The value of a statistical life in Sweden: A review of the empirical literature

An Estimation of the Monetary Value of the Person-Sievert Useful for Occupational Radiological Protection within the Healthcare System of Sweden

ABSTRACT

The As Low As Reasonably Achievable (ALARA) principle includes taking into account economic and societal factors. To consider these factors, decision-aiding techniques such as cost-benefit analysis were introduced by the International Commission on Radiological Protection (ICRP) 50 y ago. Over the years, developments in health economics have led to new ways of deriving the concept of a value of a statistical life (VSL), which now is influencing the monetary value assigned to a unit of collective dose for radiological protection purposes (the α value) used in cost-benefit analyses. The aim of the present study was to estimate an α value useful for occupational radiological protection within the healthcare system of Sweden. A survey based on the stated preference approach was developed and sent to staff who are exposed to ionizing radiation at their work in Region Västra Götaland (Sweden). The survey essentially contained two scenarios: the respondents' willingness to pay for measures against radon exposure at home and their willingness to accept compensation for x-ray exposure at work. Answers from 718 respondents were collected. In the sensitivity analysis of the survey, the overall median VSL based on the two scenarios was calculated to be $50 million (IQR $10 to 363 million). The corresponding α value was established to $1,600 person-mSv -1 ($2,100 person-mSv -1 if excess burden of taxes is excluded). The recommended α value is in the high end compared to other studies but within the interval of values being used by nuclear utilities today. The α value should be seen in the light of ICRP's recommendation about stakeholder involvement as an important part of the optimization process.

In-store or online grocery shopping before and during the COVID-19 pandemic

This paper presents results of a unique stated choice (SC) experiment to uncover the determinants of grocery shopping channel choice during the first wave of COVID-19 infections, where the most restrictive containment measures were in place. The choice sets were framed under regular and pandemic conditions, allowing for the estimation of pandemic-specific effects for each of the choice attributes. Our results show a significant overall increase of about 13%-points in online grocery shopping under pandemic conditions. Shopping and delivery costs were found to be the major decision drivers in both experimental settings, while the waiting time in front of the grocery store and risk of infection only played an secondary role. The value of delivery time savings (VDTS) decreases from about 10.8 CHF/day in the regular to 7.4 CHF/day in the pandemic case, indicating that respondents show an increased patience when waiting for the delivery of the ordered groceries. However, choice attributes related to the shopping trip, i.e. travel time and cost, do not show any notable effects. The COVID-19 death risk was valued rather low by the respondents and the relatively unrestricted Swiss containment measures are in line with the respondents' average preferences, as shown by a relatively low value of statistical life (VSL) of about 800,000 CHF.

Estimating deaths averted and cost per life saved by scaling up mRNA COVID-19 vaccination in low-income and lower-middle-income countries in the COVID-19 Omicron variant era: a modelling study

OBJECTIVES

While almost 60% of the world has received at least one dose of COVID-19 vaccine, the global distribution of vaccination has not been equitable. Only 4% of the population of low-income countries (LICs) has received a full primary vaccine series, compared with over 70% of the population of high-income nations.

DESIGN

We used economic and epidemiological models, parameterised with public data on global vaccination and COVID-19 deaths, to estimate the potential benefits of scaling up vaccination programmes in LICs and lower-middle-income countries (LMICs) in 2022 in the context of global spread of the Omicron variant of SARS-CoV2.

SETTING

Low-income and lower-middle-income nations.

MAIN OUTCOME MEASURES

Outcomes were expressed as number of avertable deaths through vaccination, costs of scale-up and cost per death averted. We conducted sensitivity analyses over a wide range of parameter estimates to account for uncertainty around key inputs.

FINDINGS

Globally, universal vaccination in LIC/LMIC with three doses of an mRNA vaccine would result in an estimated 1.5 million COVID-19 deaths averted with a total estimated cost of US$61 billion and an estimated cost-per-COVID-19 death averted of US$40 800 (sensitivity analysis range: US$7400-US$81 500). Lower estimated infection fatality ratios, higher cost-per-dose and lower vaccine effectiveness or uptake lead to higher cost-per-death averted estimates in the analysis.

CONCLUSIONS

Scaling up COVID-19 global vaccination would avert millions of COVID-19 deaths and represents a reasonable investment in the context of the value of a statistical life. Given the magnitude of expected mortality facing LIC/LMIC without vaccination, this effort should be an urgent priority.

Is prevention of suicide worth less? A comparison of the value per statistical life

This paper compares the value per statistical life (VSL) in the context of suicide prevention to that of prevention of traffic fatalities. We conducted a contingent valuation survey with questions on willingness to pay (WTP) in both contexts by administering a web questionnaire to 1038 individuals aged 18 to 80. We conjectured that WTP for a given impact on the number of fatalities would be lower for suicide prevention because suicide, at least to some degree, is the result of individuals' own decisions. However, this hypothesis was not supported by the within- or between-sample estimates of WTP or by responses to direct questions. Hence, no support is provided for the use of a lower valuation of the impact of suicide prevention than for risk-reducing programs in other fields, such as traffic safety. This implies that the same VSL should be used for evaluating suicide prevention interventions and for risk-reducing programs in other policy areas and funds for the prevention of fatalities should be directed to the area with the lowest cost per life saved.

How Much Is a Human Life Worth? A Systematic Review

OBJECTIVES

To systematically review studies eliciting monetary value of a statistical life (VSL) estimates within, and across, different sectors and other contexts; compare the reported estimates; and critically review the elicitation methods used.

METHODS

In June 2019, we searched the following databases to identify methodological and empirical studies: Cochrane Library, Compendex, Embase, Environment Complete, Informit, ProQuest, PubMed, Scopus, and Web of Science. We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines for reporting and a modified Consolidated Health Economic Evaluation Reporting Standards checklist to assess the quality of included studies.

RESULTS

We identified 1455 studies, of which we included 120 in the systematic review. A stated-preference approach was used in 76 articles, with 51%, 41%, and 8% being contingent valuation studies, discrete-choice experiments, or both, respectively. A revealed-preference approach was used in 43 articles, of which 74% were based on compensating-wage differentials. The human capital approach was used in only 1 article. We assessed most publications (87%) as being of high quality. Estimates for VSL varied substantially by context (sector, developed/developing country, socio-economic status, etc), with the median of midpoint purchasing power parity-adjusted estimates of 2019 US$5.7 million ($6.8 million, $8.7 million, and $5.3 million for health, labor market, and transportation safety sectors, respectively).

CONCLUSIONS

The large variation observed in published VSLs depends mainly on the context rather than the method used. We found higher median values for labor markets and developed countries. It is important that health economists and policymakers use context-specific VSL estimates. Methodological innovation and standardization are needed to maximize comparability of VSL estimates within, and across, sectors and methods.

A case study of cost-benefit analysis in occupational radiological protection within the healthcare system of Sweden

The aim of the present study was to demonstrate cases of cost-benefit analysis within healthcare, of how economic factors can be considered in occupational radiological protection, in agreement with the as low as reasonably achievable principle and present Swedish legislations. In the first part of the present study, a comparison of examples within health economics used by authorities and institutes in Sweden was made. The comparison focused on value of a statistical life, quality-adjusted life year, and monetary cost assigned to a unit of collective dose for radiation protection purposes (α-value). By this comparison, an α-value was determined as an interval between $45 and $450 per man-mSv, for the Swedish society in 2021. The α-value interval can be interpreted as following: Less than $45 per man-mSv is a good investment. From $45 to $450 per man-mSv, other factors than costs and collective dose are important to consider. More than $450 per man-mSv is too expensive. In the second part of the present study, seven cases of cost-benefit analyses in occupational radiological protection were provided. The present study focused specifically on cases where the relevant factors were costs and collective dose. The present case study shows a large variation in costs per collective dose from different types of occupational radiological protection, used at Skaraborg Hospital in Sweden.

Operational safety economics: Foundations, current approaches and paths for future research

Due to the COVID-19 pandemic in 2020, the trade-off between economics and epidemic prevention (safety) has become painfully clear worldwide. This situation thus highlights the significance of balancing the economy with safety and health. Safety economics, considering the interdependencies between safety and micro-economics, is ideal for supporting this kind of decision-making. Although economic approaches such as cost-benefit analysis and cost-effectiveness analysis have been used in safety management, little attention has been paid to the fundamental issues and the primary methodologies in safety economics. Therefore, this paper presents a systematic study on safety economics to analyze the foundational issues and explore the possible approaches. Firstly, safety economics is defined as a transdisciplinary and interdisciplinary field of academic research focusing on the interdependencies and coevolution of micro-economies and safety. Then we explore the role of safety economics in safety management and production investment. Furthermore, to make decisions more profitable, economic approaches are summarized and analyzed for decision-making about prevention investments and/or safety strategies. Finally, we discuss some open issues in safety economics and possible pathways to improve this research field, such as security economics, risk perception, and multi-criteria analysis.

Systematic Review to Update 'Value of a Statistical Life' Estimates for Australia

The value of a statistical life (VSL) estimates individuals’ willingness to trade wealth for mortality risk reduction. This economic parameter is often a major component of the quantified benefits estimated in the evaluation of government policies related to health and safety. This study reviewed the literature to update the VSL recommended for Australian policy appraisals. A systematic literature review was conducted to capture Australian primary studies and international review papers reporting VSL estimates published from 2007 to January 2019. International estimates were adjusted for income differences and the median VSL estimate was extracted from each review study. VSL estimates were used to calculate the value of a statistical life year. Of the 18 studies that met the inclusion criteria, two studies were primary Australian studies with a weighted mean VSL of A$7.0 million in 2017 values. The median VSL in the review studies was A$7.3 million. For Australian public policy appraisals, we recommend the consideration of a base case VSL for people of all ages and across all risk contexts of A$7.0 million. Sensitivity analyses could use a high value of A$7.3 million and a low value that reflects the value (A$4.3 million) currently recommended by the Australian government.

Cost Effectiveness of Neonatal Resuscitation at 22 Weeks of Gestation

OBJECTIVE

To evaluate the cost effectiveness of three different approaches to the care of neonates born at 22 weeks of gestation: universal resuscitation, selective resuscitation, or no resuscitation.

METHODS

We constructed a decision-analytic model using TreeAge to compare the outcomes of death and survival with and without neurodevelopmental impairment in a theoretical cohort of 5,176 neonates (an estimate of the annual number of deliveries that occur in the 22nd week of gestation in the United States). We took a societal perspective using a lifetime horizon, and all costs were expressed in 2017 U.S. dollars. Effectiveness was based on combined maternal and neonatal quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio was determined (cost/QALY) for each additional survivor. The willingness to pay threshold was set at $100,000/QALY. All model inputs were derived from the literature. Deterministic and probabilistic sensitivity analyses were performed to interrogate model assumptions.

RESULTS

Universal resuscitation would result in 373 survivors, 123 of whom would have severe disability. Selective resuscitation would produce 78 survivors with 26 affected by severe impairments. No resuscitation would result in only eight survivors and three neonates with severe sequelae. Selective resuscitation was eliminated by extended dominance because this strategy had a higher incremental cost-effectiveness ratio than universal resuscitation, which was a more effective intervention. The incremental cost-effectiveness ratio of universal resuscitation compared with no resuscitation was not cost effective at $106,691/QALY. Monte Carlo simulations demonstrated that universal resuscitation is more effective but also more expensive compared with no resuscitation, with only 35% of simulations below the willingness to pay threshold.

CONCLUSION

In our model, neither selective nor universal resuscitation of 22-week neonates is a cost-effective strategy compared with no resuscitation.

Dread and Risk Elimination Premium for the Value of a Statistical Life

The value of a statistical life (VSL) is a widely used measure for the value of mortality risk reduction. As VSL should reflect preferences and attitudes to risk, there are reasons to believe that it varies depending on the type of risk involved. It has been argued that cancer should be considered a "dread disease," which supports the use of a "cancer premium." The objective of this study is to investigate the existence of a cancer premium (for pancreatic cancer and multiple myeloma) in relation to road traffic accidents, sudden cardiac arrest, and amyotrophic lateral sclerosis (ALS). Data were collected from 500 individuals in the Swedish general population of 50-74-year olds using a web-based questionnaire. Preferences were elicited using the contingent valuation method, and a split-sample design was applied to test scale sensitivity. VSL differs significantly between contexts, being highest for ALS and lowest for road traffic accidents. A premium (92-113%) for cancer was found in relation to road traffic accidents. The premium was higher for cancer with a shorter time from diagnosis to death. A premium was also found for sudden cardiac arrest (73%) and ALS (118%) in relation to road traffic accidents. Eliminating risk was associated with a premium of around 20%. This study provides additional evidence that there exist a dread premium and risk elimination premium. These factors should be considered when searching for an appropriate value for economic evaluation and health technology assessment.

Value of a QALY and VSI estimated with the chained approach

The value of a quality-adjusted life-year (QALY) and the value of a statistical injury (VSI) are important measures within health economics and transport economics. Several studies have, therefore, estimated people's willingness to pay (WTP) for these estimates, but most results show scale insensitivity. The 'original' chained approach (CA) is a method developed to mitigate this problem by combining the contingent valuation (CV) with standard gamble (SG). In contrast to the version of the CA applied by the previous research of the WTP for a QALY, the original version allows the value of major health gains to be estimated without having the respondents express their WTP directly. The objective of this study was to estimate the value of a QALY and VSI in the context of non-fatal road traffic accidents using the original CA to test if the approach, applied to a wide range of health gains, is able to derive valid estimates and a constant value of a QALY which the previous research has not been able to show. Data were collected from a total of 800 individuals in the Swedish adult general population using two web-based questionnaires. The values of a QALY based on trimmed estimates were close to constant at €300,000 irrespective of the size of the QALY gain. The study shows that the original CA method may be a valid method to estimate the value of a QALY and VSI for major health losses. It also supports the use of a higher threshold value for a QALY than that which is currently applied by several health technology assessment agencies in different countries.

How to value safety in economic evaluations in health care? A review of applications in different sectors

Improving (feelings of) safety is an important goal of many health systems, especially in the context of recurrent threats of pandemics, and natural disasters. Measures to improve safety should be cost-effective, raising the issue of how to value safety. This is a complex task due to the intangible nature of safety. We aim to synthesize the current empirical literature on the evaluation of safety to gain insights into current methodological practices. After a thorough literature search in two databases for papers from the fields of life sciences, social sciences, physical sciences and health sciences that empirically measure the value of increasing safety, 33 papers were found and summarized. The focus of the research was to investigate the methodologies used. Attention was also paid to theoretical papers and the methodological issues they present, and the relationship between safety and three categories of covariate results: individual characteristics, individual relationship with risk, and study design. The field of research in which the most papers were found was environmental economics, followed by transportation and health. There appeared to be two main methods for valuating safety: Contingent Valuation and Discrete Choice Experiments, within which there were also differences-for example the use of open or dichotomous choice questions. Overall this paper finds that there still appears to be a long way ahead before consensus can be attained about a standardised methodology for valuating safety. Safety valuation research would benefit from learning from previous experience and the development of more standardised methods.

Measuring the end-of-life premium in cancer using individual ex ante willingness to pay

For the assessment of value of new therapies in healthcare, Health Technology Assessment (HTA) agencies often review the cost per quality-adjusted life-year (QALY) gained. Some HTA agencies accept a higher cost per QALY gained when treatment is aimed at prolonging survival for patients with a short expected remaining lifetime, a so-called end-of-life (EoL) premium. The objective of this study is to elicit the existence and size of an EoL premium in cancer. Data was collected from 509 individuals in the Swedish general population 20-80 years old using a web-based questionnaire. Preferences were elicited using subjective risk estimation and the contingent valuation (CV) method. A split-sample design was applied to test for order bias. The mean value of a QALY was MSEK4.8 (€528,000), and there was an EoL premium of 4-10% at 6 months of expected remaining lifetime. Using subjective risk resulted in more robust and valid estimates of the value of a QALY. Order of scenarios did not have a significant impact on the WTP and the result showed scale sensitivity. Our result provides some support for the use of an EoL premium based on individual preferences when expected remaining lifetime is short and below 24 months. Furthermore, we find support for a value of a QALY that is above the current threshold of several HTA agencies.

Using bayesian model to estimate the cost of traffic injuries in Iran in 2013

Background and Aim:

A significant social and economic burden inflicts by road traffic injuries (RTIs). We aimed to use Bayesian model, to present the precise method, and to estimate the cost of RTIs in Iran in 2013.

Materials and Methods:

In a cross-sectional study on costs resulting from traffic injuries, 846 people per road user were randomly selected and investigated during 3 months (1^st September–1^st December) in 2013. The research questionnaire was prepared based on the standard for willingness to pay (WTP) method considering perceived risks, especially in Iran. Data were collected along with four scenarios for occupants, pedestrians, vehicle drivers, and motorcyclists. Inclusion criterion was having at least high school education and being in the age range of 18–65 years old; risk perception was an important factor to the study and measured by visual tool. Samples who did not have risk perception were excluded from the study. Main outcome measure was cost estimation of traffic injuries using WTP method.

Results:

Mean WTP was 2,612,050 internal rate of return (IRR) among these road users. Statistical value of life was estimated according to 20,408 death cases 402,314,106,073,648 IRR, equivalent to 13,410,470,202$ based on the dollar free market rate of 30,000 IRR (purchase power parity). In sum, injury and death cases came to 1,171,450,232,238,648 IRR equivalents to 39,048,341,074$. Moreover, in 2013, costs of traffic accident constituted 6.46% of gross national income, which was 604,300,000,000$. WTP had a significant relationship with age, middle and high income, daily payment to injury reduction, more payment to time reduction, trip mileage, private cars drivers, bus, minibus vehicles, and occupants (P < 0.01).

Conclusion:

Costs of traffic injuries included noticeable portion of gross national income. If policy-making and resource allocation are made based on the scientific pieces of evidence, an enormous amount of capital can be saved through reducing death and injury rates.

The value of mortality risk reductions. Pure altruism - a confounder?

This paper examines public valuations of mortality risk reductions. We set up a theoretical framework that allows for altruistic preferences, and subsequently test theoretical predictions through the design of a discrete choice experiment. By varying the tax scenario (uniform versus individual tax), the experimental design allows us to verify whether pure altruistic preferences are present and the underlying causes. We find evidence of negative pure altruism. Under a coercive uniform tax system respondents lower their willingness to pay possibly to ensure that they are not forcing others to pay at a level that corresponds to their own - higher - valuations. This hypothesis is supported by the observation that respondents perceive other individuals' valuations to be lower than their own. Our results suggest that public valuations of mortality risk reductions may underestimate the true societal value because respondents are considering other individuals' welfare, and wrongfully perceive other people's valuations to be low.

Cost-effectiveness of tolvaptan for the treatment of hyponatraemia secondary to syndrome of inappropriate antidiuretic hormone secretion in Sweden

BACKGROUND

Tolvaptan is the only vasopressin V2 receptor antagonist licensed by the European Medicines Agency for the treatment of hyponatraemia (HN) secondary to the syndrome of inappropriate antidiuretic hormone secretion (SIADH). We have investigated the cost-effectiveness of tolvaptan versus no active treatment (NAT) in adult patients within the licensed indication who have either failed to respond to fluid restriction or for whom the use of fluid restriction is not suitable, from the societal perspective in Sweden.

METHODS

A cost-utility analysis, considering a 'general SIADH' population and two subpopulations of patients (small-cell lung cancer [SCLC] and pneumonia) to broadly represent the complex clinical pathway of SIADH, was performed. A discrete event simulation was developed to model the progression of individuals through inpatient admissions over a 30-day time horizon (180 days for the SCLC cohort). Clinical data were derived from tolvaptan trials and observational data sources. All costs are given in Swedish kronor (SEK).

RESULTS

In the 'general SIADH' population, tolvaptan was associated with reduced costs (SEK 5,779 per patient [€624]) and increased quality-adjusted life-years (QALYs) (0.0019) compared with NAT and was therefore the dominant treatment strategy. Tolvaptan was also associated with reduced costs and increased QALYs in the SCLC and pneumonia subpopulations. The most influential variables in our analysis were reduction in hospital length of stay, duration of treatment and long term treatment with tolvaptan in SCLC patients.

CONCLUSIONS

Tolvaptan represents a cost-effective treatment option in Sweden for hospitalised patients with HN secondary to SIADH who have either failed to respond to or are unsuitable for fluid restriction.

Reimbursement Decisions for Pharmaceuticals in Sweden: The Impact of Disease Severity and Cost Effectiveness

OBJECTIVE

The Swedish Dental and Pharmaceutical Benefits Agency (TLV) is the government body responsible for deciding whether outpatient drugs are to be included in the pharmaceutical benefits scheme. This paper analyzes the impact of cost effectiveness and severity of disease on reimbursement decisions for new pharmaceuticals.

METHODS

Data has been extracted from all decisions made by the TLV between 2005 and 2011. Cost effectiveness is measured as the cost per quality-adjusted life-year (QALY) gained, whereas disease severity is a binary variable (severe-not severe). In total, the dataset consists of 102 decisions, with 86 approved and 16 declined reimbursements.

RESULTS

The lowest cost per QALY of declined reimbursements is Swedish kronor (SEK) 700,000 (€ 79,100), while the highest cost per QALY of approved reimbursements is SEK1,220,000 (€ 135,600). At a cost per QALY of SEK702,000 Swedish kronor (non-severe diseases) and SEK988,000 (severe diseases), the likelihood of approval is estimated to be 50/50 (€ 79,400 and € 111,700).

CONCLUSIONS

The TLV places substantial weight on both the cost effectiveness and the severity of disease in reimbursement decisions, and the implied willingness to pay for a QALY is higher than the often cited 'rule of thumb' in Swedish policy debates.

Economic evaluation of posaconazole versus fluconazole or itraconazole in the prevention of invasive fungal infection in high-risk neutropenic patients in Sweden

BACKGROUND

In patients undergoing induction chemotherapy for acute myeloid leukemia (AML) or myelodysplastic syndromes (MDS), posaconazole has been proven more effective in the prevention of invasive fungal infection (IFI) than fluconazole or itraconazole (standard azoles) The current analysis seeks to estimate the cost effectiveness of prophylactic posaconazole compared with standard azoles in AML or MDS patients with severe chemotherapy-induced neutropenia in Sweden.

METHODS

A decision-analytic model was used to estimate life expectancy, costs, and quality-adjusted life-years (QALYs). Efficacy data were derived from a phase III clinical trial. Life expectancy and quality of life data were collected from the literature. A modified Delphi method was used to gather expert opinion on resource use for an IFI. Unit costs were captured from hospital and pharmacy pricelists. A probabilistic sensitivity analysis (PSA) was used to investigate the impact of uncertainty in the model parameters on the cost-effectiveness results.

RESULTS

The estimated mean direct cost per patient with posaconazole prophylaxis was 46,893 Swedish kronor (SEK) (€5,387) and SEK50,017 (€5,746) with standard azoles. Prophylaxis with posaconazole resulted in 0.075 QALYs gained compared with standard azoles. At a cost-effectiveness threshold of SEK500,000/QALY the PSA demonstrated a more than 95 % probability that posaconazole is cost effective versus standard azoles for the prevention of IFI in high-risk neutropenic patients in Sweden.

CONCLUSION

Given the assumptions, methods, and data used, posaconazole is expected to be cost effective compared with standard azoles when used as antifungal prophylaxis in AML or MDS patients with chemotherapy-induced prolonged neutropenia in Sweden.

Estimating cost of road traffic injuries in Iran using willingness to pay (WTP) method

We aimed to use the willingness to pay (WTP) method to calculate the cost of traffic injuries in Iran in 2013. We conducted a cross-sectional questionnaire-based study of 846 randomly selected road users. WTP data was collected for four scenarios for vehicle occupants, pedestrians, vehicle drivers, and motorcyclists. Final analysis was carried out using Weibull and maximum likelihood method. Mean WTP was 2,612,050 Iranian rials (IRR). Statistical value of life was estimated according to 20,408 fatalities 402,314,106,073,648 IRR (US$13,410,470,202 based on purchasing power parity at (February 27th, 2014). Injury cost was US$25,637,870,872 (based on 318,802 injured people in 2013, multiple daily traffic volume of 311, and multiple daily payment of 31,030 IRR for 250 working days). The total estimated cost of injury and death cases was 39,048,341,074$. Gross national income of Iran was, US$604,300,000,000 in 2013 and the costs of traffic injuries constituted 6·46% of gross national income. WTP was significantly associated with age, gender, monthly income, daily payment, more payment for time reduction, trip mileage, drivers and occupants from road users. The costs of traffic injuries in Iran in 2013 accounted for 6.64% of gross national income, much higher than the global average. Policymaking and resource allocation to reduce traffic-related death and injury rates have the potential to deliver a huge economic benefit.