Dr. Rachel Baker

Searchers versus surveyors in estimating the monetary value of a QALY: resolving a nasty dilemma for NICE

Rachel M. Baker et al. — Wed, 20 Jun 2012 07:55:51 PDT

Recently, for many health economics researchers, empirical estimation of the monetary valuation of a quality-adjusted life year (QALY) has become an important endeavour. Different philosophical and practical approaches to this have emerged. On the one hand, there is a view that, with health-care budgets set centrally, decision-making bodies within the system can iterate, from observation of a series of previous decisions, towards the value of a QALY, thus searching for such a value. Alternatively, and more consistent with the approach taken in other public sectors, individual members of the public are surveyed with the aim of directly eliciting a preference-based – also known as a willingness-to-pay-based (WTP-based) – value of a QALY. While the former is based on supply-side factors and the latter on demand, both in fact suffer from informational deficiencies. Sole reliance on either would necessitate an acceptance or accommodation of chronic inefficiencies in health-care resource allocation. On the basis of this observation, this paper makes the case that in order to approach optimal decision making in health-care provision, a framework incorporating and thus, to a degree, reconciling these two approaches is to be preferred.

Searchers versus surveyors in estimating the monetary value of a QALY: resolving a nasty dilemma for NICE

Rachel M. Baker et al. — Wed, 02 May 2012 06:10:01 PDT

Recently, for many health economics researchers, empirical estimation of the monetary valuation of a QALY has become an important endeavour. Different philosophical and practical approaches to this have emerged. On one hand, there is the view that, with health care budgets set centrally, decision-making bodies within the system can iterate, from observation of a series of previous decisions, towards the value of a QALY is, i.e. they can search for such a value. Alternatively, and more consistent with the approach taken in other public sectors, individual members of the public are surveyed with the aim of directly eliciting a preference-based – also known as a willingness-to-pay-based (WTP-based) - value of a QALY. While the former is based on supply-side factors and the latter on demand, both in fact suffer from informational deficiencies. Sole reliance on either would necessitate an acceptance or accommodation of chronic inefficiencies in healthcare resource allocation. Based on this observation, this paper makes the case that in order to approach optimal decision making in health care provision, a framework incorporating and thus, to a degree, reconciling these two approaches is to be preferred.

Q methodology

Carl Thompson et al. — Fri, 08 Jul 2011 08:19:12 PDT

Responses to standard gambles: are preferences ‘well-constructed’?

Rachel M. Baker et al. — Fri, 08 Jul 2011 08:15:28 PDT

Standard gamble (SG) is commonly used to elicit preferences in order to assess health related quality of life. There

has been little qualitative research exploring how respondents answer such questions.

An SG study was designed to elicit values for the health states associated with anti-hypertensive medication,

stroke and cardiovascular disease. This paper describes a qualitative study that was carried out alongside the SG

exercise in order to document the thought processes respondents bring to bear in formulating their responses. Data

were generated using ‘think aloud’ techniques and semi-structured interviews. Values were generally wellconstructed:

responses were thoroughly considered, and respondents made complex trade-offs and arrived at a point

of indifference. However, some respondents incorporated inappropriate information into their choices, redefining the

hypothetical ‘Option B’ resulting in problems interpreting the probabilistic information. Consideration of nonhealth

factors was commonplace, in particular the impact of choices on others. We discuss these findings in terms of

the use of qualitative methods in health economics and the wider discourse surrounding the theoretical

underpinnings of health state valuation.

Issues arising from the use of qualitative methods in health economics

Jo Coast et al. — Fri, 08 Jul 2011 08:10:43 PDT

As health economists begin to embrace qualitative methodology they inevitably face a number of issues. This paper explores these, distinguishing between those associated with the conflict between quantitative and qualitative methodologies (that has already been faced in a number of other research areas) and those associated with the potential for challenges to the discipline of mainstream economics. The former include both the acceptability of the methods (because of issues such as generalisability and reflexivity) and the acceptability of presentation. The latter appear to be essentially concerned with identity within economics. The paper concludes by noting the positive aspects of conducting qualitative research in health economics: the interesting and motivating nature of the research and, particularly, the possibilities for increasing the relevance associated with economic theory in the context of health and health services.

Guiding the design and selection of interventions to influence the implementation of evidence-based practice: an experimental simulation of a complex intervention trial.

Debbie Bonetti et al. — Mon, 27 Jun 2011 09:08:18 PDT

Q methodology in health economics

Rachel M. Baker et al. — Mon, 27 Jun 2011 09:00:26 PDT

The recognition that health economists need to understand the meaning of data if they are to adequately understand research findings which challenge conventional economic theory has led to the growth of qualitative modes of enquiry in health economics. The use of qualitative methods of exploration and description alongside mainstream quantitative techniques gives rise to a number of epistemological, ontological and methodological challenges: difficulties in accounting for subjectivity in choices, the need for rigour and transparency in method, and problems of disciplinary acceptability to health economists. This paper introduces Q methodology as a means of overcoming some of these challenges. The paper argues that Q offers a means of exploring subjectivity, beliefs and values whilst retaining the transparency, rigour and mathematical underpinnings of mainstream quantitative techniques. The various stages of Q methodological enquiry are outlined alongside potential areas of application in health economics, before discussing the strengths and limitations of the approach. We conclude that Q methodology is a useful addition to the economist’s methodological armoury and one that merits further consideration and evaluation in the health field.

Explaining variation in GP referral rates for X-rays for back pain.

Rachel M. Baker — Mon, 27 Jun 2011 08:57:51 PDT

Background Despite the availability of clinical guidelines for the management of low back pain (LBP), there continues to be wide variation in general practitioners' (GPs') referral rates for lumbar spine x-ray (LSX). This study aims to explain variation in GPs' referral rates for LSX from their accounts of the management of patients with low back pain. Methods Qualitative, semi-structured interviews with 29 GPs with high and low referral rates for LSX in North East England. Thematic analysis used constant comparative techniques. Results Common and divergent themes were identified among high- and low-users of LSX. Themes that were similar in both groups included an awareness of current guidelines for the use of LSX for patients with LBP and the pressure from patients and institutional factors to order a LSX. Differentiating themes for the high-user group included: a belief that LSX provides reassurance to patients that can outweigh risks, pessimism about the management options for LBP, and a belief that denying LSX would adversely affect doctor-patient relationships. Two specific differentiating themes are considered in more depth: GPs' awareness of their use of lumbar spine radiology relative to others, and the perceived risks associated with LSX radiation. Conclusion Several key factors differentiate the accounts of GPs who have high and low rates of referral for LSX, even though they are aware of clinical guideline recommendations. Intervention studies that aim to increase adherence to guideline recommendations on the use of LSX by changing the ordering behaviour of practitioners in primary care should focus on these factors.

Economic rationality and health and lifestyle choices for people with diabetes.

Rachel M. Baker — Mon, 27 Jun 2011 08:52:39 PDT

Economic rationality is traditionally represented by goal-oriented, maximising behaviour, or 'instrumental rationality'. Such a consequentialist, instrumental model of choice is often implicit in a biomedical approach to health promotion and education. The research reported here assesses the relevance of a broader conceptual framework of rationality (which includes 'procedural' and 'expressive' rationality as complements to an instrumental model of rationality) in a health context (type 2 diabetes).

Q methodology was used to derive 'factors' underlying health and lifestyle choices, based on factor analysis of the results of a card sorting procedure undertaken by 27 respondents with type 2 diabetes. These factors were then compared with the rationality framework and the appropriateness of an extended model of economic rationality as a means of better understanding health and lifestyle choices is assessed.

Taking a wider rational choice perspective, choices which are rendered irrational within a narrow-biomedical or strictly instrumental model, can be understood in terms of a coherent rationale, grounded in the accounts of respondents. The implications of these findings are discussed in terms of rational choice theory and diabetes management and research.

A Face-Validity Test of Response Strategies to 'Dread Risks'

Rachel M. Baker et al. — Mon, 27 Jun 2011 08:48:42 PDT

This paper reports the results of the follow-up, face-validity test on a protocol developed to explore the impact of context and baseline risk on peoples’ marginal rates of substitution between wealth and risk of death across a range of contexts using a modified risk-risk trade-off methodology. Analysis of these qualitative interviews revealed that context had different effects for different people. For some people it had almost no effect in that such respondents focussed mainly on the baseline risks they faced, whilst for others it had a marked affect on their risk-risk tradeoff. Most notably, only a minority of respondents described a behavioural strategy that could be construed as EU maximising. This has wider and extremely profound implications for the use of risk-risk trade-off measures and WTP-derived Value of Prevented Fatalities in cost-benefit analysis.

The new myth: the social value of the QALY

Werner Brouwer et al. — Mon, 27 Jun 2011 03:07:23 PDT

Throughout history there have always been people who are susceptible to myths and have tried to find the unfindable, whether it be the Holy Grail providing eternal life for its finder, the alchemic formula turning lead into gold, Bigfoot or the pot of gold at the end of the rainbow. These myths come in different forms; some are clearly placed in a religious or metaphysical context (e.g. the Holy Grail), while others are marketed with an earthly and scientific aura (e.g. the hairs of Bigfoot). At present, a new myth is seeking its way into the world. It has sought a particularly receptive bunch of people to nestle in, called health economists. We will call them 'Believers'. The Believers form a relatively friendly tribe, although some theoretical quarrels between tribe members have been reported. Their sole goal in life is to help societies in their struggle with the optimal allocation of resources in the healthcare sector.1 To that end, the Believers have designed a friendly instrument that they normally refer to as 'Economic Evaluation'. The ritual of the Economic Evaluation involves assessing the incremental costs and health gains of one healthcare intervention compared with another

Q methodology in nursing research

C. Thomson et al. — Mon, 27 Jun 2011 03:07:19 PDT

Book abstract: This title is directed primarily towards health care professionals outside of the United States. It has been written by nurses for nurses and is research-minded, conceptually and theoretically up-to-date and student-centred. It is a comprehensive introduction to nursing research that will allow readers to build up their understanding of the research process and develop confidence in its practical application.

The social value of a QALY: raising the bar or barring the raise?

Cam Donaldson et al. — Mon, 27 Jun 2011 03:07:15 PDT

Since the inception of the National Institute for Health and Clinical Excellence (NICE) in England, there have been questions about the empirical basis for the cost-per-QALY threshold used by NICE and whether QALYs gained by different beneficiaries of health care should be weighted equally. The Social Value of a QALY (SVQ) project, reported in this paper, was commissioned to address these two questions. The results of SVQ were released during a time of considerable debate about the NICE threshold, and authors with differing perspectives have drawn on the SVQ results to support their cases. As these discussions continue, and given the selective use of results by those involved, it is important, therefore, not only to present a summary overview of SVQ, but also for those who conducted the research to contribute to the debate as to its implications for NICE.

Markets and health in the home of Smith and Yunus

Cam Donaldson et al. — Mon, 27 Jun 2011 03:07:10 PDT

This article looks at markets and health economics.

“I’ve just taken you to see the man with the CD on his head”: the experience and management of recurrent sore throat in children

Catherine Locke et al. — Mon, 27 Jun 2011 03:07:01 PDT

Tonsillectomies for children with recurrent sore throat are common. There is a perception amongst medical professionals that parents are eager for surgical intervention but the parent/child perspective is overlooked in the literature. This study aimed to identify parent/child experience of recurrent sore throat. The study was qualitative, using grounded theory approach to data collection/analysis. Semi-structured, in-depth, interviews were conducted with 12 dyads of children (aged 4—16) and heir parents, attending two Ear, Nose and Throat outpatient clinics held at a hospital in North East England, referred by their General Practitioner for recurrent sore throats. Analysis revealed recurrent sore throats significantly affected the families’ quality of life.

How do respondents explain ‘willingness to pay’ responses? A review of the qualitative evidence

Rachel M. Baker et al. — Mon, 27 Jun 2011 03:06:57 PDT

Alongside a growing body of empirical research relating to willingness to pay (WTP) valuations of the environment, health and safety, there is mounting evidence of embedding, framing effects and other anomalies in responses. Gaining an understanding into how respondents arrive at WTP values is crucial to determining the possible reasons for such anomalies and helping to construct more ‘valid’ WTP instruments. This paper reports a comprehensive literature review of qualitative research conducted alongside the elicitation of WTP values in the areas of environment, transport safety and health. Our review revealed a paucity of work in this area and the need for further in-depth studies of this kind. Despite a wide range of studies in different sectors, with different focus in terms of the nature of the goods in question and the objectives of the qualitative studies, we identify four preliminary themes: mental accounting, lack of trust, moral outrage and moral satisfaction. The relevance of such findings for the design and interpretation of WTP studies is discussed.

Willingness to pay for a QALY: past, present and the future

Helen Mason et al. — Mon, 27 Jun 2011 03:06:51 PDT

This paper is focused on establishing why a willingness-to-pay per quality-adjusted life-year value is needed and how such a value can be used in healthcare decision-making. Studies that have estimated willingness-to-pay per quality-adjusted life-year values from stated preference data are reviewed and categorized into three groups. These studies are then compared within and between groups highlighting the limitations of existing studies and their suitability for use in policy-making. The future of such work will be discussed, noting key issues for consideration and debate.

Deriving distributional weights for QALYs through discrete choice experiments

Emily Lancsar et al. — Mon, 27 Jun 2011 03:06:47 PDT

This paper presents the first attempt to use a discrete choice experiment to derive distributional weights for quality adjusted life years (QALYs), based on characteristics (age and severity) of the beneficiaries. A novel approach using the Hicksian compensating variation is applied. Advantages include derivation of weights for QALYs, not just for life or life years saved, and investigation of the impact of the size of the health gain by allowing the gain to be traded against other characteristics. Results suggest one would generally not weight QALYs, except in a small number of specific cases and in those cases the weights are relatively small. Methodological challenges are highlighted as is a future research agenda.

Valuing lives equally in a benefit-cost analysis of safety projects: a method to reconcile theory and practice

Rachel M. Baker et al. — Mon, 27 Jun 2011 03:06:43 PDT

A value of statistical life (VSL) is used in cost-benefit analysis (CBA) as a monetary measure of the benefits to people from small risk reductions that arise from safety projects. Despite its widespread use in a number of countries, the concept of a VSL remains controversial, not least because it implies acceptance of the underlying ethical assumptions of CBA together with the idea that ‘social welfare’ can be measured and aggregated in some manner. In addition, to comply with theory, variable VSLs for different groups within society would be advocated. However, without fail, empirically, it is the case that those countries that employ a willingness to pay based approach to cost-benefit analysis of a safety project appraisal tend to use a single value for that accident context that is independent of the per capita income level, or indeed other personal characteristics, of the sub-group in society to which the safety improvement will actually apply. This article presents a straightforward, but theoretically justified adaptation to the calculation of a VSL which allows empirical practice by policymakers i.e. the application of a “common” VSL for any particular hazard within a given society, to be compatible with a CBA decision making approach.

What needs to be done in contingent valuation: have Smith and Sach missed the boat?

Rachel M. Baker et al. — Mon, 27 Jun 2011 03:06:39 PDT

It is possible to stretch analogies too far, which is how some readers may interpret this response to Smith and Sach’s latest journey on the good ship
‘willingness-to-pay-database’. They can be dangerous tools to use too, if only because it is difficult to resist the inclination to respond in kind!
In their paper, ‘Contingent valuation: what needs to be done?’, Smith and Sach seek to show that contingent valuation (CV) research in health is like a ship without a sail. The solution they arrive at is to suggest ‘more guidelines needed’, although it is not clear if they mean guidelines for reporting of studies or guidelines for the conduct of studies.