The practice of discounting in economic evaluations of healthcare interventions

Objectives: Discounting of costs in health-related economic evaluation is generally regarded as uncontroversial, but there is disagreement about discounting health benefits. We sought to explore the current recommendations and practice in health economic evaluations with regard to discounting of costs and benefits. Methods: Recommendations for best practice on discounting for health effects as set out by government agencies, regulatory bodies, learned journals, and leading health economics texts were surveyed. A review of a sample of primary literature on health economic evaluations was undertaken to ascertain the actual current practice on discounting health effects and costs. Results: All of the official sources recommended a positive discount rate for both health effects and costs, and most recommended a specific rate (range, 1% to 8%). The most frequently specified rates were 3% and 5%. A total of 147 studies were reviewed; most of these used a discount rate for health of either 0% (n = 50) or 5% (n = 67). Over 90% of studies used the same discount rate for both health and cost. While 28% used a zero rate for both health and cost, in 64% a nonzero rate was used for both. Studies where the health measure was in natural clinical units (direct) were significantly more likely to have a zero discount rate. Conclusion: The finding that 28% of studies did not discount costs or benefits is surprising and concerning. A lower likelihood of discounting for benefits when they are in natural units may indicate confusion regarding the rationale for discounting health effects

Income related inequalities in self assessed health in Britain: 1979-1995

Study objective: To measure and decompose income related inequalities in self assessed health in England, Scotland, and Wales, 1979-1995. Design: The relation between individual health and a non-linear transformation of equivalised income, allowing for sex, age, country, and year effects, was estimated by multiple regression. The share of health attributable to transformed income and the Gini coefficient for transformed income were calculated. Inequality in health was measured by the partial concentration index, which is the product of the. Gini coefficient and the share of health attributable to transformed income. Participants and setting: Representative annual samples of the adult population living in private households in Great Britain 1979-1995. The total analysed sample was 299 968 people. Main results: Pro-rich health inequality was largest in Wales and smallest in England over the period because the effect of increased income on health was greatest in Wales and least in England. In all three countries, pro-rich health inequality increased throughout the period. In the early 1980s this was primarily attributable to increases in income inequality. Thereafter the increased share of health attributable to income was the principal cause. Conclusions: Reductions in pro-rich health inequality can be achieved by reducing income inequality, reducing the effect of income on health, or both

Waiting lists, waiting times and admissions: an empirical analysis at hospital and general practice level

We report an empirical analysis of the responses of the supply and demand for secondary care to waiting list size and waiting times. Whereas previous empirical analyses have used data aggregated to area level, our analysis is novel in that it focuses on the supply responses of a single hospital and the demand responses of the GP practices it serves, and distinguishes between outpatient visits, inpatient admissions, daycase treatment and emergency admissions. The results are plausible and in line with the theoretical model. For example: the demand from practices for outpatient visits is negatively affected by waiting times and distance to the hospital. Increases in waiting times and waiting lists lead to increases in supply; the supply of elective inpatient admissions is affected negatively by current emergency admissions and positively by lagged waiting list and waiting time. We use the empirical results to investigate the dynamic responses to one off policy measures to reduce waiting times and lists by increasing supply

National survey of job satisfaction and retirement intentions among general practitioners in England

Objectives To measure general practitioners' intentions to quit direct patient care, to assess changes between 1998 and 2000, and to investigate associated factors, notably job satisfaction. Design Analysis of national postal surveys conducted in 1998 and 2001. Setting England. Participants 1949 general practitioner principals, of whom 790 were surveyed in 1998 and 1159 in 2001. Main outcome measures Overall job satisfaction and likelihood of leaving direct patient care in the next five years. Results The proportion of doctors intending to quit direct patient care in the next five years rose from 14% in 1998 to 22% in 2001. In both years, the main factors associated with an increased likelihood of quitting were older age and ethnic minority status. Higher job satisfaction and having children younger than 18 years were associated with a reduced likelihood of quitting. There were no significant differences in regression coefficients between 1998 and 2001, suggesting that the effect of factors influencing intentions to quit remained stable over time. The rise in intentions to quit was due mainly to a reduction in job satisfaction (1998 mean 4.64, 2001 mean 3.96) together with a slight increase in the proportion of doctors from ethnic minorities and in the mean age of doctors. Doctors' personal and practice characteristics explained little of the variation in job satisfaction within or between years. Conclusions Job satisfaction is an important factor underlying intention to quit, and attention to this aspect of doctors' working lives may help to increase the supply of general practitioners

Measuring and testing for gender discrimination in professions: the case of English family doctors

In 2004 the income of female GPs was 70%, and their wages (income per hour) were 91%, of those of male GPs. We compare estimates of gender discrimination from Oaxaca decompositions using models of wages (income/hours), OLS and 2SLS models of income, and propensity score matching. We propose a new direct test for within workplace gender discrimination based on a comparison of the differences in income of female and male GPs in practices in which all GPs are of the same gender with the differences in male and female income in mixed gender practices. We find that the coefficients on log hours in the log income models are positive but significantly less than 1, so that log wage models are misspecified. Discrimination, as measured by the unexplained difference in mean log income varied between 21% to 28%. However, our direct tests could not reject the null hypothesis of no within workplace gender discrimination.Gender discrimination. Professions. Family doctors. Propensity score matching.

Measuring quality of care with routine data: avoiding confusion between performance indicators and health outcomes

Objective To investigate the impact of factors outside the control of primary care on performance indicators proposed as measures of the quality of primary care. Design Multiple regression analysis relating admission rates standardised for age and sex for asthma, diabetes, and epilepsy to socioeconomic population characteristics and to the supply of secondary care resources. Setting 90 family health services authorities in England, 1989-90 to 1994-5. Results At health authority level socioeconomic characteristics, health status, and secondary care supply factors explained 45% of the variation in admission rates for asthma, 33% for diabetes, and 55% for epilepsy. When health authorities were ranked, only four of the 10 with the highest age-sex standardised admission rates for asthma in 1994-5 remained in the top 10 when allowance was made for socioeconomic characteristics, health status, and secondary care supply factors. There was also substantial year to year variation in the rates. Conclusion Health outcomes should relate to crude rates of adverse events in the population. These give the best indication of the size of a health problem. Performance indicators, however, should relate to those aspects of care which can be altered by the staff whose performance is being measured

Response bias in job satisfaction surveys: English general practitioners

Job satisfaction may affect the propensity to respond to job satisfaction surveys, so that estimates of average satisfaction and the effects of determinants of satisfaction may be biased. We examine response bias using data from a postal job satisfaction survey of family doctors. We link all the sampled doctors to an administrative database and so have information on the characteristics of responders and non-responders. Allowing for selection increases the estimate of mean job satisfaction in 2005 and the estimated change in mean job satisfaction between 2004 and 2005. Estimates of the determinants of job satisfaction are generally insensitive to response bias.Job satisfaction. Response bias. Sample selection. Family practitioners.

Income, relative income, and self-reported health in Britain 1979-2000

According to the relative income hypothesis, an individual’s health depends on the distribution of income in a reference group, as well as on the income of the individual. We use data on 231,208 individuals in Great Britain from 19 rounds of the General Household Survey between 1979 and 2000 to test alternative specifications of the hypothesis with different measures of relative income, national and regional reference groups, and two measures of self assessed health. All models include individual education, social class, housing tenure, age, gender and income. The estimated effects of relative income measures are usually weaker with regional reference groups and in models with time trends. There is little evidence for an independent effect of the Gini coefficient once time trends are allowed for. Deprivation relative to mean income and the Hey-Lambert-Yitzhaki measures of relative deprivation are generally negatively associated with individual health, though most such models do not perform better on the Bayesian Information Criterion than models without relative income. The only model which performs better than the model without relative income and which has a positive estimated effect of absolute income on health has relative deprivation measured as income proportional to mean income. In this model the increase in the probability of good health from a ceteris paribus reduction in relative deprivation from the upper quartile to zero is 0.010, whereas as an increase in income from the lower to the upper quartile increases the probability by 0.056. Measures of relative deprivation constructed by comparing individual income with incomes within a regional or national reference group will always be highly correlated with individual income, making identification of the separate effects of income and relative deprivation problematic

Does quality affect patients’ choice of Doctor? Evidence from England

Reforms giving users of public services choice of provider aim to improve quality. But such reforms will work only if quality affects choice of provider. We test this crucial prerequisite in the English health care market by examining the choice of 3.4 million individuals of family doctor. Family doctor practices provide primary care and control access to non-emergency hospital care, the quality of their clinical care is measured and published and care is free. In this setting, clinical quality should affect choice. We find that a 1 standard deviation increase in clinical quality would increase practice size by around 17%