1
|
Ramessur R, Dand N, Langan SM, Saklatvala J, Fritzsche MC, Holland S, Arents BWM, McAteer H, Proctor A, McMahon D, Greenwood M, Buyx AM, Messer T, Weiler N, Hicks A, Hecht P, Weidinger S, Ndlovu MN, Chengliang D, Hübenthal M, Egeberg A, Paternoster L, Skov L, De Jong EMGJ, Middelkamp-Hup MA, Mahil SK, Barker JN, Flohr C, Brown SJ, Smith CH. Defining disease severity in atopic dermatitis and psoriasis for the application to biomarker research: an interdisciplinary perspective. Br J Dermatol 2024; 191:14-23. [PMID: 38419411 PMCID: PMC11188926 DOI: 10.1093/bjd/ljae080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 03/02/2024]
Abstract
More severe atopic dermatitis and psoriasis are associated with a higher cumulative impact on quality of life, multimorbidity and healthcare costs. Proactive, early intervention in those most at risk of severe disease may reduce this cumulative burden and modify the disease trajectory to limit progression. The lack of reliable biomarkers for this at-risk group represents a barrier to such a paradigm shift in practice. To expedite discovery and validation, the BIOMarkers in Atopic Dermatitis and Psoriasis (BIOMAP) consortium (a large-scale European, interdisciplinary research initiative) has curated clinical and molecular data across diverse study designs and sources including cross-sectional and cohort studies (small-scale studies through to large multicentre registries), clinical trials, electronic health records and large-scale population-based biobanks. We map all dataset disease severity instruments and measures to three key domains (symptoms, inflammatory activity and disease course), and describe important codependencies and relationships across variables and domains. We prioritize definitions for more severe disease with reference to international consensus, reference standards and/or expert opinion. Key factors to consider when analysing datasets across these diverse study types include explicit early consideration of biomarker purpose and clinical context, candidate biomarkers associated with disease severity at a particular point in time and over time and how they are related, taking the stage of biomarker development into account when selecting disease severity measures for analyses, and validating biomarker associations with disease severity outcomes using both physician- and patient-reported measures and across domains. The outputs from this exercise will ensure coherence and focus across the BIOMAP consortium so that mechanistic insights and biomarkers are clinically relevant, patient-centric and more generalizable to current and future research efforts.
Collapse
Affiliation(s)
- Ravi Ramessur
- St John’s Institute of Dermatology
- Department of Medical and Molecular Genetics, School of Basic and Medical Biosciences, Faculty of Life Sciences & Medicine, King’s College London, London, UK
| | - Nick Dand
- Department of Medical and Molecular Genetics, School of Basic and Medical Biosciences, Faculty of Life Sciences & Medicine, King’s College London, London, UK
| | | | - Jake Saklatvala
- Department of Medical and Molecular Genetics, School of Basic and Medical Biosciences, Faculty of Life Sciences & Medicine, King’s College London, London, UK
| | - Marie-Christine Fritzsche
- Institute of History and Ethics in Medicine, TUM School of Medicine
- Department of Science, Technology and Society, School of Social Sciences and Technology, Technical University of Munich, Munich, Germany
| | | | - Bernd W M Arents
- Dutch Association for People with Atopic Dermatitis, Nijkerk, the Netherlands
| | | | | | | | | | - Alena M Buyx
- Institute of History and Ethics in Medicine, TUM School of Medicine
- Department of Science, Technology and Society, School of Social Sciences and Technology, Technical University of Munich, Munich, Germany
| | - Tamara Messer
- EURICE – European Research and Project Office GmbH, St. Ingbert, Germany
| | - Nina Weiler
- EURICE – European Research and Project Office GmbH, St. Ingbert, Germany
| | - Alexandra Hicks
- Immunology & Inflammation Research Therapeutic Area, Sanofi, Cambridge, MA, USA
| | - Peter Hecht
- Public Private Partnerships, Sanofi Partnering, Frankfurt, Germany
| | - Stephan Weidinger
- Department of Dermatology, Venerology and Allergology, University Hospital Schleswig-Holstein, Kiel, Germany
| | | | | | - Matthias Hübenthal
- Department of Dermatology, Quincke Research Center, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Alexander Egeberg
- Department of Dermatology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lavinia Paternoster
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | - Lone Skov
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Dermatology and Allergy, Copenhagen University Hospital – Herlev and Gentofte, Copenhagen, Denmark
| | - Elke M G J De Jong
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Maritza A Middelkamp-Hup
- Department of Dermatology, Amsterdam Public Health, Infection and Immunity, Amsterdam UMC, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Satveer K Mahil
- St John’s Institute of Dermatology
- Department of Medical and Molecular Genetics, School of Basic and Medical Biosciences, Faculty of Life Sciences & Medicine, King’s College London, London, UK
| | - Jonathan N Barker
- St John’s Institute of Dermatology
- Department of Medical and Molecular Genetics, School of Basic and Medical Biosciences, Faculty of Life Sciences & Medicine, King’s College London, London, UK
| | - Carsten Flohr
- Unit for Paediatric and Population-Based Dermatology Research, St John’s Institute of Dermatology, Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, UK
| | - Sara J Brown
- Centre for Genomic and Experimental Medicine, University of Edinburgh, Edinburgh, UK
- Department of Dermatology, NHS Lothian, Edinburgh, UK
| | | |
Collapse
|
2
|
Ehlert A. Severity and death. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2024; 27:217-226. [PMID: 38329625 PMCID: PMC11076339 DOI: 10.1007/s11019-024-10193-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/31/2023] [Indexed: 02/09/2024]
Abstract
This article discusses the relationship between two theories about the badness of death, the Life-Comparative Account and the Gradualist Account, and two methods of operationalizing severity in health care priority setting, Absolute Shortfall and Proportional Shortfall. The aim is that theories about the badness of death can influence and inform the idea of the basis of severity as a priority setting criterion. I argue that there are strong similarities between the Life-Comparative Account and Absolute Shortfall, and since the Life-Comparative Account is one of the most reasonable accounts of the badness of death, this provides some support for using Absolute Shortfall. I also argue that it is difficult to find support for Proportional Shortfall from theories about the badness of death, and also, that it is difficult to find support for Gradualist Account from theories about severity.
Collapse
Affiliation(s)
- Adam Ehlert
- Department of Public Health and Caring Sciences, Centre for Research Ethics and Bioethics (CRB), Uppsala University, Uppsala, Sweden.
| |
Collapse
|
3
|
Hausman DM. Problems with NICE's severity weights. Soc Sci Med 2024; 348:116833. [PMID: 38636210 DOI: 10.1016/j.socscimed.2024.116833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/19/2024] [Accepted: 03/23/2024] [Indexed: 04/20/2024]
Abstract
This essay examines the implications, plausibility, and justification of the severity weighting that NICE (The National Institute for Health and Care Excellence) has endorsed for technology assessments in the U.K. It argues that the assignment by NICE of additional weights to health conditions which involve a large absolute or proportional shortfall of future expected QALYs (Quality-Adjusted Life Years) as compared to those who do not have these health conditions is not well supported and has troubling implications. The literature concerned with attitudes toward prioritizing severity has found a variety of notions of severity, and it is questionable to what extent those studies bear on whether to assign greater weights to health states involving large absolute or proportional shortfalls. In addition, the severity weighting is not well supported by either egalitarian or prioritarian political philosophy, because it is concerned only with the future and focuses only on health rather than well-being in general.
Collapse
Affiliation(s)
- Daniel M Hausman
- Center for Population-Level Bioethics, Rutgers University, 112 Paterson Street, New Brunswick, NJ, 08901, United States.
| |
Collapse
|
4
|
Ackermann A, Pappinen J, Nurmi J, Nordquist H, Torkki P. The Estimated Cost-Effectiveness of Physician-Staffed Helicopter Emergency Medical Services Compared to Ground-Based Emergency Medical Services in Finland. Air Med J 2024; 43:229-235. [PMID: 38821704 DOI: 10.1016/j.amj.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/30/2023] [Accepted: 12/12/2023] [Indexed: 06/02/2024]
Abstract
OBJECTIVE Because the unit cost of helicopter emergency medical services (HEMS) is higher than traditional ground-based emergency medical services (EMS), it is important to further investigate the impact of HEMS. The aim of this study was to evaluate the cost-effectiveness of physician-staffed HEMS compared with ground-based EMS in Finland under current practices. METHODS The incremental cost-effectiveness ratio was evaluated using the differences in outcomes and costs between HEMS and ground-based EMS. The estimated mortality within 30 days and quality-adjusted life years (QALYs) were used to measure health benefits. Quality of life was estimated according to the EuroQoL scale, and a 1-way sensitivity analysis was conducted on the QALY indexes ranging from 0.6 to 0.8. Survival rates were calculated according to the national HEMS database, and the cost structure was estimated at 48 million euros based on financial statements. RESULTS HEMS prevented the 30-day mortality of 68.1 patients annually, with an incremental cost-effectiveness ratio of €43,688 to €56,918/QALY. Fixed costs accounted for 93% of HEMS expenses because of 24/7 operations, making the capacity utilization rate a major determinant of total costs. CONCLUSION HEMS intervention is cost-effective compared with ground-based EMS and is acceptable from a societal willingness-to-pay perspective. These findings contribute valuable insights for health care management decision making and highlight the need for future research for service optimization.
Collapse
Affiliation(s)
- Axel Ackermann
- Faculty of Medicine, Department of Public Health, University of Helsinki, Helsinki, Finland.
| | - Jukka Pappinen
- Faculty of Medicine, Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Jouni Nurmi
- Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, FinnHEMS 10, Vantaa, Finland
| | - Hilla Nordquist
- Department of Healthcare and Emergency Care, South-Eastern Finland University of Applied Sciences, Kotka, Finland
| | - Paulus Torkki
- Faculty of Medicine, Department of Public Health, University of Helsinki, Helsinki, Finland
| |
Collapse
|
5
|
Jølstad B, Stenmarck MS, Barra M. Preparing popular views for inclusion in a reflective equilibrium: A case study on illness severity. Soc Sci Med 2024; 348:116794. [PMID: 38555745 DOI: 10.1016/j.socscimed.2024.116794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 03/12/2024] [Accepted: 03/14/2024] [Indexed: 04/02/2024]
Abstract
Principles for priority setting in health care are typically forged by experts influenced by the normative literature on priority setting. Meanwhile, their implementation is subject to democratic deliberation, political pressures, and administrative bureaucracy. Sometimes expert proposals are democratically rejected. This points towards a problem: on the one hand, the fact that a majority shares a moral belief does not inherently validate this belief. On the other hand, when justifying a position to others, we cannot expect much success without engaging with their moral judgments. In this work we examine the possibility of including so-called popular views in a reflective equilibrium process. In reflective equilibrium processes, we are usually interested in considered judgments rather than mere intuitions. Popular views, arguably, often do not meet this standard. To mitigate this, we propose to bolster popular views by linking them with theoretical frameworks echoing similar moral perspectives. We use illness severity as a case study and show that a set of popular accounts can provide considered judgments that merit inclusion in a publicly informed reflective equilibrium process. This is plausibly a way forward in the search for priority setting principles that are both normatively sound and acceptable to the public. Our method provides a general framework for refining available data on popular views on moral questions, including when we cannot assess the consideredness of such views.
Collapse
Affiliation(s)
- Borgar Jølstad
- The Health Services Research Unit-HØKH, Akershus University Hospital HF, Lørenskog, Norway; Centre for Medical Ethics (CME), Institute of Health and Society, Faculty of Medicine, University of Oslo, Norway.
| | - Mille Sofie Stenmarck
- The Health Services Research Unit-HØKH, Akershus University Hospital HF, Lørenskog, Norway; Faculty of Medicine, University of Oslo, Norway
| | - Mathias Barra
- The Health Services Research Unit-HØKH, Akershus University Hospital HF, Lørenskog, Norway
| |
Collapse
|
6
|
Pedersen AKB, Skinner MS, Sogstad M. Needs assessment in long-term care: expression of national principles for priority setting in service allocation. BMC Health Serv Res 2024; 24:530. [PMID: 38671489 PMCID: PMC11046954 DOI: 10.1186/s12913-024-10889-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Long-term care services for older adults are characterised by increasing needs and scarce resources. Political strategies have led to the reorganisation of long-term care services, with an increased focus on "ageing in place" and efficient use of resources. There is currently limited research on the processes by which resource allocation decisions are made by service allocators of long-term care services for older adults. The aim of this study is to explore how three political principles for priority setting in long-term care, resource, severity and benefit, are expressed in service allocation to older adults. METHODS This qualitative study uses data from semi-structured individual interviews, focus groups and observations of service allocators who assess needs and assign long-term care services to older adults in Norway. The data were supplemented with individual decision letters from the allocation office, granting or denying long-term care services. The data were analysed using reflexive thematic analysis. RESULTS The allocators drew on all three principles for priority setting when assessing older adults' long-term care needs and allocating services. We found that the three principles pushed in different directions in the allocation process. We identified six themes related to service allocators' expression of the principles: (1) lowest effective level of care as a criterion for service allocation (resource), (2) blanket allocation of low-cost care services (resource), (3) severity of medical and rehabilitation needs (severity), (4) severity of care needs (severity), (5) benefit of generous service allocation (benefit) and (6) benefit of avoiding services (benefit). CONCLUSIONS The expressions of the three political principles for priority setting in long-term care allocation are in accordance with broader political trends and discourses regarding "ageing in place", active ageing, an investment ideology, and prioritising those who are "worse off". Increasing attention to the rehabilitation potential of older adults and expectations that they will take care of themselves increase the risk of not meeting frail older adults' care needs. Additionally, difficulties in defining the severity of older adults' complex needs lead to debates regarding "worse off" versus potentiality in future long-term care services allocation. TRIAL REGISTRATION Not applicable.
Collapse
Affiliation(s)
- Ann Katrin Blø Pedersen
- Centre for Care Research, Department of Health Sciences in Gjøvik, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Teknologivegen 22, 2815, Gjøvik, Norway.
| | - Marianne Sundlisæter Skinner
- Centre for Care Research, Department of Health Sciences in Gjøvik, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Teknologivegen 22, 2815, Gjøvik, Norway.
| | - Maren Sogstad
- Centre for Care Research, Department of Health Sciences in Gjøvik, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Teknologivegen 22, 2815, Gjøvik, Norway.
| |
Collapse
|
7
|
Mahdiani H, Münch N, Paul NW. A QALY is [still] a QALY is [still] a QALY? : Evaluating proportional shortfall as the answer to the problem of equity in healthcare allocations. BMC Med Ethics 2024; 25:35. [PMID: 38521941 PMCID: PMC10960401 DOI: 10.1186/s12910-024-01036-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 03/11/2024] [Indexed: 03/25/2024] Open
Abstract
Despite clinical evidence of drug superiority, therapeutic modalities, like combination immunotherapy, are mostly considered cost-ineffective due to their high costs per life year(s) gained. This paper, taking an ethical stand, reevaluates the standard cost-effectiveness analysis with that of the more recent justice-enhanced methods and concludes by pointing out the shortcomings of the current methodologies.
Collapse
Affiliation(s)
- Hamideh Mahdiani
- Institute for History, Philosophy and Ethics of Medicine, Johannes Gutenberg University Medical Center, Am Pulverturm 13, 55131, Mainz, Germany.
| | - Nikolai Münch
- Institute for History, Philosophy and Ethics of Medicine, Johannes Gutenberg University Medical Center, Am Pulverturm 13, 55131, Mainz, Germany
| | - Norbert W Paul
- Institute for History, Philosophy and Ethics of Medicine, Johannes Gutenberg University Medical Center, Am Pulverturm 13, 55131, Mainz, Germany
| |
Collapse
|
8
|
Kapiriri L, Ieystn W, Vélez CM, Essue BM, Susan G, Danis M, Aguilera B. A global comparative analysis of the criteria and equity considerations included in eighty-six national COVID-19 plans. Health Policy 2024; 140:104961. [PMID: 38228031 DOI: 10.1016/j.healthpol.2023.104961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 12/06/2023] [Accepted: 12/08/2023] [Indexed: 01/18/2024]
Abstract
Systematic priority setting (PS), based on explicit criteria, is thought to improve the quality and consistency of the PS decisions. Among the PS criteria, there is increased focus on the importance of equity considerations and vulnerable populations. This paper discusses the PS criteria that were included in the national COVID-19 pandemic plans, with specific focus on equity and on the vulnerable populations considered. Secondary synthesis of data, from a global comparative study that examined the degree to which the COVID-19 plans included PS, was conducted. Only 32 % of the plans identified explicit criteria. Severity of the disease and/or disease burden were the commonly mentioned criteria. With regards to equity considerations and prioritizing vulnerable populations, 22 countries identified people with co-morbidities others mentioned children, women etc. Low social-economic status and internally displaced population were not identified in any of the reviewed national plans. The limited inclusion of explicit criteria and equity considerations highlight a need for policy makers, in all contexts, to consider instituting and equipping PS institutions who can engage diverse stakeholders in identifying the relevant PS criteria during the post pandemic period. While vulnerability will vary with the type of health emergency- awareness of this and having mechanisms for identifying and prioritizing the most vulnerable will support equitable pandemic responses.
Collapse
Affiliation(s)
- Lydia Kapiriri
- Department of Health, Aging & Society, McMaster University, 1280 Main Street West, Kenneth Taylor Hall Room 226, Hamilton, Ontario L8S 4M4, Canada.
| | - Williams Ieystn
- School of Social Policy, HSMC, Park House, University of Birmingham, Edgbaston, Birmingham B15 2RT, UK
| | - Claudia-Marcela Vélez
- Department of Health, Aging & Society, McMaster University, 1280 Main Street West, Kenneth Taylor Hall Room 226, Hamilton, Ontario L8S 4M4, Canada
| | - Beverley M Essue
- Centre for Global Health Research, St. Michael's Hospital, 30 Bond St, Toronto, Ontario M5B 1W8, Canada
| | - Goold Susan
- Internal Medicine and Health Management and Policy. Center for Bioethics and Social Sciences in Medicine, University of Michigan. 2800 Plymouth Road, Bldg. 14, G016, Ann Arbor, MI 48109-2800, USA
| | - Marion Danis
- Section on Ethics and Health Policy, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892, USA
| | - Bernardo Aguilera
- Facultad de Medicina y Ciencia, Universidad San Sebastian, Providencia, Santiago, Chile
| |
Collapse
|
9
|
Sandman L, Liliemark J. Should Severity Assessments in Healthcare Priority Setting be Risk- and Time-Sensitive? HEALTH CARE ANALYSIS 2023; 31:169-185. [PMID: 37526761 PMCID: PMC10693510 DOI: 10.1007/s10728-023-00460-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Severity plays an essential role in healthcare priority setting. Still, severity is an under-theorised concept. One controversy concerns whether severity should be risk- and/or time-sensitive. The aim of this article is to provide a normative analysis of this question. METHODS A reflective equilibrium approach is used, where judgements and arguments concerning severity in preventive situations are related to overall normative judgements and background theories in priority-setting, aiming for consistency. Analysis, discussion, and conclusions: There is an argument for taking the risk of developing a condition into account, and we do this when we consider the risk of dying in the severity assessment. If severity is discounted according to risk, this will 'dilute' severity, depending on how well we are able to delineate the population, which is dependent on the current level of knowledge. This will potentially have a more far-reaching effect when considering primary prevention, potentially the de-prioritisation of effective preventive treatments in relation to acute, less-effective treatments. The risk arguments are dependent on which population is being assessed. If we focus on the whole population at risk, with T0 as the relevant population, this supports the risk argument. If we instead focus on the population of as-yet (at T0) unidentified individuals who will develop the condition at T1, risk will become irrelevant, and severity will not be risk sensitive. The strongest argument for time-sensitive severity (or for discounting future severity) is the future development of technology. On a short timescale, this will differ between different diagnoses, supporting individualised discounting. On a large timescale, a more general discounting might be acceptable. However, we need to also consider the systemic effects of allowing severity to be risk- and time-sensitive.
Collapse
Affiliation(s)
- Lars Sandman
- Department of Health, Medicine and Caring Sciences, National Centre for Priorities in Health, Linköping University, Linköping, SE-581 83, Sweden.
| | - Jan Liliemark
- Department of Health, Medicine and Caring Sciences, National Centre for Priorities in Health, Linköping University, Linköping, SE-581 83, Sweden
| |
Collapse
|
10
|
Jølstad B. Adaptation and illness severity: the significance of suffering. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2023; 26:413-423. [PMID: 37178191 PMCID: PMC10425500 DOI: 10.1007/s11019-023-10155-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/15/2023]
Abstract
Adaptation to illness, and its relevance for distribution in health care, has been the subject of vigorous debate. In this paper I examine an aspect of this discussion that seems so far to have been overlooked: that some illnesses are difficult, or even impossible, to adapt to. This matters because adaptation reduces suffering. Illness severity is a priority setting criterion in several countries. When considering severity, we are interested in the extent to which an illness makes a person worse-off. I argue that no plausible theory of well-being can disregard suffering when determining to what extent someone is worse-off in terms of health. We should accept, all else equal, that adapting to an illness makes the illness less severe by reducing suffering. Accepting a pluralist theory of well-being allows us to accept my argument, while still making room for the possibility that adaptation is sometimes, all things considered, bad. Finally, I argue that we should conceptualize adaptability as a feature of illness, and thereby account for adaptation on a group level for the purposes of priority setting.
Collapse
Affiliation(s)
- Borgar Jølstad
- The Health Services Research Unit-HØKH, Akershus University Hospital (Ahus), Sykehusveien 25, Akershus Universitetssykehus HF, Postboks 1000, 1478, Lørenskog, Norway.
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.
| |
Collapse
|
11
|
Oliveira CB, Ferreira GE, Buchbinder R, Machado GC, Maher CG. Do national health priorities align with Global Burden of Disease estimates on disease burden? An analysis of national health plans and official governmental websites. Public Health 2023; 222:66-74. [PMID: 37523950 DOI: 10.1016/j.puhe.2023.06.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/19/2023] [Accepted: 06/27/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVE To investigate the alignment of national health priorities with a country's burden of disease as measured by disability-adjusted life years (DALYs). METHODS We identified priorities in national health plans and the 20 most burdensome conditions measured by DALYs from the 2017 Global Burden of Disease Study. We computed point-biserial correlations (rpb) between DALYs and being nominated as a health priority and the pooled proportion (95% confidence intervals [CIs]) of the 20 most burdensome conditions nominated as a priority across countries. RESULTS We identified national health plans and official governmental websites in 145 countries. There was little to no correlation (rpb = 0.06, 95% CI: 0.02 to 0.09) between national DALY data and whether a condition was nominated as a health priority. The pooled proportion of the 20 most burdensome conditions nominated as priorities across countries was 46%. HIV/AIDS had the greatest number of nominations as a national health priority (62 countries) as well as the greatest match with the burden of disease (among the top 20 most burdensome conditions in 51 [82%] countries). Low back pain, headache disorders and congenital birth defects had the lowest proportion of nominations as health priorities in countries where they were in the top 20 most burdensome conditions (6%, 6% and 11%, respectively). CONCLUSION Globally, there were low correlations between national health priorities and GBD estimates on disease burden. Failing to prioritise health priorities according to burden may mean that insufficient resources have been directed to improve health outcomes for people with those health conditions.
Collapse
Affiliation(s)
- C B Oliveira
- Faculty of Medicine, University of Western São Paulo (UNOESTE), Presidente Prudente, Sao Paulo, Brazil; Physical Therapy Department, Faculty of Science and Technology, Sao Paulo State University, Presidente Prudente, Brazil; Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia.
| | - G E Ferreira
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia; Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - R Buchbinder
- Musculoskeletal Health and Wiser Health Care Units, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - G C Machado
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia; Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - C G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia; Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
12
|
Deering K, Brimblecombe N, Matonhodze JC, Nolan F, Collins DA, Renwick L. Methodological procedures for priority setting mental health research: a systematic review summarising the methods, designs and frameworks involved with priority setting. Health Res Policy Syst 2023; 21:64. [PMID: 37365647 DOI: 10.1186/s12961-023-01003-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 05/18/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Research priority setting aims to identify research gaps within particular health fields. Given the global burden of mental illness and underfunding of mental health research compared to other health topics, knowledge of methodological procedures may raise the quality of priority setting to identify research with value and impact. However, to date there has been no comprehensive review on the approaches adopted with priority setting projects that identify mental health research, despite viewed as essential knowledge to address research gaps. Hence, the paper presents a summary of the methods, designs, and existing frameworks that can be adopted for prioritising mental health research to inform future prioritising projects. METHOD A systematic review of electronic databases located prioritisation literature, while a critical interpretive synthesis was adopted whereby the appraisal of methodological procedures was integrated into the synthesis of the findings. The synthesis was shaped using the good practice checklist for priority setting by Viergever and colleagues drawing on their following categories to identify and appraise methodological procedures: (1) Comprehensive Approach-frameworks/designs guiding the entire priority setting; (2) Inclusiveness -participation methods to aid the equal contribution of stakeholders; (3) Information Gathering-data collecting methods to identify research gaps, and (4) Deciding Priorities-methods to finalise priorities. RESULTS In total 903 papers were located with 889 papers removed as either duplicates or not meeting the inclusion and exclusion criteria. 14 papers were identified, describing 13 separate priority setting projects. Participatory approaches were the dominant method adopted but existing prioritisation frameworks were modified with little explanation regarding the rationale, processes for adaptation and theoretical foundation. Processes were predominately researcher led, although with some patient involvement. Surveys and consensus building methods gathered information while ranking systems and thematic analysis tend to generate finalised priorities. However, limited evidence found about transforming priorities into actual research projects and few described plans for implementation to promote translation into user-informed research. CONCLUSION Prioritisation projects may benefit from justifying the methodological approaches taken to identify mental health research, stating reasons for adapting frameworks alongside reasons for adopting particular methods, while finalised priorities should be worded in such a way as to facilitate their easy translation into research projects.
Collapse
Affiliation(s)
- Kris Deering
- University of Exeter Medical School, St Luke's Campus, 79 Heavitree Rd, Exeter, EX1 2LT, United Kingdom.
| | - Neil Brimblecombe
- London South Bank University, 103 Borough Road, London, SE1 0AA, United Kingdom
| | - Jane C Matonhodze
- University of Greenwich, Avery Hill Campus, Southwood Site, Avery Hill Road, London, SE9 2UG, United Kingdom
| | - Fiona Nolan
- Anglia Ruskin University, Chelmsford Campus Bishop Hall Lane, Chelmsford, CM1 1SQ, United Kingdom
| | - Daniela A Collins
- London South Bank University, 103 Borough Road, London, SE1 0AA, United Kingdom
| | - Laoise Renwick
- The University of Manchester, Oxford Rd, Manchester, M13 9PL, United Kingdom
| |
Collapse
|
13
|
Solberg CT, Barra M, Sandman L, Hoffmann B. Severity as a moral qualifier of malady. BMC Med Ethics 2023; 24:25. [PMID: 37004054 PMCID: PMC10064741 DOI: 10.1186/s12910-023-00903-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 03/10/2023] [Indexed: 04/03/2023] Open
Abstract
The overarching aim of this article is to scrutinize how severity can work as a qualifier for the moral impetus of malady. While there is agreement that malady is of negative value, there is disagreement about precisely how this is so. Nevertheless, alleviating disease, injury, and associated suffering is almost universally considered good. Furthermore, the strength of a diseased person's moral claims for our attention and efforts will inevitably vary. This article starts by reflecting on what kind of moral impetus malady incites. We then analyze how severity may qualify this impetus. We do so by discussing the relationship between severity and need, well-being and disvalue, death, urgency, rule of rescue, and distributive justice. We then summarize our thoughts about severity as a moral qualifier. We conclude that severity is, and should continue to be seen, as a morally significant concept that deserves continued attention in the future.
Collapse
Affiliation(s)
- Carl Tollef Solberg
- Centre for Medical Ethics (CME), Institute of Health and Society, Faculty of Medicine, University of Oslo, Kirkeveien 166, Postbox 1130, 0318, Oslo, Norway.
- The Health Services Research Unit-HØKH, Akershus University Hospital HF, Lørenskog, Norway.
| | - Mathias Barra
- The Health Services Research Unit-HØKH, Akershus University Hospital HF, Lørenskog, Norway
| | - Lars Sandman
- Department of Health, Medicine and Caring Sciences, The National Centre for Priorities in Health, Linköping University, Linköping, Sweden
| | - Bjørn Hoffmann
- Centre for Medical Ethics (CME), Institute of Health and Society, Faculty of Medicine, University of Oslo, Kirkeveien 166, Postbox 1130, 0318, Oslo, Norway
- Institute for the Health Sciences, Norwegian University of Science and Technology, PO Box 191, N-2802, Gjøvik, Norway
| |
Collapse
|
14
|
Synnott PG, Voehler D, Enright DE, Kowal S, Ollendorf DA. The Value of New: Consideration of Product Novelty in Health Technology Assessments of Pharmaceuticals. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:305-314. [PMID: 36529826 DOI: 10.1007/s40258-022-00779-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/27/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Efforts to understand how treatments affect patients and society have broadened the criteria that health technology assessment (HTA) organizations apply to value assessments. We examined whether HTA agencies in eight countries consider treatment novelty in methods and deliberations. METHODS We defined a novel pharmaceutical product to be one that offers a new approach to treatment (e.g., new mechanism of action), addresses an unmet need (e.g., targets a rare condition without effective treatments), or has a broader impact beyond what is typically measured in an HTA. We reviewed peer-reviewed publications and technical guidance materials from HTA organizations in Australia, Canada, England, France, The Netherlands, Norway, Sweden, and the United States (US). In addition, we explored how HTA organizations integrated novelty considerations into deliberations and recommendations related to two newer therapies-voretigene neparvovec for an inherited retinal disorder and ocrelizumab for multiple sclerosis. RESULTS None of the HTA organizations acknowledge treatment novelty as an explicit value criterion in their assessments of pharmaceutical products. However, drugs that have novel characteristics are given special consideration, particularly when they address an unmet need. Several organizations document a willingness to expend more resources and accept greater evidence uncertainty for such treatments. Qualitative deliberations about the additional unquantified potential benefits of treatment may also influence HTA recommendations. CONCLUSION Major HTA organizations do not recognize novelty as an explicit value criterion, although drugs with novel characteristics may receive special consideration. There is an opportunity for organizations to codify their approach to evaluating novelty in value assessment.
Collapse
Affiliation(s)
- Patricia G Synnott
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, 800 Washington Street, #063, Boston, MA, 02111, USA.
| | - Dominic Voehler
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, 800 Washington Street, #063, Boston, MA, 02111, USA
| | - Daniel E Enright
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, 800 Washington Street, #063, Boston, MA, 02111, USA
| | - Stacey Kowal
- Genentech, Inc, 1 DNA Way, South San Francisco, CA, 94080, USA
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, 800 Washington Street, #063, Boston, MA, 02111, USA
| |
Collapse
|
15
|
Gustavsson E, Björk J. The Ethical Relevance of "Alternatives" in Health Care Priority Setting - The Case of Preexposure Prophylaxis (PrEP) of HIV. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2022; 95:359-365. [PMID: 36187410 PMCID: PMC9511950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Preexposure prophylaxis for HIV is a drug that reduces the risk for an HIV-negative person to acquire HIV if taken prior to sex. It has been suggested that it is important for resource allocation decisions that there are alternatives (such as abstinence, masturbation, etc.) for individuals potentially benefitted by this prophylaxis. In this paper we explore this idea from an ethical perspective in relation to three notions often discussed in priority setting ethics, namely responsibility, outcomes, and severity of disease. While the relevance of alternatives may be explained in terms by responsibility-sensitive priority setting, such a view comes with several challenges. We then discuss two other ways in which this intuition could be better explained: (a) in terms of total outcome of health, and (b) in terms of severity of the condition.
Collapse
Affiliation(s)
- Erik Gustavsson
- Division of Philosophy and Applied Ethics, Department
of Culture and Society, Linköping University, Linköping, Sweden,The National Centre for Priorities in Health,
Department of Health, Medicine and Caring Sciences, Linköping University,
Linköping, Sweden,To whom all correspondence should be addressed:
Erik Gustavsson, Division of Philosophy and Applied Ethics, Department of
Culture and Society, Linköping University, Linköping, Sweden;
| | - Joar Björk
- Stockholm Centre for Healthcare Ethics (CHE), LIME,
Karolinska Institutet, Stockholm, Sweden,Department of Research and Development, Region
Kronoberg, Växjö, Sweden
| |
Collapse
|
16
|
Skedgel C, Henderson N, Towse A, Mott D, Green C. Considering Severity in Health Technology Assessment: Can We Do Better? VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:1399-1403. [PMID: 35393254 DOI: 10.1016/j.jval.2022.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 02/08/2022] [Accepted: 02/12/2022] [Indexed: 06/14/2023]
Abstract
There is strong evidence that individuals and the public assign relatively greater value to health gains from relatively more severe health states. This preference is increasingly reflected in health technology assessment, with some consideration of severity incorporated by health technology assessment bodies in, among others, The Netherlands, England and Wales, Norway, Sweden, and the United States. If a societal "severity premium" is to be considered fairly and consistently, we argue that a more explicit and quantitative approach is needed. We highlight drawbacks of categorical approaches, especially discontinuities between severity categories that arguably violate concepts of vertical equity, and argue that a more continuous approach to understanding severity is needed. We also note challenges to more explicit approaches, including implications of a lower threshold for less severe conditions and the relative complexity of calculating a continuous severity adjustment.
Collapse
Affiliation(s)
| | | | | | - David Mott
- Office of Health Economics, London, England, UK
| | | |
Collapse
|
17
|
Tranvåg EJ, Haaland ØA, Robberstad B, Norheim OF. Appraising Drugs Based on Cost-effectiveness and Severity of Disease in Norwegian Drug Coverage Decisions. JAMA Netw Open 2022; 5:e2219503. [PMID: 35767256 PMCID: PMC9244608 DOI: 10.1001/jamanetworkopen.2022.19503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Rising health care costs are a major health policy challenge globally. Norway has implemented a priority-setting system intended to balance cost-effectiveness and concerns for fair distribution, but little is known about this strategy and whether it works in practice. OBJECTIVE To present and evaluate a systematic drug appraisal method that uses the severity of disease to account for a fair distribution of health in cost-effectiveness analysis, forming the basis for price negotiations and coverage decisions. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study uses confidential drug price information and publicly available data from health technology assessments and logistic and linear regression analyses to evaluate drug coverage decisions for the Norwegian specialized health care sector from 2014 to 2019. MAIN OUTCOMES AND MEASURES Drug coverage decisions by Norwegian authorities and incremental cost-effectiveness and severity of disease measured as absolute shortfall of quality adjusted life years. RESULTS Between 2014 and 2019, a total of 188 drugs were appraised, of which 113 were cancer drugs. The overall coverage rate was 73% (138 of 188). The number of annual appraisals increased during the observation period. Based on 83 chosen decisions, regression analysis showed that incremental cost-effectiveness ratios (ICER) based on negotiated drug prices, adjusted for severity-differentiated cost-effectiveness thresholds, was the variable that best projected drug approvals (OR, 0.60; 95% CI, 0.42-0.86). An increase in the ICER by $10 000 was associated with a reduction in the odds for approval of 40% for drugs assessed from 2018 to 2019. CONCLUSIONS AND RELEVANCE This cross-sectional study demonstrated how concerns for efficiency and fair distribution of health can be implemented systematically into drug appraisals and reimbursement decisions. New, expensive drugs are expected to escalate health care costs in the years to come, and it may be feasible to control costs by negotiating the prices of new drugs while appraising both their cost-effectiveness and how their health benefits are distributed.
Collapse
Affiliation(s)
- Eirik Joakim Tranvåg
- Bergen Centre for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Centre for Cancer Biomarkers, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Øystein Ariansen Haaland
- Bergen Centre for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Bjarne Robberstad
- Research Group in Health Economics, Leadership, and Translational Ethics Research, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Ole Frithjof Norheim
- Bergen Centre for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Centre for Cancer Biomarkers, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| |
Collapse
|
18
|
Attitudes towards priority setting in the norwegian health care system: a general population survey. BMC Health Serv Res 2022; 22:444. [PMID: 35382816 PMCID: PMC8980508 DOI: 10.1186/s12913-022-07806-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 03/15/2022] [Indexed: 01/04/2023] Open
Abstract
Background In an ideal world, everyone would receive medical resources in accordance with their needs. In reality, resources are often scarce and have an alternative use. Thus, we are forced to prioritize. Although Norway is one of the leading countries in normative priority setting work, few descriptive studies have been conducted in the country. To increase legitimacy in priority setting, knowledge about laypeople’s attitudes is central. The aim of the study is therefore to assess the general population’s attitudes towards a broad spectrum of issues pertinent to priority setting in the Norwegian publicly financed health care system. Methods We developed an electronic questionnaire that was distributed to a representative sample of 2 540 Norwegians regarding their attitudes towards priority setting in Norway. A total of 1 035 responded (response rate 40.7%). Data were analyzed with descriptive statistics and binary logistic regression. Results A majority (73.0%) of respondents preferred increased funding of publicly financed health services at the expense of other sectors in society. Moreover, a larger share of the respondents suggested either increased taxes (37.0%) or drawing from the Government Pension Fund Global (31.0%) as sources of funding. However, the respondents were divided on whether it was acceptable to say “no” to new cancer drugs when the effect is low and the price is high: 38.6% somewhat or fully disagreed that this was acceptable, while 46.5% somewhat or fully agreed. Lastly, 84.0% of the respondents did not find it acceptable that the Norwegian municipalities have different standards for providing care services. Conclusion Although the survey suggests support for priority setting among Norwegian laypeople, it has also revealed that a significant minority are reluctant to accept it. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07806-9.
Collapse
|
19
|
Kapiriri L, Razavi SD. Equity, justice, and social values in priority setting: a qualitative study of resource allocation criteria for global donor organizations working in low-income countries. Int J Equity Health 2022; 21:17. [PMID: 35135553 PMCID: PMC8822856 DOI: 10.1186/s12939-021-01565-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 10/03/2021] [Indexed: 12/02/2022] Open
Abstract
Background There is increasing acceptance of the importance of social values such as equity and fairness in health care priority setting (PS). However, equity is difficult to define: the term means different things to different people, and the ways it is understood in theory often may not align with how it is operationalized. There is limited literature on how development assistance partner organizations (DAP) conceptualize and operationalize equity in their health care prioritization decisions that affect low-income countries (LIC). This paper explores whether and how equity is a consideration in DAP priority setting processes. Methods This was a qualitative study involving 38 in-depth interviews with DAPs involved in health-system PS for LICs and a review of their respective webpages. Results While several PS criteria were identified, direct articulation of equity as an explicit criterion was lacking. However, the criterion was implied in some of the responses in terms of prioritizing vulnerable populations. Where mentioned, respondents discussed the difficulties of operationalizing equity as a PS criterion since vulnerability is associated with several varying and competing factors including gender, age, geography, and income. Some respondents also suggested that equity could be operationalized in terms of an organization not supporting the pre-existing inequities. Although several organizations’ webpages identify addressing inequities as a guiding principle, there were variations in how they spoke about its operationalization. While intersectionalities in vulnerabilities complicate its operationalization, if organizations explicitly articulate their equity focus the other organizations who also have equity as a guiding principle may, instead of focusing on the same aspect, concentrate on other dimensions of vulnerability. That way, all organizations will contribute to achieving equity in all the relevant dimensions. Conclusions Since most development organizations support some form of equity, this paper highlights a need for an internationally recognized framework that recognizes the intersectionalities of vulnerability, for mainstreaming and operationalizing equity in DAP priority setting and resource allocation. Such a framework will support consistency in the conceptualization of and operationalization of equity in global health programs. There is a need for studies which to assess the degree to which equity is actually integrated in these programs. Equity has become an increasingly important focus in the health and social science literature, however, equity is a contested concept. While development assistance partners supporting health development subscribe to equity as a guiding principle, they struggle with its operationalization. There is need for a general framework that explicitly conceptualizes the operationalization of equity in health development.
Collapse
Affiliation(s)
- Lydia Kapiriri
- Department of Health, Aging and Society, McMaster University, 1280 Main street West, Hamilton, Ontario, Canada.
| | - S Donya Razavi
- Department of Health, Aging and Society, McMaster University, 1280 Main street West, Hamilton, Ontario, Canada
| |
Collapse
|
20
|
Newson AJ, Dive L. Taking seriousness seriously in genomic health. Eur J Hum Genet 2022; 30:140-141. [PMID: 34782753 PMCID: PMC8821609 DOI: 10.1038/s41431-021-01002-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 11/01/2021] [Indexed: 02/03/2023] Open
Affiliation(s)
- Ainsley J. Newson
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, Sydney School of Public Health, Sydney Health Ethics, The University of Sydney, Sydney, 2006 NSW Australia
| | - Lisa Dive
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, Sydney School of Public Health, Sydney Health Ethics, The University of Sydney, Sydney, 2006 NSW Australia
| |
Collapse
|
21
|
Magalhaes M. Should rare diseases get special treatment? JOURNAL OF MEDICAL ETHICS 2022; 48:86-92. [PMID: 34815319 DOI: 10.1136/medethics-2021-107691] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 11/01/2021] [Indexed: 06/13/2023]
Abstract
Orphan drug policy often gives 'special treatment' to rare diseases, by giving additional priority or making exceptions to specific drugs, based on the rarity of the conditions they aim to treat. This essay argues that the goal of orphan drug policy should be to make prevalence irrelevant to funding decisions. It aims to demonstrate that it is severity, not prevalence, which drives our judgments that important claims are being overlooked when treatments for severe rare diseases are not funded. It shows that prioritising severity avoids problems caused by prioritising rarity, and that it is compatible with a range of normative frameworks. The implications of a severity-based view for drug development are then derived. The severity-based view also accounts for what is wrong with how the current system of drug development unfairly neglects common diseases that burden the developing world. Lastly, the implications of a severity-based view for current orphan drug policies are discussed.
Collapse
Affiliation(s)
- Monica Magalhaes
- Center for Population-Level Bioethics, Rutgers University, New Brunswick, New Jersey, USA
| |
Collapse
|
22
|
How to fairly allocate scarce medical resources? Controversial preferences of healthcare professionals with different personal characteristics. HEALTH ECONOMICS POLICY AND LAW 2021; 17:398-415. [PMID: 34108069 DOI: 10.1017/s1744133121000190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The scarcity of medical resources is widely recognized, and therefore priority setting is inevitable. This study examines whether Portuguese healthcare professionals (physicians vs nurses): (i) share the moral guidance proposed by ethicists and (ii) attitudes toward prioritization criteria vary among individual and professional characteristics. A sample of 254 healthcare professionals were confronted with hypothetical prioritization scenarios involving two patients distinguished by personal or health characteristics. Descriptive statistics and parametric analyses were performed to evaluate and compare the adherence of both groups of healthcare professionals regarding 10 rationing criteria: waiting time, treatment prognosis measured in life expectancy and quality of life, severity of health conditions measured in pain and immediate risk of dying, age discrimination measured in favoring the young over older and favoring the youngest over the young, merit evaluated positively or negatively, and parenthood. The findings show a slight adherence to the criteria. Waiting time and patient pain were the conditions considered fairer by respondents in contrast with the ethicists normative. Preferences for distributive justice vary by professional group and among participants with different political orientations, rationing experience, years of experience, and level of satisfaction with the NHS. Decision-makers should consider the opinion of ethicists, but also those of healthcare professionals to legitimize explicit guidelines.
Collapse
|
23
|
Norfjord van Zyl M, Tillgren P, Asp M. The politicians' perspectives on participation in mammographic screening: an interview-based study from a region in Sweden. ACTA ACUST UNITED AC 2021; 79:52. [PMID: 33865449 PMCID: PMC8052730 DOI: 10.1186/s13690-021-00576-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/07/2021] [Indexed: 11/23/2022]
Abstract
Background Breast cancer is the most common cancer type among women globally. To facilitate early detection, all 40–74-year-old female residents of Sweden are invited to participate in a population-based mammographic screening programme. Approximately 20% of all invited women decline the offer, and if this is due to systematic differences that can be adjusted, it can indicate inequity in healthcare. Assessment of and being updated about the health and healthcare of the residents are largely the responsibilities of the self-governed regions in Sweden. The understanding of the residents’ health serves as a basis for decision making and priority setting. This study aims to describe how politicians representing a region in Sweden perceive women’s participation in mammographic screening and the politicians’ own possibility to promote such participation. Methods Qualitative thematic analysis was conducted on the data obtained from individual semi-structured interviews held in 2019. The interviewees comprised ten politicians (six women and four men, 38–71 years old) representing a sub-committee focusing on public health and healthcare issues. Results Two main themes have been identified: 1) expected actions and 2) expected conditions for acting, including a total of four sub-themes. According to the politicians, the expected actions, such as obtaining information and being updated about matters regarding mammographic screening, concern both the women invited to the screening and the politicians themselves. Additionally, for both the individual and the healthcare organisation, here represented by the politicians, expected actions entail a shared commitment to maintain health. The expected conditions for acting refer to the politician’s awareness of the factors influencing the women’s decision to undergo or refuse the screening and having the resources to enable taking actions to facilitate participation. Conclusions Expected actions and expected conditions for acting are tightly connected and entail some form of prioritisation by the politicians. Setting the priorities can be based on information about the purpose of the screening and an understanding of social determinants’ impacts on women’s decision to refrain from mammographic screening, as well as available resources. Supplementary Information The online version contains supplementary material available at 10.1186/s13690-021-00576-6.
Collapse
Affiliation(s)
- Maria Norfjord van Zyl
- Division of Public Health Sciences, School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23, Västerås, Sweden.
| | - Per Tillgren
- Division of Public Health Sciences, School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23, Västerås, Sweden
| | - Margareta Asp
- Division of Caring Sciences and Health Care Pedagogics, School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23, Västerås, Sweden
| |
Collapse
|
24
|
Responsibility for Funding Refractive Correction in Publicly Funded Health Care Systems: An Ethical Analysis. HEALTH CARE ANALYSIS 2020; 29:59-77. [PMID: 33367979 PMCID: PMC7870629 DOI: 10.1007/s10728-020-00423-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 10/30/2022]
Abstract
Allocating on the basis of need is a distinguishing principle in publicly funded health care systems. Resources ought to be directed to patients, or the health program, where the need is considered greatest. In Sweden support of this principle can be found in health care legislation. Today however some domains of what appear to be health care needs are excluded from the responsibilities of the publicly funded health care system. Corrections of eye disorders known as refractive errors is one such domain. In this article the moral legitimacy of this exception is explored. Individuals with refractive errors need spectacles, contact lenses or refractive surgery to do all kinds of thing, including participating in everyday activities, managing certain jobs, and accomplishing various goals in life. The relief of correctable visual impairments fits well into the category of what we typically consider a health care need. The study of refractive errors does belong to the field of medical science, interventions to correct such errors can be performed by medical means, and the skills of registered health care professionals are required when it comes to correcting refractive error. As visual impairments caused by other conditions than refractive errors are treated and funded within the public health care system in Sweden this is an inconsistency that needs to be addressed.
Collapse
|
25
|
Hausman D. Hope or despair: a response to 'Do not despair about severity-yet'. JOURNAL OF MEDICAL ETHICS 2020; 46:559. [PMID: 32241806 DOI: 10.1136/medethics-2020-106162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 03/03/2020] [Indexed: 06/11/2023]
Abstract
This is a brief response to 'Do not despair about severity-yet' by Barra et al It argues that they have no serious criticisms of Daniel Hausman's essay, 'The Significance of Severity'" and that indeed their work lends further support to his view that there is no justification for prioritising severity. As policy-akers, Barra and his coauthors are more constrained by popular attitudes, which apparently favour prioritising severity.
Collapse
Affiliation(s)
- Daniel Hausman
- Department of Philosophy, University of Wisconsin-Madison, Madison, WI 53711, USA
| |
Collapse
|
26
|
Johansson KA, Økland JM, Skaftun EK, Bukhman G, Norheim OF, Coates MM, Haaland ØA. Estimating Health Adjusted Age at Death (HAAD). PLoS One 2020; 15:e0235955. [PMID: 32663229 PMCID: PMC7360045 DOI: 10.1371/journal.pone.0235955] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 06/25/2020] [Indexed: 11/18/2022] Open
Abstract
Objectives At any point in time, a person’s lifetime health is the number of healthy life years they are expected to experience during their lifetime. In this article we propose an equity-relevant health metric, Health Adjusted Age at Death (HAAD), that facilitates comparison of lifetime health for individuals at the onset of different medical conditions, and allows for the assessment of which patient groups are worse off. A method for estimating HAAD is presented, and we use this method to rank four conditions in six countries according to several criteria of “worse off” as a proof of concept. Methods For individuals with specific conditions HAAD consists of two components: past health (before disease onset) and future expected health (after disease onset). Four conditions (acute myeloid leukemia (AML), acute lymphoid leukemia (ALL), schizophrenia, and epilepsy) are analysed in six countries (Ethiopia, Haiti, China, Mexico, United States and Japan). Data from 2017 for all countries and for all diseases were obtained from the Global Burden of Disease Study database. In order to assess who are the worse off, we focus on four measures: the proportion of affected individuals who are expected to have HAAD<20 (T20), the 25th and 75th percentiles of HAAD for affected individuals (Q1 and Q3, respectively), and the average HAAD (aHAAD) across all affected individuals. Results Even in settings where aHAAD is similar for two conditions, other measures may vary. One example is AML (aHAAD = 59.3, T20 = 2.0%, Q3-Q1 = 14.8) and ALL (58.4, T20 = 4.6%, Q3-Q1 = 21.8) in the US. Many illnesses, such as epilepsy, are associated with more lifetime health in high-income settings (Q1 in Japan = 59.2) than in low-income settings (Q1 in Ethiopia = 26.3). Conclusion Using HAAD we may estimate the distribution of lifetime health of all individuals in a population, and this distribution can be incorporated as an equity consideration in setting priorities for health interventions.
Collapse
Affiliation(s)
- Kjell Arne Johansson
- Department of Global Public Health and Primary Care, Bergen Centre for Ethics and Priority Setting (BCEPS), University of Bergen, Bergen, Norway
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway
| | - Jan-Magnus Økland
- Department of Global Public Health and Primary Care, Bergen Centre for Ethics and Priority Setting (BCEPS), University of Bergen, Bergen, Norway
| | - Eirin Krüger Skaftun
- Department of Global Public Health and Primary Care, Bergen Centre for Ethics and Priority Setting (BCEPS), University of Bergen, Bergen, Norway
| | - Gene Bukhman
- Program in Global NCDs and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ole Frithjof Norheim
- Department of Global Public Health and Primary Care, Bergen Centre for Ethics and Priority Setting (BCEPS), University of Bergen, Bergen, Norway
- Harvard T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
| | - Matthew M. Coates
- Program in Global NCDs and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Øystein Ariansen Haaland
- Department of Global Public Health and Primary Care, Bergen Centre for Ethics and Priority Setting (BCEPS), University of Bergen, Bergen, Norway
- * E-mail:
| |
Collapse
|
27
|
Rand L, Dunn M, Slade I, Upadhyaya S, Sheehan M. Understanding and using patient experiences as evidence in healthcare priority setting. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2019; 17:20. [PMID: 31572067 PMCID: PMC6757378 DOI: 10.1186/s12962-019-0188-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 09/03/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND In many countries, committees make priority-setting decisions in order to control healthcare costs. These decisions take into account relevant criteria, including clinical effectiveness, cost-effectiveness, and need, and are supported by evidence usually drawn from clinical and economic studies. These sources of evidence do not include the specific perspective and information that patients can provide about the condition and treatment. METHODS Drawing on arguments from political philosophy and ethics that are the ethical basis for many priority-setting bodies, the authors argue that criteria like need and its effects on patients and caregivers are best supported by evidence generated from patients' experiences. Social sciences and mixed-methods research support the generation and collection of robust evidence. RESULTS Patient experience is required for a decision-making process that considers all relevant evidence. For fair priority-setting, decision-makers should consider relevant evidence and reasons, so patient experience evidence should not be ignored. Patient experience must be gathered in a way that generates high quality and methodologically rigorous evidence. Established quantitative and qualitative methods can assure that evidence is systematic, adherent to quality standards, and valid. Patient, like clinical, evidence should be subject to a transparent review process. DISCUSSION Considering all relevant evidence gives each person an equal opportunity at having their treatment funded. Patient experience gives context to the clinical evidence and also directly informs our understanding of the nature of the condition and its effects, including patients' needs, how to meet them, and the burden of illness. Such evidence also serves to contextualise reported effects of the treatment. The requirement to include patient experience as evidence has important policy implications for bodies that make priority-setting decisions since it proposes that new types of evidence reviews are commissioned and considered.
Collapse
Affiliation(s)
- Leah Rand
- Board on Health Sciences Policy, National Academies of Sciences, Engineering, and Medicine, 500 Fifth Street NW, Washington, DC 20009 USA
| | - Michael Dunn
- Ethox Centre, Nuffield Department of Population Health, Big Data Institute, La Ka Shing Centre for Health Information and Discovery, University of Oxford, Old Road Campus, Oxford, OX3 7LF UK
- Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, UK
| | - Ingrid Slade
- Ethox Centre, Nuffield Department of Population Health, Big Data Institute, La Ka Shing Centre for Health Information and Discovery, University of Oxford, Old Road Campus, Oxford, OX3 7LF UK
| | - Sheela Upadhyaya
- Highly Specialised Technology Program, Centre for Health Technology Evaluation, National Institute for Health and Care Excellence, 10 Spring Gardens, London, SW1A 2BU UK
| | - Mark Sheehan
- Ethox Centre, Nuffield Department of Population Health, Big Data Institute, La Ka Shing Centre for Health Information and Discovery, University of Oxford, Old Road Campus, Oxford, OX3 7LF UK
| |
Collapse
|