The Monetary Value of Informal Care: Obtaining Pure Time Valuations Using a Discrete Choice Experiment

On spillovers in economic evaluations: definition, mapping review and research agenda

An important issue in economic evaluations is determining whether all relevant impacts are considered, given the perspective chosen for the analysis. Acknowledging that patients are not isolated individuals has important implications in this context. Increasingly, the term "spillovers" is used to label consequences of health interventions on others. However, a clear definition of spillovers is lacking, and as a result, the scope of the concept remains unclear. In this study, we aim to clarify the concept of spillovers by proposing a definition applicable in health economic evaluations. To illustrate the implications of this definition, we highlight the diversity of potential spillovers through an expanded impact inventory and conduct a mapping review that outlines the evidence base for the different types of spillovers. In the context of economic evaluations of health interventions, we define spillovers as all impacts from an intervention on all parties or entities other than the users of the intervention under evaluation. This definition encompasses a broader range of potential costs and effects, beyond informal caregivers and family members. The expanded impact inventory enables a systematic approach to identifying broader impacts of health interventions. The mapping review shows that the relevance of different types of spillovers is context-specific. Some spillovers are regularly included in economic evaluations, although not always recognised as such, while others are not. A consistent use of the term "spillovers", improved measurement of these costs and effects, and increased transparency in reporting them are still necessary. To that end, we propose a research agenda.

Putting a Dollar Value on Informal Care Time Provided to People Living With Dementia: A Discrete Choice Experiment

OBJECTIVES

Informal care represents a significant cost driver in dementia but monetizing informal care hours to inform cost-of-illness or economic evaluation studies remains a challenge. This study aimed to use a discrete choice experiment to estimate the value of informal care time provided to people with dementia in Australia accounting for positive and negative impacts of caregiving.

METHODS

Attributes and levels were derived from a literature review, interviews with carers, and advice received from an advisory group. Attributes included 4 positive and negative caregiving experiences, in addition to "hours of care provided" and the "monetary compensation from the government." A D-efficient design was constructed with 2 generic alternatives that represented hypothetical informal caregiving situations. The discrete choice experiment survey was administered online to a representative sample of the Australian general population and a group of informal carers of people with dementia. The willingness to accept estimates were calculated for the 2 samples separately using the mixed logit model in the willingness to pay space.

RESULTS

Based on 700 respondents included in the analysis (n = 488 general public, n = 212 informal carers), the mean willingness to accept for an additional hour of informal care, corrected for the positive and negative impacts of informal care, was $21 (95% CI 18-23) for the general public and $20 (95% CI 16-25) for the informal carers sample.

CONCLUSION

The estimates generated in this study can be used to inform future cost-of-illness studies and economic evaluations, ensuring that informal care time is considered in future policy and funding decisions.

Informal care at old age at home and in nursing homes: determinants and economic value

This paper provides a comprehensive analysis of informal care receipt by the French individuals aged 60 or older. The literature has focused on the community, leaving informal care in residential care settings in the shadow. We leverage data from a representative survey (CARE) conducted in 2015-2016 on both community-dwelling individuals and nursing home residents. Focusing on the 60+ with activity restrictions, we show that 76% of nursing home residents receive help with the activities of daily living from relatives, against 55% in the community. The number of hours conditional on receipt is yet 3.5 times higher in the community. Informal care represents 186 million hours per month and a value equivalent to 1.1% of GDP at least, care in the community representing 95% of the total. We investigate the determinants of informal care receipt. Using an Oaxaca-type approach, we disentangle between two mechanisms explaining that nursing home residents are more likely to receive informal care, namely the differences in population composition (endowments) and the differences in the association of individual characteristics with informal care (coefficients). Both are found to have a similar contribution. Our results imply that private costs make up for the majority (76%) of the costs associated with long-term care provision once informal care is taken into account. They also highlight that informal care is extremely common for nursing home residents. Existing evidence on the determinants of informal care receipt in the community has, however, limited relevance to understand informal care behaviors in nursing homes.

Research trends in contemporary health economics: a scientometric analysis on collective content of specialty journals

INTRODUCTION

Health economics is a thriving sub-discipline of economics. Applied health economics research is considered essential in the health care sector and is used extensively by public policy makers. For scholars, it is important to understand the history and status of health economics-when it emerged, the rate of research output, trending topics, and its temporal evolution-to ensure clarity and direction when formulating research questions.

METHODS

Nearly 13,000 articles were analysed, which were found in the collective publications of the ten most specialised health economic journals. We explored this literature using patterns of term co-occurrence and document co-citation.

RESULTS

The research output in this field is growing exponentially. Five main research divisions were identified: (i) macroeconomic evaluation, (ii) microeconomic evaluation, (iii) measurement and valuation of outcomes, (iv) monitoring mechanisms (evaluation), and (v) guidance and appraisal. Document co-citation analysis revealed eighteen major research streams and identified variation in the magnitude of activities in each of the streams. A recent emergence of research activities in health economics was seen in the Medicaid Expansion stream. Established research streams that continue to show high levels of activity include Child Health, Health-related Quality of Life (HRQoL) and Cost-effectiveness. Conversely, Patient Preference, Health Care Expenditure and Economic Evaluation are now past their peak of activity in specialised health economic journals. Analysis also identified several streams that emerged in the past but are no longer active.

CONCLUSIONS

Health economics is a growing field, yet there is minimal evidence of creation of new research trends. Over the past 10 years, the average rate of annual increase in internationally collaborated publications is almost double that of domestic collaborations (8.4% vs 4.9%), but most of the top scholarly collaborations remain between six countries only.

Informal caregiving and the allocation of time: implications for opportunity costs and measurement

Informal care requires a considerable time investment from providers that inherently involves trade-offs against various uses of time. We examine what other uses of time are forgone when individuals provide informal care. We further consider how caregiving is linked to a range of rarely explored time use characteristics relating to multitasking, the fragmentation and the timing of activities. We use data from 5670 adults across 11003 diary days from the 2014/15 UK Time Use Survey. Using a 'doubly robust' approach of entropy balancing and regression adjustment, we find carers spend an additional 49.0 min on non-market work, 2.9 min on personal care, 5.8 min on leisure and 2.9 min on miscellaneous activities on weekdays. They spend 46.1 min less on market work and 14.4 min less on sleep. Carers report more time stress, more multitasking, and more fragmented time. We estimate with attribution factors that 16% and 11% of reported household task activity is due to caregiving on weekday and weekend days, respectively. These findings provide evidence on additional opportunity costs faced by carers and possible channels through which carer labour market and health outcomes are realised. The attribution factors we calculate can be applied to total reported caregiving time to avoid overestimation when this is incorporated into economic evaluations.

The concept of informal care: ambiguities and controversies on its scientific and political uses

Starting from an analysis of the scientific and political uses of the concept of informal care, this paper raises questions and launches the debate on the causes and effects of its uses. Recognizing the diversity and the contradictions found across the use of the term, it explains how its predominant use in Europe can be problematic. First, although it is widely recognized that care is provided primarily by women, this gender dimension is not emphasized in a concept that obscures the sexual division. Second, it does not render explicit that informal care is work, despite being unpaid. Third, the allusion to informality is likely to generate confusion with informal employment of care workers. Finally, studies often focus exclusively on care provided by family members, without distinguishing the spaces in which the work takes place and the social relationships it involves, namely the family or community. In Europe, where documents from (non)governmental organizations focus mainly on long-term care related to demographic aging, it is the care crisis of formal care provision systems, faced with financial fragility, reduction in funds and insufficient supply to meet the demand, that brings informal care to the political and scientific agendas. This paper argues that it is necessary to define conceptual boundaries that allow international studies on the dimension and value of this care work to be compared. It also advocates the importance of making visible that this is work, unpaid and female-dominated, since this view supports action guidelines more focused on social transformation and empowerment.

A review of caregiver costs included in cost-of-illness studies

INTRODUCTION

Economic evaluations typically focus solely on patient-specific costs with economic spillovers to informal caregivers less frequently evaluated. This may systematically underestimate the burden resulting from disease.

AREAS COVERED

Cost-of-illness (COI) analyses that identified costs borne to caregiver(s) were identified using PubMed and Embase. We extracted study characteristics, clinical condition, costs, and cost methods. To compare caregiver costs reported across studies, estimated a single 'annual caregiver cost' amount in 2021 USD.

EXPERT OPINION

A total of 51 studies met our search criteria for inclusion with estimates ranging from $30 - $86,543. The majority (63%, 32/51) of studies estimated caregiver time costs with fewer studies reporting productivity or other types of costs. Caregiver costs were frequently reported descriptively (69%, 35/51), with fewer studies reporting more rigorous methods of estimating costs. Only 27% (14/51) of studies included used an incremental analysis approach for caregiver costs. In a subgroup analysis of dementia-focused studies (n = 16), we found the average annual cost of caregiving time for patients with dementia was $30,562, ranging from $4,914 to $86,543. We identified a wide range in annual caregiver cost estimates, even when limiting by condition and cost type.

Valuation of Informal Care Provided to People Living With Dementia: A Systematic Literature Review

OBJECTIVES

This study aimed to identify the methods used to determine the value of informal care provided to people living with dementia and to estimate the average hourly unit cost by valuation method.

METHODS

A literature search in MEDLINE Complete, CINAHL, PsycINFO, EconLit, EMBASE and NHS Economic Evaluation Database was undertaken. Following the screening of title, abstract, and full text, characteristics of eligible studies were extracted systematically and analyzed descriptively. The corresponding hourly cost estimates were converted into 2018 US dollars based on purchasing power parities for gross domestic product.

RESULTS

A total number of 111 articles were included in this review from 3106 post-deduplication records. Three main valuation methodologies were identified: the replacement cost method (n = 50), the opportunity cost approach (n = 36), and the stated preference method based on willingness to pay (n = 3), with 16 studies using multiple methods and 6 studies not specifying the valuation method. The amount of informal care increased as the condition of dementia progressed, which was reflected in the cost of informal care. The average hourly unit cost used to value informal care was US $16.78 (SD = US $12.11). Although the unit cost was approximately US $15 per hour when using the opportunity cost method and US $14 when using the stated preference method, the highest unit cost was obtained when using the replacement cost method (US $18.37, SD = US $13.12).

CONCLUSIONS

Although costs of informal care should be considered when undertaking an economic evaluation or estimating the overall costs of dementia from a policy and priority-setting perspective, further research into applying consistent approaches to valuation is warranted.

The Challenges of Measuring Informal Care Time: A Review of the Literature

Economic evaluations increasingly include the value of informal care, for example, in terms of caregiver health effects or time costs. If an economic evaluation uses caregiving time costs, appropriate measurement of caregiving time is an important first step prior to its valuation. There is no comprehensive overview of the measurement challenges for caregiving time. In this literature review, we searched Medline, Embase, Econlit and Scopus to identify measurement issues and associated studies which reported informal care time that addressed them. The search identified 27 studies that addressed nine measurement issues. There is limited evidence on how to address these issues, although some have received relatively more attention, including incremental time (considered in 16 studies), time measurement method comparisons (six studies) and the inclusion of intangible tasks (four studies). Non-response (considered in only one study) and carer and recipient identification (two studies) were the most wide-reaching measurement concerns, as these determine who is identified as carers. There was no evidence on the consequences of these measurement challenges in terms of impacts on cost-effectiveness ratios and on the total cost of health conditions, which would be a crucial next step. Future research on these issues should consider a range of different settings, as informal care is highly heterogeneous. The measurement of informal care is key for its inclusion in economic evaluations but there is little consensus on how to appropriately measure this type of care.

Measuring Financial Burden in Families of Children Living With Life-Limiting Conditions: A Scoping Review of Cost Indicators and Outcome Measures

OBJECTIVES

This study aimed to provide a comprehensive overview of cost indicators and outcome measures used to measure financial burden in families of children with life-limiting conditions.

METHODS

A scoping review methodology was used to map the existing literature and provide an overview of available cost indicators and outcome measures. Key medical, economic, and scientific databases were systematically searched to identify relevant articles published in 2000 or later.

RESULTS

The database search yielded 7194 records, including 30 articles eligible for final inclusion. Retrieved cost indicators and outcome measures fell into 3 broad categories: direct costs, indirect costs, and financial support. No study comprehensively assessed all 3 categories. Cost indicators used to measure direct costs were grouped into 5 medical and 11 nonmedical out-of-pocket expenses categories, of which 5 were commonly assessed (ie, treatment and diagnostics, travel and transport, accommodation, food, childcare and home help). Half of the reviewed studies included assessments of indirect costs, most commonly estimating work-related income loss by evaluating employment disruptions. Assessments of opportunity costs arising from informal caregiving and of financial support were rarely included.

CONCLUSIONS

Current estimates of the financial burden faced by families of children with life-limiting conditions are inconsistent and often incomplete, likely resulting in severe underestimations of the costs these families incur. We hope that the framework presented in this article will contribute to a more comprehensive assessment of illness-related financial burden and help guide future policies in this area.

Economic evaluation of nurse-led stroke aftercare addressing long-term psychosocial outcome: a comparison to care-as-usual

OBJECTIVE

To examine the cost-effectiveness of nurse-led stroke aftercare addressing psychosocial outcome at 6 months post stroke, compared with care-as-usual.

DESIGN

Economic evaluation within a comparative effectiveness research design.

SETTING

Primary care (2016-2017) and community settings (2011-2013) in the Netherlands.

PARTICIPANTS

Persons who suffered from ischaemic or haemorrhagic stroke, or a transient ischaemic attack and were discharged home after visiting the emergency department, hospitalisation or inpatient rehabilitation.

INTERVENTIONS

Nurse-led stroke aftercare at 6 months post stroke addressing psychosocial functioning by providing screening, psycho-education, emotional support and referral to specialist care when needed. Care-as-usual concerned routine follow-up care including secondary prevention programmes and a consultation with the neurologist at 6 weeks post stroke.

PRIMARY AND SECONDARY OUTCOME MEASURES

Main outcome measure of cost-effectiveness was quality-adjusted life years (QALYs) estimated by the quality of life measured by the five-dimensional, three-level EuroQol. Costs were assessed using a cost-questionnaire. Secondary outcomes were mood (Hospital Anxiety and Depression Scale) and social participation (Utrecht Scale for Evaluation of Rehabilitation-Participation) restrictions subscale.

RESULTS

Health outcomes were significantly better in stroke aftercare for QALYs (Δ=0.05; 95% CI 0.01 to 0.09) and social participation (Δ=4.91; 95% CI 1.89 to 7.93) compared with care-as-usual. Total societal costs were €1208 higher in stroke aftercare than in care-as-usual (95% CI -€3881 to €6057). Healthcare costs were in total €1208 higher in stroke aftercare than in care-as-usual (95% CI -€3881 to €6057). Average costs of stroke aftercare were €91 (SD=€3.20) per person. Base case cost-effectiveness analyses showed an incremental cost-effectiveness ratio of €24 679 per QALY gained. Probability of stroke aftercare being cost-effective was 64% on a €50 000 willingness-to-pay level.

CONCLUSIONS

Nurse-led stroke aftercare addressing psychosocial functioning showed to be a low-cost intervention and is likely to be a cost-effective addition to care-as-usual. It plays an important role by screening and addressing psychosocial problem, not covered by usual care.

What's the Cost? Measuring the Economic Impact of Pediatric Sepsis

Sepsis, life-threatening organ dysfunction secondary to infection, hospitalizes nearly 75,000 children each year in the United States. Most children survive sepsis. However, there is increasing recognition of the longer-term consequences of pediatric sepsis hospitalization on both the child and their family, including medical, psychosocial, and financial impacts. Here, we describe family spillover effects (the impact of illness on caregivers) of pediatric sepsis, why measurement of family spillover effects is important, and the ways in which family spillover effects can be measured.

Use of Productivity Loss/Gain in Cost-Effectiveness Analyses for Drugs: A Systematic Review

BACKGROUND

Inclusion of productivity losses and gains in cost-effectiveness analyses for drugs is recommended by pharmacoeconomic guidelines in some countries and is considered optional in others. Often guidelines recommend analysis based on the payer perspective, but suggest that a supplemental analysis based on the societal perspective may be submitted that includes productivity losses/gains. However, there is no universally recognized framework for the approach to including productivity losses and gains in pharmacoeconomic analyses.

OBJECTIVES

This study aimed to systematically review literature on cost-effectiveness analyses of drug interventions that included costs associated with productivity losses/gains and to summarize the types cost elements included and cost calculation methods employed. Moreover, this study examines variations in the calculation of productivity losses/gains by target disease type, geographic region, income group, period of analysis, and analysis time horizon-as well as the impact of their inclusion on the study outcomes.

METHODS

A search of three databases was performed, including MEDLINE, Embase, and the Cochrane Library, to identify cost-effectiveness and cost-utility analyses that included indirect costs such as productivity losses/gains. Publications from January 2010 to October 2019 were examined and selected for inclusion by two independent reviewers. In addition to the citation details, data on the country of analysis, country income group, target disease area, study sponsorship, type of analysis, study design, time horizon, analysis perspective, productivity loss/gain elements included, the approach used to estimate productivity losses/gains, and the impact of their inclusion on the study outcome-namely the incremental cost effectiveness ratio-were extracted and summarized.

RESULTS

The search strategy identified 5038 unique studies, and 208 were included in the final analysis. Among the studies reviewed, 165 (79%) were conducted in high-income countries and 160 (77%) were conducted for North American and European/Central Asian countries. The productivity loss/gain elements included in the analysis were reported for 169 studies (81%). Absenteeism only was included for 98 studies (47%), and absenteeism plus presenteeism was included for 29 studies (14%). Absenteeism plus some other element such as costs associated with unemployment and/or early retirement was included for 32 studies (15%) examined. Only one out of four of the studies reviewed included information on the approach used to estimate productivity losses/gains, which was predominantly the human capital approach. One-hundred forty-four studies (69%) reported the impact of including productivity losses/gains on the ICER, with 110 studies (53%) reporting that their inclusion contributed to more favorable cost-effectiveness.

CONCLUSIONS

Although inclusion of productivity losses/gains was shown to have a favorable impact on evaluations for many studies, their impact and method of calculation was often not reported or was unclear. Further examination and discussion is needed to consider the optimal framework for considering productivity losses/gains in cost-effectiveness analyses, including the appropriate cost elements to include (e.g., patient absenteeism, caregiver absenteeism, presenteeism, unemployment, etc.) and how those costs should be estimated.

Head-to-Head Comparison of the Psychometric Properties of 3 Carer-Related Preference-Based Instruments

OBJECTIVES

To compare the psychometric properties of the Adult Social Care Outcomes Toolkit for carers (ASCOT-Carer), the Carer Experience Scale (CES), and the Care-related Quality of Life (CarerQol) to inform the choice of instrument in future studies.

METHODS

Data were derived from a 2018 online survey of informal carers in Australia. Reliability was assessed via internal consistency (Cronbach alpha, α) and test-retest reliability (intraclass correlation coefficient, ICC) for respondents who self-reported no change in their quality of life as a carer over 2 weeks. Convergent validity was evaluated via predetermined hypotheses about associations (Spearman's rank correlation) with existing, validated measures. Discriminative validity was assessed based on the ability of the carer-related scores to distinguish between different informal care situations (Mann-Whitney U, Kruskal-Wallis one-way analysis of variance).

RESULTS

Data from 500 carers were analyzed. The ASCOT-Carer demonstrated a higher degree of internal consistency, possibly due to a unidimensional structure, and test-retest reliability than the CarerQol and CES (α = 0.87, 0.65, 0.59; ICC, 0.87, 0.67, 0.81, respectively). All 3 instruments exhibited convergent validity and detected statistically significant associations between carer-related scores and different informal care situations, except for the CarerQol-7D and sole carer status.

CONCLUSIONS

The ASCOT-Carer, CarerQol, and CES performed reasonably well psychometrically; the ASCOT-Carer exhibited the best psychometric properties overall in this sample of Australian informal carers. Findings should be used in conjunction with consideration of research goals, carer population, targeted carer-related constructs, and prevailing perspectives on the economic evaluation to inform choice of instrument in future studies.

Cost-Utility Analyses of Interventions for Informal Carers: A Systematic and Critical Review

BACKGROUND

Demographic and epidemiological changes place an increasing reliance on informal carers. Some support programmes exist, but funding is often limited. There is a need for economic evaluation of interventions for carers to assist policymakers in prioritizing carer support.

OBJECTIVE

Our aim was to systematically review and critically appraise cost-utility analyses of interventions for informal carers, in order to assess the methods employed and the quality of the reporting.

METHODS

A systematic review of databases was conducted using MEDLINE, Embase, PsycINFO, and EconLit of items published between 1950 and February 2019. Published studies were selected if they involved a cost-utility analysis of an intervention mainly or jointly targeting informal carers. The reporting quality of economic analyses was evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement.

RESULTS

An initial set of 1364 potentially relevant studies was identified. The titles and the abstracts were then screened, resulting in the identification of 62 full-text articles that warranted further assessment of their eligibility. Of these, 20 economic evaluations of informal carer interventions met the inclusion criteria. The main geographical area was the UK (n = 11). These studies were conducted in mental and/or behavioural (n = 15), cardiovascular (n = 3) or cancer (n = 2) clinical fields. These cost-utility analyses were based on randomized clinical trials (n = 16) and on observational studies (n = 4), of which only one presented a Markov model-based economic evaluation. Four of the six psychological interventions were deemed to be cost effective versus two of the four education/support interventions, and four of the nine training/support interventions. Two articles achieved a CHEERS score of 100% and nine of the economic evaluations achieved a score of 85% in terms of the CHEERS criteria for high-quality economic studies.

CONCLUSIONS

Our critical review highlights the lack of cost-utility analyses of interventions to support informal carers. However, it also shows the relative prominence of good reporting practices in these analyses that other studies might be able to build on.

Development of a casemix classification to predict costs of home care in the Netherlands: a study protocol

INTRODUCTION

Compared with fee-for-service systems, prospective payment based on casemix classification is thought to promote more efficient, needs-based care provision. We aim to develop a casemix classification to predict the costs of home care in the Netherlands.

METHODS AND ANALYSIS

The research is designed as a multicentre, cross-sectional cohort study using quantitative methods to identify the relative cost predictors of home care and combine these into a casemix classification, based on individual episodes of care. The dependent variable in the analyses is the cost of home care utilisation, which is operationalised through various measures of formal and informal care, weighted by the relative wage rates of staff categories. As independent variables, we will use data from a recently developed Casemix Short-Form questionnaire, combined with client information from participating home care providers' (nursing) classification systems and data on demographics and care category (ie, a classification mandated by health insurers). Cost predictors are identified using random forest variable importance measures, and then used to build regression tree models. The casemix classification will consist of the leaves of the (pruned) regression tree. Internal validation is addressed by using cross-validation at various stages of the modelling pathways. The Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis statement was used to prepare this study protocol.

ETHICS AND DISSEMINATION

The study was classified by an accredited Medical Research Ethics Committee as not subject to the Dutch Medical Research Involving Human Subjects Act. Findings are expected in 2020 and will serve as input for the development of a new payment system for home care in the Netherlands, to be implemented at the discretion of the Dutch Ministry of Health, Welfare and Sports. The results will also be published in peer-reviewed publications and policy briefs, and presented at (inter)national conferences.

Societal costs of informal care of community-dwelling frail elderly people

Aims: The aims of this study are to describe informal care activities and to estimate the societal cost of informal care of community-dwelling frail elderly people in Sweden. Methods: This study was performed within the frame of the TREEE project that included 408 frail elderly patients. At index hospitalisation (baseline), primary informal caregivers of the patients were provided with a questionnaire on informal care during a period of three months. Questions concerning other (secondary) informal caregivers were also included. A rough estimate of the total cost of informal care of frail elderly people in Sweden was obtained by combining data from this study with published data and official statistics. Results: In total, 176 informal caregivers responded, and 89% had provided informal care. The informal caregivers (primary and secondary) provided care for an average of 245 hours over three months. Taking care of the home was the dominating activity. In total, the mean cost of informal care was estimated to approximately 18,000 SEK (€1878) over three months, corresponding to an annual cost of approximately 72,000 SEK (€7477) per frail elderly person. The total annual societal costs of informal care of community dwelling frail elderly people aged 75 years and older in Sweden was estimated to be approximately 11,000 million SEK (€1150 million). Conclusions: The care of frail elderly people provided by informal caregivers is extensive and represents a great economic value. Although our calculations are associated with uncertainty, the size indicates that supporting informal caregivers should be a priority for society.

Quantifying Family Spillover Effects in Economic Evaluations: Measurement and Valuation of Informal Care Time

Spillover effects on the welfare of family members may refer to caregiver health effects, informal care time costs, or both. This review focuses on methods that have been used to measure and value informal care time and makes suggestions for their appropriate use in cost-of-illness and cost-effectiveness analyses. It highlights the importance of methods to value informal care time that are independent of caregiver health effects in order to minimize double counting of spillover effects. Although the concept of including caregiver time costs in economic evaluations is not new, relatively few societal perspective cost-effectiveness analyses have included informal care, with the exception of dementia. This is due in part to challenges in measuring and valuing time costs. Analysts can collect information on time spent in informal care or can assess its impact in displacing other time use, notably time in paid employment. A key challenge is to ensure appropriate comparison groups that do not require informal care to be able to correctly estimate attributable informal care time or foregone market work. To value informal care time, analysts can use estimates of hourly earnings in either opportunity cost or replacement cost approaches. Researchers have used widely varying estimates of hourly earnings. Alternatively, stated-preference methods (i.e. contingent valuation, conjoint analysis) can be used to value the effect of informal care on utility, but this can entail double counting with health effects. Lack of consensus and standardization of methods makes it difficult to compare estimates of informal care costs.