Aversion to health inequalities in healthcare prioritisation: a multicriteria optimisation perspective

Quality- and productivity-adjusted life years: From QALYs to PALYs and beyond

We develop a unified framework for the measurement and valuation of health and productivity. Within this framework, we characterize evaluation functions allowing for compromises between the classical quality-adjusted life years (QALYs) and its polar productivity-adjusted life years (PALYs). Our framework and characterization results provide a new normative basis for the economic evaluation of health care interventions, as well as occupational health and safety policies, aimed to impact both health and productivity of individuals.

Considering equity in priority setting using transmission models: Recommendations and data needs

OBJECTIVES

Disease transmission models are used in impact assessment and economic evaluations of infectious disease prevention and treatment strategies, prominently so in the COVID-19 response. These models rarely consider dimensions of equity relating to the differential health burden between individuals and groups. We describe concepts and approaches which are useful when considering equity in the priority setting process, and outline the technical choices concerning model structure, outputs, and data requirements needed to use transmission models in analyses of health equity.

METHODS

We reviewed the literature on equity concepts and approaches to their application in economic evaluation and undertook a technical consultation on how equity can be incorporated in priority setting for infectious disease control. The technical consultation brought together health economists with an interest in equity-informative economic evaluation, ethicists specialising in public health, mathematical modellers from various disease backgrounds, and representatives of global health funding and technical assistance organisations, to formulate key areas of consensus and recommendations.

RESULTS

We provide a series of recommendations for applying the Reference Case for Economic Evaluation in Global Health to infectious disease interventions, comprising guidance on 1) the specification of equity concepts; 2) choice of evaluation framework; 3) model structure; and 4) data needs. We present available conceptual and analytical choices, for example how correlation between different equity- and disease-relevant strata should be considered dependent on available data, and outline how assumptions and data limitations can be reported transparently by noting key factors for consideration.

CONCLUSIONS

Current developments in economic evaluations in global health provide a wide range of methodologies to incorporate equity into economic evaluations. Those employing infectious disease models need to use these frameworks more in priority setting to accurately represent health inequities. We provide guidance on the technical approaches to support this goal and ultimately, to achieve more equitable health policies.

The Impact of Foreign Trade on Health Inequality in China: Evidence From China Family Panel Studies (CFPS)

Objectives: To assess the health inequality caused by foreign trade in China using individual self-rated health data from China Family Panel Studies (CFPS).

Methods: The GMM model was used to explore the direct and indirect effects of foreign trade on health level, and the concentration index method was then used to decompose the contribution of foreign trade to health inequality.

Results: The direct effect of foreign trade does not contribute to the current health inequality, although the indirect effects of trade contribute to health inequality through inequalities in income and healthcare utilization. The indirect pollution effect of trade does not cause health inequality. Subsequently, the direct effect of trade aggravates the dynamic expansion trend of health inequality, whereas the indirect effects of trade alleviate the increasing trend of health inequality.

Conclusion: Although foreign trade improves the overall health level in China, it contributes to health inequality. Optimizing product structure of trade, adjusting income distribution, and enhancing medical securities for low-income groups are necessary to alleviate the health inequality caused by foreign trade.

Selection of healthcare waste disposal firms using a multi-method approach

The aim of this study is to propose a hybrid multi criteria decision making model with a linear programming (LP) model to tackle the issue of safe disposal of hazardous and infectious healthcare waste. For this, ten criteria in this study have been identified from literature and field surveys which are modelled using Decision making trial and evaluation (DEMATEL) and Analytic network process (ANP) methods to select the best disposal firm i.e. single sourcing for a hospital. We found that Experience of the firm, Technology for disposal, and Waste collection infrastructure acts as the most vital criteria in selecting a healthcare waste disposal firm for single sourcing. Furthermore, to optimize the total value of disposal and mitigating the risk involved in disposing waste through single sourcing; the LP model considering constraints such as waste lose constraint and waste processing constraint etc. Is solved for multiple sourcing using Lingo 18.0. The solution to LP results into allocation of 500, 500, and 1000 (kg/day) disposables to healthcare waste disposal firms D1, D2 and D3, respectively. The multi-method approach proposed in this study helps the hospital management in selecting economically, socially, and environmentally sustainable healthcare waste disposal firm.

Trading off health and financial protection benefits with multiobjective optimization

Countries which are introducing a system of Universal health coverage have to make a number of key tradeoffs, of which one is the tradeoff between the level of coverage and the degree to which patients are exposed to potentially catastrophic financial risk. In this study, we first present a way in which decision makers might be supported to focus on in a particular part of the tradeoff curve and ultimately choose an efficient solution. We then introduce some multiobjective optimization models for generating the tradeoff curves given data about potential treatment numbers, costs, and benefits. Using a dataset from Malawi, we demonstrate the approach and suggest a core index metric to make specific observations on the individual treatments. Moreover, as there has been some debate about the best way to measure financial exposure, we also investigate the extent to sensitivity of our results to the precise technical choice of financial exposure metric. Specifically, we consider two metrics, which are the total number of cases protected from catastrophic expenditure and a convex penalty function that penalizes out-of-pocket expenditures in an increasingly growing way, respectively.

Proposition of a Shared and Value-Oriented Work Structure for Hospital-Based Health Technology Assessment and Enterprise Risk Management Processes

BACKGROUND

Healthcare organizations have invested efforts on hospital-based health technology assessment (HB-HTA) and enterprise risk management (ERM) processes for novel systems to obtain more accurate data on which to base strategic decisions. This study proposes to analyze how HB-HTA and ERM processes can share personal resources and skills to achieve principles with value-oriented results.

METHODS

Literature on ERM and HB-HTA and data from interviews with healthcare managers compose the research data sources, which were submitted to a qualitative data analysis. It was oriented to identify the association between ERM and HB-HTA application in hospitals and the common principles between both processes, in addition to proposing the capability to share personal resources between both teams in a matrix.

RESULTS

The common principles and personal background suggested for HB-HTA and ERM teams allowed the build of a matrix identifying how both teams can work in an integrated manner being more effective and value-oriented. The shared resource matrix reports how each professional (with a specific background) may interact with each activity associated to HB-HTA or ERM implementation guidelines.

CONCLUSIONS

The identification of common principles and capabilities between ERM and HB-HTA suggested advances with the literature from both research areas. The opportunity to share personal resources also contributes to the implementation of those processes in hospitals with less financial resources, approaching its own management to be more efficient with the care chain.

Universal health insurance, health inequality and oral cancer in Taiwan

INTRODUCTION

The introduction of universal health insurance coverage aims to provide equal accessibility and affordability of health care, but whether such a policy eliminates health inequalities has not been conclusively determined. This research aims to examine the healthcare outcomes of oral cancer and determine whether the universal coverage system in Taiwan has reduced health inequality.

METHODS

Linking the databases of the National Cancer Registry with the National Mortality Registry in Taiwan, we stratified patients with oral squamous cell carcinoma by gender and income to estimate the incidence rate, cumulative incidence rate aged from 20 to 79 (CIR20-79), life expectancy, and expected years of life lost (EYLL). The difficulties with asymmetries and short follow-up periods were resolved through applying survival analysis extrapolation methods.

RESULTS

While all people showed a general improvement in life expectancy after the introduction of the NHI, the estimated change in EYLL's of the high-, middle-, and low-income female patients were found to have +0.3, -0.5 and -7 years of EYLL, respectively, indicating a reduction in health inequality. Improvements for the male patients were unremarkable. There was no drop in the CIR20-79 of oral cancer in disadvantaged groups as in those with higher incomes.

CONCLUSIONS

Universal coverage alone may not reduce health inequality across different income groups for oral cancer unless effective preventive measures are implemented for economically disadvantaged regions.

ERM for Health Care Organizations: An Economic Enterprise Risk Management Innovation Program (E2RMhealth care)

BACKGROUND

In recent years, health care organizations have looked to enterprise risk management (ERM) for novel systems to obtain more accurate data on which to base risk strategies.

OBJECTIVE

This study proposes a conceptual ERM framework specifically designed for health care organizations.

METHODS

We explore how hospitals in the United States and Brazil are structuring and implementing ERM processes within their management structure. This study incorporates interviews with 15 chief risk officers (8 from the United States and 7 from Brazil) with qualitative data analysis using NVivo (QSR International software).

RESULTS

The interviews confirm that adopting ERM for health care organizations has gained momentum and become a priority, and that the demand for risk economic assessment orientation is common among health care risk managers.

CONCLUSION

We propose an ERM model for health care (Economic Enterprise Risk Management in Health Care) divided into four maturity levels and complemented by an implementation timeline. The model is accompanied by guidelines to orient the gradual implementation of ERM, including orientation to perform risk economic assessment.

Allocation rules for global donors

In recent years, donors such as the Bill and Melinda Gates Foundation have made an enormous contribution to the reduction of the global burden of disease. It has been argued that such donors should prioritise interventions based on their cost-effectiveness, that is to say, the ratio of costs to benefits. Against this, we argue that the donor should fund not the most cost-effective interventions, but rather interventions which are just cost-ineffective for the country, thus encouraging the country to contribute its own domestic resources to the fight against disease. We demonstrate that our proposed algorithm can be justified within the context of a model of the problem as a leader-follower game, in which a donor chooses to subsidise interventions which are implemented by a country. We argue that the decision rule we propose provides a basis for the allocation of aid money which is efficient, fair and sustainable.

Defining Elements of Value in Health Care-A Health Economics Approach: An ISPOR Special Task Force Report [3]

The third section of our Special Task Force report identifies and defines a series of elements that warrant consideration in value assessments of medical technologies. We aim to broaden the view of what constitutes value in health care and to spur new research on incorporating additional elements of value into cost-effectiveness analysis (CEA). Twelve potential elements of value are considered. Four of them-quality-adjusted life-years, net costs, productivity, and adherence-improving factors-are conventionally included or considered in value assessments. Eight others, which would be more novel in economic assessments, are defined and discussed: reduction in uncertainty, fear of contagion, insurance value, severity of disease, value of hope, real option value, equity, and scientific spillovers. Most of these are theoretically well understood and available for inclusion in value assessments. The two exceptions are equity and scientific spillover effects, which require more theoretical development and consensus. A number of regulatory authorities around the globe have shown interest in some of these novel elements. Augmenting CEA to consider these additional elements would result in a more comprehensive CEA in line with the "impact inventory" of the Second Panel on Cost-Effectiveness in Health and Medicine. Possible approaches for valuation and inclusion of these elements include integrating them as part of a net monetary benefit calculation, including elements as attributes in health state descriptions, or using them as criteria in a multicriteria decision analysis. Further research is needed on how best to measure and include them in decision making.

Constrained Optimization Methods in Health Services Research-An Introduction: Report 1 of the ISPOR Optimization Methods Emerging Good Practices Task Force

Providing health services with the greatest possible value to patients and society given the constraints imposed by patient characteristics, health care system characteristics, budgets, and so forth relies heavily on the design of structures and processes. Such problems are complex and require a rigorous and systematic approach to identify the best solution. Constrained optimization is a set of methods designed to identify efficiently and systematically the best solution (the optimal solution) to a problem characterized by a number of potential solutions in the presence of identified constraints. This report identifies 1) key concepts and the main steps in building an optimization model; 2) the types of problems for which optimal solutions can be determined in real-world health applications; and 3) the appropriate optimization methods for these problems. We first present a simple graphical model based on the treatment of "regular" and "severe" patients, which maximizes the overall health benefit subject to time and budget constraints. We then relate it back to how optimization is relevant in health services research for addressing present day challenges. We also explain how these mathematical optimization methods relate to simulation methods, to standard health economic analysis techniques, and to the emergent fields of analytics and machine learning.

Using Cost-Effectiveness Analysis to Address Health Equity Concerns

This articles serves as a guide to using cost-effectiveness analysis (CEA) to address health equity concerns. We first introduce the "equity impact plane," a tool for considering trade-offs between improving total health-the objective underpinning conventional CEA-and equity objectives, such as reducing social inequality in health or prioritizing the severely ill. Improving total health may clash with reducing social inequality in health, for example, when effective delivery of services to disadvantaged communities requires additional costs. Who gains and who loses from a cost-increasing health program depends on differences among people in terms of health risks, uptake, quality, adherence, capacity to benefit, and-crucially-who bears the opportunity costs of diverting scarce resources from other uses. We describe two main ways of using CEA to address health equity concerns: 1) equity impact analysis, which quantifies the distribution of costs and effects by equity-relevant variables, such as socioeconomic status, location, ethnicity, sex, and severity of illness; and 2) equity trade-off analysis, which quantifies trade-offs between improving total health and other equity objectives. One way to analyze equity trade-offs is to count the cost of fairer but less cost-effective options in terms of health forgone. Another method is to explore how much concern for equity is required to choose fairer but less cost-effective options using equity weights or parameters. We hope this article will help the health technology assessment community navigate the practical options now available for conducting equity-informative CEA that gives policymakers a better understanding of equity impacts and trade-offs.

Decision rules for allocation of finances to health systems strengthening

A key dilemma in global health is how to allocate funds between disease-specific "vertical projects" on the one hand and "horizontal programmes" which aim to strengthen the entire health system on the other. While economic evaluation provides a way of approaching the prioritisation of vertical projects, it provides less guidance on how to prioritise between horizontal and vertical spending. We approach this problem by formulating a mathematical program which captures the complementary benefits of funding both vertical projects and horizontal programmes. We show that our solution to this math program has an appealing intuitive structure. We illustrate our model by computationally solving two specialised versions of this problem, with illustrations based on the problem of allocating funding for infectious diseases in sub-Saharan Africa. We conclude by reflecting on how such a model may be developed in the future and used to guide empirical data collection and theory development.

Multiple Criteria Decision Analysis for Health Care Decision Making--Emerging Good Practices: Report 2 of the ISPOR MCDA Emerging Good Practices Task Force

Health care decisions are complex and involve confronting trade-offs between multiple, often conflicting objectives. Using structured, explicit approaches to decisions involving multiple criteria can improve the quality of decision making. A set of techniques, known under the collective heading, multiple criteria decision analysis (MCDA), are useful for this purpose. In 2014, ISPOR established an Emerging Good Practices Task Force. The task force's first report defined MCDA, provided examples of its use in health care, described the key steps, and provided an overview of the principal methods of MCDA. This second task force report provides emerging good-practice guidance on the implementation of MCDA to support health care decisions. The report includes: a checklist to support the design, implementation and review of an MCDA; guidance to support the implementation of the checklist; the order in which the steps should be implemented; illustrates how to incorporate budget constraints into an MCDA; provides an overview of the skills and resources, including available software, required to implement MCDA; and future research directions.