Assessing the benefits of health care: how far should we go?

Conceptualising 'Benefits Beyond Health' in the Context of the Quality-Adjusted Life-Year: A Critical Interpretive Synthesis

There is growing interest in extending the evaluative space of the quality-adjusted life-year framework beyond health. Using a critical interpretive synthesis approach, the objective was to review peer-reviewed literature that has discussed non-health outcomes within the context of quality-adjusted life-years and synthesise information into a thematic framework. Papers were identified through searches conducted in Web of Science, using forward citation searching. A critical interpretive synthesis allows for the development of interpretations (synthetic constructs) that go beyond those offered in the original sources. The final output of a critical interpretive synthesis is the synthesising argument, which integrates evidence from across studies into a coherent thematic framework. A concept map was developed to show the relationships between different types of non-health benefits. The critical interpretive synthesis was based on 99 papers. The thematic framework was constructed around four themes: (1) benefits affecting well-being (subjective well-being, psychological well-being, capability and empowerment); (2) benefits derived from the process of healthcare delivery; (3) benefits beyond the recipient of care (spillover effects, externalities, option value and distributional benefits); and (4) benefits beyond the healthcare sector. There is a wealth of research concerning non-health benefits and the evaluative space of the quality-adjusted life-year. Further dialogue and debate are necessary to address conceptual and normative challenges, to explore the societal willingness to sacrifice health for benefits beyond health and to consider the equity implications of different courses of action.

Social Prescribing in National Health Service Primary Care: What Are the Ethical Considerations?

Policy Points Social prescribing is proposed as a way of improving patients' health and well-being by attending to their non-clinical needs. This is done by connecting patients with community assets (typically voluntary or charitable organizations) that provide social and personal support. In the United Kingdom, social prescribing is used to improve patient well-being and reduce use of National Health Service resources. Although social prescribing schemes hold promise, evidence of their effects and effectiveness is sparse. As more information on social prescribing is gathered, it will be important to consider the associated ethical issues for patients, clinicians, link workers, and community assets.

What is the right level of spending needed for health and care in the UK?

The health and care sector plays a valuable role in improving population health and societal wellbeing, protecting people from the financial consequences of illness, reducing health and income inequalities, and supporting economic growth. However, there is much debate regarding the appropriate level of funding for health and care in the UK. In this Health Policy paper, we look at the economic impact of the COVID-19 pandemic and historical spending in the UK and comparable countries, assess the role of private spending, and review spending projections to estimate future needs. Public spending on health has increased by 3·7% a year on average since the National Health Service (NHS) was founded in 1948 and, since then, has continued to assume a larger share of both the economy and government expenditure. In the decade before the ongoing pandemic started, the rate of growth of government spending for the health and care sector slowed. We argue that without average growth in public spending on health of at least 4% per year in real terms, there is a real risk of degradation of the NHS, reductions in coverage of benefits, increased inequalities, and increased reliance on private financing. A similar, if not higher, level of growth in public spending on social care is needed to provide high standards of care and decent terms and conditions for social care staff, alongside an immediate uplift in public spending to implement long-overdue reforms recommended by the Dilnot Commission to improve financial protection. COVID-19 has highlighted major issues in the capacity and resilience of the health and care system. We recommend an independent review to examine the precise amount of additional funds that are required to better equip the UK to withstand further acute shocks and major threats to health.

Empirical Validity of a Generic, Preference-Based Capability Wellbeing Instrument (ICECAP-A) in the Context of Spinal Cord Injury

BACKGROUND

Assessing the validity of generic instruments across different clinical contexts is an important area of methodological research in economic evaluation and outcomes measurement.

OBJECTIVE

Our objective was to examine the empirical validity of a generic, preference-based capability wellbeing instrument (ICECAP-A) in the context of spinal cord injury.

METHODS

This study consisted of a secondary analysis of data collected using an online cross-sectional survey. The survey included questions regarding demographics, injury classifications and characteristics, secondary health conditions, quality of life and wellbeing, and functioning in activities of daily living. Analysis comprised the descriptive assessment of Spearman's rank correlations between item-/dimension-level data for the ICECAP-A and four preference-based health-related quality of life (HRQoL) instruments, and discriminant and convergent validity approaches to examine 21 evidence-informed or theoretically derived constructs. Constructs were defined using participant and injury characteristics and responses to a range of health, wellbeing and functioning outcomes.

RESULTS

Three hundred sixty-four individuals completed the survey. Mean index score for the ICECAP-A was 0.761; 12 (3%) individuals reported full capability (upper anchor; score = 1), and there were no reports of zero capabilities (lower anchor; score = 0). The strongest correlations were dominated by items and dimensions on the comparator (HRQoL) instruments that are non-health aspects of quality of life, such as happiness and control over one's life (including self-care). Of 21 hypothesised constructs, 19 were confirmed in statistical tests, the exceptions being the exploratory hypotheses regarding education and age at injury.

CONCLUSION

The ICECAP-A is an empirically valid outcome measure for assessing capability wellbeing in people with spinal cord injury living in a community setting. The extent to which the ICECAP-A provides complementary information to preference-based HRQoL instruments is dependent on the comparator.

Strength of public preferences for endovascular or open aortic aneurysm repair

Background

This study evaluated public preferences for the treatment processes for abdominal aortic aneurysm repair in order to allow them to be incorporated into a cost-effectiveness analysis.

Methods

This was a telephone survey using a trade-off method in UK resident adults (aged at least 18 years) with no previous diagnosis of a vascular condition.

Results

Some 167 of 209 participants (79·9 per cent) stated that they would prefer endovascular aneurysm repair (EVAR), 40 (19·1 per cent) preferred open surgery and two (1·0 per cent) stated no preference. Participants preferred EVAR because of the less invasive nature of the intervention and quicker recovery. Participants preferring open surgery cited reasons such as having a single follow-up appointment, and a procedure that felt more permanent. When participants were asked to make a sacrifice in order to have their preferred treatment, 122 (58·4 per cent) favoured EVAR, 18 (8·6 per cent) favoured open surgery and 69 (33·0 per cent) had no preference. Those preferring EVAR were willing to give up a mean of 0·135 expected quality-adjusted life-years (QALYs) to have EVAR, compared with a willingness to give up 0·033 expected QALYs among those preferring open repair.

Conclusion

These results indicate a clear preference for EVAR over open surgery for aortic aneurysm.

Using Nominal Group Technique to Identify Key Attributes of Oncology Treatments for a Discrete Choice Experiment

Background. Responding to rising oncology therapy costs, multiple value frameworks are emerging. However, input from economists in their design and conceptualization has been limited, and no existing framework has been developed using preference weightings as legitimate indicators of value. This article outlines use of the nominal group technique to identify valued treatment attributes (such as treatment inconvenience) and contextual considerations (such as current life expectancy) to inform the design of a discrete choice experiment to develop a preference weighted value framework for future decision makers. Methods. Three focus groups were conducted in 2017 with cancer patients, oncology physicians, and nurses. Using the nominal group technique, participants identified and prioritized cancer therapy treatment and delivery attributes as well as contextual issues considered when choosing treatment options. Results. Focus groups with patients (n = 8), physicians (n = 6), and nurses (n = 10) identified 30 treatment attributes and contextual considerations. Therapy health gains was the first priority across all groups. Treatment burden/inconvenience to patients and their families and quality of evidence were prioritized treatment attributes alongside preferences for resource use and cost (to patients and society) attributes. The groups also demonstrated that contextual considerations when choosing treatment varied across the stakeholders. Patients prioritized existence of alternative treatments and oncologist/center reputation while nurses focused on administration harms, communication, and treatment innovation. The physicians did not prioritize any contextual issues in their top rankings. Conclusions. The study demonstrates that beyond health gains, there are treatment attributes and contextual considerations that are highly prioritized across stakeholder groups. These represent important candidates for inclusion in a discrete choice experiment seeking to provide weighted preferences for a value framework for oncology treatment that goes beyond health outcomes.

An Investigation of the Overlap Between the ICECAP-A and Five Preference-Based Health-Related Quality of Life Instruments

BACKGROUND

The ICEpop CAPability measure for Adults (ICECAP-A) is a measure of capability wellbeing developed for use in economic evaluations. It was designed to overcome perceived limitations associated with existing preference-based instruments, where the explicit focus on health-related aspects of quality of life may result in the failure to capture fully the broader benefits of interventions and treatments that go beyond health. The aim of this study was to investigate the extent to which preference-based health-related quality of life (HRQoL) instruments are able to capture aspects of capability wellbeing, as measured by the ICECAP-A.

METHODS

Using data from the Multi Instrument Comparison project, pairwise exploratory factor analyses were conducted to compare the ICECAP-A with five preference-based HRQoL instruments [15D, Assessment of Quality of Life 8-dimension (AQoL-8D), EQ-5D-5L, Health Utilities Index Mark 3 (HUI-3), and SF-6D].

RESULTS

Data from 6756 individuals were used in the analyses. The ICECAP-A provides information above that garnered from most commonly used preference-based HRQoL instruments. The exception was the AQoL-8D; more common factors were identified between the ICECAP-A and AQoL-8D compared with the other pairwise analyses.

CONCLUSION

Further investigations are needed to explore the extent and potential implications of 'double counting' when applying the ICECAP-A alongside health-related preference-based instruments.

What Drives Responses to Willingness-to-pay Questions? A Methodological Inquiry in the Context of Hypertension Self-management

Background: The use of economic evaluation to determine the cost-effectiveness of health interventions is recommended by decision-making bodies internationally. Understanding factors that explain variations in costs and benefits is important for policy makers. Objective: This work aimed to test a priori hypotheses defining the relationship between benefits of using self-management equipment (measured using the willingness-to-pay (WTP) approach) and a number of demographic and other patient factors. Methods: Data for this study were collected as part of the first major randomised controlled trial of self-monitoring combined with self-titration in hypertension (TASMINH2). A contingent valuation framework was used with patients asked to indicate how much they were willing to pay for equipment used for self-managing hypertension. Descriptive statistics, simple statistical tests of differences and multivariate regression were used to test six a priori hypotheses. Results: 393 hypertensive patients (204 in the intervention and 189 in the control) were willing to pay for self-management equipment and 85% of these (335) provided positive WTP values. Three hypotheses were accepted: higher WTP values were associated with being male, higher household incomes and satisfaction with the equipment. Prior experiences of using this equipment, age and changes in blood pressure were not significantly related to WTP. Conclusion: The majority of hypertensive patients who had taken part in a self-management study were prepared to purchase the self-monitoring equipment using their own funds, more so for men, those with higher incomes and those with greater satisfaction. Further research based on bigger and more diverse populations is recommended.

Development and preliminary user testing of the DCIDA (Dynamic computer interactive decision application) for 'nudging' patients towards high quality decisions

Background

Patient decision aids (PtDA) are developed to facilitate informed, value-based decisions about health. Research suggests that even when informed with necessary evidence and information, cognitive errors can prevent patients from choosing the option that is most congruent with their own values. We sought to utilize principles of behavioural economics to develop a computer application that presents information from conventional decision aids in a way that reduces these errors, subsequently promoting higher quality decisions.

Method

The Dynamic Computer Interactive Decision Application (DCIDA) was developed to target four common errors that can impede quality decision making with PtDAs: unstable values, order effects, overweighting of rare events, and information overload. Healthy volunteers were recruited to an interview to use three PtDAs converted to the DCIDA on a computer equipped with an eye tracker. Participants were first used a conventional PtDA, and then subsequently used the DCIDA version. User testing was assessed based on whether respondents found the software both usable: evaluated using a) eye-tracking, b) the system usability scale, and c) user verbal responses from a ‘think aloud’ protocol; and useful: evaluated using a) eye-tracking, b) whether preferences for options were changed, and c) and the decisional conflict scale.

Results

Of the 20 participants recruited to the study, 11 were male (55%), the mean age was 35, 18 had at least a high school education (90%), and 8 (40%) had a college or university degree. Eye-tracking results, alongside a mean system usability scale score of 73 (range 68–85), indicated a reasonable degree of usability for the DCIDA. The think aloud study suggested areas for further improvement. The DCIDA also appeared to be useful to participants wherein subjects focused more on the features of the decision that were most important to them (21% increase in time spent focusing on the most important feature). Seven subjects (25%) changed their preferred option when using DCIDA.

Conclusion

Preliminary results suggest that DCIDA has potential to improve the quality of patient decision-making. Next steps include larger studies to test individual components of DCIDA and feasibility testing with patients making real decisions.

Cancer patients' willingness to pay for blood transfusions at home: results from a contingent valuation study in a French cancer network

Home blood transfusion may be an interesting alternative to hospital transfusion, especially when given with curative or palliative intent or for terminal care in advanced-stage cancer patients. However, there is limited information about patients' attitude toward this type of care. The purpose of this study was to measure French cancer patients' willingness to pay (WTP) for home blood transfusion and to analyze determinants of their choice. A contingent valuation survey was administered to 139 patients receiving transfusions in the framework of a regional home care network or in the hospital outpatient department. Participation was high (90%). Most patients (65%) had received home care, including 43% blood transfusions. Just under half of the patients gave a zero WTP, among which we identified 8 protest bidders. The median WTP for home blood transfusion was 26.5 <euro> per patient. In multivariate analysis, long home-hospital distance, poor quality of life, and previous experience of home care were identified as important factors in determining how much more patients would be willing to pay for transfusion at home. These results demonstrate the benefits of developing domiciliary services to improve patient well-being, notably for the weakest among them. The significant impact of previous home care experience on WTP is probably related to the strong involvement of physicians from the blood center and to their active contribution to a high-level homecare network. Some of our findings could be useful for policy decision-making regarding home care.

Exploring non-health outcomes of health promotion: the perspective of participants in a lifestyle behaviour change intervention

OBJECTIVE

To provide insights into health promotion outcomes that are not captured by conventional measures of health outcome used in economic evaluation studies, such as EQ5D based QALYs.

METHODS

Twelve semi-structured interviews and five focus group discussions were conducted with participants of a randomized controlled trial (n=52) evaluating the effectiveness of a theory-based lifestyle intervention in Dutch adults at risk for diabetes mellitus and/or cardiovascular disease. Transcripts were analysed by two independent researchers using a thematic analysis approach.

RESULTS

In total we identified twelve non-health outcome themes that were important from the participant perspective. Four of these were reported as direct outcomes of the lifestyle intervention and eight were reported as consequences of lifestyle behaviour change. Our findings also suggest that lifestyle behaviour change may have spillover effects to other people in the participants' direct environment.

CONCLUSION

This study provides evidence that in the context of lifestyle behaviour change EQ5D based QALYs capture health promotion outcomes only partially. More insights are needed into non-health outcomes and spillover effects produced by health promotion in other contexts and how participants and society value these. Methods to account for these outcomes within an economic evaluation framework need to be developed and tested.

QALYs and carers

When going 'beyond the patient', to measure QALYs for unpaid carers, a number of additional methodological considerations and value judgements must be made. While there is no theoretical reason to restrict the measurement of QALYs to patients, decisions have to be made about which carers to consider, what instruments to use and how to aggregate and present QALYs for carers and patients. Current, albeit limited, practice in measuring QALY gains to carers in economic evaluation varies, suggesting that there may be inconsistency in judgements about whether interventions are deemed cost effective. While conventional health-related quality-of-life tools can, in theory, be used to estimate QALYs, there are both theoretical and empirical concerns over the suitability of their use with carers. Measures that take a broader view of health or well-being may be more appropriate. Incorporating QALYs of carers in economic evaluations may have important distributional consequences and, therefore, greater normative discussion over the appropriateness of incorporating these impacts is required. In the longer term, more flexible forms of cost-per-QALY analysis may be required to take account of the broader impacts on carers and the weight these impacts should receive in decision making.

Development of a self-report measure of capability wellbeing for adults: the ICECAP-A

PURPOSE

The benefits of health and social care are not confined to patient health alone and therefore broader measures of wellbeing may be useful for economic evaluation. This paper reports the development of a simple measure of capability wellbeing for adults (ICECAP-A).

METHODS

In-depth, informant-led, interviews to identify the attributes of capability wellbeing were conducted with 36 adults in the UK. Eighteen semi-structured, repeat interviews were carried out to develop a capability-based descriptive system for the measure. Informants were purposively selected to ensure variation in socio-economic status, age, sex, ethnicity and health. Data analysis was carried out inductively and iteratively alongside interviews, and findings were used to shape the questions in later interviews.

RESULTS

Five over-arching attributes of capability wellbeing were identified for the measure: "stability", "attachment", "achievement", "autonomy" and "enjoyment". One item, with four response categories, was developed for each attribute for the ICECAP-A descriptive system.

CONCLUSIONS

The ICECAP-A capability measure represents a departure from traditional health economics outcome measures, by treating health status as an influence over broader attributes of capability wellbeing. Further work is required to value and validate the attributes and test the sensitivity of the ICECAP-A to healthcare interventions.

Using discrete choice experiments to go beyond clinical outcomes when evaluating clinical practice

BACKGROUND

This study builds on the results of a randomized controlled trial concerned with examining the effect of reducing waiting times on the health status of patients referred for non-urgent rheumatology opinion. No difference in clinical outcomes was found between a 'fast-track' and 'ordinary' appointment system. This suggests that rationing by waiting times is not detrimental to health. However, such an approach ignores the value patients attach to reducing waiting time.

OBJECTIVES

To estimate the monetary value of reducing waiting time, as well as changes in duration of appointment and the introduction of a pain management service, in the provision of rheumatology services.

METHODS

Discrete choice experiment (DCE).

SETTING

The main outpatient clinic of the rheumatology service for the Lothian and Borders region.

SUBJECTS

262 patients who had received a specialist rheumatology opinion--73 had received fast-track treatment, 65 standard care and 124 were non-trial patients.

RESULTS

A response rate of 71% was achieved. Patients valued a 9-week reduction in waiting time at 131 pounds sterling. However, the introduction of a pain management service was valued at 209 pounds sterling. Thus, the latter is of more value to respondents. Evidence was also found of the internal consistency and theoretical validity of the DCE approach.

CONCLUSIONS

The reduction of waiting times is a central plank of NHS policy. Whilst a reduction in waiting time is of value, a pain management service is of more benefit than a 9-week reduction in waiting time. DCE were shown to be a potentially useful technique for valuing different aspects of health care interventions.

Measuring costs and consequences in economic evaluation in asthma

Formal economic evaluation is playing an increasingly important role in health-care decision-making. This is shown by the requirement to present economic data to support applications for public reimbursement for new pharmaceuticals in Australia and the provinces of Canada, and by the appraisal process initiated by the National Institute for Clinical Excellence in the U.K. This growing role of economic analysis applies as much to the field of asthma as anywhere. This paper provides a detailed review of applied economic studies in asthma. The review is used to explore a range of methodological issues in the field including the choice of perspective and maximand, whether to use disease-specific or generic measures of outcome and whether decision-makers should receive disaggregated cost and consequence data or results that focus on an incremental cost-effectiveness ratio. It is concluded that, given the heterogeneity in decision-makers' objectives and constraints, economic studies should be planned and executed in such a way as to maximize flexibility in how results are presented.

Economic evaluation in obstetrics and gynaecology: principles and practice

Greater attention in health care over the last 2 decades has been placed on determining how best to spend the resources available. Economic evaluation is a commonly used tool to compare health-care services and treatments on the basis of costs and benefits. However, the principles on which economic evaluations are based are not well understood, and guidelines for conducting such evaluations in practice are often not followed. This paper describes the overarching principle of opportunity cost, and highlights the implication that decision-making in health care should necessarily be based on both costs and benefits. Two notions of efficiency, technical and allocative, are also presented, and the important point is made that the specific type of economic evaluation chosen must be based not on the unit of benefit in the given study, as is commonly done, but rather on the type of efficiency being addressed. The 3 primary types of economic evaluation are outlined, and a common pitfall in economic evaluation, the incremental cost-effectiveness ratio, is critiqued. Finally, a number of methodological considerations when conducting economic evaluations in practice are presented.

Shared treatment decision making in a collectively funded health care system: possible conflicts and some potential solutions

In recent years there has been a growth in the advocacy of shared decision making (SDM) between clinicians and patients as a way of practicing medicine. Although there is a range of perspectives on what SDM means, in essence it refers to greater involvement of the individual patient in deliberations about appropriate forms of clinical management. The patient's perception of the role of the doctor in SDM is crucial: for it to work successfully, the patient needs to be able to be confident that the doctor is focused on which treatment will generate the greatest benefit for them. However, the doctor also has responsibilities to others, in particular to other patients and potential patients within the collectively funded health care system. This dual responsibility can create a range of dilemmas for the clinician in the context of SDM: Should they inform patients about all effective treatments or just those that the health care system considers cost-effective? Do they risk losing patients from their books if they inform patients about their responsibilities to the health care system? SDM also raises questions about the wider principles of the health care system: Are its equity principles consistent with SDM? Should patients with a strong preference for an effective but non-cost-effective treatment be permitted to pay for it privately? This paper describes the nature of the conflicts that are likely to emerge if SDM diffuses within collectively funded health care systems, and considers a range of policy responses. It argues that the risk of conflict may be reduced by making a clear distinction between clinical guidelines (focusing on effectiveness) and system guidelines (focusing on cost-effectiveness).

Economic approaches to doctor/nurse skill mix: problems, pitfalls, and partial solutions

Against a background of government calls for a radical change in the way the medical workforce is planned and trained, the concept of skill mix seeks to match clinical presentation to an intervention based on an appropriate level of skill and training. Health economics is not the only framework within which these changes can be analysed. However unless the economic issues are thought through clearly there is a danger that resources may be used inefficiently. The aims of this paper are to outline the economic issues in the area of doctor/nurse skill mix and the problems of obtaining correct solutions from the perspective of efficiency. It concludes by offering a pragmatic framework which can facilitate decisions in this area. Although this paper is written from the perspective of primary care, it is equally relevant to skill mix in the secondary care sector.

Defining quality of care

This paper defines quality of health care. We suggest that there are two principal dimensions of quality of care for individual patients; access and effectiveness. In essence, do users get the care they need, and is the care effective when they get it? Within effectiveness, we define two key components--effectiveness of clinical care and effectiveness of inter-personal care. These elements are discussed in terms of the structure of the health care system, processes of care, and outcomes resulting from care. The framework relates quality of care to individual patients and we suggest that quality of care is a concept that is at its most meaningful when applied to the individual user of health care. However, care for individuals must placed in the context of providing health care for populations which introduces additional notions of equity and efficiency. We show how this framework can be of practical value by applying the concepts to a set of quality indicators contained within the UK National Performance Assessment Framework and to a set of widely used indicators in the US (HEDIS). In so doing we emphasise the differences between US and UK measures of quality. Using a conceptual framework to describe the totality of quality of care shows which aspects of care any set of quality indicators actually includes and measures and, and which are not included.

Benefit valuation in economic evaluation of cancer therapies. A systematic review of the published literature

Generic measures of benefit which employ individuals' preferences, such as the quality-adjusted life-year (QALY), are, in principle, the most appropriate outcome measure to use in the economic evaluation of cancer therapies. They can reflect the trade-offs between health-related quality of life (HR-QOL) and length of life, between different dimensions of HR-QOL and between the process (e.g. convenience) and outcome characteristics of treatments. This paper reviews the methods literature on preference-based measures of benefit in economic evaluation, with the aim of establishing good practice for applied studies using these methods. A systematic review of applied economic evaluations of cancer therapies which have used these types of benefit measure was performed with the aim of establishing whether studies in this area adhere to good practice. In total, 29 studies were reviewed, and the results showed that, in general, good methods are not being adopted. This may be due, in part, to authors not having the space in journals to detail their methods fully, but it is likely also to reflect the fact that good methods for the use of preference-based measures of benefit in economic evaluation have not been adequately disseminated.

Evidence-informed patient choice. Practical issues of involving patients in decisions about health care technologies

Evidence-informed patient choice involves providing people with research-based information about the effectiveness of health care options and promoting their involvement in decisions about their treatment. Although the concept seems desirable, the processes and outcomes of evidence-informed patient choice are poorly understood, and it should be carefully evaluated.