Valuing health at the end of life: A review of stated preference studies in the social sciences literature

Understanding the National Institute for Health and Care Excellence Severity Premium: Exploring Its Implementation and the Implications for Decision Making and Patient Access

OBJECTIVES

This study aimed to evaluate the impact of the National Institute for Health and Care Excellence's (NICE) new severity modifier, which has replaced the end-of-life (EoL) premium, on future NICE recommendations, considering past decision-making patterns.

METHODS

NICE technology appraisals (TAs) published between January 2020 and December 2022 were reviewed. Summary statistics were generated to assess how the new severity modifier might affect hypothetical decision making in historical TAs.

RESULTS

A total of 138 data points were identified from 132 TAs. Although the EoL premium was applied in 46 appraisals (33%), 57 (39%) qualify for a severity-based quality-adjusted life-year (QALY) multiplier. Only 19 appraisals (14.6%) not receiving an EoL premium met the severity criteria, the majority (17) qualifying for a 1.2× multiplier. In appraisals predicted to meet the severity criteria, 45 (79%) were in oncology, making them 4.04 times (95% CI 1.91-9.02) more likely to qualify for a severity modifier than nononcology indications. Among historically EoL indications, 42 (91%) were predicted to meet the severity criteria, making them 14.8 times (95% CI 6.37-37.6) more likely to qualify for a severity modifier.

CONCLUSIONS

The new severity modifier will predominantly benefit oncology indications, continuing their previous explicit prioritization under the EoL decision modifier. However, the new severity modifier is harder to achieve and less generous; only a fraction of appraisals qualify for the highest effective £51 000 per QALY threshold. The vast majority of indications previously approved at £50 000 per QALY would now need to meet a cost-effectiveness threshold of <£36 000. This may necessitate greater pricing flexibility from manufacturers and increase the likelihood of negative recommendations.

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.

Public preferences in healthcare resource allocation: A discrete choice experiment in South Korea

OBJECTIVES

This study aimed to explore the public view on priority-setting criteria for healthcare resource allocation. Specifically, it investigates how the value of a quality-adjusted life year (QALY) varies depending on patient characteristics.

METHODS

A discrete choice experiment was conducted using an online sample of the general South Korean population. Respondents were presented with two competing treatment scenarios. The attributes of the scenarios were age at disease onset, life expectancy without treatment, life-years gain with treatment, health-related quality of life (HRQoL) without treatment, and HRQoL gains with treatment. Two hundred choice sets were generated and randomly allocated into 20 blocks. A conditional logit model was used to estimate the factors affecting the respondents' choices.

RESULTS

A total of 3,482 respondents completed the survey. The larger the QALY gain, the more likely it was that the scenario would be chosen but with a diminishing marginal value. Respondents prioritized 40-year-old patients over 5-year-olds and 5-year-olds over 70-year-olds and prioritized baseline HRQoL of 40% and 60% over 20%. Patients at the end of life were not preferred to those with a longer life expectancy.

CONCLUSION

Overall, respondents preferred health-maximizing options without explicit consideration for end-of-life patients or those with poor health. In addition, they revealed a kinked preference for patient age, prioritizing middle-aged patients over children and older people.

The value of a QALY towards the end of life and its determinants: Experimental evidence

OBJECTIVES

Individual and societal willingness to pay (WTP) for end-of-life medical interventions continue to be subject to considerable uncertainty. This study aims at deriving both types of WTP estimates for an extension of survival time and an improvement of quality of life amounting to a QALY.

METHODS

A discrete choice experiment (DCE) involving a hypothetical novel drug for the treatment of terminal cancer involving 1529 Swiss residents was performed in 2014. In its individual setting, respondents choose between the status quo and a hypothetical drug with varying characteristics and out-of-pocket payments, adopting the perspective of a terminal cancer patient. In the societal setting, participants are asked to choose between the status quo and a social health insurance contract with and without coverage of the novel drug and a varying insurance contribution.

RESULTS

In the individual setting, respondents put a higher value on their quality of life than on their survival time whereas in the societal setting, they put a higher value on extra survival time. The combination of the two extensions results in a mean individual WTP per QALY of CHF 96,150 (1 CHF = 1 USD as of 2014). Mean societal WTP for a QALY even amounts to CHF 213,500 in favor of an adult patient, CHF 255,600 for a child, and CHF 153,600 for a person aged over 70 years, respectively. While estimated societal values consistently exceed their individual counterparts, they vary considerably with respondents' socioeconomic characteristics in both settings.

CONCLUSIONS

This research finds that individual WTP for an extension of survival time to one year is dominated by WTP for health-related quality of life whereas for societal WTP, it is the other way round. Both individual and societal WTP values exhibit a great deal of heterogeneity, with the latter depending on the type of beneficiary.

Perception of Medical Students on the Need for End-of-Life Care: A Q-Methodology Study

End-of-life care and the limitation of therapeutic effort are among the most controversial aspects of medical practice. Many subjective factors can influence decision-making regarding these issues. The Q methodology provides a scientific basis for the systematic study of subjectivity by identifying different thought patterns. This methodology was performed to find student profiles in 143 students at Cantabria University (Spain), who will soon deal with difficult situations related to this topic. A chi-square test was used to compare proportions. We obtained three profiles: the first seeks to ensure quality of life and attaches great importance to the patient’s wishes; the second prioritizes life extension above anything else; the third incorporates the economic perspective into medical decision-making. Those who had religious beliefs were mostly included in profile 2 (48.8% vs. 7.3% in profile 1 and 43.9% in profile 3), and those who considered that their beliefs did not influence their ethical principles, were mainly included in profile 3 (48.5% vs. 24.7% in profile 1 and 26.8% in profile 2). The different profiles on end-of-life care amongst medical students are influenced by personal factors. Increasing the clinical experience of students with terminally ill patients would contribute to the development of knowledge-based opinion profiles and would avoid reliance on personal experiences.

No Time to Waste: An Appraisal of Value at the End of Life

OBJECTIVES

The use of economic evaluations of end-of-life interventions may be limited by an incomplete appreciation of how patients and society perceive value at end of life. The objective of this study was to evaluate how patients, caregivers, and society value gains in quantity of life and quality of life (QOL) at the end of life. The validity of the assumptions underlying the use of the quality-adjusted life-years (QALY) as a measure of preferences at end of life was also examined.

METHODS

MEDLINE, Embase, CINAHL, PsycINFO, and PubMed were searched from inception to February 22, 2021. Original research studies reporting empirical data on healthcare priority setting at end of life were included. There was no restriction on the use of either quantitative or qualitative methods. Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all included studies. The primary outcomes were the value of gains in quantity of life and the value of gains in QOL at end of life.

RESULTS

A total of 51 studies involving 53 981 participants reported that gains in QOL were generally preferred over quantity of life at the end of life across stakeholder groups. Several violations of the underlying assumptions of the QALY to measure preferences at the end of life were observed.

CONCLUSIONS

Most patients, caregivers, and members of the general public prioritize gains in QOL over marginal gains in life prolongation at the end of life. These findings suggest that policy evaluations of end-of-life interventions should favor those that improve QOL. QALYs may be an inadequate measure of preferences for end-of-life care thereby limiting their use in formal economic evaluations of end-of-life interventions.

What Aspects of Illness Influence Public Preferences for Healthcare Priority Setting? A Discrete Choice Experiment in the UK

BACKGROUND

Decisions on funding new healthcare technologies assume that all health improvements are valued equally. However, public reaction to health technology assessment (HTA) decisions suggests there are health attributes that matter deeply to them but are not currently accounted for in the assessment process. We aimed to determine the relative importance of attributes of illness that influence the value placed on alleviating that illness.

METHOD

We conducted a discrete choice experiment survey that presented general public respondents with 15 funding decisions between hypothetical health conditions. The conditions were defined by five attributes that characterise serious illnesses, plus the health gain from treatment. Respondent preferences were modelled using conditional logistic regression and latent class analysis.

RESULTS

905 members of the UK public completed the survey in November 2017. Respondents generally preferred to provide treatments for conditions with 'better' characteristics. The exception was treatment availability, where respondents preferred to provide treatments for conditions where there is no current treatment, and were prepared to accept lower overall health gain to do so. A subgroup of respondents preferred to prioritise 'worse' health states.

CONCLUSION

This study suggests a preference among the UK public for treating an unmet need; however, it does not suggest a preference for prioritising other distressing aspects of health conditions, such as limited life expectancy, or where patients are reliant on care. Our results are not consistent with the features currently prioritised in UK HTA processes, and the preference heterogeneity we identify presents a major challenge for developing broadly acceptable policy.

Association between high cost user status and end-of-life care in hospitalized patients: A national cohort study of patients who die in hospital

BACKGROUND

Studies comparing end-of-life care between patients who are high cost users of the healthcare system compared to those who are not are lacking.

AIM

The objective of this study was to describe and measure the association between high cost user status and several health services outcomes for all adults in Canada who died in acute care, compared to non-high cost users and those without prior healthcare use.

SETTINGS AND PARTICIPANTS

We used administrative data for all adults who died in hospital in Canada between 2011 and 2015 to measure the odds of admission to the intensive care unit (ICU), receipt of invasive interventions, major surgery, and receipt of palliative care during the hospitalization in which the patient died. High cost users were defined as those in the top 10% of acute healthcare costs in the year prior to a person's hospitalization in which they died.

RESULTS

Among 252,648 people who died in hospital, 25,264 were high cost users (10%), 112,506 were non-high cost users (44.5%) and 114,878 had no prior acute care use (45.5%). After adjustment for age and sex, high cost user status was associated with a 14% increased odds of receiving an invasive intervention, a 15% increased odds of having major surgery, and an 8% lower odds of receiving palliative care compared to non-high cost users, but opposite when compared to patients without prior healthcare use.

CONCLUSIONS

Many patients receive aggressive elements of end-of-life care during the hospitalization in which they die and a substantial number do not receive palliative care. Understanding how this care differs between those who were previously high- and non-high cost users may provide an opportunity to improve end of life care for whom better care planning and provision ought to be an equal priority.

Willingness to Pay for Health-Related Quality of Life Gains in Relation to Disease Severity and the Age of Patients

OBJECTIVES

Decision-making frameworks that draw on economic evaluations increasingly use equity weights to facilitate a more equitable and fair allocation of healthcare resources. These weights can be attached to health gains or reflected in the monetary threshold against which the incremental cost-effectiveness ratios of (new) health technologies are evaluated. Currently applied weights are based on different definitions of disease severity and do not account for age-related preferences in society. However, age has been shown to be an important equity-relevant characteristic. This study examines the willingness to pay (WTP) for health-related quality of life (QOL) gains in relation to the disease severity and age of patients, and the outcome of the disease.

METHODS

We obtained WTP estimates by applying contingent-valuation tasks in a representative sample of the public in The Netherlands (n = 2023). We applied random-effects generalized least squares regression models to estimate the effect of patients' disease severity and age, size of QOL gains, disease outcome (full recovery/death 1 year after falling ill), and respondent characteristics on the WTP.

RESULTS

Respondents' WTP was higher for more severely ill and younger patients and for larger-sized QOL gains, but lower for patients who died. However, the relations were nonlinear and context dependent. Respondents with a lower age, who were male, had a higher household income, and a higher QOL stated a higher WTP for QOL gains.

CONCLUSIONS

Our results suggest that-if the aim is to align resource-allocation decisions in healthcare with societal preferences-currently applied equity weights do not suffice.

Willingness to pay for quality and length of life gains in end of life patients of different ages

Health gains are increasingly weighted in economic evaluations of new health technologies to guide resource-allocation decisions in healthcare. In Norway and the Netherlands weights are, for example, based on the disease severity of patients. In England and Wales, a higher weight is attached to quality-adjusted life-years (QALYs) gained from life-extending end-of-life (EOL) treatments. Societal preferences for QALY gains in EOL patients are increasingly examined. Although the available evidence suggests that gains in health-related quality of life (QOL) may be preferred to gains in life expectancy (LE), little is known about the influence of EOL patients' age on these preferences. In this study, we examine the willingness to pay (WTP) for QOL and LE gains in EOL patients of different ages in a sample (n = 803) of the general public in the Netherlands. We found that WTP was relatively higher for QOL and LE gains in younger EOL patients. We further found indications suggesting that WTP may be relatively higher for QOL gains at the EOL, except for patients aged 20 for whom we observed a higher WTP for LE gains. Our results may inform discussions on attaching differential weights to QOL and LE gains in EOL patients of different ages with the objective to better align resource-allocation decisions with societal preferences.

Public values and plurality in health priority setting: What to do when people disagree and why we should care about reasons as well as choices

CONTEXT

'What does 'The Public' think?' is a question often posed by researchers and policy makers, and public values are regularly invoked to justify policy decisions. Over time there has been a participatory turn in the social and health sciences, including health technology assessment and priority setting in health, towards citizen participation such that public policies reflect public values. It is one thing to agree that public values are important, however, and another to agree on how public values should be elicited, deliberated upon and integrated into decision-making. Surveys of public values rarely deliver unanimity, and preference heterogeneity, or plurality, is to be expected.

METHODS

This paper examines the role of public values in health policy and how to elicit, analyse, and present values, in the face of plurality. We delineate the strengths and weaknesses of aggregative and deliberative methods before setting out a new empirical framework, drawing on Sunstein's Incompletely Theorised Agreements, based on three levels: principles, policies and patients. The framework is illustrated using a recognised policy dilemma - the provision of high cost, limited-effect medicines intended to extend life for people with terminal illnesses.

FINDINGS

Application of the multi-level framework to public values permits transparent consideration of plurality, including analysis of coherence and consensus, in a way that offers routes to policy recommendations that are based on public values and justified in those terms.

CONCLUSIONS

Using the new framework and eliciting quantitative and qualitative data across levels of abstraction has the potential to inform policy recommendations grounded in public values, where values are plural. This is not to suggest that one solution will magically emerge, but rather that choices between policies can be explicitly justified in relation to the properties of public values, and a much clearer understanding of (in)consistencies and areas of consensus.

Severity as a Priority Setting Criterion: Setting a Challenging Research Agenda

Priority setting in health care is ubiquitous and health authorities are increasingly recognising the need for priority setting guidelines to ensure efficient, fair, and equitable resource allocation. While cost-effectiveness concerns seem to dominate many policies, the tension between utilitarian and deontological concerns is salient to many, and various severity criteria appear to fill this gap. Severity, then, must be subjected to rigorous ethical and philosophical analysis. Here we first give a brief history of the path to today’s severity criteria in Norway and Sweden. The Scandinavian perspective on severity might be conducive to the international discussion, given its long-standing use as a priority setting criterion, despite having reached rather different conclusions so far. We then argue that severity can be viewed as a multidimensional concept, drawing on accounts of need, urgency, fairness, duty to save lives, and human dignity. Such concerns will often be relative to local mores, and the weighting placed on the various dimensions cannot be expected to be fixed. Thirdly, we present what we think are the most pertinent questions to answer about severity in order to facilitate decision making in the coming years of increased scarcity, and to further the understanding of underlying assumptions and values that go into these decisions. We conclude that severity is poorly understood, and that the topic needs substantial further inquiry; thus we hope this article may set a challenging and important research agenda.

Prioritizing Communication in the Provision of Palliative Care for the Trauma Patient

Purpose of Review

Communication skills in the ICU are an essential part of the care of trauma patients. The goal of this review is to summarize key aspects of our understanding of communication with injured patients in the ICU.

Recent Findings

The need to communicate effectively and empathetically with patients and identify primary goals of care is an essential part of trauma care in the ICU. The optimal design to support complex communication in the ICU will be dependent on institutional experience and resources. The best/worst/most likely model provides a structural model for communication.

Summary

We have an imperative to improve the communication for all patients, not just those at the end of their life. A structured approach is important as is involving family at all stages of care. Communication skills can and should be taught to trainees.

Consumer Reactions to E. Coli and Antibiotic Residue Recalls: Utility Maximization vs. Regret Minimization

Food safety remains a major issue to many consumers. Previous studies examining the economic impact of food safety recalls have focused on Class I recalls. Antibiotic residue in meat products, a Class II recall, has increased in consumer importance yet little is known about how much research and development expenditure should be allocated to reduce antibiotic residue pre- and post-harvest. This study compares demand elasticities and the decrease in willingness to pay in response to either an E. coli (Class I) or antibiotic residue (Class II) recall. We compare and contrast two competing behavioral frameworks, Random Utility and Regret Minimizing. Modeling behavior using the random regret framework is found to be more powerful for assessing consumer responses. In addition, we explore if different groups of consumers exist that either maximize utility or minimize regret. Consumer devaluations of E. coli (Class I) are 40-65% larger than antibiotic residue (Class II). Approximately 60% of consumers are identified as regret minimizers and 40% were identified as utility maximizers. While industry response and government policy recommendations differed conditional on modeling framework, the regret minimizing framework required smaller price discounts than regret minimizing to maintain the same level of market share.

The relative value of different QALY types

The oft-applied assumption in the use of Quality Adjusted Life Years (QALYs) in economic evaluation, that all QALYs are valued equally, has been questioned from the outset. The literature has focused on differential values of a QALY based on equity considerations such as the characteristics of the beneficiaries of the QALYs. However, a key characteristic which may affect the value of a QALY is the type of QALY itself. QALY gains can be generated purely by gains in survival, purely by improvements in quality of life, or by changes in both. Using a discrete choice experiment and a new methodological approach to the derivation of relative weights, we undertake the first direct and systematic exploration of the relative weight accorded different QALY types and do so in the presence of equity considerations; age and severity. Results provide new evidence against the normative starting point that all QALYs are valued equally.

How averse are the UK general public to inequalities in health between socioeconomic groups? A systematic review

There is growing interest in the use of "distributionally-sensitive" forms of economic evaluation that capture both the impact of an intervention upon average population health and the distribution of that health amongst the population. This review aims to inform the conduct of distributionally sensitive evaluations in the UK by answering three questions: (1) How averse are the UK public towards inequalities in lifetime health between socioeconomic groups? (2) Does this aversion differ depending upon the type of health under consideration? (3) Are the UK public as averse to inequalities in health between socioeconomic groups as they are to inequalities in health between neutrally framed groups? EMBASE, MEDLINE, EconLit, and SSCI were searched for stated preference studies relevant to these questions in October 2017. Of the 2155 potentially relevant papers identified, 15 met the predefined hierarchical eligibility criteria. Seven elicited aversion to inequalities in health between socioeconomic groups, and eight elicited aversion between neutrally labelled groups. We find general, although not universal, evidence for aversion to inequalities in lifetime health between socioeconomic groups, albeit with significant variation in the strength of that preference across studies. Second, limited evidence regarding the impact of the type of health upon aversion. Third, some evidence that the UK public are more averse to inequalities in lifetime health when those inequalities are presented in the context of socioeconomic inequality than when presented in isolation.

Goals of Care: Understanding the Outcomes that Matter Most

Advanced care planning is a critically important part of the care of seriously and critically ill patients. A responsibility of all physicians as part of primary palliative care, advanced care planning discussions are more than discussions about code status and should begin early and proceed in parallel with recovery-focused care. Strategies and best practices for advanced care planning in the elective setting and when time is short are reviewed, as are the myriad legal documents that can be used to provide a physical representation of the advanced care planning discussions.

Advanced therapy medicinal products and health technology assessment principles and practices for value-based and sustainable healthcare

BACKGROUND

Advanced therapy medicinal products (ATMPs) are beginning to reach European markets, and questions are being asked about their value for patients and how healthcare systems should pay for them.

OBJECTIVES

To identify and discuss potential challenges of ATMPs in view of current health technology assessment (HTA) methodology-specifically economic evaluation methods-in Europe as it relates to ATMPs, and to suggest potential solutions to these challenges.

METHODS

An Expert Panel reviewed current HTA principles and practices in relation to the specific characteristics of ATMPs.

RESULTS

Three key topics were identified and prioritised for discussion-uncertainty, discounting, and health outcomes and value. The panel discussed that evidence challenges linked to increased uncertainty may be mitigated by collection of follow-on data, use of value of information analysis, and/or outcomes-based contracts. For discount rates, an international, multi-disciplinary forum should be established to consider the economic, social and ethical implications of the choice of rate. Finally, consideration of the feasibility of assessing the value of ATMPs beyond health gain may also be key for decision-making.

CONCLUSIONS

ATMPs face a challenge in demonstrating their value within current HTA frameworks. Consideration of current HTA principles and practices with regards to the specific characteristics of ATMPs and continued dialogue will be key to ensuring appropriate market access.

CLASSIFICATION CODE

I.