Month: January 2018

Statements of purpose: a view from the admissions committee

I recently had the opportunity to serve on a graduate program admissions committee and had a few reflections on the application process that I wanted to share. In particular, I wanted to give some advice to applicants on what makes a good statement of purpose and how you can use that document to put your best foot forward in the application process.

Graduate programs in health economics and outcomes research (HEOR) recruit from a number of undergraduate and master’s-level fields. This intersection of disciplines, in addition to the lack of undergraduate programs specific to HEOR, creates a unique set of considerations that applicants need to keep in mind when writing their statements of purpose. Here are a few brief tips on writing a successful statement of purpose in your application to HEOR programs:

Tip 1. Establish your connection to the field

First, it needs to be abundantly clear to the reader that the applicant understands what HEOR is. While some students – such as those with a previous master’s degree – may have been able to engage directly with the field, others have to demonstrate their familiarity more explicitly. This advice is especially applicable to clinicians, who bring an invaluable perspective to HEOR studies but are rarely able to participate in research during their clinical training.

Writers can demonstrate an understanding of HEOR in their statements of purpose by talking about specific classes they have taken or mentors who have talked to them about the field. It’s also vital for applicants to demonstrate an understanding of current issues in the field. Keeping up with HEOR blogs and journals is a great way to gain this understanding! The Academic Health Economists’ Blog and Healthcare Economist are among my favorites.

Tip 2. Clarify your goals

Next, the admissions committee will be curious of what your goals are and how a graduate degree in HEOR might help get you there. This means writing about what you plan to do after graduate school. Nobody is going to hold you accountable to what you say in your statement of purpose, but discussing goals demonstrates to the admissions committee that you have reflected on your future and that you can be somewhat self-directed should you enter the program. Graduate school should not be a way of postponing your entry into the “real world.”

Tip 3. Demonstrate your knowledge of the specific program

It’s important to demonstrate abundantly that you have researched your target programs thoroughly. Especially for smaller programs, it’s helpful to know how you heard about the program. If a mentor suggested you apply, mention this! With the HEOR community being relatively small, there’s a good chance that someone on the admissions committee will know your mentor, which is likely to work in your favor.

Tip 4. Polish your writing

Graduate training is a massive investment for both the school and the student. When making decisions about who to admit, the admissions committee uses the statement of purpose to assess your writing skills, the rationale for your decision to apply to their program, and your suitability for a career in HEOR. A well-written statement can pique the interest of everyone on the committee, while a poorly written one can make a candidate seem less interesting, even when every other part of their application looks ideal. Polish your statement into a masterpiece that showcases your enthusiasm for the field and you’ll be a step ahead in the admissions process.

Value in Health Care in 2018: A Broader Approach with New Research Needs

 

uw by drone
Photo of the University of Washington campus by Ben Babusis

Meng Li

 

In 1950, national health expenditure as a share of gross domestic product in the United States was 5%. The share rose to 18% in 2016. Such rapid growth of healthcare expenditure has spurred widespread interest in value assessments of medical technologies, in general, and of new medicines, in particular. The American College of Cardiology-American Heart Association (ACC-AHA), American Society of Clinical Oncology (ASCO), Institute for Clinical and Economic Review (ICER), Memorial Sloan Kettering Cancer Center, and National Comprehensive Cancer Network (NCCN) are among the organizations that have proposed and implemented new value assessment frameworks. Given their different perspectives and decision-making needs, these organizations have identified a wide range of different factors underlying value, to name a few:  clinical benefit vs. risks, magnitude of net benefit, precision of estimate, cost-effectiveness, budget impact, affordability, novelty, research and development cost, rarity, and population health burden. Most of these existing frameworks, however, lack a consistent theoretical foundation in health economics, which has led to omission of important components of benefits or costs given their perspectives.

To inform the shift towards a more value-based healthcare system in the US, the International Society for Pharmacoeconomics and Outcomes Research (ISPOR, https://www.ispor.org) started the Initiative on US Value Assessment Frameworks in 2016. The objectives of the Initiative are to describe the conceptual basis for value, examine existing value frameworks, identify novel elements of value, and recommend good practice in value assessment. In contrast with many existing frameworks, the approach to value taken by the Initiative is grounded in health economics, yet recognizes special circumstances when a microeconomic approach cannot easily accommodate all relevant elements of value.

In the final report by the Initiative, to be published in February, many novel elements of value are identified and defined: productivity, adherence-improving factors, reduction in uncertainty, fear of contagion, insurance value, severity of disease, value of hope, real option value, equity, and scientific spillovers, along with the conventional quality-adjusted life-years (QALY) gained and net costs. Among these conventional and novel elements, QALY gains, net costs, and adherence-improving factors are value concepts from the health system perspective, while the rest are from the broader societal perspective. The Initiative also identified a number of additional value elements that are currently impractical to estimate due to lack of data or appropriate methodologies, such as fit with existing programs or infrastructure, end-of-life alternatives, ethical considerations related to manipulation of genetic materials, fears associated with specific types of therapies, etc.

Following the Second Panel on Cost-Effectiveness in Health and Medicine, whose report was published in the Fall of 2016, the Initiative recommended using cost-per-QALY-gained as the starting point for decision-making for healthcare resource allocation, and that other novel elements of value should be considered when relevant and if practical. The Initiative proposed the concept of “augmented cost-effectiveness analysis (CEA)”, where more measures of value besides health gains, societal costs, and financial risk protection are considered in a value assessment. Their report outlines several potential approaches to incorporating these novel elements into value assessments. One is to incorporate them either in the cost or in the QALY in the cost-per-QALY-gained ratio. Another approach is to monetize all health and related benefits, therefore converting the CEA into a cost-benefit analysis. A third approach is to compare element-by-element, which is in line with the “Impact Inventory,” a framework for considering consequences of an intervention as they impact different sectors put forth by the Second Panel. Finally, a fourth approach is to use multi-criteria decision analysis. Each of these approaches has its own advantages and methodological challenges, and more research and experience are needed in the application of augmented CEA.

Authors of the Initiative report also address issues around budgets and thresholds. The general recommendation is to base reimbursement policies on what is good value for money given a health plan’s budget. Good value for money can be achieved by using an explicit cost-per-QALY-gained threshold along with modifiers to that threshold. Both thresholds and modifiers for public and private health plans should reflect plan members’ or taxpayers’ preferences. The novel elements of value mentioned above are candidates for modifiers to the thresholds.

In contrast to other highly industrialized nations, stakeholders in the US have not fully embraced using cost-effectiveness to inform resource allocation decisions in healthcare. The US has the highest per capita spending on healthcare in the world, while life expectancy of Americans is lagging behind 30 or so countries and has even declined for the past two years. Many now believe that this is partly due to a misalignment between value and payment, and realigning the two is critical to bending the healthcare cost curve. It is encouraging to see new value assessment frameworks for medical technologies gaining visibility and some traction in the US. In order for them to have a greater impact on reimbursement decisions, the research community needs to make sure these frameworks are conceptually and methodologically sound and the assessment processes are transparent. The ISPOR Initiative has broadened our view of what constitutes value in health care; more research is needed to understand and estimate novel elements of value in different healthcare decision contexts and their implications.

Book Review

Difficult Choices Between What is Best for Science or Best for Our Career

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RIGOR MORTISHow Sloppy Science Creates Worthless Cures, Crushes Hope, and Wastes Billions
By Richard Harris
288 pages, Perseus Books Group, List Price $28

In “Rigor Mortis: How Sloppy ScienceCreates Worthless Cures, Crushes Hope, and Wastes Billions,” Richard Harris provides compelling evidence through a series of stories and statistics that medical research is plagued by unnecessary errors despite our technology, effort, money, and passion to make a positive impact. This review takes the perspective of a graduate student in health sciences with the aim of assessing the value of Rigor Mortis for the next generation of scientists.  While the book focuses more on sloppy biological science, his concerns are equally valid in the areas of data science and disease modeling.

Richard Harris, a journalist at NPR who writes about science, has started an important conversation about the broad impact of our current scientific culture: we are publishing too many scientific studies which may have false or unreproducible results. Graduate students in health science research or related fields should not be surprised by Harris’s premise. The pressure to produce a large quantity of publications, instead of fewer and higher quality papers, weighs on every grad student in the world.

In 2017, the CHOICE Institute asked its members to read Rigor Mortis and discuss its implications for our field. One emerging theme was that trainees need to be able to report unethical behaviors without fearing adverse consequences. While required annual courses from the University of Washington Biomedical Research Integrity Series challenge students to reconsider their own personal conflicts of interest in publishing research, this remains a difficult ideal to implement in the face of other pressures. Around the lunch table in our grad student lounge, the book sparked an uncomfortable conversation about multiple testing during regression model fitting, and the long stretch of grey area between a dusty, pre-specified analysis plan and our shiny, new hypothesis-generating exploratory findings.

Harris’s storytelling reminded me of a book I love by David Quammen called “Spillover.” Both Rigor Mortis and Spillover are written by distinguished journalists about very complicated and technical problems. Using New York Times reader-friendly language,  both authors include conversations with scientists from around the world to share their stories so that the layperson can understand.

Both books highlight a common dilemma in academia: Should I do what is best for science or what is best for my career? Further, is this an incentives problem or a system problem? The current structure and business of research guide us to make choices that will enhance our career, while science is still often perceived as an altruistic pursuit for the greater good. The book offers a challenge to academic researchers: who among us can claim “no conflict of interest”?

rigor_mortis2
“Attending the panel that rejected his paper proposal, the grad student inwardly trashes each presenter’s research.” — Lego Grad Student

Applying the book’s messages to health economics and outcomes research

I experienced this dilemma when deciding whether to share my HIV disease model. Scientific knowledge and methodology should be completely transparent, yet software coding to implement these techniques is intellectual property that we should not necessarily give away for free. My dilemma isn’t unique. Disease modelers everywhere struggle with this question: should we post our Excel spreadsheet or R code online for others to review and validate and risk having our discovery poached?

This is just one example of tension Harris highlights in his book, and why it is so complex to change our current scientific culture. Scientific advancement is ideally a collective good, but individuals will always need personal incentives to innovate.

Key book takeaways for young scientists

  1. Use valid ingredients
  2. Show your work
  3. No HARKing (Hypothesizing After the Results of the study are Known)
  4. Don’t jump to conclusions (and discourage others from doing this with your results)
  5. Be tough. People may try to discredit you if your hypothesis goes against their life’s work, or for any number of reasons.
  6. Be confident in your science.
  7. Recognize the tension between your own achievement and communal scientific advancement

Further discussions for fixing a broken system

  1. If money is being wasted in biomedical science and research, how do we fix the system to save money without sacrificing incentives to produce valuable innovations? One of our CHOICE Institute graduates, Carrie Bennette, asked this very question in cancer research and you can read about her findings here.
  2. Incentives need to be changed. Academic promotions should not be dependent on the number of our publications but the quality and impact of our contributions. Can we change the culture obsessed with impact factor and promote alternatives such as the H-index or Google Scholar metrics?
  3. Academic tenure systems are antiquated. How do we balance the trade-offs between hiring a post-doc or hiring a permanent staff scientist? Post-doc positions train the next generation and are cheap, however they result in workflow discontinuity from frequent turnover. Permanent staff scientists are trained to stay for a longer period of time, but would disrupt an engrained academic pipeline.

Conclusion

I think all students in any science-related field would benefit from reading this book. Cultural and systematic change will happen faster when we have uncomfortable conversations at the table with our colleagues and mentors. Additionally, we need to take the baton Richard Harris has passed us and start running with our generation of colleagues toward finding and implementing solutions. As our influence in our respective fields grows, so too does our responsibility.

Rigor Mortis is available in hardcover on Amazon for $18.65 and Audible for $19.95.

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Welcome to Incremental Thoughts, the CHOICE students’ blog

choice-who-we-are-16x9aColleagues and friends,

Welcome to our new blog! The graduate students of the Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute at the University of Washington are excited to share our experience as students in health economics and outcomes research (HEOR) with you and to learn from your experiences in return.

This project came about from a meeting of our student chapter of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR), when we thought through ways to network more with other students and to find ways to engage with the conversations around HEOR taking place online. Blogs and Twitter have made the field’s luminaries easier than ever to contact, but at the meeting it emerged that many of us felt like opportunities for students to voice their unique perspective were lacking.

Thus, this blog. We’ll be featuring a broad range of articles here: upcoming research from our students, advice from our faculty for early career professionals in the field, and tips and tutorials on both established and newer methods.

Our blog is a collaborative effort, and we have many people to thank. We’re able to pay for this thanks to a grant from the ISPOR student network. And of course, the support of our professors has been essential — in particular, our senior editors Beth Devine and Ryan Hansen.

We’d love to have you along for this experiment!

Your editors,

Elizabeth Brouwer

Nathaniel Hendrix