Trading Bankruptcy for Health: A Discrete-Choice Experiment

Financial Toxicity and Willingness-to-Pay for Cancer Treatment Among People With Multiple Myeloma

PURPOSE

This study used willingness-to-pay (WTP) exercises to explore the relationships between race, financial toxicity, and treatment decision making among people with cancer.

METHODS

A convenience sample of people with multiple myeloma who attended an academic medical center in 2022 was surveyed. Financial toxicity was assessed by the Comprehensive Score for financial Toxicity, with scores <26 indicating financial toxicity. WTP was assessed with (1) a discrete choice experiment (DCE), (2) fixed-choice tasks, and (3) a bidding game.

RESULTS

In total, 156 people were approached, and 130 completed the survey. The majority of the sample was White (n = 99), whereas 24% (n = 31) was African American or Black. Forty-six percent (n = 60) of the sample were experiencing financial toxicity. In the DCE, the relative importance of cost was twice as high for those with financial toxicity (30% compared with 14%; P < .001). In the fixed-choice tasks, they were twice as likely to accept a treatment with shorter progression-free survival but lower costs (adjusted odds ratio [aOR], 2.47; P = .049). In the bidding game, the median monthly WTP of those with financial toxicity was half that of those without ($100 in US dollars [USD] compared with $200 USD; P < .001). Only in the bidding game was race statistically associated with WTP; after controlling for financial toxicity, African American or Black participants were three times as likely (aOR, 3.06; P = .007) to report a lower WTP.

CONCLUSION

Across all three exercises, participants with financial toxicity reported lower WTP than those without. As financial toxicity disproportionally affects some segments of patients, it is possible that financial toxicity contributes to cancer disparities.

Quantifying Value of Hope

BACKGROUND

'Hope' is a construct in patient-centered value frameworks, but few studies have attempted to measure the value of hope separately from treatment-related gains in quality of life and survival to support its application in economic evaluation.

OBJECTIVE

To generate quantitative information on the "value of hope".

METHODS

We designed a discrete-choice experiment in which treatment alternatives varied the probability of achieving 10-year survival, expected survival as the weighted sum of short-term and long-term survival, health status, and out-of-pocket cost. Two-hundred patients with cancer or history of cancer recruited by Cancer Support Community each completed 10 choice questions. We used mixed-logit and latent-class models to analyze the choice data.

RESULTS

Relative to fixed survival periods of two, three or five years with 0% chance of 10-year survival, participants positively valued treatments with 5% and 10% chances of 10-year survival. However, participants negatively valued a 20% chance of 10-year survival that required an offsetting 80% chance of shorter survival. This finding was particularly strong when expected survival was two years. Compared to a 0% chance, dollar-equivalent values of 5% and 10% chances of long-term survival were $5,975 and $12,421, respectively, independent of health status or expected survival. The corresponding value for 20% versus 0% chance of long-term survival was negative. Latent-class analysis revealed 4 groups with distinct preference patterns.

CONCLUSIONS

Our findings affirm positive value for hope independent of expected survival and health status. However, this finding does not universally hold in all situations nor across all groups.

Patients Place More of an Emphasis on Physical Recovery Than Return to Work or Financial Recovery

BACKGROUND

Value-based healthcare models aim to incentivize healthcare providers to offer interventions that address determinants of health. Understanding patient priorities for physical and socioeconomic recovery after injury can help determine which services and resources are most useful to patients.

QUESTIONS/PURPOSES

(1) Do trauma patients consistently identify a specific aspect/domain of recovery as being most important at 6 weeks, 6 months, and 12 months after an injury? (2) Does the relative importance of those domains change within the first year after injury? (3) Are differences in priorities greater between patients than for a given patient over time? (4) Are different recovery priorities associated with identifiable biopsychosocial factors?

METHODS

Between June 2018 and December 2018, 504 adult patients with fractures of the extremities or pelvis were surgically treated at the study site. For this prospective longitudinal study, we purposefully sampled patients from 6 of the 12 orthopaedic attendings' postoperative clinics. The participating surgeons surgically treated 243 adult patients with fractures of the extremities or pelvis. Five percent (11 of 243) of patients met inclusion criteria but missed their appointments during the 6-week recruitment window and could not be consented. We excluded 4% (9 of 243) of patients with a traumatic brain injury, 1% (2) of patients with a spinal cord injury, and 5% (12) of non-English-speaking patients (4% Spanish speaking [10]; 1% other languages [2]). Eighty-six percent of eligible patients (209 of 243) were approached for consent, and 5% (11 of 209) of those patients refused to participate. All remaining 198 patients consented and completed the baseline survey; 83% (164 of 198 patients) completed at least 6 months of follow-up, and 68% (134 of 198 patients) completed the 12-month assessment. The study participants' mean age was 44 ± 17 years, and 63% (125 of 198) were men. The primary outcome was the patient's recovery priorities, assessed at 6 weeks, 6 months, and 12 months after fracture using a discrete choice experiment. Discrete choice experiments are a well-established method for eliciting decisional preferences. In this technique, respondents are presented with a series of hypothetical scenarios, described by a set of plausible attributes or outcomes, and asked to select their preferred scenario. We used hierarchical Bayesian modeling to calculate individual-level estimates of the relative importance of physical recovery, work-related recovery, and disability benefits, based on the discrete choice experiment responses. The hierarchical Bayesian model improves upon more commonly used regression techniques by accounting for the observed response patterns of individual patients and the sequence of scenarios presented in the discrete choice experiment when calculating the model estimates. We computed the coefficient of variation for the three recovery domains and compared the between-patient versus within-patient differences using asymptotic tests. Separate prognostic models were fit for each of the study's three recovery domains to assess marginal changes in the importance of the recovery domain based on patient characteristics and factors that remained constant over the study (such as sex or preinjury work status) and patient characteristics and factors that varied over the study (including current work status or patient-reported health status). We previously published the 6-week results. This paper expands upon the prior publication to evaluate longitudinal changes in patient recovery priorities.

RESULTS

Physical recovery was the respondents' main priority at all three timepoints, representing 60% ± 9% of their overall concern. Work-related recovery and access to disability benefits were of secondary importance and were associated with 27% ± 6% and 13% ± 7% of the patients' concern, respectively. The patients' concern for physical recovery was 6% (95% CrI 4% to 7%) higher at 12 months after fracture that at 6 weeks postfracture. The mean concern for work-related recovery increased by 7% (95% CrI 6% to 8%) from 6 weeks to 6 months after injury. The mean importance of disability benefits increased by 2% (95% CrI 1% to 4%) from 6 weeks to 6 months and remained 2% higher (95% CrI 0% to 3%) at 12 months after the injury. Differences in priorities were greater within a given patient over time than between patients as measured using the coefficient of variation (physical recovery [245% versus 7%; p < 0.001], work-related recovery [678% versus 12%; p < 0.001], and disability benefits [620% versus 33%; p < 0.001]. There was limited evidence that biopsychosocial factors were associated with variation in recovery priorities. Patients' concern for physical recovery was 2% higher for every 10-point increase in their Patient-reported Outcome Measure Information System (PROMIS) physical health status score (95% CrI 1% to 3%). A 10-point increase in the patient's PROMIS mental health status score was associated with a 1% increase in concern for work-related recovery (95% CrI 0% to 2%).

CONCLUSION

Work-related recovery and accessing disability benefits were a secondary concern compared with physical recovery in the 12 months after injury for patients with fractures. However, the importance of work-related recovery was elevated after the subacute phase. Priorities were highly variable within a given patient in the year after injury compared with between-patient differences. Given this variation, orthopaedic surgeons should consider assessing and reassessing the socioeconomic well-being of their patients throughout their continuum of care.

LEVEL OF EVIDENCE

Level II, therapeutic study.

"Sell an Ox" - The Price of Cure for Hepatitis C in Two Countries

Chronic hepatitis C virus (HCV) infection, associated with severe liver disease and cancer, affects 70 million people worldwide. New treatments with direct-acting-antivirals offer cure for about 95% of affected individuals; however, treatment costs may be prohibitive in both the poorest and richest nations. Opting for cure may require sacrificing essential household assets. We highlight the financial dilemmas involved, drawing parallels between Ethiopia and the United States, countries where universal health coverage does not yet exist. The World Health Organization (WHO) declaration for HCV eradication by 2030 will only become reality if universal access to efficacious and affordable treatment is guaranteed for everyone.

Distinguishing moral hazard from access for high-cost healthcare under insurance

CONTEXT

Health policy has long been preoccupied with the problem that health insurance stimulates spending ("moral hazard"). However, much health spending is costly healthcare that uninsured individuals could not otherwise access. Field studies comparing those with more or less insurance cannot disaggregate moral hazard versus access. Moreover, studies of patients consuming routine low-dollar healthcare are not informative for the high-dollar healthcare that drives most of aggregate healthcare spending in the United States.

METHODS

We test indemnities as an alternative theory-driven counterfactual. Such conditional cash transfers would maintain an opportunity cost for patients, unlike standard insurance, but also guarantee access to the care. Since indemnities do not exist in U.S. healthcare, we fielded two blinded vignette-based survey experiments with 3,000 respondents, randomized to eight clinical vignettes and three insurance types. Our replication uses a population that is weighted to national demographics on three dimensions.

FINDINGS

Most or all of the spending due to insurance would occur even under an indemnity. The waste attributable to moral hazard is undetectable.

CONCLUSIONS

For high-cost care, policymakers should be more concerned about the foregone efficient spending for those lacking full insurance, rather than the wasteful spending that occurs with full insurance.

Valuing mortality risk in the time of COVID-19

In evaluating the appropriate response to the COVID-19 pandemic, a key parameter is the rate of substitution between wealth and mortality risk, conventionally summarized as the value per statistical life (VSL). For the United States, VSL is estimated as approximately $10 million, which implies the value of preventing 100,000 COVID-19 deaths is $1 trillion. Is this value too large? There are reasons to think so. First, VSL is a marginal rate of substitution and the potential risk reductions are non-marginal. The standard VSL model implies the rate of substitution of wealth for risk reduction is smaller when the risk reduction is larger, but a closed-form solution calibrated to estimates of the income elasticity of VSL shows the rate of decline is modest until the value of a non-marginal risk reduction accounts for a substantial share of income; average individuals are predicted to be willing to spend more than half their income to reduce one-year mortality risk by 1 in 100. Second, mortality risk is concentrated among the elderly, for whom VSL may be smaller and who would benefit from a persistent risk reduction for a shorter period because of their shorter life expectancy. Third, the pandemic and responses to it have caused substantial losses in income that should decrease VSL. In contrast, VSL is plausibly larger for risks (like COVID-19) that are dreaded, uncertain, catastrophic, and ambiguous. These arguments are evaluated and key issues for improving estimates are highlighted.

Incorporating content related to value and cost-considerations in clinical decision-making: enhancements to medical education

Although incorporating cost-considerations during healthcare decision-making is increasingly important to American patients and physicians, content related to these constructs is not routinely included in medical education. As a result, physicians are ill-equipped to consider costs. This study sought input from practicing physicians on perceived deficiencies in current teaching and recommendations for necessary content to include in medical teaching. We conducted a qualitative descriptive study using semi-structured interviews utilizing a purposeful maximum variation sample of cardiologists and neonatologists practicing in diverse settings. We analyzed interviews using conventional content analysis. 18 cardiologists and 17 neonatologists participated in this study. Respondents perceived that current teaching does not impart sufficient knowledge of value and cost considerations to achieve patient-centered, high-value decision-making. They identified the following priority areas for education related to healthcare costs: the business of medicine and information about out-of-pocket patient costs, training in health research interpretation skills to critically appraise evidence, and communication skills to engage patients as partners in shared decision-making. Participants recommended a variety of teaching methods, including didactic sessions on core topics, role modeling and case studies. American physicians perceive learning needs related to the incorporation of costs into clinical decision-making that can inform curriculum development initiatives in this field. Physicians perceive knowledge of these topics and skills to be crucial to achieving patient-centered high-value care. Concomitant health system reforms supporting the needs of the patient at its center are essential to enable physicians to focus on a patient-centered approach to healthcare delivery.

ISOPT Clinical Hot Topic Panel Discussion on Ocular Drug Delivery

Ocular drug delivery offers unique challenges and opportunities in the era of novel therapeutic agents ranging from small molecules to gene therapies. Noninvasive delivery of drugs into the back of the eye or any part of the eye is extremely limited by short precorneal residence time and formidable biological barriers. The eye is a sensitive, sensory organ that requires a high level of material and procedural safety, while achieving therapeutic efficacy. Some recent advances and unmet needs for ocular drug delivery and disposition are discussed in this article. Specifically, nanomedicines, physical and chemical means to enhance delivery, stimuli-responsive delivery systems, the role of vitreal binding on ocular pharmacokinetics, and the influence of aging eye on drug delivery, and the associated unmet needs are highlighted. Additionally, the unmet needs in the medication management for the elderly patients with eye diseases are discussed.

Latent class analysis of the social determinants of health-seeking behaviour for delivery among pregnant women in Malawi

INTRODUCTION

In the era of Sustainable Development Goals, reducing maternal and neonatal mortality is a priority. With one of the highest maternal mortality ratios in the world, Malawi has a significant opportunity for improvement. One effort to improve maternal outcomes involves increasing access to high-quality health facilities for delivery. This study aimed to determine the role that quality plays in women's choice of delivery facility.

METHODS

A revealed-preference latent class analysis was performed with data from 6625 facility births among women in Malawi from 2013 to 2014. Responses were weighted for national representativeness, and model structure and class number were selected using the Bayesian information criterion.

RESULTS

Two classes of preferences exist for pregnant women in Malawi. Most of the population 65.85% (95% CI 65.847% to 65.853%) prefer closer facilities that do not charge fees. The remaining third (34.15%, 95% CI 34.147% to 34.153%) prefers central hospitals, facilities with higher basic obstetric readiness scores and locations further from home. Women in this class are more likely to be older, literate, educated and wealthier than the majority of women.

CONCLUSION

For only one-third of pregnant Malawian women, structural quality of care, as measured by basic obstetric readiness score, factored into their choice of facility for delivery. Most women instead prioritise closer care and care without fees. Interventions designed to increase access to high-quality care in Malawi will need to take education, distance, fees and facility type into account, as structural quality alone is not predictive of facility type selection in this population.

Health-system-adapted data envelopment analysis for decision-making in universal health coverage

OBJECTIVE

To develop and test a method that allows an objective assessment of the value of any health policy in multiple domains.

METHODS

We developed a method to assist decision-makers with constrained resources and insufficient knowledge about a society's preferences to choose between policies with unequal, and at times opposing, effects on multiple outcomes. Our method extends standard data envelopment analysis to address the realities of health policy, such as multiple and adverse outcomes and a lack of information about the population's preferences over those outcomes. We made four modifications to the standard analysis: (i) treating the policy itself as the object of analysis, (ii) allowing the method to produce a rank-ordering of policies; (iii) allowing any outcome to serve as both an output and input; and (iv) allowing variable return to scale. We tested the method against three previously published analyses of health policies in low-income settings.

RESULTS

When applied to previous analyses, our new method performed better than traditional cost-effectiveness analysis and standard data envelopment analysis. The adapted analysis could identify the most efficient policy interventions from among any set of evaluated policies and was able to provide a rank ordering of all interventions.

CONCLUSION

Health-system-adapted data envelopment analysis allows any quantifiable attribute or determinant of health to be included in a calculation. It is easy to perform and, in the absence of evidence about a society's preferences among multiple policy outcomes, can provide a comprehensive method for health-policy decision-making in the era of sustainable development.