This paper examines the impact that the Great Recession had on individuals' health behaviours and risk factors such as diet choices, smoking, alcohol consumption, and Body Mass Index, as well as on intermediate health outcomes in England. We exploit data on about 9000 households from the Health Survey for England for the period 2001-2013 and capture the change in macroeconomic conditions using regional unemployment rates and an indicator variable for the onset of the recession. Our findings indicate that the recession is associated with a decrease in the number of cigarettes smoked - which translated into a moderation in smoking intensity - and a reduction in alcohol intake. The recession indicator itself is associated with a decrease in fruit intake, a shift of the BMI distribution towards obesity, an increase in medicines consumption, and the likelihood of suffering from diabetes and mental health problems. These associations are often stronger for the less educated and for women. When they exist, the associations with the unemployment rate (UR) are nevertheless similar before and after 2008. Our results suggest that some of the health risks and intermediate health outcomes changes may be due to mechanisms not captured by worsened URs. We hypothesize that the uncertainty and the negative expectations generated by the recession may have influenced individual health outcomes and behaviours beyond the adjustments induced by the worsened macroeconomic conditions. The net effect translated into the erosion of the propensity to undertake several health risky behaviours but an exacerbation of some morbidity indicators. Overall, we find that the recession led to a moderation in risky behaviours but also to worsening of some risk factors and health outcomes.

Background Trastuzumab improves survival in HER2+ breast cancer patients, with some evidence of adverse cardiac side effects. Current recommendations are to give adjuvant trastuzumab for one year or until recurrence, although trastuzumab treatment for only 9 or 10 weeks has shown similar survival rates to 12-month treatment. We present here a multi-arm joint analysis examining the relative cost-effectiveness of different durations of adjuvant trastuzumab. Methods and findings Network meta-analysis (NMA) was used to examine which trials’ data to include in the cost-effectiveness analysis (CEA). A network using FinHer (9 weeks vs. zero) and BCIRG006 (12 months vs. zero) trials offered the only jointly randomisable network so these trials were used in the CEA. The 3-arm CEA compared costs and quality-adjusted life-years (QALYs) associated with zero, 9-week and 12-month adjuvant trastuzumab durations in early breast cancer, using a decision tree followed by a Markov model that extrapolated the results to a lifetime time horizon. Pairwise incremental cost-effectiveness ratios (ICERs) were also calculated for each pair of regimens and used in budget impact analysis, and the Bucher method was used to check face validity of the findings. Addition of the PHARE trial (6 months vs. 12 months) to the network, in order to create a 4-arm CEA including the 6-month regimen, was not possible as late randomisation in this trial resulted in recruitment of a different patient population as evidenced by the NMA findings. The CEA results suggest that 9 weeks’ trastuzumab is cost-saving and leads to more QALYs than 12 months’, i.e. the former dominates the latter. The cost-effectiveness acceptability frontier (CEAF) favours zero trastuzumab at willingness-to-pay levels below £2,500/QALY and treatment for 9 weeks above this threshold. The combination of the NMA and Bucher investigations suggests that the 9-week duration is as efficacious as the 12-month duration for distant-disease-free survival and overall survival, and safer in terms of fewer adverse cardiac events. Conclusions Our CEA results suggest that 9-week trastuzumab dominates 12-month trastuzumab in cost-effectiveness terms at conventional thresholds of willingness to pay for a QALY, and the 9-week regimen is also suggested to be as clinica...

Healthcare funding decisions in the UK rely on health state valuations of the general public. However, it has been shown that there is disparity between the valuation of the impact of hypothetical conditions on health and the reported health by those experiencing them. Patients' adaptation to health states is among the most common explanations for this discrepancy. Being diagnosed with a disease appears to affect individual perception of health over time so that better subjective health may be reported over a disease trajectory. This paper examines adaptation to health states using a longitudinal dataset. We use four waves of the British Cohort Study (BCS70), which tracks a sample of British individuals since birth in 1970 and contains information on self-assessed health (SAH), morbidity, and socioeconomic characteristics. We implement a dynamic ordered probit model controlling for health state dependence. Results are supportive of the existence of adaptation: Time since diagnosis has a positive impact on SAH. Moreover, adaptation happens over relatively long durations. We do not find significant results proving different adaptation paths for patients reporting prior better SAH. The analysis by specific conditions generally supports the existence of adaptation, but results are statistically significant only for a subset of conditions.

The healthcare system in Malta is financed through global budgets and healthcare is provided free at the point of use. This paper is a first attempt to examine the feasibility of introducing a Diagnosis Related Groups casemix system for Malta, not necessarily for payment and funding purposes, but as a tool to help describe, manage and measure resource use. This is particularly challenging in view of the constraints and characteristics of a small state country. The study evaluates the applicability of the MS-DRG (Version 27.0) Grouper to describe acute hospital activity on the island. The classification of 151,615 admissions between 2009-2011 resulted in 636 DRG categories. Around half of these DRGs accounted for 99% of the total activity at the hospital, while 296 DRG categories had fewer than 15 cases over the period. Patient length of stay is used to explain resource use and the Coefficient of Multiple Determination obtained was of 0.19 (improving to 0.25 when a number of trimming algorithms were applied). A good proportion of the resulting DRGs had a Coefficient of Variation, which indicates a low degree of variability within the obtained DRG groups. This presents good evidence to support the introduction of a DRG system in Malta particularly in view of the recent drive towards more public-private partnerships and legislation on cross-border patient treatment.

Objectives: To compare patterns of technological adoption of minimally invasive surgery for radical prostatectomy across the United States and England. Data Sources: We examine radical prostatectomy in the United States and England between 2005 and 2017, using de-identified administrative claims data from the OptumLabs Data Warehouse in the United States and the Hospital Episodes Statistics in England. Study Design: We conducted a longitudinal analysis of robotic, laparoscopic, and open surgery for radical prostatectomy. We compared the trends of adoption over time within and across countries. Next, we explored whether differential adoption patterns in the two health systems are associated with differences in volumes and patient characteristics. Finally, we explored the relationship between these adoption patterns and length of stay, 30-day readmission, and urology follow-up visits. Data Collection: Open, laparoscopic, and robotic radical prostatectomies are identified using Office of Population Censuses and Surveys Classification of Interventions and Procedures (OPCS) codes in England and International Classification of Diseases ninth revision (ICD9), ICD10, and Current Procedural Terminology (CPT) codes in the United States. Principal Findings: We identified 66,879 radical prostatectomies in England and 79,358 in the United States during 2005-2017. In both countries, open surgery dominates until 2009, where it is overtaken by minimally invasive surgery. The adoption of robotic surgery is faster in the United States. The adoption rates and, as a result, the observed centralization of volume, have been different across countries. In both countries, patients undergoing radical prostatectomies are older and have more comorbidities. Minimally invasive techniques show decreased length of stay and 30-day readmissions compared to open surgery. In the United States, robotic approaches were associated with lower length of stay and readmissions when compared to laparoscopic. Conclusions: Robotic surgery has become the standard approach for radical proctectomy in the United States and England, showing decreased length of stay and in 30-day readmissions compared to open surgery. Adoption rates and specialization differ across countries, likely a product of differences in cost-containment efforts.