Ethics and opportunity costs: have NICE grasped the ethics of priority setting?

Ethical challenges faced when there is a mismatch between guidelines, patient autonomy and clinical practice

This editorial reviews the ethical day-to-day challenges faced by pain specialists when managing each patient's unique requirements, in light of guidelines, clinical practice and interpretation of evidence relating to the assessment and management of chronic pain.

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.

Cancer Care Coordinators to Improve Tamoxifen Persistence in Breast Cancer: How Heterogeneity in Baseline Prognosis Impacts on Cost-Effectiveness

OBJECTIVES

To assess the cost-effectiveness of a cancer care coordinator (CCC) in helping women with estrogen receptor positive (ER+) early breast cancer persist with tamoxifen for 5 years.

METHODS

We investigated the cost-effectiveness of a CCC across eight breast cancer subtypes, defined by progesterone receptor (PR) status, human epidermal growth factor receptor 2 (HER2) status, and local/regional spread. These subtypes range from excellent to poorer prognoses. The CCC helped in improving tamoxifen persistence by providing information, checking-in by phone, and "troubleshooting" concerns. We constructed a Markov macrosimulation model to estimate health gain (in quality-adjusted life-years or QALYs) and health system costs in New Zealand, compared with no CCC. Participants were modeled until death or till the age of 110 years. Some input parameters (e.g., the impact of a CCC on tamoxifen persistence) had sparse evidence. Therefore, we used estimates with generous uncertainty and conducted sensitivity analyses.

RESULTS

The cost-effectiveness of a CCC for regional ER+/PR-/HER2+ breast cancer (worst prognosis) was NZ $23,400 (US $15,800) per QALY gained, compared with NZ $368,500 (US $248,800) for local ER+/PR+/HER2- breast cancer (best prognosis). Using a cost-effectiveness threshold of NZ $45,000 (US $30,400) per QALY, a CCC would be cost-effective only in the four subtypes with the worst prognoses.

CONCLUSIONS

There is value in investigating cost-effectiveness by different subtypes within a disease. In this example of breast cancer, the poorer the prognosis, the greater the health gains from a CCC and the better the cost-effectiveness. Incorporating heterogeneity in a cost-utility analysis is important and can inform resource allocation decisions. It is also feasible to undertake in practice.

Expanded HTA, Legitimacy and Independence Comment on "Expanded HTA: Enhancing Fairness and Legitimacy"

This brief commentary seeks to develop the analysis of Daniels, Porteny and Urrutia of the implications of expansion of the scope of health technology assessment (HTA) beyond issues of safety, efficacy, and cost-effectiveness. Drawing in particular on experience in the United Kingdom, it suggests that such expansion can be understood not only as a response to the problem of insufficiency of evidence, but also to that of legitimacy. However, as expansion of HTA also renders it more visibly political in character, it is plausible that its legitimacy may be undermined, rather than enhanced by, independence from the policy process.

BARRIERS AND FACILITATORS INFLUENCING ETHICAL EVALUATION IN HEALTH TECHNOLOGY ASSESSMENT

Objectives: The objective of this study was to explore barriers and facilitators influencing the integration of ethical considerations in health technology assessment (HTA).

Methods: The study consisted of two complementary approaches: (a) a systematic review of the literature; and (b) an eighteen-item online survey that was distributed to fifty-six HTA agencies affiliated with the International Network of Agencies for Health Technology Assessment.

Results: The review identified twenty-six relevant articles. The most often cited barriers in the literature were: scarcity, heterogeneity and complexity of ethical analysis methods; challenges in translating ethical analysis results into knowledge that is useful for decision makers; and lack of organizational support in terms of required expertise, time and financial resources. The most frequently cited facilitators included: usage of value-based appraisal methods, stakeholder and public engagement, enhancement of practice guidelines, ethical expertise, and educational interventions.

Representatives of twenty-six (46.5 percent) agencies from nineteen countries completed the survey. A median of 10 percent (interquartile range, 5 percent to 50 percent) of the HTA products produced by the agencies was reported to include an assessment of ethical aspects. The most commonly perceived barriers were: limited ethical knowledge and expertise, insufficient time and resources, and difficulties in finding ethical evidence or using ethical guidelines. Educational interventions, demand by policy makers, and involvement of ethicists in HTA were the most commonly perceived facilitators.

Conclusions: Our results emphasize the importance of simplification of ethics methodology and development of good practice guidelines in HTA, as well as capacity building for engaging HTA practitioners in ethical analyses.

[Equal access to medical services over the lifespan]

Demand for health services is in principle unlimited, in contrast to resources. People covered by public health funds in principle have equal access to treatment according to the highest level of medical evidence available. In order to restrict expenditure the legislator stipulates different instruments. These include reference pricing for generics as well as price capping. The legislator still shies from price fixing which is well established in other states. Instead, office-based physicians are confronted by law with rationing decisions concerning their own services as well as services prescribed where the mentally ill are at special risk of becoming victims of intransparency, as exemplified by the heterogeneity of the prescription of psychotropic drugs. A systematic prioritization approach following internationally available models might open new perspectives.

Self inflicted harm--NICE in ethical self destruct mode?

Some very bad old arguments need removing from NICE's latest report