In the final issue of the year, we introduce a series on ethics in publishing with (an original) piece on plagiarism. You’ll also find advice here on how health economists can develop a more global outlook, what journal editors look for from potential authors, how to maintain good relationships with your chosen agency, and how to make the best use of graphics. And there’s a full report on the recent ISPOR meting in Copenhagen.

This issue also marks HOC’s first year of publication. I thank all those who have contributed to the publication’s success, including Rx Communications’ CEO Ruth Whittington, HOC project manager Chris Gardiner, and editorial manager Adelina Pagliocca; production/copy editor Janet Beaumont; and contributing writers Kevin Frick, Mary Gabb, Clare Gurton, Ruth Murray, and Robert Hand.

We look forward to providing information and ideas for healthcare economists in the coming year. Meanwhile, I wish all of you a happy and healthy 2007.

David Woods
HOC editor

“In matters of style, swim with the current; in matters of principle, stand like a rock.”
Thomas Jefferson, 3rd president of US (1743–1826)

Ethics in publishing: 1 – Plagiarism

by David Woods

Such ethical issues as truth, deception, confidentiality, paternalism, relativism, conflict of interest, and personal and social responsibility have an impact both on healthcare and on publishing. We’ll be examining some of these issues in future issues of HOC; but we’ll start here with deception, whose most obvious example is plagiarism.

Plagiarism has been a hot topic recently. Reporters have been fired from such august publications as the New York Times for fabricating stories. And in the UK, Ian McEwan was accused of using some brief wording in his best selling novel Atonement that was drawn too directly from another author’s romantic novel. But plagiarism isn’t new. The Financial Times notes (and I’m quoting here with full attribution; not copying) that ‘Shakespeare... took a large number of his plots straight from a contemporary source, Holinshed’s Chronicles,’ and that ‘no less upright a figure than T.S. Eliot grandly declared that ‘immature poets imitate; mature poets steal.’’

Plagiarism is often hard to pin down since much published work can be a mixture of originality and half digested ideas vaguely plucked from memory. Nonetheless, it’s the imperative to compete or to ‘get there first’ that can sink writers and publications into an ethical swamp. According to the Freedom Forum Media Studies Center: ‘Seventy six per cent of [Americans] believe that journalists often or sometimes plagiarise material and 66% said that stories are often made up and passed off as real.’ Respondents to the survey blamed the rash of debacles on weak editing and pressure to beat the competition.

In medicine, if there’s a serious error, there’s a funeral and a lengthy lawsuit; in publishing, an error usually produces an apology and a retraction in four-point type buried in a subsequent issue of the publication.

In medical publishing, the issue is far more critical than in the general media. At the American Medical Publishers Association’s annual meeting a couple of years ago, The Economist’s then healthcare correspondent Shereen El Feki observed that publications can carry outlandish medical stories, stir up a furore with them, and then later countermand them. ‘Oops, sorry, we were wrong about [name the substance] being a cancer cure. At the same meeting, mathematician and author (Innumeracy) John Allen Paulos noted the tendency for writers in scientific publications to play fast and loose with numbers and statistics.

Publish or perish may be part of the problem, and peer review may be part of the solution. But not always. There can be selective underreporting of unfavourable results and overhyping of positive ones.

Plagiarism comes from the Latin for kidnapper. Rather than paying a ransom for it after your work is published, be vigilant as you write it. And don’t give your editors cause to suspect you of literary theft. Unlike Shakespeare’s editors, they can Google you if they think some part of your work may be less than pristinely original.

Google, by the way, apparently has some 10 million entries for plagiarism. The first one listed is plagiarism.org. One hopes they all meet ethical standards.

How health economists can develop a global perspective

By Kevin D Frick

Health economists interacting with colleagues and clients often need to have a global perspective, which means not limiting one’s view to what is going on in one’s own country… and that goes beyond economics.

So, how does a health economist develop a holistic and global perspective? Keep up with academic and trade journals covering economic topics that are not limited to your own country; be sure to read non-economic articles too. For example, a health economist who has become expert in infectious disease might include clinical epidemiology articles relevant to infectious disease in your country and in others. However, to interpret data effectively and make predictions you will need to go beyond just economic and clinical epidemiology. Read about sociologic and political issues related to infectious disease. While these other disciplines don’t always look at issues in exactly the same way as economists do, the ideas that come from the other disciplines may help you to understand how people think about infectious disease and how policy makers are likely to use clinical epidemiology data and economic data together to make policy.

Remember that as health economists we are interested in how people make decisions. There is no better way to find out how people make decisions than to cultivate a global approach both geographically and professionally.

What are journal editors looking for from health economists?

By Mary Gabb

For most researchers (of any clinical denomination), the manuscript submission process is fraught with more questions than answers. Christine Laine, MD, MPH, senior deputy editor of the Annals of Internal Medicine, says that the most important advice for health economists wanting to submit their research to clinical journals is to remember the journal’s audience. Specifically, she says:

• Relate the findings to outcomes: clinical outcomes are important to clinicians, so any article published in the Annals should reflect this. Any HE article should take the societal perspective and results should be expressed in cost/quality-adjust life-year, not cost/hospitalisation averted or cost/cancer case detected, for example.
• Avoid any cutoff figure: any cutoff for an intervention to be considered ‘cost effective’ in HE circles may not be such a clear distinction in clinical discourse and should not be part of the discussion in a research article.
• Use as little jargon as possible: if you must use HE-related terms, provide the definition within the article text.
• Make the methods transparent: the Annals of Internal Medicine reviewers look for assumption models created from a systematic literature review (rather than a single source), which should be cited. Also, make the model available to others, to determine if the results can be repeated.
• Use a multi-way probabilistic sensitivity analysis: these types of analyses are considered to be more scientifically rigorous and are therefore preferred.
• Use the structure provided by the journals: the Annals provides a specific structure for the abstract and body of HE-related articles. Authors should follow those instructions.

As a top-tier journal, the Annals of Internal Medicine publishes only 6% of the manuscripts it receives, and most of the HE-related articles are cost-effectiveness analyses that affect healthcare policy decisions. Dr. Laine says that HE research will interest clinicians if the work is placed in a context that is relevant to clinicians’ priorities.

Maintaining good relationships with your chosen agency

by Clare Gurton

Once you’ve selected an agency be sure that you are clear about the roles and responsibilities of each person and that you develop a clear action plan for the projects. This should include the aims, the expected outcome, responsibilities, and a time schedule.
Next, make arrangements that are appropriate to the nature and purpose of the work and that will be effective in developing and maintaining relationships. Establish realistic methods to monitor and review progress regularly. Also, make sure that confidentiality is a part of all the projects the agency is and will be involved in.

There are several key factors in maintaining effective and fruitful working relationships. Among them are:

• Trust: This is the foundation for any successful collaboration. People in trusting relationships seek input from one another (and actually use it), allowing all participants to do their jobs without unnecessary oversight. People who trust colleagues can also openly discuss successes and failures – and learn from them.
• Diversity: Successful working relationships encourage it. Diversity broadens the number of potential solutions and enables people to learn from one another.
• Flexibility: Keeping an open mind in working relationships is vital – it encourages new ideas and helps those involved to look for ways to continually learn and improve.
• Respect: Respectful interactions are considerate, honest and tactful. People who respect one another value each others’ opinions and willingly change their minds in response to what others say.
• Effective communication: Communication is an important aspect of a good working relationship – when things go silent, they frequently go wrong. Face-to-face interaction or telephone conversations are preferable to written messages with potentially unclear meanings or emotional content... and emails or memos are suitable for more routine messages. Know the importance of each and when to use them.

How to make the best use of graphics

by Ruth B Murray

The power of a graph lies in its ability to convey a variety of complex relationships in a way that is difficult to describe in words, but is easily comprehended from a picture. When designing a graph, consider these points:

• Avoid fussy, excessively complicated graph design.
• Don’t use 3D graphs. They are usually harder to interpret and more cluttered than 2D graphs (see Figure 1).
• Reduce clutter by removing key borders and gridlines
  (see Figure 1b).
• Avoid bold shading or cross hatching which can cause distracting visual effects (Figure 2).
• Use colour and shading sparingly as it distracts from the message.
• Avoid graph designs that use keys. Where keys are unavoidable, use the simplest key available (Figure 1b).
• When adding text, use plain English, and avoid jargon and repetition. In addition, use the same typeface as the graph (preferably a sans serif font), avoid fancy lettering and fonts, don’t mix upper and lower case lettering, and don’t box the text.
• Where several graphs are used for similar types of information use, where possible, the same scales on the x- and y-axes.
• Where practicable avoid truncating the axes, unless it will inform rather than mislead the reader (Figure 3).

Abstract submission deadlines

Please note that dates were correct at time of sending this email; HOC cannot be responsible for any amendments.

By Adelina Pagliocca

Rx Communications and Greenflint had great pleasure in attending the 9th annual European meeting of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR), 28–31 October in Copenhagen. Representing Rx were marketing manager Chris Gardiner (pictured centre), editorial manager Adelina Pagliocca (left), and project manager Maggie Jones (right).

Our booth featured Rx sister company Greenflint, whose models are designed to help in early-stage decisions, cutting costs, making strategic decisions during development, and developing a promotional message. Modelling was the theme, with attendees invited to craft models out of red and green clay. With red clay, attendees were asked to create a communication tool, and with the green clay, to model their favourite thing. This creative challenge produced, amongst other entries, a dove carrying an olive branch, a football match between Copenhagen and England, ‘probably’ Denmark’s best export (the famous lager, see left), and a Christmas tree. All entries and winners for both competitions can be viewed at the Rx and Greenflint websites.

Asking critical questions

The theme of the congress was ‘Asking critical questions’. The first plenary session was introduced by Bengt Jønsson, PhD, who initiated the discussion on the use of health technology assessment (HTA) as a basis for reimbursement and priorities in health care. Richard Bergström, MScPharm, presented the HTA principles adopted by EFPIA and industry’s perspective on promoting good use of HTA. Audun Hågå, MSc, discussed priority decisions from a government perspective focusing on Nordic countries. One key message was the need for increased communication between industry and payers, and a decision on the best practices for Europe.

The second plenary session was a debate between Professor Paul Glasziou, PhD, FRACGP, and Ivar Sonbo Kristiansen, MD, PhD, MPH, moderated by Kjeld Møller Pedersen. This session examined questions surrounding evidence based medicine (EBM). Dr Kristiansen questioned the use of EBM in health policy; he urged the audience to be more humble in interpreting the results of randomised clinical trials (RCT), and suggested that EBM does not improve patients’ health. The speaker questioned the Cochrane collaboration, suggesting it is an anti-industry movement that should be consulted with caution. Professor Glasziou retaliated by providing examples of when an RCT is required, although he agreed that RCTs are not always the best approach, suggesting that the best study design depends on the type of question one is attempting to answer. With regards to the Cochrane collaboration, Professor Glasziou explained the background and stressed that the collaboration is not anti-industry, and when used properly is a good tool to aid physicians in choosing the correct medication for their patients.

The third plenary session addressed the societal value of the QALY. Professor Dorte Gyrd-Hansen, PhD, gave a critical view demonstrating that the task of performing a linear translation from QALYs to willingness to pay (WTP) is theoretically and empirically unattainable. The speaker stressed that we need to think carefully about study design and interpretation of results. Professor Martin Buxton, BA (Soc Sci), argued that ‘social’ WTP values are interesting but of no immediate relevance. The speaker stressed that a health system is responsible for the entire population and a WTP threshold needs to be set. This threshold should ensure that technologies adopted are always more valuable than other new alternative and any displaced activities.

In addition to these plenary sessions, there were 28 thought-provoking workshops, 6 issue panel presentations, 64 contributed presentations, and almost 600 posters.

We will start the new year with some exciting new features, including interviews and a news and events section.