New working paper – ‘The relationship between individual risk and cost-effectiveness in screening interventions’

I’ve just released a new working paper, along with my co-authors Profs Marilyn James and David Whynes. You can access it through RePEc here. The paper discusses the (somewhat obvious) relationship between a person’s risk of developing a disease and the cost-effectiveness of screening them. This is important because publicly-funded screening interventions will, in the future, I suspect, have to discriminate based on risk.

Here’s the abstract:

Advancements in our understanding of the causes and correlates of disease mean that we are now able to estimate an individual’s level of risk. This, and the ever-increasing need for healthcare interventions to be cost-effective, has led to calls for the introduction of risk-based screening. Risk-based screening would involve the use of information about an individual’s risk factors to decide whether or not they should be eligible for screening, or the frequency with which they should be invited to attend screening. Evidence is emerging that targeted screening, towards those at higher risk, can increase the cost-effectiveness of a screening programme. The relationship between individual risk and the cost-effectiveness of screening an individual is implicitly recognised in current population screening programmes in the UK. However, the nature of this relationship, and its implications for cost-effectiveness analysis, has not been presented in the academic literature. In this study we propose that an individual’s risk of developing a disease has a consistent and quantifiable relationship with the cost-effectiveness of screening them. We suggest a simple modification to standard methods of cost-effectiveness analysis that enables the incorporation of individual risk. Using numerical examples we demonstrate the nature of the relationship between risk and cost-effectiveness and suggest means of optimising a screening intervention. This can be done either by defining a minimum level of risk for eligibility or by defining the optimal recall period for screening. We suggest that methods of decision modelling could enable such an analysis to be carried out, and that information on individual risk could be used to optimise the cost-effectiveness of population screening programmes.

I’d really appreciate any comments you might have on this paper. Feel free to post below or alternatively please send me an email.

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#100wordreview – Quack Policy. Abusing Science in the Cause of Paternalism (Jamie Whyte) [Book]


I found this IEA publication very difficult to read, because almost every paragraph is flawed; sometimes logically, often evidentially and at times morally. The book takes what any undergrad might learn in Econ101 and applies it to current challenges and policy responses in health and climate change. All with gusto and arrogance. Whyte has little regard for the policy context, or for much of economic thought from the last 40 years. Most arguments depend on false analogies, which are painful to read. In the author’s own words: “Science progresses by ignoring mere opinion, expert or otherwise”. Thank goodness for that.

#100wordreview – Never Again? The story of the Health and Social Care Act 2012 (Nicholas Timmins) [Book]

I increasingly find politics a bore, even in relation to health and economic policy. Timmins’s Never Again? precludes my usual reaction, providing a lucid and engaging narrative. The story guides us through the Act’s conception, rejection, amendment and assent, identifying the key players from academia and Westminster along the way. The book enables you to leave your political inclinations at the door, and at times I found myself sympathising with Lansley! It also provides a nice overview of the ultimate nature of the Act at the end of its tumultuous journey; something I struggled to figure out at the time.

What would an evidence-based health service really look like?

I’m talking about the big stuff. If we were to scrap the NHS and design a new service from the ground up, what would an evidence-based health service look like? Who should fund services? Who should provide services? Who should be accountable to patients?

It seems that many developing countries actually face this challenge of building a health service from scratch. I hope they have a better grasp of the evidence than me.

There are probably some issues on which the evidence would be clear; universal coverage would be an obvious starting point. Public financing solves a lot of problems (demand-side socialism, as Tony Culyer puts it). Beyond that I’m left wondering. A number of sources summarise some of the evidence on NHS reforms, such as Cam Donaldson’s Credit Crunch Health Care, but I can’t find anything comprehensive. I’d really like it if somebody could recruit a PhD student to review all the evidence for the design of a health service and summarise where the evidence is strong and where it is weakObviously this would require a definition of objectives and decision rules. Simultaneously maximising health, equality of health and access to services seems a relatively uncontentious goal. So what kind of service would best provide this?

We have some idea of what the service shouldn’t look like, and that’s what they have in the United States. Little else is certain. The debate over the changes to the NHS brought in by the Health and Social Care Bill 2010 was relatively light on evidence, though a few issues were brought to the table. In a poll on the Academic Health Economists’ Blog, a majority voted that the Health and Social Care Bill should have been rejected. I’d like to think that this was at least partly informed by the readers’ understanding of the evidence. However, for someone to reject a bill does not mean that they can offer a better alternative, even if they do have some idea about the evidence. Maybe if we had a better grasp of the evidence we’d have a better idea of what we want our health service to look like.