A Systematic Review of Demand-Side Methods of Estimating the Societal Monetary Value of Health Gain

A methodological guide for implementing and interpreting results of probabilistic analysis

INTRODUCTION

Probabilistic analysis, also referred to as probabilistic sensitivity analysis (PSA), is used extensively in cost-effectiveness evaluations of health technologies. We present methodological guidance for implementing probabilistic analysis and interpreting its results for policy and decision-making.

METHODS

We review the methodological issues related to common practices in probabilistic analysis, explore aspects that are currently not widely addressed in the health economics literature, and provide an overview of recent methodological developments.

RESULTS

We use examples to highlight the advantages and disadvantages of common tools used for presenting probabilistic analysis results, including the cost-effectiveness acceptability curve (CEAC), cost-effectiveness acceptability frontier (CEAF), and value of information (VOI) analysis. We raise and address issues related to using Monte Carlo standard error to determine the number of iterations required, the implications of large uncertainty, and the credibility and meaningfulness of small differences in quality-adjusted life-years (QALYs). We then discuss evolving methods in probabilistic analysis, cautious uses of probabilistic analysis, and factors impacting parameter uncertainty.

CONCLUSIONS

A deeper understanding of probabilistic analysis methods enables health economists and decision-makers to more effectively address and interpret parameter uncertainty in health economic evaluations, which is essential for making informed policy decisions.

Monetary valuation of one year in full capability and health based on demographics, health status, income and well-being

BACKGROUND

Budget constraints in health-care systems have led to the popularity of Cost Effectiveness Thresholds (CET) to achieve efficient allocation of resources. The capability approach has been hailed for its potentially richer evaluative capabilities compared to the QALY in terms of thresholds. Extensive research, however, is still limited.

RESEARCH DESIGN AND METHODS

This study estimated the monetary value of a year in full capability (YFC) and compared it to monetary value of a QALY for the Hungarian population. Data was collected from a large, cross sectional, representative online survey on the adult Hungarian population. Applying the wellbeing valuation method, health, capability, and income were then regressed against wellbeing to estimate 'shadow prices' for one QALY and YFC controlling for gender, age, employment, education, marital and social support. To examine 'core' regression coefficients, a robustness check was conducted.

RESULTS

Health (VAS) and capability (ICECAP-A) had a positive and significant effect on Subjective Well-Being. The monetary values of one QALY and one YFC were 39 459 EUR and 58 148 EUR respectively.

CONCLUSIONS

These tools provide a systematic approach to determining 'compensating income' for certain illnesses, disabilities and levels of pain. The capability approach shown to be broader than the QALY.

Population normative data for OxCAP-MH capability scores

AIM

The study aims to establish the first set of normative data for OxCAP-MH capability instrument and to examine its association with sociodemographic and anxiety/depression severity variables.

METHODS

A large-sample cross-sectional online survey was conducted among the Hungarian adult general population in 2021. OxCAP-MH standardized mean scores were compared across age, sex, education level, residence, employment, and marital status. Linear regression analysis was employed to determine the impact of sociodemographic and anxiety/depression severity on the OxCAP-MH score.

RESULTS

In total, N = 2000 individuals completed the survey. The sample mean age was 47.1, with female majority (53.4%). Most respondents had completed primary education (51%), were active on labour market (52.4%), lived in larger cities (70.0%), and were married/in relationship (61.1%). Nearly half of the participants reported experiencing depression (48.5%), anxiety (44.3%), and 38.6% reported having both. The mean OxCAP-MH score for the total sample was 67.2 (SD = 14.4), the highest in the non-depressed (74.4) and non-anxious (73.6) subgroups, the lowest among those with extremely severe depression (45.0) and severe anxiety (47.7). Regression results indicated that older individuals (by β = 0.1), males (β = 2.3), those with secondary or higher education (β = 2.7 and 4.5) and students (β = 6.8) had significantly (p<0.01) higher mental capabilities. Respondents with mild, moderate, severe, or extremely severe depression (β =  -6.6, -9.6, -13.8, -18.3) and those with mild, moderate, or severe anxiety (β =  -4.1, -7.7, -10.3) had lower capability scores.

CONCLUSION

The OxCAP-MH instrument effectively differentiated capabilities across sociodemographic groups and highlighting the impact of depression and anxiety severity on general population's mental capability.

A systematic review on the direct approach to elicit the demand-side cost-effectiveness threshold: Implications for low- and middle-income countries

Several literature review studies have been conducted on cost-effectiveness threshold values. However, only a few are systematic literature reviews, and most did not investigate the different methods, especially in-depth reviews of directly eliciting WTP per QALY. Our study aimed to 1) describe the different direct approach methods to elicit WTP/QALY; 2) investigate factors that contribute the most to the level of WTP/QALY value; and 3) investigate the relation between the value of WTP/QALY and GDP per capita and give some recommendations on feasible methods for eliciting WTP/QALY in low- and middle-income countries (LMICs). A systematic review concerning select studies estimating WTP/QALY from a direct approach was carried out in seven databases, with a cut off date of 03/2022. The conversion of monetary values into 2021 international dollars (i$) was performed via CPI and PPP indexes. The influential factors were evaluated with Bayesian model averaging. Criteria for recommendation for feasible methods in LMICs are made based on empirical evidence from the systematic review and given the resource limitation in LMICs. A total of 12,196 records were identified; 64 articles were included for full-text review. The WTP/QALY method and values varied widely across countries with a median WTP/QALY value of i$16,647.6 and WTP/QALY per GDP per capita of 0.53. A total of 11 factors were most influential, in which the discrete-choice experiment method had a posterior probability of 100%. Methods for deriving WTP/QALY vary largely across studies. Eleven influential factors contribute most to the level of values of WTP/QALY, in which the discrete-choice experiment method was the greatest affected. We also found that in most countries, values for WTP/QALY were below 1 x GDP per capita. Some important principles are addressed related to what LMICs may be concerned with when conducting studies to estimate WTP/QALY.

Systematic review of the impact of health care expenditure on health outcome measures: implications for cost-effectiveness thresholds

OBJECTIVE

Empirical estimates of the impact of healthcare expenditure on health outcome measures may inform the cost-effectiveness threshold (CET) for guiding funding decisions. This study aims to systematically review studies that estimated this, summarize and compare the estimates by country income level.

METHODS

We searched PubMed, Scopus, York Research database, and [anonymized] for Reviews and Dissemination database from inception to 1 August 2023. For inclusion, a study had to be an original article, estimating the impact of healthcare expenditure on health outcome measures at a country level, and presented estimates, in terms of cost per quality-adjusted life year (QALY) or disability-adjusted life year (DALY).

RESULTS

We included 18 studies with 385 estimates. The median (range) estimates were PPP$ 11,224 (PPP$ 223 - PPP$ 288,816) per QALY gained and PPP$ 5,963 (PPP$ 71 - PPP$ 165,629) per DALY averted. As ratios of Gross Domestic Product per capita (GDPPC), these estimates were 0.376 (0.041-182.840) and 0.318 (0.004-37.315) times of GDPPC, respectively.

CONCLUSIONS

The commonly used CET of GDPPC seems to be too high for all countries, but especially low-to-middle-income countries where the potential health losses from misallocation of the same money are greater.

REGISTRATION

The review protocol was published and registered in PROSPERO (CRD42020147276).

A Framework for the Fair Pricing of Medicines

As high-cost medicines put increasing pressure on public health care budgets, the need to identify 'fair' prices for medicines has never been greater. This paper proposes a framework, built upon fundamental economic principles, that allows for the consideration of 'fair' prices for medicines. The framework incorporates key considerations from conventional supply-side and demand-side approaches for specifying a cost-effectiveness 'threshold', including the health opportunity cost borne by other patients ([Formula: see text]) and society's willingness to pay for marginal improvements in population health ([Formula: see text]). The costs incurred by manufacturers in developing and supplying new medicines are also considered, as are the incentives for manufacturers to strategically price up to any common price per unit of benefit (cost-effectiveness 'threshold') specified by the payer. The framework finds that, at any 'fair' price, a medicine's dynamically calculated incremental cost-effectiveness ratio (ICER) lies below [Formula: see text]. When pricing medicines collectively, the framework finds that a common price below [Formula: see text] is required to maximize population health (consumer surplus) or to maximize total welfare (consumer and producer surplus). This framework has important policy implications for payers who wish to improve population health outcomes from constrained health care budgets. In particular, existing approaches to 'value-based pricing' should be reconsidered to ensure that patients receive a 'fair' share of the resulting economic surplus.

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.

VOLY: The Monetary Value of a Life-Year at the End of Patients' Lives

OBJECTIVE

We explored the monetary value of the end-of-life (EoL) health gains, that is, the value of a life-year (VOLY) gained at the end of a patient's life in Croatia. We tested whether the nature of the illness under valuation (cancer and/or rare disease) is a factor in the valuation of EoL-VOLYs. The aim was for our results to contribute to the health and longevity valuation literature and more particularly to the debate on the appropriate cost-effectiveness threshold for EoL treatments as well as to provide input into the debate on the justifiability of a cancer and/or a rare disease premium when evaluating therapies.

METHODS

A contingent valuation was conducted in an online survey using a representative sample of the Croatian population (n = 1500) to calculate the willingness to pay for gains in the remaining life expectancy at the EoL, from the social-inclusive-individual perspective, using payment scales and an open-ended payment vehicle. Our approach mimics the actual decision-making problem of deciding whether to reimburse therapies targeting EoL conditions such as metastatic cancer whose main purpose is to extend life (and not add quality to life).

RESULTS

Average EoL-VOLY across all scenarios was estimated at €67,000 (median €40,000). In scenarios that offered respondents 1 full year of life extension, EoL-VOLY was estimated at €33,000 (median €22,000). Our results show that the type of illness is irrelevant for EoL-VOLY evaluations.

CONCLUSIONS

The pressure to reimburse expensive therapies targeting EoL conditions will continue to increase. Delivering "value for money" in healthcare, both in countries with relatively higher and lower budget restrictions, requires the valuation of different types of health gains, which should, in turn, affect our ability to evaluate their cost effectiveness.

The Broader Opportunity Costs in the Broader Cost-Effectiveness Analysis Framework

BACKGROUND

The traditional cost-effectiveness analysis framework usually takes a healthcare system perspective, where the aim is to maximise population health from a fixed budget allocated to healthcare. Extensions to this framework have been suggested, including: (i) incorporating impacts that fall outside the healthcare sector; (ii) accounting for outcomes beyond health; and (iii) assessing equity considerations. Several alternatives have been proposed that serve these purposes, for example, the extended "impact inventory", the "beyond-the-QALY" approach and the distributional cost-effectiveness analysis.

OBJECTIVE

This paper aims to develop a comprehensive framework that incorporates into the cost-effectiveness analysis framework some of its most advocated extensions and provides a means of arriving at a unidimensional cost-effectiveness analysis result measure.

METHODS

Building on previous work, I proposed a framework that explicitly incorporates the full extent of the opportunity costs that arise when new dimensions and distributional concerns are included in cost-effectiveness analyses. A hypothetical example is provided as a way of illustration.

RESULTS

Operationalising the proposed framework requires system-wide representative values and/or robust estimates concerning: (i) selecting dimensions; (ii) measuring opportunity costs associated with each dimension; (iii) quantifying equity weights and percentages of beneficiaries and losers meeting equity considerations; and (iv) attaching monetary values to dimensions measured using a non-monetary metric.

CONCLUSIONS

Extending the cost-effectiveness analysis framework entails extending the measurement of the opportunity costs of funding decisions. This implies populating an ambitious puzzle that in some cases poses fundamental conceptual and empirical questions. Potential routes of further research that might facilitate such undertaking are proposed.

Informing a cost-effectiveness threshold for Saudi Arabia

BACKGROUND

Saudi Arabia's Vision 2030 aims to reform health care across the Kingdom, with health technology assessment being adopted as one tool promising to improve the efficiency with which resources are used. An understanding of the opportunity costs of reimbursement decisions is key to fulfilling this promise and can be used to inform a cost-effectiveness threshold. This paper is the first to provide a range of estimates of this using existing evidence extrapolated to the context of Saudi Arabia.

METHODS AND MATERIALS

We use four approaches to estimate the marginal cost per unit of health produced by the healthcare system; drawing from existing evidence provided by a cross-country analysis, two alternative estimates from the UK context, and based on extrapolating a UK estimate using evidence on the income elasticity of the value of health. Consequences of estimation error are explored.

RESULTS

Based on the four approaches, we find a range of SAR 42,046 per QALY gained (48% of GDP per capita) to SAR 215,120 per QALY gained (246% of GDP per capita). Calculated potential central estimates from the average of estimated health gains based on each source gives a range of SAR 50,000-75,000. The results are in line with estimates from the emerging literature from across the world.

CONCLUSION

A cost-effectiveness threshold reflecting health opportunity costs can aid decision-making. Applying a cost-effectiveness threshold based on the range SAR 50,000 to 75,000 per QALY gained would ensure that resource allocation decisions in healthcare can in be informed in a way that accounts for health opportunity costs.

LIMITATIONS

A limitation is that it is not based on a within-country study for Saudi Arabia, which represents a promising line of future work.

Willingness to Pay for One Additional Quality Adjusted Life Year: A Population Based Survey from China

OBJECTIVE

The aim of this study was to estimate the population's willingness to pay (WTP) for an additional quality-adjusted life-year (QALY) in China.

METHODS

The WTP for an additional QALY (WTP/Q) was estimated using a contingent valuation survey with quota sampling and snowball sampling, using a pre-designed questionnaire with 18 hypothetical scenarios. The change in health state was depicted by the EQ-5D-5L. The questionnaires were completed by telephone and face-to-face interviews. Two-part regression models were used to test validity and how different factors affect WTP/Q.

RESULTS

A total of 2008 people participated in this survey and provided 3265 WTP responses for further analysis. The average WTP/Q for the entire sample is 113,120 Renminbi (RMB) (USD 16,884), which is 1.75 times the gross domestic product (GDP) per capita. For the quality-of-life improvement scenarios, the mean WTP/Q is RMB 78,907 (USD 11,777, 1.22 times GDP per capita), which is significantly lower than the life extension scenarios (RMB 177,761, USD 26,531, 2.76 times GDP per capita). Age was found to be negatively related to positive WTP. Educational level was positively related to the probability of reporting positive WTP and the level of WTP/Q. Although the EQ-5D-5L utility scores of respondents did not prove to be statistically significant determinants of WTP/Q, the two dimensions of EQ-5D-5L, pain/discomfort and anxiety/depression, had an impact on WTP/Q. In addition, WTP/Q was higher when the health outcome had a 50% probability of occurring than when the health outcome was 100% certain. WTP/Q was higher when a lower health gain was presented to the respondent.

CONCLUSION

This study provides empirical evidence of the monetary value of an additional QALY from a sample of the Chinese population. In addition, a higher threshold for end-of-life therapies should be considered.

What are the impacts of increasing cost-effectiveness Threshold? a protocol on an empirical study based on economic evaluations conducted in Thailand

Background

Economic evaluations have been widely used to inform and guide policy-making process in healthcare resources allocation as a part of an evidence package. An intervention is considered cost-effective if an ICER is less than a cost-effectiveness threshold (CET), where a CET represents the acceptable price for a unit of additional health gain which a decision-maker is willing to pay. There has been discussion to increase a CET in many settings such as the United Kingdom and Thailand. To the best of our knowledge, Thailand is the only country that has an explicit CET and has revised their CET, not once but twice. Hence, the situation in Thailand provides a unique opportunity for evaluating the impact of changing CET on healthcare expenditure and manufacturers’ behaviours in the real-world setting. Before we decide whether a CET should be increased, information on what happened after the CET was increased in the past could be informative and helpful.

Objectives

This study protocol describes a proposed plan to investigate the impact of increased cost-effectiveness threshold using Thailand as a case study. Specifically, we will examine the impact of increasing CET on the drug prices submitted by pharmaceutical companies to the National List of Essential Medicine (NLEM), the decision to include or exclude medications in the NLEM, and the overall budget impact.

Materials and designs

Retrospective data analysis of the impact of increased CET on national drug committee decisions in Thailand (an upper middle-income country) will be conducted and included data from various sources such as literature, local organizations (e.g. Thai Food and Drug Administration), and inputs from stakeholder consultation meetings. The outcomes include: (1) drug price submitted by the manufacturers and final drug price included in the NLEM if available; (2) decisions about whether the drug was included in the NLEM for reimbursement; and (3) budget impact. The independent variables include a CET, the variable of interest, which can take values of THB100,000, THB120,000, or THB160,000, and potential confounders such as whether this drug was for a chronic disease, market size, and primary endpoint. We will conduct separate multivariable regression analysis for each outcome specified above.

Discussion

Understanding the impact of increasing the CET would be helpful in assisting the decision to use and develop an appropriate threshold for one’s own setting. Due to the nature of the study design, the findings will be prone to confounding effect and biases; therefore, the analyses will be adjusted for potential confounders and statistical methods will be explored to minimize biases. Knowledge gained from the study will be conveyed to the public through various disseminations such as reports, policy briefs, academic journals, and presentations.

Economic evaluation of psychological treatments for common mental disorders in low- and middle-income countries: a systematic review

Common mental disorders (CMDs) constitute a major public health and economic burden on low- and middle-income countries (LMICs). Systematic reviews of economic evaluations of psychological treatments for CMDs are limited. This systematic review examines methods, reports findings and appraises the quality of economic evaluations of psychological treatments for CMDs in LMICs. We searched a range of bibliographic databases (including PubMed, EconLit, APA-PsycINFO and Cochrane library) and the African Journals Online (AJoL) and Google Scholar platforms. We used a pre-populated template to extract data and the Drummond & Jefferson checklist for quality appraisal. We present results as a narrative synthesis. The review included 26 studies, mostly from Asia (12) and Africa (9). The majority were cost-effectiveness analyses (12), some were cost-utility analyses (5), with one cost-benefit analysis or combinations of economic evaluations (8). Most interventions were considered either cost-effective or potentially cost-effective (22), with 3 interventions being not cost-effective. Limitations were noted regarding appropriateness of conclusions drawn on cost-effectiveness, the use of cost-effectiveness thresholds and application of 'societal' incremental cost-effectiveness ratios to reflect value for money (VfM) of treatments. Non-specialist health workers (NSHWs) delivered most of the treatments (16) for low-cost delivery at scale, and costs should reflect the true opportunity cost of NSHWs' time to support the development of a sustainable cadre of health care providers. There is a 4-fold increase in economic evaluations of CMD psychological treatments in the last decade over the previous one. Yet, findings from this review highlight the need for better application of economic evaluation methodology to support resource allocation towards the World Health Organization recommended first-line treatments of CMDs. We suggest impact inventories to capture societal economic gains and propose a VfM assessment framework to guide researchers in evaluating cost-effectiveness.