Imperial College London

DrMarisaMiraldo

Business School

Associate Professor in Health Economics
 
 
 
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Contact

 

+44 (0)20 7594 9764m.miraldo Website CV

 
 
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Location

 

281Business School BuildingSouth Kensington Campus

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Summary

 

Publications

Publication Type
Year
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88 results found

DAeth J, Ghosal S, Grimm F, Haw D, Koca E, Lau K, Moret S, Rizmie D, Deeny S, Perez-Guzman P, Ferguson N, Hauck K, Smith P, Forchini G, Wiesemann W, Miraldo Met al., 2021, Optimal national prioritization policies for hospital care during the SARS-CoV-2 pandemic, Nature Computational Science, ISSN: 2662-8457

In response to unprecedent surges in the demand for hospital care during the SARS-CoV-2 pandemic, health systems have prioritized COVID patients to life-saving hospital care to the detriment of other patients. In contrast to these ad hoc policies, we develop a linear programming framework to optimally schedule elective procedures and allocate hospital beds among all planned and emergency patients to minimize years of life lost. Leveraging a large dataset of administrative patient medical records, we apply our framework to the National Health System in England and show that an extra 50,750-5,891,608 years of life can be gained in comparison to prioritization policies that reflect those implemented during the pandemic. Significant health gains are observed for neoplasms, diseases of the digestive system, and injuries & poisoning. Our open-source framework provides a computationally efficient approximation of a large-scale discrete optimization problem that can be applied globally to support national-level care prioritization policies.

Journal article

Ohrnberger J, Segal A, Forchini G, Miraldo M, Skarp J, Nedjati-Gilani G, Laydon D, Ghani A, Ferguson N, Hauck Ket al., 2021, The impact of a COVID-19 lockdown on work productivity under good and poor compliance, European Journal of Public Health, ISSN: 1101-1262

BackgroundIn response to the COVID-19 pandemic, governments across the globe have imposed strict social distancing measures. Public compliance to such measures is essential for their success yet the economic consequences of compliance are unknown. This is the first study to analyse the effects of good compliance compared to poor compliance to a COVID-19 suppression strategy (i.e. lockdown) on work productivity. MethodsWe estimate the differences in work productivity comparing a scenario of good compliance with one of poor compliance to the UK government COVID-19 suppression strategy. We use projections of the impact of the UK suppression strategy on mortality and morbidity from an individual-based epidemiological model combined with an economic model representative of the labour force in Wales and England. ResultsWe find that productivity effects of good compliance significantly exceed those of poor compliance and increase with the duration of the lockdown. After three months of the lockdown, work productivity in good compliance is £398.58 million higher compared with that of poor compliance. 75% of the differences is explained by productivity effects due to morbidity and non-health reasons and 25% attributed to avoided losses due to pre-mature mortality.ConclusionGood compliance to social distancing measures exceeds positive economic effects, in addition to health benefits. This is an important finding for current economic and health policy. It highlights the importance to set clear guidelines for the public, to build trust and support for the rules and if necessary, to enforce good compliance to social distancing measures.

Journal article

Shaikh M, Tymoszuk U, Williamon A, Miraldo Met al., 2021, Socioeconomic inequalities in arts engagement and depression among older adults in the United Kingdom: Evidence from the English Longitudinal Study of Ageing, Public Health, ISSN: 0033-3506

ObjectivesArts engagement has been positively linked with mental health and wellbeing; however, socioeconomic inequalities may be prevalent in access to and uptake of arts engagement reflecting on inequalities in mental health. This study estimated socioeconomic inequality and horizontal inequity (unfair inequality) in arts engagement and depression symptoms of older adults in England. Trends in inequality and inequity were measured over a period of ten years.Study DesignRepeated cross-sectional studyMethodsIn this analysis we used data from six waves (waves 2 to 7) of the nationally representative English Longitudinal Study of Ageing. We estimated socioeconomic inequality using concentration curves that plot the distribution of arts engagement and depression symptoms against the distribution of wealth. Concentration index was used to measure the magnitude of the inequality. Unfair inequality was then calculated for need-standardised arts engagement using a horizontal inequity index (HII).ResultsThe study sample included adults aged 50 and older from waves 2 (2004/2005, n=6,620) to 7 (2014/2015, n=3,329). Engagement with cinema, galleries, and theatre was pro-rich unequal i.e. concentrated among the wealthier, but inequality in depression was pro-poor unequal i.e. concentrated more among the less wealthy. While pro-rich inequality in arts engagement decreased from wave 2 (conc. index: 0·291, 95% CI 0·27 to 0·31) to wave 7 (conc. index: 0·275, 95% CI 0·24 to 0·30), pro-poor inequality in depression increased from wave 2 (conc. index: -0·164, 95% CI -0·18 to -0·14) to wave 7 (conc. index: -0·189, 95% CI -0·21 to -0·16). Depression-standardised arts engagement showed horizontal inequity that increased from wave 2 (HII: 0·455, 95% CI 0·42 to 0·48) to wave 7 (HII: 0·464, 95% CI 0·42 to 0·50).ConclusionsOur findings suggest that while socioeconomic

Journal article

Simmons B, Ariyoshi K, Ohmagari N, Pulcini C, Huttner B, Gandra S, Satta G, Moja L, Sharland M, Magrini N, Miraldo M, Cooke Get al., 2021, Progress towards antibiotic use targets in eight high-income countries, Bulletin of the World Health Organization, Vol: 99, Pages: 550-561, ISSN: 0042-9686

Objective To compare antibiotic sales in eight high-income countries using the 2019 World Health Organization (WHO) Access, Watch andReserve (AWaRe) classification and the target of 60% consumption of Access category antibiotics.Methods We analysed data from a commercial database of sales of systemic antibiotics in France, Germany, Italy, Japan, Spain, Switzerland,United Kingdom of Great Britain and Northern Ireland, and United States of America over the years 2013–2018. We classified antibioticsaccording to the 2019 AWaRe categories: Access, Watch, Reserve and Not Recommended. We measured antibiotic sales per capita in standardunits (SU) per capita and calculated Access group sales as a percentage of total antibiotic sales.Findings In 2018, per capita antibiotic sales ranged from 7.4 SU (Switzerland) to 20.0 SU (France); median sales of Access group antibioticswere 10.9 SU per capita (range: 3.5–15.0). Per capita sales declined moderately over 2013–2018. The median percentage of Access groupantibiotics was 68% (range: 22–77 %); the Access group proportion increased in most countries between 2013 and 2018. Five countriesexceeded the 60% target; two countries narrowly missed it (>55% in Germany and Italy). Sales of Access antibiotics in Japan were low(22%), driven by relatively high sales of oral cephalosporins and macrolides.Conclusion We have identified changes to prescribing that could allow countries to achieve the WHO target. The 60% Access group targetprovides a framework to inform national antibiotic policies and could be complemented by absolute measures and more ambitious valuesin specific settings.

Journal article

Song P, Gupta A, Goon IY, Hasan M, Mahmood S, Pradeepa R, Siddiqui S, Frost GS, Kusuma D, Miraldo M, Sassi F, Wareham NJ, Ahmed S, Anjana RM, Brage S, Forouhi NG, Jha S, Kasturiratne A, Katulanda P, Khawaja KI, Loh M, Mridha MK, Wickremasinghe AR, Kooner JS, Chambers JCet al., 2021, Data resource profile: Understanding the patterns and determinants of health in South Asians—the South Asia Biobank, International Journal of Epidemiology, Vol: 50, Pages: 717-718e, ISSN: 0300-5771

Journal article

Christen P, D'Aeth J, Lochen A, McCabe R, Rizmie D, Schmit N, Nayagam S, Miraldo M, Aylin P, Bottle A, Perez Guzman P, Donnelly C, Ghani A, Ferguson N, White P, Hauck Ket al., 2021, The J-IDEA pandemic planner: a framework for implementing hospital provision interventions during the COVID-19 pandemic, Medical Care, Vol: 59, Pages: 371-378, ISSN: 0025-7079

Background : Planning for extreme surges in demand for hospital care of patientsrequiring urgent life-saving treatment for COVID-19, whilst retaining capacity for otheremergency conditions, is one of the most challenging tasks faced by healthcareproviders and policymakers during the pandemic. Health systems must be wellpreparedto cope with large and sudden changes in demand by implementinginterventions to ensure adequate access to care. We developed the first planning toolfor the COVID-19 pandemic to account for how hospital provision interventions (suchas cancelling elective surgery, setting up field hospitals, or hiring retired staff) will affectthe capacity of hospitals to provide life-saving care.Methods : We conducted a review of interventions implemented or considered in 12 European countries in March-April 2020, an evaluation of their impact on capacity, anda review of key parameters in the care of COVID-19 patients. This information wasused to develop a planner capable of estimating the impact of specific interventions ondoctors, nurses, beds and respiratory support equipment. We applied this to ascenario-based case study of one intervention, the set-up of field hospitals in England,under varying levels of COVID-19 patients.Results : The J-IDEA pandemic planner is a hospital planning tool that allows hospitaladministrators, policymakers and other decision-makers to calculate the amount ofcapacity in terms of beds, staff and crucial medical equipment obtained byimplementing the interventions. Flexible assumptions on baseline capacity, the numberof hospitalisations, staff-to-beds ratios, and staff absences due to COVID-19 make theplanner adaptable to multiple settings. The results of the case study show that whilefield hospitals alleviate the burden on the number of beds available, this intervention isfutile unless the deficit of critical care nurses is addressed first.Discussion : The tool supports decision-makers in delivering a fast and effectiveresponse to

Journal article

Lau K, Dorigatti I, Miraldo M, Hauck Ket al., 2021, SARIMA-modelled greater severity and mortality during the 2010/11 post-pandemic influenza season compared to the 2009 H1N1 pandemic in English hospitals, International Journal of Infectious Diseases, Vol: 105, Pages: 161-171, ISSN: 1201-9712

ObjectiveThe COVID-19 pandemic demonstrates the need for understanding pathways to healthcare demand, morbidity, and mortality of pandemic patients. We estimate H1N1 (1) hospitalization rates, (2) severity rates (length of stay, ventilation, pneumonia, and death) of those hospitalized, (3) mortality rates, and (4) time lags between infections and hospitalizations during the pandemic (June 2009 to March 2010) and post-pandemic influenza season (November 2010 to February 2011) in England.MethodsEstimates of H1N1 infections from a dynamic transmission model are combined with hospitalizations and severity using time series econometric analyses of administrative patient-level hospital data.ResultsHospitalization rates were 34% higher and severity rates of those hospitalized were 20%–90% higher in the post-pandemic period than the pandemic. Adults (45–64-years-old) had the highest ventilation and pneumonia hospitalization rates. Hospitalizations did not lag infection during the pandemic for the young (<24-years-old) but lagged by one or more weeks for all ages in the post-pandemic period.DiscussionThe post-pandemic flu season exhibited heightened H1N1 severity, long after the pandemic was declared over. Policymakers should remain vigilant even after pandemics seem to have subsided. Analysis of administrative hospital data and epidemiological modelling estimates can provide valuable insights to inform responses to COVID-19 and future influenza and other disease pandemics.

Journal article

Simmons B, Ariyoshi K, Ohmagari N, Pulcini C, Huttner B, Gandra S, Satta G, Moja L, Sharland M, Magrini N, Miraldo M, Cooke Get al., 2021, Progress towards WHO AWaRe targets: an analysis of data from high-incomecountries, 2013-2018, Bulletin of the World Health Organization, ISSN: 0042-9686

Objectives: To compare antibiotic consumption in eight high-income countries in reference to the 2019 World Health Organization (WHO) AWaRe classification (Access, Watch, and Reserve) and the 60% Access use consumption target.Methods: Sales data (IQVIA) were analysed for systemic antibiotics from 2013-2018 for France, Italy, Japan, Germany, Spain, Switzerland, United Kingdom, and United States. Antibiotics were classified as Access, Watch, Reserve, and Not Recommended according to the 2019 WHO AWaRe categories. The primary objectives were to calculate: i) antibiotic sales per capita in standard units (SU/capita) overall and by AWaRe category; and ii) the Access percentage, defined as total SU of Access group antibiotics by the total antibiotic SU. Findings: In 2018, there was variability among countries in sales per capita, ranging from 7.4 (Switzerland) to 20.0 (France) SU/capita; median Access sales was 10.9 SU/capita (range 3.5-15.0). Per capita sales moderately declined over time (p<0.01). Median Access percentage was 68% (range 22-77%); Access proportion increased in most countries between 2013 and 2018. Five countries studied exceeded the 60% target; two narrowly missed it (≥55% in Italy and Germany). Access use in Japan was low (22%), driven by a relatively high use of oral cephalosporins and macrolides.Conclusion: Most countries studied are achieving the 60% Access target, however per capita consumption differed significantly. The AWaRe classification provides a framework to inform national antibiotic policies and the 60% indicator provides a target for optimised use. The target should be complemented by absolute measures and adapted to more ambitious values in specific settings.

Journal article

Singh S, Shaikh M, Hauck K, Miraldo Met al., 2021, Impacts of introducing and lifting nonpharmaceutical interventions on COVID-19 daily growth rate and compliance in the United States, Proceedings of the National Academy of Sciences of USA, Vol: 118, ISSN: 0027-8424

We evaluate the impacts of implementing and lifting nonpharmaceutical interventions (NPIs) in US counties on the daily growth rate of COVID-19 cases and compliance, measured through the percentage of devices staying home, and evaluate whether introducing and lifting NPIs protecting selective populations is an effective strategy. We use difference-in-differences methods, leveraging on daily county-level data and exploit the staggered introduction and lifting of policies across counties over time. We also assess heterogenous impacts due to counties’ population characteristics, namely ethnicity and household income. Results show that introducing NPIs led to a reduction in cases through the percentage of devices staying home. When counties lifted NPIs, they benefited from reduced mobility outside of the home during the lockdown, but only for a short period. In the long term, counties experienced diminished health and mobility gains accrued from previously implemented policies. Notably, we find heterogenous impacts due to population characteristics implying that measures can mitigate the disproportionate burden of COVID-19 on marginalized populations and find that selectively targeting populations may not be effective.

Journal article

Barrenho E, Miraldo M, Propper C, Walsh Bet al., 2021, The importance of surgeons and their peers in adoption and diffusion of innovation: an observational study of laparoscopic colectomy adoption and diffusion in England, Social Science and Medicine, Vol: 272, ISSN: 0277-9536

Little is known about the role of clinicians in accounting for adoption and diffusion of medical innovations, especially within the English National Health System. This study examines the importance of surgical consultants and their work-based networks on the diffusion of an important innovation, minimally invasive elective laparoscopic colectomy for colorectal cancer. The study used linked patient-level and workforce data on 260,110 elective colectomies and 1288 consultants between 2000 and 2014, to examine adoption of laparoscopic colectomy pre- and post-introduction of clinical guidelines and total share of colectomies performed laparoscopically by adopters. Laparoscopy as a share of elective colectomy increased from 0% in 2000 to 53% in 2014. Surgeons, rather than hospitals, were the principal agents accounting for the increase and explain 46.6% of the variance in laparoscopic colectomy use. Female surgeons, surgeons trained outside the United Kingdom, and recent graduates had higher rates of laparoscopy adoption. More experienced surgeons and surgeons with more peers who perform laparoscopy were more likely to adopt, adopt early and have greater use of laparoscopy. Targeting clinicians, rather than hospitals, is central to increasing adoption and diffusion of new medical technologies.

Journal article

D'Aeth J, Ghosal S, Grimm F, Haw D, Koca E, Lau K, Moret S, Rizmie D, Deeny S, Perez Guzman P, Ferguson N, Hauck K, Smith P, Wiesemann W, Forchini G, Miraldo Met al., 2020, Report 40: Optimal scheduling rules for elective care to minimize years of life lost during the SARS-CoV-2 pandemic: an application to England

SummaryCountries have deployed a wide range of policies to prioritize patients to hospital care to address unprecedent surges in demand during the course of the pandemic. Those policies included postponing planned hospital care for non-emergency cases and rationing critical care.We develop a model to optimally schedule elective hospitalizations and allocate hospital general and critical care beds to planned and emergency patients in England during the pandemic. We apply the model to NHS England data and show that optimized scheduling leads to lower years of life lost and costs than policies that reflect those implemented in England during the pandemic. Overall across all disease areas the model enables an extra 50,750 - 5,891,608 years of life gained when compared to standard policies, depending on the scenarios. Especially large gains in years of life are seen for neoplasms, diseases of the digestive system, and injuries & poisoning.

Report

Haw D, Forchini G, Christen P, Bajaj S, Hogan A, Winskill P, Miraldo M, White P, Ghani A, Ferguson N, Smith P, Hauck Ket al., 2020, Report 35: How can we keep schools and universities open? Differentiating closures by economic sector to optimize social and economic activity while containing SARS-CoV-2 transmission

There is a trade-off between the education sector and other economic sectors in the control of SARS-Cov-2 transmission. Here we integrate a dynamic model of SARS-CoV-2 transmission with a 63-sector economic model reflecting sectoral heterogeneity in transmission and economic interdependence between sectors. We identify COVID-19 control strategies which optimize economic production while keeping schools and universities operational and constraining infections such that emergency hospital capacity is not exceeded. The model estimates an economic gain of between £163bn and £205bn for the United Kingdom compared to a blanket lockdown of non-essential activity over six months, depending on hospital capacity. Sectors identified as potential priorities for closure are contact-intensive and/or less economically productive.

Report

McCabe R, Schmit N, Christen P, D'Aeth J, Løchen A, Rizmie D, Nayagam AS, Miraldo M, Aylin P, Bottle R, Perez-Guzman PN, Ghani A, Ferguson N, White P, Hauck Ket al., 2020, Adapting hospital capacity to meet changing demands during the COVID-19 pandemic, BMC Medicine, Vol: 18, Pages: 1-12, ISSN: 1741-7015

BackgroundTo calculate hospital surge capacity, achieved via hospital provision interventions implemented for the emergency treatment of coronavirus disease 2019 (COVID-19) and other patients through March to May 2020; to evaluate the conditions for admitting patients for elective surgery under varying admission levels of COVID-19 patients.MethodsWe analysed National Health Service (NHS) datasets and literature reviews to estimate hospital care capacity before the pandemic (pre-pandemic baseline) and to quantify the impact of interventions (cancellation of elective surgery, field hospitals, use of private hospitals, deployment of former medical staff and deployment of newly qualified medical staff) for treatment of adult COVID-19 patients, focusing on general and acute (G&A) and critical care (CC) beds, staff and ventilators.ResultsNHS England would not have had sufficient capacity to treat all COVID-19 and other patients in March and April 2020 without the hospital provision interventions, which alleviated significant shortfalls in CC nurses, CC and G&A beds and CC junior doctors. All elective surgery can be conducted at normal pre-pandemic levels provided the other interventions are sustained, but only if the daily number of COVID-19 patients occupying CC beds is not greater than 1550 in the whole of England. If the other interventions are not maintained, then elective surgery can only be conducted if the number of COVID-19 patients occupying CC beds is not greater than 320. However, there is greater national capacity to treat G&A patients: without interventions, it takes almost 10,000 G&A COVID-19 patients before any G&A elective patients would be unable to be accommodated.ConclusionsUnless COVID-19 hospitalisations drop to low levels, there is a continued need to enhance critical care capacity in England with field hospitals, use of private hospitals or deployment of former and newly qualified medical staff to allow some or all elective surge

Journal article

Hansen C, Miraldo M, Hauck K, Ohrnberger Jet al., 2020, Is the road to good health paved in gold? HIV and mining in Sub-Saharan Africa, Publisher: OXFORD UNIV PRESS, Pages: V837-V837, ISSN: 1101-1262

Conference paper

Hauck K, Miraldo M, Singh S, 2020, Integrating motherhood and employment: a 22-year analysis investigatingimpacts of US workplace breastfeeding policy, Social Science and Medicine – Population Health, Vol: 11, ISSN: 2352-8273

The United States has one of the lowest exclusive breastfeeding rates among high-income countries. Most experts agree that there is a lack of mother-friendly workplace policies compared to other countries. Since 1995, 25 states have implemented workplace breastfeeding legislation allowing mothers to express and store breast milk in the workplace. There is heterogeneity in policy enforceability where 17 states have weak enforceability while eight states have strict enforceability and require employers to offer provisions to breastfeed at the workplace. Using difference-in-differences methods, we examine the impact of this policy on state-level breastfeeding rates and assess how that impact differs with policy enforceability. We use data from the Centers for Disease Control on breastfeeding, supplementing with socio-economic data from the Panel Study of Income Dynamics, Current Population Survey, the US Census Bureau and several other datasets over 22 years from 1990 to 2011. We find that states with legislation experienced a 2.3-percentage point increase in breastfeeding rates compared to states without legislation while states with weak enforceability experienced a 3.1-percentage point increase compared to states without legislation. We also find that policies do not start to have an impact until 1–2 years after they were signed into law. Considering the recent assault on breastfeeding from the current administration, our study is a timely and important contribution that strengthens the evidence base for the health benefits of workplace breastfeeding policies.

Journal article

Aurino E, Olney J, Miraldo M, Watson Ket al., 2020, Chronic Syndemic meets Viral pandemic, Publisher: BMJ Opinion

Working paper

McCabe R, Schmit N, Christen P, D'Aeth J, Lochen A, Rizmie D, Nayagam AS, Miraldo M, Aylin P, Bottle R, Perez Guzman PN, Ghani A, Ferguson N, White PJ, Hauck Ket al., 2020, Report 27 Adapting hospital capacity to meet changing demands during the COVID-19 pandemic

To meet the growing demand for hospital care due to the COVID-19 pandemic, England implemented a range of hospital provision interventions including the procurement of equipment, the establishment of additional hospital facilities and the redeployment of staff and other resources. Additionally, to further release capacity across England’s National Health Service (NHS), elective surgery was cancelled in March 2020, leading to a backlog of patients requiring care. This created a pressure on the NHS to reintroduce elective procedures, which urgently needs to be addressed. Population-level measures implemented in March and April 2020 reduced transmission of SARS-CoV-2, prompting a gradual decline in the demand for hospital care by COVID-19 patients after the peak in mid-April. Planning capacity to bring back routine procedures for non-COVID-19 patients whilst maintaining the ability to respond to any potential future increases in demand for COVID-19 care is the challenge currently faced by healthcare planners.In this report, we aim to calculate hospital capacity for emergency treatment of COVID-19 and other patients during the pandemic surge in April and May 2020; to evaluate the increase in capacity achieved via five interventions (cancellation of elective surgery, field hospitals, use of private hospitals, and deployment of former and newly qualified medical staff); and to determine how to re-introduce elective surgery considering continued demand from COVID-19 patients. We do this by modelling the supply of acute NHS hospital care, considering different capacity scenarios, namely capacity before the pandemic (baseline scenario) and after the implementation of capacity expansion interventions that impact available general and acute (G&A) and critical care (CC) beds, staff and ventilators. Demand for hospital care is accounted for in terms of non-COVID-19 and COVID-19 patients. Our results suggest that NHS England would not have had sufficient daily capacity

Report

Christen P, D'Aeth J, Lochen A, McCabe R, Rizmie D, Schmit N, Nayagam AS, Miraldo M, White P, Aylin P, Bottle R, Perez Guzman PN, Donnelly C, Ghani A, Ferguson N, Hauck Ket al., 2020, Report 15: Strengthening hospital capacity for the COVID-19 pandemic

Planning for extreme surges in demand for hospital care of patients requiring urgent life-saving treatment for COVID-19, and other conditions, is one of the most challenging tasks facing healthcare commissioners and care providers during the pandemic. Due to uncertainty in expected patient numbers requiring care, as well as evolving needs day by day, planning hospital capacity is challenging. Health systems that are well prepared for the pandemic can better cope with large and sudden changes in demand by implementing strategies to ensure adequate access to care. Thereby the burden of the pandemic can be mitigated, and many lives saved. This report presents the J-IDEA pandemic planner, a hospital planning tool to calculate how much capacity in terms of beds, staff and ventilators is obtained by implementing healthcare provision interventions affecting the management of patient care in hospitals. We show how to assess baseline capacity, and then calculate how much capacity is gained by various healthcare interventions using impact estimates that are generated as part of this study. Interventions are informed by a rapid review of policy decisions implemented or being considered in 12 European countries over the past few months , an evaluation of the impact of the interventions on capacity using a variety of research methods, and by a review of key parameters in the care of COVID-19 patients.The J-IDEA planner is publicly available, interactive and adaptable to different and changing circumstances and newly emerging evidence. The planner estimates the additional number of beds, medical staff and crucial medical equipment obtained under various healthcare interventions using flexible inputs on assumptions of existing capacities, the number of hospitalisations, beds-to-staff ratios, and staff absences due to COVID-19. A detailed user guide accompanies the planner. The planner was developed rapidly and has limitations which we will address in future iterations. It support

Report

Goiana-Da-Silva K, Cruz-e-Silva D, Bartlett O, Vasconcelos J, Nunes AM, Ashrafian H, Miraldo M, do Céu Machado M, Araújo F, Darzi Aet al., 2020, The ethics of taxing sugar-sweetened beverages to improve public health, Frontiers in Public Health, Vol: 8, ISSN: 2296-2565

The World Health Organization highlights fiscal policies as priority interventions for the promotion of healthy eating in its Action Plan for the Prevention and Control of Non-communicable Diseases. The taxation of sugar sweetened beverages (SSBs) in particular is noted to be an effective measure, and SSBs taxes have already been implemented in several countries worldwide. However, although the evidence base suggests that this will be effective in helping to combat rising obesity rates, opponents of SSBs taxation argue that it is illiberal and paternalistic, and therefore should be avoided. Bioethical analysis may play an essential role in clarifying whether policymakers should adopt SSBs taxes as part of wider obesity strategy. In this article we argue that no single ethical theory can account for the complexities inherent in obesity prevention strategy, especially the liberal theories relied upon by opponents of SSBs taxation. We contend that a pluralist approach to the ethics of SSBs taxation must be adopted as the only suitable way of accounting for the multiple overlapping, and sometimes, conflicting factors that are relevant to determining the moral acceptability of such an intervention.

Journal article

Goiana-da-Silva F, Severo M, Cruz-E-Silva D, Gregório MJ, Allen L, Muc M, Morais Nunes A, Torres D, Miraldo M, Ashrafian H, Rito A, Wickramasinghe K, Breda J, Darzi A, Araújo F, Lopes Cet al., 2020, Projected impact of the Portuguese sugar-sweetened beverages tax on obesity incidence across different age groups: a modelling study, PLoS Medicine, Vol: 17, Pages: 1-17, ISSN: 1549-1277

BackgroundExcessive consumption of sugar has a well-established link with obesity. Preliminary results show that a tax levied on sugar-sweetened beverages (SSBs) by the Portuguese government in 2017 led to a drop in sales and reformulation of these products. This study models the impact the market changes triggered by the tax levied on SSBs had on obesity incidence across various age groups in Portugal.Methods and findingsWe performed a national market analysis and population-wide modelling study using market data for the years 2014–2018 from the Portuguese Association of Non-Alcoholic Drinks (GlobalData and Nielsen Consumer Panel), dietary data from a national survey (IAN-AF 2015–2016), and obesity incidence data from several cohort studies. Dietary energy density from SSBs was calculated by dividing the energy content (kcal/gram) of all SSBs by the total food consumption (in grams). We used the potential impact fraction (PIF) equation to model the projected impact of the tax-triggered change in sugar consumption on obesity incidence, through both volume reduction and reformulation. Results showed a reduction of 6.6 million litres of SSBs sold per year. Product reformulation led to a decrease in the average energy density of SSBs by 3.1 kcal/100 ml. This is estimated to have prevented around 40–78 cases of obesity per year between 2016 and 2018, with the biggest projected impact observed in adolescents 10 to <18 years old. The model shows that the implementation of this tax allowed for a 4 to 8 times larger projected impact against obesity than would be achieved though reformulation alone. The main limitation of this study is that the model we used includes data from various sources, which can result in biases—despite our efforts to mitigate them—related to the methodological differences between these sources.ConclusionsThe tax triggered both a reduction in demand and product reformulation. These, together, can reduce obesity levels

Journal article

Goiana-Da-Silva K, Cruz-e-Silva D, Allen L, Calhau C, Rito A, Bento A, Miraldo M, Darzi Aet al., 2019, Portugal’s voluntary food reformulation agreement and the WHO reformulation targets, Journal of Global Health, Vol: 9, ISSN: 2047-2978

Journal article

Rizmie D, Miraldo M, Atun R, de Preux Let al., 2019, The effect of extreme temperature on emergency admissions across vulnerable populations in England: an observational study, Lancet Public Health Science 2019 Conference, Publisher: Elsevier, Pages: S7-S7

BackgroundClimate change poses an unfamiliar challenge to population health and health-systems resilience. Although previous studies have estimated morbidity attributable to heat or cold across cities, we provide, to our knowledge, the first large-scale, population-wide assessment of the effect of extreme temperatures on excess emergency admissions in England and among vulnerable populations, who could be disproportionately affected.MethodsIn this observational study, we combined all daily inpatient admissions during 2001–12 in England with meteorological data using inverse distance weighting. We exploited random daily variation in temperature experienced by hospitals and a 30-day lag period, using a distributed lag model with multiple fixed-effects controlling for seasonal factors, to examine interaction effects across diseases with age and the indices of multiple deprivation.FindingsWe analysed 29 371 084 emergency admissions. A day with temperature above 30°C was associated with 3·5 more admissions per hospital (SE 0·45), relative to a 10–15°C day. This increased to 14·1 excess admissions per hospital (SE 5·56) over the following 30 days, generating 786 excess admissions across England per heatwave day. A day under –5°C generated 3·8 more admissions per hospital (SE 0·33), or 966 excess admissions across England. This increased to 62·3 admissions per hospital (SE 4·83) over the following 30 days. These effects were heterogeneous across age and deprivation level. Populations older than 74 years were up to 8 times more affected by extreme temperatures. Individuals living in low-employment and low-income areas were 2–10 times more likely to be admitted during a temperature shock. These results were statistically significant (p<0·0001) and passed several robustness and falsification tests.InterpretationTo our knowledge, this is the first study to determine heterogene

Conference paper

Lau K, Miraldo M, Galizzi MM, Hauck Ket al., 2019, Social norms and free-riding in influenza vaccine decisions in the UK: an online experiment, National Conference on Public Health Science Dedicated to New Research in UK Public Health, Publisher: Elsevier, Pages: S65-S65, ISSN: 0140-6736

Conference paper

Miraldo M, Goiana-da-Silva F, Cruz-e-Silva D, Morais Nunes A, Carriço M, Costa F, Darzi A, Araujo Fet al., 2019, Disrupting the landscape: how the Portuguese National Health Service built an omnichannel communication platfor, Public Health Panorama, Vol: 5, Pages: 314-323, ISSN: 2412-544X

Noncommunicable diseases (NCDs) are the leading causes of death, disease and disability in the WHO European Region and are largely preventable. The private sector has long been using marketing to influence and change people’s lifestyles. In some cases, particularly the food sector, health-compromising content is prioritized over health-promoting content. However, this case study aims to illustrate how governments working on tight budgets can partner with private media companies to their own advantage in order to increase the impact of health messages and thus improve the health literacy of the population. The omnichannel communication platform and associated campaigns initiated by the Portuguese government and described in this case study serve as a practical example of a national health literacy initiative successfully reaching a wide audience. Indeed, the Portuguese National Health Service entered high on the list of the most impactful communication campaigns in Portugal.This might have implications for other countries as although further progress is required to analyse any impact of the campaigns, this example showcases the potential advantages of partnering with the media in that by using the same communication channels as multinational food and tobacco companies, governments may be able to level the playing field in terms of influence through marketing and communication, which might help to reverse unhealthy lifestyles among their populations.

Journal article

Simmons B, Cooke GS, Miraldo M, 2019, Effect of voluntary licences for hepatitis C medicines on access to treatment: a difference-in-differences analysis, The Lancet Global Health, Vol: 7, Pages: e1189-e1196, ISSN: 2214-109X

BackgroundVoluntary licences are increasingly being used to expand access to patented essential medicines in low-income and middle-income countries (LMICs). Since 2014, non-exclusive voluntary licences have been issued by Gilead and Bristol-Myers Squibb for key drugs for hepatitis C virus (HCV) infection. We aimed to evaluate the effect of these licences on access to HCV treatment.MethodsWe conducted a difference-in-differences analysis, exploiting the staggered and selective introduction of voluntary licensing in different countries, to identify the effect of voluntary licensing agreements on treatment uptake. We extracted Polaris Observatory data on the total number of people infected with HCV, diagnosed with HCV, and treated for HCV, and constructed a longitudinal panel of LMICs over a 13-year period (2004–16). Countries were included if they were classified as LMICs by the World Bank in 2014, and had available data on HCV outcomes. The exposure was defined as inclusion in any voluntary licence agreement for HCV drugs. Treatment uptake was calculated as the number of people treated for HCV in a given year per 1000 living people ever diagnosed with HCV. We fit difference-in-differences linear regression models controlling for different confounders that could influence treatment access and uptake, including country and year fixed effects and a range of country-level factors. We additionally assessed the dynamics of the effect and the robustness of our findings.Findings35 countries were included in the panel: 19 in the intervention group and 16 in the control group. In the simplest model, adjusting only for country and year fixed effects, voluntary licences were associated with an increase in the annual number of people accessing HCV treatment of 69·3 per 1000 diagnosed (95% CI 46·7–91·9; p=0·0060). After adjusting for country-level covariates, this increase was 53·6 per 1000 diagnosed (25·8–81·5; p=

Journal article

Goiana-da-Silva F, Cruz-E-Silva D, Allen L, Gregório MJ, Severo M, Nogueira PJ, Nunes AM, Graça P, Lopes C, Miraldo M, Breda J, Wickramasinghe K, Darzi A, Araújo F, Mikkelsen Bet al., 2019, Modelling impacts of food industry co-regulation on noncommunicable disease mortality, Portugal, Bulletin of the World Health Organization, Vol: 97, Pages: 450-459, ISSN: 0042-9686

Objective: To model the reduction in premature deaths attributed to noncommunicable diseases if targets for reformulation of processed food agreed between the Portuguese health ministry and the food industry were met. Methods: The 2015 co-regulation agreement sets voluntary targets for reducing sugar, salt and trans-fatty acids in a range of products by 2021. We obtained government data on dietary intake in 2015-2016 and on population structure and deaths from four major noncommunicable diseases over 1990-2016. We used the Preventable Risk Integrated ModEl tool to estimate the deaths averted if reformulation targets were met in full. We projected future trends in noncommunicable disease deaths using regression modelling and assessed whether Portugal was on track to reduce baseline premature deaths from noncommunicable diseases in the year 2010 by 25% by 2025, and by 30% before 2030. Findings: If reformulation targets were met, we projected reductions in intake in 2015-2016 for salt from 7.6 g/day to 7.1 g/day; in total energy from 1911 kcal/day to 1897 kcal/day due to reduced sugar intake; and in total fat (% total energy) from 30.4% to 30.3% due to reduced trans-fat intake. This consumption profile would result in 248 fewer premature noncommunicable disease deaths (95% CI: 178 to 318) in 2016. We projected that full implementation of the industry agreement would reduce the risk of premature death from 11.0% in 2016 to 10.7% by 2021. Conclusion: The co-regulation agreement could save lives and reduce the risk of premature death in Portugal. Nevertheless, the projected impact on mortality was insufficient to meet international targets.

Journal article

Simmons B, Cooke G, Miraldo M, 2019, The impact of voluntary licences for hepatitis C on access to treatment: a difference-in-differences analysis, The Lancet Global Health, ISSN: 2214-109X

Background. Voluntary licences are increasingly being utilised as a mechanism to increase access to patented essential medicines in low- and middle-income countries (LMICs). Since 2014, non-exclusive voluntary licences have been issued for key medicines for the treatment of hepatitis C (HCV), an important challenge to global health for which elimination targets have recently been set. We utilized HCV treatment rate data to carry out the first evaluation of the impact of these licences on access to treatment.Methods. We exploit the staggered and selective introduction of voluntary licensing in different countries to identify the impact of voluntary licensing agreements on access to treatment measured as the HCV treatment rate. We do so with difference-in-differences methods applied to a panel of 35 LMICs over a 13-year period (2004-2016). The analyses control for country and year fixed effects and a range of country-level factors that may influence access and treatment uptake. Findings. The intervention group consisted of 19 countries; the remaining 16 countries formed the control group. In the simplest model adjusting only for country and year fixed effects, voluntary licences were associated with an increase in annual treatment rate of 69·3 per 1,000 diagnosed with HCV (95%CI 46·7,91·9; p=0·006). After adjusting for country-level covariates, the impact of licences was 53·6 per 1,000 diagnosed with HCV (95%CI 25·8,81·5; 0·035). The effect of licensing increased over time and was largest in the second year after implementation. Results were robust to alternative specifications.Interpretation. Voluntary licensing initiatives appear to have had a significant impact on increasing HCV treatment rate in eligible countries. This evidence provides support for expansion of licensing strategies to include more countries and more treatments. The results suggest voluntary licensing may be an effective mechanism for increas

Journal article

Crea G, Galizzi M, Linnosmaa I, Miraldo Met al., 2019, Physician altruism and moral hazard: (no) evidence from Finnish national prescriptions data, Journal of Health Economics, Vol: 65, Pages: 153-169, ISSN: 0167-6296

We test the physicians’ altruism and moral hazard hypotheses using a national panel register containing all 2003–2010 statins prescriptions in Finland. We estimate the likelihood that physicians prescribe generic versus branded versions of statins as a function of the shares of the difference between what patients have to pay out of their pocket and what is covered by the insurance, controlling for patient, physician, and drug characteristics. We find that the estimated coefficients and the average marginal effects associated with moral hazard and altruism are nearly zero, and are orders of magnitude smaller than the ones associated with other explanatory factors such as the prescriptions’ year and the physician specialization. When the analysis distinctly accounts for both the patient and the insurer shares of expenditure, the estimated coefficients directly reject the altruism and moral hazard hypotheses. Instead, we find strong and robust evidence of habits persistence in prescribing branded drugs.

Journal article

Miraldo M, Silva F, Gregorio M, Cruz-e-Silva D, Severo M, Nogueira P, Nunes A, Graça P, Lopes C, Breda J, Allen L, Wickramasinghe K, Darzi A, Mikkelsen B, Araújo Fet al., 2019, Modelling the impact of a food industry co-regulation agreement on Portugal’s non-communicable disease mortality, Bulletin of the World Health Organization, ISSN: 0042-9686

ObjectiveIn this paper we model the reduction in premature mortality associated with Noncommunicacle Diseases as a result of the establishment of a co-regulation agreement between the Portuguese Ministry of Health and the Portuguese food industry. We also assess whether Portugal is on track to meet the international targets of reducing baseline 2010 premature deaths from noncommunicable diseases by 25% by 2025, and by 30% before 2030. We also aimed to model the impact of the industry co-regulation agreement on premature mortality.MethodsThe 2015co-regulation agreement agreement between the Portuguese food industry and the Portuguese government sets targets of reducing sugar by 20%, salt content by 16% (30% for bread), and <2g trans fatty acids per 100g of fat in a range of products by 2021. The WHO Europe-endorsed PRIME modelling tool was used to estimate the number of Noncommunicacle Diseases deaths that would be averted if these reformulation targets were fully met in the year 2016. Using data on population structure, Noncommunicacle Diseases mortality, and dietary intake from the Portuguese Directorate General of Health, we calculated the actual trends on premature mortality probability for Noncommunicacle Diseases, and projected future trends using regression modelling. FindingsThe risk of premature Noncommunicacle Diseases mortality fell from 13.9% to 10.9% between 2000-2010 but remained relatively unchanged up until 2016. We project that the risk will rise to 11.0% by 2030. If the industry reformulation targets are met we estimate reductions in salt intake of around 7%; total energy reductions from 1,911Kcal/day to 1,897 kcal/day due to reduced sugar intake; and reductions in total fat (% total energy) from 30.4% to 30.3% due to reduced trans fat intake. The PRIME modelling tool calculates that this consumption profile would have resulted in 873 fewer Noncommunicacle Diseases deaths (95%CI 483–1,107) and 247 fewer premature Noncommunicacle Diseases

Journal article

Miraldo M, Lau K, Hauck K, 2019, Excess influenza hospital admissions and costs due to the 2009 H1N1 pandemic in England, Health Economics, Vol: 28, Pages: 175-188, ISSN: 1057-9230

Influenza pandemics considerably burden affected health systems due to surges in inpatient admissions and associated costs. Previous studies underestimate or overestimate 2009/2010 influenza A/H1N1 pandemic hospital admissions and costs. We robustly estimate overall and age‐specific weekly H1N1 admissions and costs between June 2009 and March 2011 across 170 English hospitals. We calculate H1N1 admissions and costs as the difference between our administrative data of all influenza‐like‐illness patients (seasonal and pandemic alike) and a counterfactual of expected weekly seasonal influenza admissions and costs established using time‐series models on prepandemic (2004–2008) data.We find two waves of H1N1 admissions: one pandemic wave (June 2009–March 2010) with 10,348 admissions costing £20.5 million and one postpandemic wave (November 2010–March 2011) with 11,775 admissions costing £24.8 million. Patients aged 0–4 years old have the highest H1N1 admission rate, and 25‐ to 44‐ and 65+‐year‐olds have the highest costs. Our estimates are up to 4.3 times higher than previous reports, suggesting that the pandemic's burden on hospitals was formerly underassessed. Our findings can help hospitals manage unexpected surges in admissions and resource use due to pandemics.

Journal article

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