistics Norway with survey data from the Tromsø study, a representative sample of the Norwegian population aged ≥ 40. HRQoL is measured using the EQ-5D-5L and EQ-VAS instruments. Life expectancy and QALE at 40 years of age are calculated using the Sullivan-Chiang method and are stratified by educational attainment. Inequality is measured as the absolute and relative gap between individuals with lowest (i.e. primary school) and highest (university degree 4 + years) educational attainment. RESULTS: People with the highest educational attainment can expect to live longer lives (men: + 17.9% (95%CI: 16.4 to 19.5%), women: + 13.0% (95%CI: 10.6 to 15.5%)) and have higher QALE (men: + 22.4% (95%CI: 20.4 to 24.4%), women: + 18.3% (95%CI: 15.2 to 21.6%); measured using EQ-5D-5L) than individuals with primary school education. Relative inequality is larger when HRQoL is measured using EQ-VAS. CONCLUSION: Health inequalities by educational attainment become wider when measured in QALE rather than LE, and the degree of this widening is larger when measuring HRQoL by EQ-VAS than by EQ-5D-5L. We find a sizable educational gradient in lifetime health in Norway, one of the most developed and egalitarian societies in the world. Our estimates provide a benchmark against which other countries can be compared.

Need, demand, supply in health care: working definitions, and their implications for defining access.

Effective policymaking in health care systems begins with a clear typology of the terminology - need, demand, supply and access to care - and their interrelationships. However, the terms are contested and their meaning is rarely stated explicitly. This paper offers working definitions of need, demand and supply. We draw on the international literature and use a Venn diagram to explain the terms. We then define access to care, reviewing alternative and competing definitions from the literature. We conclude by discussing potential applications of our conceptual framework to help to understand the interrelationships and trade-offs between need, demand, supply and access in health care.

Impact of prevention in primary care on costs in primary and secondary care for people with serious mental illness.

A largely unexplored part of the financial incentive for physicians to participate in preventive care is the degree to which they are the residual claimant from any resulting cost savings. We examine the impact of two preventive activities for people with serious mental illness (care plans and annual reviews of physical health) by English primary care practices on costs in these practices and in secondary care. Using panel two-part models to analyze patient-level data linked across primary and secondary care, we find that these preventive activities in the previous year are associated with cost reductions in the current quarter both in primary and secondary care. We estimate that there are large beneficial externalities for which the primary care physician is not the residual claimant: the cost savings in secondary care are 4.7 times larger than the cost savings in primary care. These activities are incentivized in the English National Health Service but the total financial incentives for primary care physicians to participate were considerably smaller than the total cost savings produced. This suggests that changes to the design of incentives to increase the marginal reward for conducting these preventive activities among patients with serious mental illness could have further increased welfare.

Quality-Adjusted Life Expectancy Norms for the English Population.

OBJECTIVES: The National Institute for Health and Care Excellence in England has implemented severity-of-disease modifiers that give greater weight to health benefits accruing to patients who experience a larger shortfall in quality-adjusted life-years (QALYs) under current standard of care than healthy individuals. This requires an estimate of quality-adjusted life expectancy (QALE) of the general population based on age and sex. Previous QALE population norms are based on nearly 30-year-old assessments of health-related quality of life in the general population. This study provides updated QALE estimates for the English population based on age and sex. METHODS: 5-level version of EQ-5D data for 14 412 participants from the Health Survey for England (waves 2017 and 2018) were pooled, and health-related quality of life population norms were calculated. These norms were combined with official life tables from the Office for National Statistics for 2017 to 2019 using the Sullivan method to derive QALE estimates based on age and sex. Values were discounted using 0%, 1.5%, and 3.5% discount rates. RESULTS: QALE at birth is 68.24 QALYs for men and 68.21 QALYs for women. These values are significantly lower than previously published QALE population norms based on the older 3-level version of EQ-5D data. CONCLUSION: This study provides new QALE population norms for England that serve to establish absolute and relative QALY shortfalls for the purpose of health technology assessments.

Inequality of opportunity in a land of equal opportunities: The impact of parents' health and wealth on their offspring's quality of life in Norway.

BACKGROUND: The literature on Inequality of opportunity (IOp) in health distinguishes between circumstances that lie outside of own control vs. efforts that - to varying extents - are within one's control. From the perspective of IOp, this paper aims to explain variations in individuals' health-related quality of life (HRQoL) by focusing on two separate sets of variables that clearly lie outside of own control: Parents' health is measured by their experience of somatic diseases, psychological problems and any substance abuse, while parents' wealth is indicated by childhood financial conditions (CFC). We further include own educational attainment which may represent a circumstance, or an effort, and examine associations of IOp for different health outcomes. HRQoL are measured by EQ-5D-5L utility scores, as well as the probability of reporting limitations on specific HRQoL-dimensions (mobility, self-care, usual-activities, pain & discomfort, and anxiety and depression). METHOD: We use unique survey data (N = 20,150) from the egalitarian country of Norway to investigate if differences in circumstances produce unfair inequalities in health. We estimate cross-sectional regression models which include age and sex as covariates. We estimate two model specifications. The first represents a narrow IOp by estimating the contributions of parents' health and wealth on HRQoL, while the second includes own education and thus represents a broader IOp, alternatively it provides a comparison of the relative contributions of an effort variable and the two sets of circumstance variables. RESULTS: We find strong associations between the circumstance variables and HRQoL. A more detailed examination showed particularly strong associations between parental psychological problems and respondents' anxiety and depression. Our Shapley decomposition analysis suggests that parents' health and wealth are each as important as own educational attainment for explaining inequalities in adult HRQoL. CONCLUSION: We provide evidence for the presence of the lasting effect of early life circumstances on adult health that persists even in one of the most egalitarian countries in the world. This suggests that there may be an upper limit to how much a generous welfare state can contribute to equal opportunities.

Socioeconomic inequalities in HRQoL in England: an age-sex stratified analysis.

BACKGROUND: Socioeconomic status is a key predictor of lifetime health: poorer people can expect to live shorter lives with lower average health-related quality-of-life (HRQoL) than richer people. In this study, we aimed to improve understanding of the socioeconomic gradient in HRQoL by exploring how inequalities in different dimensions of HRQoL differ by age. METHODS: Data were derived from the Health Survey for England for 2017 and 2018 (14,412 participants). HRQoL was measured using the EQ-5D-5L instrument. We estimated mean EQ-5D utility scores and reported problems on five HRQoL dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression) for ages 16 to 90+ and stratified by neighbourhood deprivation quintiles. Relative and absolute measures of inequality were assessed. RESULTS: Mean EQ-5D utility scores declined with age and followed a socioeconomic gradient, with the lowest scores in the most deprived areas. Gaps between the most and least deprived quintiles emerged around the age of 35, reached their greatest extent at age 60 to 64 (relative HRQoL of most deprived compared to least deprived quintile: females = 0.77 (95% CI: 0.68-0.85); males = 0.78 (95% CI: 0.69-0.87)) before closing again in older age groups. Gaps were apparent for all five EQ-5D dimensions but were greatest for mobility and self-care. CONCLUSION: There are stark socioeconomic inequalities in all dimensions of HRQoL in England. These inequalities start to develop from early adulthood and increase with age but reduce again around retirement age.

Program Evaluation of Population- and System-Level Policies: Evidence for Decision Making.

BACKGROUND: Policy evaluations often focus on ex post estimation of causal effects on short-term surrogate outcomes. The value of such information is limited for decision making, as the failure to reflect policy-relevant outcomes and disregard for opportunity costs prohibits the assessment of value for money. Further, these evaluations do not always consider all relevant evidence, other courses of action, or decision uncertainty. METHODS: In this article, we explore how policy evaluation could better meet the needs of decision making. We begin by defining the evidence required to inform decision making. We then conduct a literature review of challenges in evaluating policies. Finally, we highlight potential methods available to help address these challenges. RESULTS: The evidence required to inform decision making includes the impacts on the policy-relevant outcomes, the costs and associated opportunity costs, and the consequences of uncertainty. Challenges in evaluating health policies are described using 8 categories: 1) valuation space; 2) comparators; 3) time of evaluation; 4) mechanisms of action; 5) effects; 6) resources, constraints, and opportunity costs; 7) fidelity, adaptation, and level of implementation; and 8) generalizability and external validity. Methods from a broad set of disciplines are available to improve policy evaluation, relating to causal inference, decision-analytic modeling, theory of change, realist evaluation, and structured expert elicitation. LIMITATIONS: The targeted review may not identify all possible challenges, and the methods covered are not exhaustive. CONCLUSIONS: Evaluations should provide appropriate evidence to inform decision making. There are challenges in evaluating policies, but methods from multiple disciplines are available to address these challenges. IMPLICATIONS: Evaluators need to carefully consider the decision being informed, the necessary evidence to inform it, and the appropriate methods.[Box: see text].

Who keeps on working? The importance of resilience for labour market participation.

BACKGROUND: It is widely recognized that individuals' health and educational attainments, commonly referred to as their human capital, are important determinants for their labour market participation (LMP). What is less recognised is the influence of individuals' latent resilience traits on their ability to sustain LMP after experiencing an adversity such as a health shock. AIM: We investigate the extent to which resilience is independently associated with LMP and moderates the effect of health shocks on LMP. METHOD: We analysed data from two consecutive waves of a Norwegian prospective cohort study. We followed 3,840 adults who, at baseline, were healthy and worked full time. Binary logistic regression models were applied to explain their employment status eight years later, controlling for age, sex, educational attainment, health status at baseline, as well as the occurrences of three types of health shocks (cardiovascular diseases, cancer, psychological problems). Individuals' resilience, measured by the Resilience Scale for Adults (RSA), entered as an independent variable and as an interaction with the indicators of health shocks. In separate models, we explore the role of two further indicators of resilience; locus of control, and health optimism. RESULTS: As expected, health shocks reduce the probability to keep on working full-time. While both the RSA and the two related indicators all suggest that resilience increases the probability to keep on working, we did not find evidence that resilience moderates the association between health shocks and LMP. CONCLUSION: Higher levels of resilience is associated with full-time work as individuals age.

Healthcare Costs for People with Serious Mental Illness in England: An Analysis of Costs Across Primary Care, Hospital Care, and Specialist Mental Healthcare.

BACKGROUND: Serious mental illness (SMI) is a set of disabling conditions associated with poor outcomes and high healthcare utilisation. However, little is known about patterns of utilisation and costs across sectors for people with SMI. OBJECTIVE: The aim was to develop a costing methodology and estimate annual healthcare costs for people with SMI in England across primary and secondary care settings. METHODS: A retrospective observational cohort study was conducted using linked administrative records from primary care, emergency departments, inpatient admissions, and community mental health services, covering financial years 2011/12-2013/14. Costs were calculated using bottom-up costing and are expressed in 2013/14 British pounds (GBP). Determinants of annual costs by sector were estimated using generalised linear models. RESULTS: Mean annual total healthcare costs for 13,846 adults with SMI were £4989 (median £1208), comprising 19% from primary care (£938, median £531), 34% from general hospital care (£1717, median £0), and 47% from inpatient and community-based specialist mental health services (£2334, median £0). Mean annual costs related specifically to mental health, as distinct from physical health, were £2576 (median £290). Key predictors of total cost included physical comorbidities, ethnicity, neighbourhood deprivation, SMI diagnostic subgroup, and age. Some associations varied across care context; for example, older age was associated with higher primary care and hospital costs, but lower mental healthcare costs. CONCLUSIONS: Annual healthcare costs for people with SMI vary significantly across clinical and socioeconomic characteristics and healthcare sectors. This analysis informs policy and research, including estimation of health budgets for particular patient profiles, and economic evaluation of health services and policies.

Paying for efficiency: Incentivising same-day discharges in the English NHS.

We study a pay-for-efficiency scheme that encourages hospitals to admit and discharge patients on the same calendar day when clinically appropriate. Since 2010, hospitals in the English NHS are incentivised by a higher price for patients treated as same-day discharge than for overnight stays, despite the former being less costly. We analyse administrative data for patients treated during 2006-2014 for 191 conditions for which same-day discharge is clinically appropriate - of which 32 are incentivised. Using difference-in-difference and synthetic control methods, we find that the policy had generally a positive impact with a statistically significant effect in 14 out of the 32 conditions. The median elasticity is 0.24 for planned and 0.01 for emergency conditions. Condition-specific design features explain some, but not all, of the differential responses.

Aggregate Distributional Cost-Effectiveness Analysis of Health Technologies.

BACKGROUND: Health inequalities can be partially addressed through the range of treatments funded by health systems. Nevertheless, although health technology assessment agencies assess the overall balance of health benefits and costs, no quantitative assessment of health inequality impact is consistently undertaken. OBJECTIVES: To assess the inequality impact of technologies recommended under the NICE single technology appraisal process from 2012 to 2014 using an aggregate distributional cost-effectiveness framework. METHODS: Data on health benefits, costs, and patient populations were extracted from the NICE website. Benefits for each technology were distributed to social groups using the observed socioeconomic distribution of hospital utilization for the targeted disease. Inequality measures and estimates of cost-effectiveness were compared using the health inequality impact plane and combined using social welfare indices. RESULTS: Twenty-seven interventions were evaluated. Fourteen interventions were estimated to increase population health and reduce health inequality, 8 to reduce population health and increase health inequality, and 5 to increase health and increase health inequality. Among the latter 5, social welfare analysis, using inequality aversion parameters reflecting high concern for inequality, indicated that the health gain outweighs the negative health inequality impact. CONCLUSIONS: The methods proposed offer a way of estimating the health inequality impacts of new health technologies. The methods do not allow for differences in technology-specific utilization and health benefits, but require less resources and data than conducting full distributional cost-effectiveness analysis. They can provide useful quantitative information to help policy makers consider how far new technologies are likely to reduce or increase health inequalities.

Prospective payment systems and discretionary coding-Evidence from English mental health providers.

Reimbursement of English mental health hospitals is moving away from block contracts and towards activity and outcome-based payments. Under the new model, patients are categorised into 20 groups with similar levels of need, called clusters, to which prices may be assigned prospectively. Clinicians, who make clustering decisions, have substantial discretion and can, in principle, directly influence the level of reimbursement the hospital receives. This may create incentives for upcoding. Clinicians are supported in their allocation decision by a clinical clustering algorithm, the Mental Health Clustering Tool, which provides an external reference against which clustering behaviour can be benchmarked. The aims of this study are to investigate the degree of mismatch between predicted and actual clustering and to test whether there are systematic differences amongst providers in their clustering behaviour. We use administrative data for all mental health patients in England who were clustered for the first time during the financial year 2014/15 and estimate multinomial multilevel models of over, under, or matching clustering. Results suggest that hospitals vary systematically in their probability of mismatch but this variation is not consistently associated with observed hospital characteristics.

General practitioners and emergency departments (GPED)-efficient models of care: a mixed-methods study protocol.

INTRODUCTION: Pressure continues to grow on emergency departments in the UK and throughout the world, with declining performance and adverse effects on patient outcome, safety and experience. One proposed solution is to locate general practitioners to work in or alongside the emergency department (GPED). Several GPED models have been introduced, however, evidence of effectiveness is weak. This study aims to evaluate the impact of GPED on patient care, the primary care and acute hospital team and the wider urgent care system. METHODS AND ANALYSIS: The study will be divided into three work packages (WPs). WP-A; Mapping and Taxonomy: mapping, description and classification of current models of GPED in all emergency departments in England and interviews with key informants to examine the hypotheses that underpin GPED. WP-B; Quantitative Analysis of National Data: measurement of the effectiveness, costs and consequences of the GPED models identified in WP-A, compared with a no-GPED model, using retrospective analysis of Hospital Episode Statistics Data. WP-C; Case Studies: detailed case studies of different GPED models using a mixture of qualitative and quantitative methods including: non-participant observation of clinical care, semistructured interviews with staff, patients and carers; workforce surveys with emergency department staff and analysis of available local routinely collected hospital data. Prospective case study sites will be identified by completing telephone interviews with sites awarded capital funding by the UK government to implement GPED initiatives. The study has a strong patient and public involvement group that has contributed to study design and materials, and which will be closely involved in data interpretation and dissemination. ETHICS AND DISSEMINATION: The study has been approved by the National Health Service East Midlands-Leicester South Research Ethics Committee: 17/EM/0312. The results of the study will be disseminated through peer-reviewed journals, conferences and a planned programme of knowledge mobilisation. TRIAL REGISTRATION NUMBER: ISRCTN51780222.

Socioeconomic inequality of access to healthcare: Does choice explain the gradient?

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.

Multidimensional performance assessment of public sector organisations using dominance criteria.

Public sector organisations pursue multiple objectives and serve a number of stakeholders. But stakeholders are rarely explicit about the valuations they attach to different objectives, nor are these valuations likely to be identical. This complicates the assessment of their performance because no single set of weights can be chosen legitimately to aggregate outputs into unidimensional composite scores. We propose the use of dominance criteria in a multidimensional performance assessment framework to identify best practice and poor performance under relatively weak assumptions about stakeholders' preferences. We use as an example providers of hip replacement surgery in the English National Health Service and estimate multivariate multilevel models to study their performance in terms of length of stay, readmission rates, post-operative patient-reported health status and waiting time. We find substantial correlation between objectives and demonstrate that ignoring the correlation can lead to incorrect assessments of performance.

Hospital Surgical Volumes and Mortality after Coronary Artery Bypass Grafting: Using International Comparisons to Determine a Safe Threshold.

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 percent overall, 5.2 percent (95 percent CI: 4.0-6.4) in low-volume hospitals, and 2.1 percent (95 percent 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.