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Peasgood T, Bailey C, Chen G, De Silva A, De Silva Perera U, Norman R, Shah K, Viney R, Devlin N. Rationale, conceptual issues, and resultant protocol for a mixed methods Person Trade Off (PTO) and qualitative study to estimate and understand the relative value of gains in health for children and young people compared to adults. PLoS One 2024; 19:e0302886. [PMID: 38829857 PMCID: PMC11146702 DOI: 10.1371/journal.pone.0302886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 04/11/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Economic evaluation of healthcare typically assumes that an identical health gain to different patients has the same social value. There is some evidence that the public may give greater value to gains for children and young people, although this evidence is not always consistent. We present a mixed methods study protocol where we aim to explore public preferences regarding health gains to children and young people relative to adults, in an Australian setting. METHODS This study is a Person Trade Off (PTO) choice experiment that incorporates qualitative components. Within the PTO questions, respondents will be asked to choose between treating different groups of patients that may differ in terms of patient characteristics and group size. PTO questions will be included in an online survey to explore respondent views on the relative value of health gains to different age groups in terms of extending life and improving different aspects of quality of life. The survey will also contain attitudinal questions to help understand the impact of question style upon reported preferences. Additionally, the study will test the impact of forcing respondents to express a preference between two groups compared with allowing them to report that the two groups are equivalent. One-to-one 'think aloud', semi-structured interviews will be conducted to explore a sub-sample of respondents' motivations and views in more detail. Focus groups will be conducted with members of the public to discuss the study findings and explore their views on the role of public preferences in health care prioritisation based on patient age. DISCUSSION Our planned study will provide valuable information to healthcare decision makers in Australia who may need to decide whether to pay more for health gains for children and young people compared with adults. Additionally, the methodological test of forcing respondent choice or allowing them to express equivalence will contribute towards developing best practice methods in PTO studies. The rationale for and advantages of the study approach and potential limitations are discussed in the protocol.
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Affiliation(s)
- Tessa Peasgood
- Health Economics Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
- Division of Population Health, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Cate Bailey
- Health Economics Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Gang Chen
- Centre for Health Economics, Monash University, Melbourne, Australia
| | - Ashwini De Silva
- Health Economics Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | | | - Richard Norman
- School of Population Health, Curtin University, Perth, Australia
| | - Koonal Shah
- National Institute for Health and Care Excellence, London, United Kingdom
| | - Rosalie Viney
- Faculty of Health, Centre for Health Economics, Research and Evaluation (CHERE), University of Technology Sydney, Ultimo, Australia
| | - Nancy Devlin
- Health Economics Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
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Johnston KM, Audhya IF, Dunne J, Feeny D, Neumann P, Malone DC, Szabo SM, Gooch KL. Comparing Preferences for Disease Profiles: A Discrete Choice Experiment from a US Societal Perspective. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:343-352. [PMID: 38253973 PMCID: PMC11021240 DOI: 10.1007/s40258-023-00869-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/18/2023] [Indexed: 01/24/2024]
Abstract
OBJECTIVES There is increasing interest in expanding the elements of value to be considered when making health policy decisions. To help inform value frameworks, this study quantified preferences for disease attributes in a general public sample and examined which combination of attributes (disease profiles) are considered most important for research and treatment. METHODS A discrete choice experiment (DCE) was conducted in a US general population sample, recruited through online consumer panels. Respondents were asked to select one of a set of health conditions they believed to be most important, characterized by attributes defined by a previous qualitative study: onset age; cause of disease; life expectancy; caregiver requirement; symptom burden (characterized by the Health Utilities Index with varying levels of ambulation independence, dexterity limitations, and degree of pain and discomfort); and disease prevalence. A fractional factorial DCE design was implemented using R, and 60 choice sets were generated (separated into blocks of 10 per participant). Data were analyzed using a mixed-logit regression model, and results used to assess the likelihood of preferring disease profiles. Based on individual attribute preferences, overall preferences for disease profiles, including a profile aligned with Duchenne muscular dystrophy (DMD), were compared. RESULTS Fifty-two percent of respondents (n = 537) were female, and 70.6% were aged 18-54 years. Attributes considered most important were those related to life expectancy (odds ratio [OR], 95% confidence interval [CI] 1.88 [1.56-2.27] for a 50% reduction in remaining life expectancy vs no impact), and symptom burden (OR [95% CI] 1.84 [1.47-2.31] for severe vs mild burden). Greater importance was also found for pediatric onset, caregiver requirement, and diseases affecting more people. As an example of disease profile preferences, a DMD-like pediatric inherited disease with 50% reduction in life expectancy, extensive caregiver requirement, severe symptom burden, and 1:5000 prevalence had 2.37-fold higher odds of being selected as important versus an equivalent disease with adult onset and no life expectancy reduction. CONCLUSIONS Of disease attributes included in this DCE, respondents valued higher prevalence of disease, life expectancy and symptom burden as most important for prioritizing research and treatment. Based on expressed attribute preferences, a case study of an inherited pediatric disease involving substantial reductions to length and quality of life and requiring caregiver support has relatively high odds of being identified as important compared to diseases reflecting differing attribute profiles. These findings can help inform expansions of value frameworks by identifying important attributes from the societal perspective.
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Affiliation(s)
| | - Ivana F Audhya
- Sarepta Therapeutics, Inc., 215 First Street, Cambridge, MA, USA
| | - Jessica Dunne
- Broadstreet HEOR, 201-343 Railway St., Vancouver, BC, V6A 1A4, Canada
| | | | | | | | - Shelagh M Szabo
- Broadstreet HEOR, 201-343 Railway St., Vancouver, BC, V6A 1A4, Canada
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Bae EY, Lim MK, Lee B, Bae G, Hong J. Public preferences in healthcare resource allocation: A discrete choice experiment in South Korea. Health Policy 2023; 138:104932. [PMID: 37924559 DOI: 10.1016/j.healthpol.2023.104932] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 09/13/2023] [Accepted: 10/15/2023] [Indexed: 11/06/2023]
Abstract
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.
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Affiliation(s)
- Eun-Young Bae
- College of Pharmacy, Gyeongsang National University, Jinju, Republic of Korea; Institute of Pharmacy, Gyeongsang National University, Jinju, Republic of Korea.
| | - Min Kyoung Lim
- Health Insurance Research Institute, National Health Insurance Service, Wonju, Republic of Korea
| | - Boram Lee
- Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
| | - Green Bae
- College of Pharmacy, Ewha Womans University, Seoul, Republic of Korea
| | - Jihyung Hong
- Department of Healthcare Management, College of Social Science, Gachon University, Seongnam-si, Gyeonggi-do, Republic of Korea
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Cadham CJ, Prosser LA. Eliciting Trade-Offs Between Equity and Efficiency: A Methodological Scoping Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:943-952. [PMID: 36805575 DOI: 10.1016/j.jval.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/09/2023] [Accepted: 02/12/2023] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To identify differences in the approaches and results of studies that elicit equity-efficiency trade-offs that can inform equity-informative cost-effectiveness analysis for healthcare resource allocation. METHODS We searched Ovid (Medline), EconLit, and Scopus prior to June 25, 2021. Inclusion criteria were: (1) peer-reviewed or (2) gray literature; (3) published in English; (4) survey-based; (5) parameterized a social welfare function to quantify inequality aversion or (6) elicited a trade-off in equity and efficiency characteristics of health interventions. Exclusion criteria were: (1) studies that did not conduct a trade-off or (2) theoretical studies. We abstracted details on study methods, results, and limitations. Studies were grouped by following approach: (1) social welfare function or (2) preference ranking and distributional weighting. We described findings separately for each approach category. RESULTS Seventy-seven papers were included, 28 parameterized social welfare functions and 49 were classified as preference ranking and distributional weighting. Study methods were heterogeneous. Studies were conducted across 29 countries. Sample sizes and composition, survey methods and question framing varied. Preferences for equity were mixed. Across both approach categories: 39 studies were classified as clear evidence of inequality aversion; 33 found mixed evidence; and 4 had no evidence of aversion. Evidence of between and within-study heterogeneity was found. Preferences for equity may differ by gender, profession, political ideology, income, and education. CONCLUSIONS Substantial variability in study methods limit the direct comparability of findings and their use in equity-informed cost-effectiveness analysis. Future researches using representative samples that explore within and between country heterogeneity is needed.
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Affiliation(s)
- Christopher J Cadham
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA.
| | - Lisa A Prosser
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA; Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, Medical School, University of Michigan, Ann Arbor, MI, USA
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Lee D, McCarthy G, Saeed O, Allen R, Malottki K, Chandler F. The Challenge for Orphan Drugs Remains: Three Case Studies Demonstrating the Impact of Changes to NICE Methods and Processes and Alternative Mechanisms to Value Orphan Products. PHARMACOECONOMICS - OPEN 2023; 7:175-187. [PMID: 36315388 PMCID: PMC10043140 DOI: 10.1007/s41669-022-00378-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The National Institute for Health and Care Excellence (NICE) is responsible for ensuring that patients in England and Wales can access clinically and cost-effective treatments. However, NICE's processes pose significant reimbursement challenges for treatments for rare diseases. While some orphan medicines have been appraised via the highly specialised technology route, most are appraised via the single technology appraisal programme, a route that is expected to be increasingly used given new more restrictive highly specialised technology criteria. This often results in delays to access owing to differences in applicable thresholds and the single technology appraisal approach being ill-equipped to deal with the inevitable decision uncertainty. NICE recently published their updated methods and process manual, which includes a new severity-of-disease modifier and an instruction to be more flexible when considering uncertainty in rare diseases. However, as the threshold gap between the single technology appraisal and highly specialised technology programmes remains, it is unlikely that these changes alone will address the problem. OBJECTIVE We explored the potential impact of quality-adjusted life-year weights in decision making. METHODS We explored the impact of NICE's new severity-of-disease modifier weighting and two alternative methods (the use of alternative quality-adjusted life-year weights and the fair rate of return), using three recent single technology appraisals of orphan medicines (caplacizumab, teduglutide and pirfenidone for mild idiopathic pulmonary fibrosis). RESULTS Our results suggest NICE's severity-of-disease modifier would not have affected the recommendations. Using alternative methods, based upon achievement of an incremental cost-effectiveness ratio below standard thresholds, patients could have received access to caplacizumab approximately 5 months earlier, and the appraisals for teduglutide and pirfenidone would have resulted in a positive recommendation following appraisal consultation meeting 1 when neither of these products was available over 5 years from the initial submission. CONCLUSION Ultimately, moving from a restrictive end-of-life modifier to one based on disease severity is a more equitable approach likely to benefit many therapies, including orphan products. However, NICE's single technology appraisal updates are unlikely to result in faster reimbursement of orphan medicines, nor will they address concerns around market access for orphan medicines in the UK.
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Affiliation(s)
- Dawn Lee
- University of Exeter Medical School, South Cloisters, St Luke's Campus, Exeter, EX1 2LU, UK.
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Powell A, Dolan P. Moving to Personalized Medicine Requires Personalized Health Plans. J Particip Med 2022; 14:e35798. [PMID: 35925669 PMCID: PMC9389374 DOI: 10.2196/35798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/19/2022] [Accepted: 06/22/2022] [Indexed: 11/13/2022] Open
Abstract
When individuals, families, and employers select health plans in the United States, they are typically only shown the financial structure of the plans and their provider networks. This variation in financial structure can lead patients to have health plans aligned with their financial needs, but not with their underlying nonfinancial preferences. Compounding the challenge is the fact that managed care organizations have historically used a combination of population-level budget impact models, cost-effectiveness analyses, medical necessity criteria, and current medical consensus to make coverage decisions. This approach to creating and presenting health plan options does not consider heterogeneity in patient and family preferences and values, as it treats populations as uniform. Similarly, it does not consider that there are some situations in which patients are price-insensitive. We seek to highlight the challenges posed by presenting health plans to patients in strictly financial terms, and to call for more consideration of nonfinancial patient preferences in the health plan design and selection process.
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Affiliation(s)
- Adam Powell
- Payer+Provider Syndicate, Newton, MA, United States
| | - Paul Dolan
- London School of Economics and Political Science, London, United Kingdom
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Card KG, Adshade M, Hogg RS, Jollimore J, Lachowsky NJ. What public health interventions do people in Canada prefer to fund? A discrete choice experiment. BMC Public Health 2022; 22:1178. [PMID: 35698077 PMCID: PMC9189791 DOI: 10.1186/s12889-022-13539-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 05/27/2022] [Indexed: 11/10/2022] Open
Abstract
Objective To assess public support of tailored and targeted public health interventions for marginalized communities. Methods We conducted a discrete choice experiment using a web-based survey advertised to Facebook and Instagram users living in Canada, aged > 16. Participants were asked to choose between funding two hypothetical public health programs. Each program was described by its purpose; expected increase in life expectancy; and target audience. Demographically weighted generalized linear mixed-effects models were constructed to identify program factors associated with program selection. Results Participants completed up to 8 discrete choice comparison exercises each resulting in 23,889 exercises were completed by 3054 participants. Selected programs were less likely to focus on prevention (vs. treatment). For each 1-year increase in the marginal years of life gained, there was a 15% increase in the odds of a program being selected. Interventions tailored to marginalized communities or targeting stigmatized health conditions were less likely to be selected compared to interventions targeted to the general population or targeting chronic health conditions. Noteworthy exceptions included an increased preference for interventions aligning with the perceived needs or cultural expectations for marginalized communities. Conclusions Stigmatizing perceptions of health conditions and key populations likely influence public health programming preferences of Canadians. Public health implications Informational campaigns highlighting disparities experienced by marginalized populations may improve support for targeted and tailored interventions.
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Affiliation(s)
- Kiffer G Card
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada. .,School of Public Health and Social Policy, University of Victoria, Victoria, BC, Canada. .,British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada. .,Community-based Research Centre, Vancouver, BC, Canada.
| | - Marina Adshade
- Vancouver School of Economics, University of British Columbia, Vancouver, BC, Canada
| | - Robert S Hogg
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.,British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | | | - Nathan J Lachowsky
- School of Public Health and Social Policy, University of Victoria, Victoria, BC, Canada.,Community-based Research Centre, Vancouver, BC, Canada
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Quinn KL, Krahn M, Stukel TA, Grossman Y, Goldman R, Cram P, Detsky AS, Bell CM. No Time to Waste: An Appraisal of Value at the End of Life. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:S1098-3015(22)01966-0. [PMID: 35690518 DOI: 10.1016/j.jval.2022.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 04/13/2022] [Accepted: 05/02/2022] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- Kieran L Quinn
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada.
| | - Murray Krahn
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada; Toronto Health Economics and Technology Assessment Collaborative, Toronto, ON, Canada
| | - Thérèse A Stukel
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada
| | - Yona Grossman
- Arts and Science Program, McMaster University, Hamilton, ON, Canada
| | - Russell Goldman
- Interdepartmental Division of Palliative Care, Sinai Health System, Toronto, ON, Canada; Temmy Latner Centre for Palliative Care, Toronto, ON, Canada
| | - Peter Cram
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Allan S Detsky
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Chaim M Bell
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada
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Prados MJ, Liu Y, Jun H, Lam J, Mattke S. Projecting the long-term societal value of a disease-modifying treatment for Alzheimer's disease in the United States. Alzheimers Dement 2022; 18:142-151. [PMID: 35142025 PMCID: PMC9303743 DOI: 10.1002/alz.12578] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/10/2021] [Accepted: 12/10/2021] [Indexed: 11/18/2022]
Abstract
Introduction We estimate societal value of a disease‐modifying Alzheimer's disease (AD) treatment that reduces progression by 30% in early stages. Methods Using the International Society for Pharmacoeconomics and Outcomes Research value flower as framework, we estimate gross societal value, that is, not including treatment cost, from avoided medical and social care costs, productivity and quality‐adjusted life‐years (QALY) gains for patients and caregivers, adjusting for severity of disease, value of financial insurance, and value of insurance for currently unafflicted adults with a Markov model. Results Predicted societal value from 2021 until 2041 is $2.62 trillion for the overall afflicted US population and $986 billion for the 2021 prevalent cohort or $134,418 per person, with valuation of patients’ QALY gains (63%) and avoided nursing‐home costs (20%) as largest components. Delays in access because of health system capacity constraints could reduce realized value between 52% and 69%. The value of insurance for the unafflicted is $4.52 trillion or $18,399 on average per person. Discussion With a total of $5.5 trillion, the projected gross societal value of a hypothetical AD treatment is substantial, which may help to put the cost of treatment into perspective.
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Affiliation(s)
- Maria J Prados
- University of Southern California, Los Angeles, California, USA
| | - Ying Liu
- University of Southern California, Los Angeles, California, USA
| | - Hankyung Jun
- University of Southern California, Los Angeles, California, USA
| | - Jenny Lam
- University of Southern California, Los Angeles, California, USA
| | - Soeren Mattke
- University of Southern California, Los Angeles, California, USA
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Freath LL, Curry AS, Cork DMW, Audhya IF, Gooch KL. QALYs and ambulatory status: societal preferences for healthcare decision making. J Med Econ 2022; 25:888-893. [PMID: 35713217 DOI: 10.1080/13696998.2022.2090152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND This research aimed to review the theoretical and methodological aspects of the quality-adjusted life year (QALY) which give rise to potential for bias against certain patient populations, including those with problems with walking or an inability to walk (ambulatory disabilities), when health technology assessment decisions rely on QALY gain to show cost-effectiveness. Societal preferences for treating ambulatory versus non-ambulatory patients were also investigated. METHODS We reviewed published literature to identify information on theoretical underpinnings of the QALY, measurement of utilities for QALY assessment, and empirical evidence of societal preferences for the treatment of ambulatory and non-ambulatory patients. RESULTS AND DISCUSSION Health states which represent mobility impairment and the inability to walk receive low valuation from general public preferences. Non-ambulatory patients, for example those with advanced neuromuscular disease, have lower utilities determined by standardized preference-based measurement (PBM) tools. Any treatment that increases survival but could not restore ambulation would result in lower lifetime QALY gains for non-ambulatory versus ambulatory patients. Treatments could therefore potentially be deemed less cost-effective, or not cost-effective at all for this patient population.Empirical research indicates a societal preference for equal treatment of patients regardless of ambulatory status. The main limitation of our review was the non-systematic approach to evidence search and review, however, given the broad scope of content required to meet the aims of the review, we believe that the targeted approach was appropriate. The evidence presented in this article highlights the need for alternatives to strict QALY-based approaches to prevent avoidable health inequities when determining cost-effectiveness of healthcare interventions for non-ambulatory populations against fixed cost-effectiveness thresholds. An alternative metric, the Equal Value of Life Years Gained (evLYG), has been proposed as a supplementary measure for use alongside the QALY for its potential to alleviate bias against disabled patient populations during the assessment of healthcare treatments.
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Affiliation(s)
- Lorna L Freath
- Animal and Plant Health, Animal and Plant Health Agency, Newcastle upon Tyne, UK
| | - Alistair S Curry
- Genesis Research, West One, Genesis Research LLC, Newcastle upon Tyne, United Kingdom
| | - David M W Cork
- Genesis Research, West One, Genesis Research LLC, Newcastle upon Tyne, United Kingdom
| | - Ivana F Audhya
- Global Market Access, Sarepta Therapeutics Inc, Cambridge, MA, USA
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Morrell L, Buchanan J, Rees S, Barker RW, Wordsworth S. What Aspects of Illness Influence Public Preferences for Healthcare Priority Setting? A Discrete Choice Experiment in the UK. PHARMACOECONOMICS 2021; 39:1443-1454. [PMID: 34409564 PMCID: PMC8599241 DOI: 10.1007/s40273-021-01067-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 05/03/2023]
Abstract
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.
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Affiliation(s)
- Liz Morrell
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF, UK.
- Oxford-UCL Centre for the Advancement of Sustainable Medical Innovation, Radcliffe Department of Medicine, University of Oxford, Oxford, UK.
| | - James Buchanan
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Sian Rees
- Oxford Academic Health Science Network, Oxford, UK
| | - Richard W Barker
- Oxford-UCL Centre for the Advancement of Sustainable Medical Innovation, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
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Morrell L, Buchanan J, Roope LSJ, Pouwels KB, Butler CC, Hayhoe B, Tonkin-Crine S, McLeod M, Robotham JV, Holmes A, Walker AS, Wordsworth S. Public preferences for delayed or immediate antibiotic prescriptions in UK primary care: A choice experiment. PLoS Med 2021; 18:e1003737. [PMID: 34460825 PMCID: PMC8439451 DOI: 10.1371/journal.pmed.1003737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 09/14/2021] [Accepted: 07/15/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Delayed (or "backup") antibiotic prescription, where the patient is given a prescription but advised to delay initiating antibiotics, has been shown to be effective in reducing antibiotic use in primary care. However, this strategy is not widely used in the United Kingdom. This study aimed to identify factors influencing preferences among the UK public for delayed prescription, and understand their relative importance, to help increase appropriate use of this prescribing option. METHODS AND FINDINGS We conducted an online choice experiment in 2 UK general population samples: adults and parents of children under 18 years. Respondents were presented with 12 scenarios in which they, or their child, might need antibiotics for a respiratory tract infection (RTI) and asked to choose either an immediate or a delayed prescription. Scenarios were described by 7 attributes. Data were collected between November 2018 and February 2019. Respondent preferences were modelled using mixed-effects logistic regression. The survey was completed by 802 adults and 801 parents (75% of those who opened the survey). The samples reflected the UK population in age, sex, ethnicity, and country of residence. The most important determinant of respondent choice was symptom severity, especially for cough-related symptoms. In the adult sample, the probability of choosing delayed prescription was 0.53 (95% confidence interval (CI) 0.50 to 0.56, p < 0.001) for a chesty cough and runny nose compared to 0.30 (0.28 to 0.33, p < 0.001) for a chesty cough with fever, 0.47 (0.44 to 0.50, p < 0.001) for sore throat with swollen glands, and 0.37 (0.34 to 0.39, p < 0.001) for sore throat, swollen glands, and fever. Respondents were less likely to choose delayed prescription with increasing duration of illness (odds ratio (OR) 0.94 (0.92 to 0.96, p < 0.001)). Probabilities of choosing delayed prescription were similar for parents considering treatment for a child (44% of choices versus 42% for adults, p = 0.04). However, parents differed from the adult sample in showing a more marked reduction in choice of the delayed prescription with increasing duration of illness (OR 0.83 (0.80 to 0.87) versus 0.94 (0.92 to 0.96) for adults, p for heterogeneity p < 0.001) and a smaller effect of disruption of usual activities (OR 0.96 (0.95 to 0.97) versus 0.93 (0.92 to 0.94) for adults, p for heterogeneity p < 0.001). Females were more likely to choose a delayed prescription than males for minor symptoms, particularly minor cough (probability 0.62 (0.58 to 0.66, p < 0.001) for females and 0.45 (0.41 to 0.48, p < 0.001) for males). Older people, those with a good understanding of antibiotics, and those who had not used antibiotics recently showed similar patterns of preferences. Study limitations include its hypothetical nature, which may not reflect real-life behaviour; the absence of a "no prescription" option; and the possibility that study respondents may not represent the views of population groups who are typically underrepresented in online surveys. CONCLUSIONS This study found that delayed prescription appears to be an acceptable approach to reducing antibiotic consumption. Certain groups appear to be more amenable to delayed prescription, suggesting particular opportunities for increased use of this strategy. Prescribing choices for sore throat may need additional explanation to ensure patient acceptance, and parents in particular may benefit from reassurance about the usual duration of these illnesses.
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Affiliation(s)
- Liz Morrell
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - James Buchanan
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom
- NIHR Biomedical Research Centre Oxford, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Laurence S. J. Roope
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom
- NIHR Biomedical Research Centre Oxford, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Koen B. Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom
| | - Christopher C. Butler
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom
- Nuffield Department of Primary Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Benedict Hayhoe
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Sarah Tonkin-Crine
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom
- Nuffield Department of Primary Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Monsey McLeod
- NIHR Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
- Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London, United Kingdom
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, United Kingdom
| | - Julie V. Robotham
- Modelling and Economics Unit, National Infection Service, Public Health England, London, United Kingdom
| | - Alison Holmes
- NIHR Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
| | - A. Sarah Walker
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom
- NIHR Biomedical Research Centre Oxford, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
- Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom
- NIHR Biomedical Research Centre Oxford, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
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Baker R, Mason H, McHugh N, Donaldson C. 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. Soc Sci Med 2021; 277:113892. [PMID: 33882440 PMCID: PMC8135121 DOI: 10.1016/j.socscimed.2021.113892] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/18/2021] [Accepted: 03/30/2021] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Rachel Baker
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Scotland, UK.
| | - Helen Mason
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Scotland, UK
| | - Neil McHugh
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Scotland, UK
| | - Cam Donaldson
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Scotland, UK
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Aranda-Reneo I, Rodríguez-Sánchez B, Peña-Longobardo LM, Oliva-Moreno J, López-Bastida J. Can the Consideration of Societal Costs Change the Recommendation of Economic Evaluations in the Field of Rare Diseases? An Empirical Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:431-442. [PMID: 33641778 DOI: 10.1016/j.jval.2020.10.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 09/22/2020] [Accepted: 10/11/2020] [Indexed: 05/27/2023]
Abstract
OBJECTIVES To analyze whether the adoption of a societal perspective would alter the results and conclusions of economic evaluations for rare disease-related healthcare technologies. METHODS A search strategy involving all the active substances considered as orphan drugs by the European Medicines Agency plus a list of 76 rare diseases combined with economic-related terms was conducted on Medline and the Cost-Effectiveness Registry from the beginning of 2000 until November 2018. We included studies that considered quality-adjusted life years as an outcome, were published in a scientific journal, were written in English, included informal care costs or productivity losses, and separated the results according to the applied perspective. RESULTS We found 14 articles that fulfilled the inclusion criteria. Productivity losses were considered in 12 studies, the human capital approach being the method most frequently used. Exclusively, informal care was considered in 2 articles, being valued through the opportunity cost method. The 14 articles selected resulted in 26 economic evaluation estimations, from which incremental cost-utility ratio values changed from cost-effective to dominant in 3 estimates, but the consideration of societal costs only modified the authors' conclusion in 1 study. CONCLUSIONS The presence of societal costs in the economic evaluation of rare diseases did not affect the conclusions of the studies except in a single specific case. In those studies where the societal perspective was considered, we did not find significant changes in the economic evaluation results due to the higher costs of treatments and the low quality-adjusted life-years gained.
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Affiliation(s)
- Isaac Aranda-Reneo
- University of Castilla-La Mancha, Faculty of Social Science, Economics and Finance Department, Talavera de la Reina (Toledo), Spain.
| | - Beatriz Rodríguez-Sánchez
- University of Castilla-La Mancha, Faculty of Social Science, Economics and Finance Department, Talavera de la Reina (Toledo), Spain
| | - Luz María Peña-Longobardo
- University of Castilla-La Mancha, Faculty of Social Science, Economics and Finance Department, Talavera de la Reina (Toledo), Spain
| | - Juan Oliva-Moreno
- University of Castilla-La Mancha, Faculty of Social Science, Economics and Finance Department, Talavera de la Reina (Toledo), Spain
| | - Julio López-Bastida
- University of Castilla-La Mancha, Faculty of Health, Nursing Department, Talavera de la Reina (Toledo), Spain
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Avanceña ALV, Prosser LA. Examining Equity Effects of Health Interventions in Cost-Effectiveness Analysis: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:136-143. [PMID: 33431148 DOI: 10.1016/j.jval.2020.10.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 09/09/2020] [Accepted: 10/06/2020] [Indexed: 05/10/2023]
Abstract
OBJECTIVE This systematic review aims to catalogue and describe published applications of equity-informative cost-effectiveness analysis (CEAs). METHODS Following PRISMA guidelines, we searched Medline for English-language, peer-reviewed CEAs published on or before August 2019. We included CEAs that evaluated 2 or more alternatives; explicitly mentioned equity as a consideration or decision-making principle; and applied an equity-informative CEA method to analyze or examine at least 1 equity criterion in an applied CEA. We extracted data on selected characteristics and analyzed reporting quality using the CHEERS checklist. RESULTS Fifty-four articles identified through a search and bibliography reviews met the inclusion criteria. All articles were published on or after 2010, with 80% published after 2015. Most studies evaluated primary prevention interventions in disease areas such as cancer, infectious diseases, and cardiovascular disease. Equity impact analysis alone was the most common equity-informative CEA (56%), followed by equity impact analysis with financial protection effects (30%). At least 11 different equity criteria have been used in equity-informative CEAs; socioeconomic status and race/ethnicity were used most frequently. Seventy-eight percent of studies reported finding "greater value" in an intervention after examining its distributional effects. CONCLUSION The number of equity-informative CEAs is increasing, and the wide range of equity criteria, diseases, interventions, settings, and populations represented suggests that broad application of these methods is feasible but will require further refinement. Inclusion of equity into CEAs may shift the value of evaluated interventions and can provide crucial additional information for decision makers.
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Affiliation(s)
- Anton L V Avanceña
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA.
| | - Lisa A Prosser
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA; Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics, Medical School, University of Michigan, Ann Arbor, Michigan, USA
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Morrell L, Buchanan J, Roope LSJ, Pouwels KB, Butler CC, Hayhoe B, Moore MV, Tonkin-Crine S, McLeod M, Robotham JV, Walker AS, Wordsworth S. Delayed Antibiotic Prescription by General Practitioners in the UK: A Stated-Choice Study. Antibiotics (Basel) 2020; 9:E608. [PMID: 32947965 PMCID: PMC7558347 DOI: 10.3390/antibiotics9090608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/10/2020] [Accepted: 09/14/2020] [Indexed: 12/15/2022] Open
Abstract
Delayed antibiotic prescription in primary care has been shown to reduce antibiotic consumption, without increasing risk of complications, yet is not widely used in the UK. We sought to quantify the relative importance of factors affecting the decision to give a delayed prescription, using a stated-choice survey among UK general practitioners. Respondents were asked whether they would provide a delayed or immediate prescription in fifteen hypothetical consultations, described by eight attributes. They were also asked if they would prefer not to prescribe antibiotics. The most important determinants of choice between immediate and delayed prescription were symptoms, duration of illness, and the presence of multiple comorbidities. Respondents were more likely to choose a delayed prescription if the patient preferred not to have antibiotics, but consultation length had little effect. When given the option, respondents chose not to prescribe antibiotics in 51% of cases, with delayed prescription chosen in 21%. Clinical features remained important. Patient preference did not affect the decision to give no antibiotics. We suggest that broader dissemination of the clinical evidence supporting use of delayed prescription for specific presentations may help increase appropriate use. Establishing patient preferences regarding antibiotics may help to overcome concerns about patient acceptance. Increasing consultation length appears unlikely to affect the use of delayed prescription.
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Affiliation(s)
- Liz Morrell
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (J.B.); (L.S.J.R.); (K.B.P.); (S.W.)
| | - James Buchanan
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (J.B.); (L.S.J.R.); (K.B.P.); (S.W.)
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
- NIHR Biomedical Research Centre Oxford, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
| | - Laurence S. J. Roope
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (J.B.); (L.S.J.R.); (K.B.P.); (S.W.)
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
- NIHR Biomedical Research Centre Oxford, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
| | - Koen B. Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (J.B.); (L.S.J.R.); (K.B.P.); (S.W.)
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
| | - Christopher C. Butler
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Benedict Hayhoe
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London W2 1PG, UK;
| | - Michael V. Moore
- Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK;
| | - Sarah Tonkin-Crine
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Monsey McLeod
- NIHR Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, Imperial College London, London SW7 2AZ, UK;
- Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London W2 1NY, UK
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London SW7 2AZ, UK
| | - Julie V. Robotham
- Modelling and Economics Unit, National Infection Service, Public Health England, London SE1 8UG, UK;
| | - A. Sarah Walker
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
- NIHR Biomedical Research Centre Oxford, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
- Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (J.B.); (L.S.J.R.); (K.B.P.); (S.W.)
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
- NIHR Biomedical Research Centre Oxford, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
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Afsharmanesh G, Mehralian G, Peiravian F. Attributes Development for Pharmaceutical Subsidization: A Qualitative Study. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH : IJPR 2020; 19:203-217. [PMID: 32922481 PMCID: PMC7462491 DOI: 10.22037/ijpr.2019.15507.13136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Discrete choice experiments (DCES) as a stated preference method have used increasingly to determine preferences attached to some attributes associated to health. Although, the validity of this type of studies comprehensively depends on the appropriate determination of attributes and attribute-levels for DCES, there is little rigorous evidence regarding which factors or attributes and attribute- levels should be counted for eliciting public preferences in health resource allocation. This paper responds to such question by carefully doing a qualitative study. A qualitative study used semi-structured interviews, which were audio recorded, transcribed and subject to thematic analysis. Sixteen participants had been key informants and decision makers of pharmaceutical and health system. Initially, by conducting a meticulous literature review, an inclusive list of attributes associated with intended policy was identified. Qualitative data for the development of attributes and their levels were collected using 16 key informant interviews and were analyzed by software MAXQDA followed by a focus group discussion (FGD) with 7 people, well-familiar with the notion pharmaceutical policy and Pharmacoeconomics. The 311 codes in four main dimensions were initially identified by conducting interviews. However, for being manageable within a DCE, they were classified and limited to four attributes, including severity of disease without treatment, health gain after treatment, frequency of patients, and cost of treatment per patient. This qualitative study provides enough evidence for designing and doing a precise discrete choice experiment answering the question about public preferences in pharmaceutical subsidization and contributes empirical evidence to the limited methodological literature on attributes development for DCE, specifically within low and middle-income countries.
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Affiliation(s)
- Gita Afsharmanesh
- Department of Pharmacoeconomics and Pharma Management, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Gholamhossein Mehralian
- Department of Pharmacoeconomics and Pharma Management, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farzad Peiravian
- Department of Pharmacoeconomics and Pharma Management, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Asada Y, Urquhart R, Brown M, Warner G, McNally M, Murphy A. Troutville: Where People Discuss Fairness Issues. CANADIAN JOURNAL OF BIOETHICS 2020. [DOI: 10.7202/1068765ar] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Context. Public engagement efforts in health policy have posed many value-laden questions, yet those that appreciate the complexity and diversity of the concept of health equity are rare. We introduce the Fairness Dialogues, a new method for deliberating health equity among the general public. We provide its theoretical underpinning and present its empirical illustration and qualitative assessment. Methods. Primarily informed by the scholarship of deliberation, we designed the Fairness Dialogues, featured by reason-giving and inclusive group deliberation using a hypothetical scenario (the town of Troutville) that presents carefully designed, simple, open-ended cases focusing on a chosen equity and fairness issue. To assess whether the Fairness Dialogues encourages reflective views, we conducted a qualitative investigation by focusing on fairness and unfairness of inequalities in life expectancy. Findings. Our results revealed the complex intuitions that people have and their curiosity, patience, and willingness to scrutinize them in-depth through a small group dialogue. Intuitions shared by our study participants are similar to those presented in the scholarly philosophical literature. Conclusions. The Fairness Dialogues is a promising method to incorporate the public’s views into policy-making involving value judgment and to develop the capacity of the public to discuss value-laden questions in a reflective and inclusive manner.
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Affiliation(s)
- Yukiko Asada
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia
| | - Robin Urquhart
- Department of Surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia
| | - Marion Brown
- School of Social Work, Faculty of Health, Dalhousie University, Halifax, Nova Scotia
| | - Grace Warner
- School of Occupational Therapy, Faculty of Health, Dalhousie University, Halifax, Nova Scotia
| | - Mary McNally
- Department of Dental Clinical Sciences, Faculty of Dentistry; Department of Bioethics, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia
| | - Andrea Murphy
- College of Pharmacy, Faculty of Health, Dalhousie University, Halifax, Nova Scotia
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Lancsar E, Gu Y, Gyrd-Hansen D, Butler J, Ratcliffe J, Bulfone L, Donaldson C. The relative value of different QALY types. JOURNAL OF HEALTH ECONOMICS 2020; 70:102303. [PMID: 32061405 DOI: 10.1016/j.jhealeco.2020.102303] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 01/26/2020] [Accepted: 01/29/2020] [Indexed: 05/19/2023]
Abstract
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.
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Affiliation(s)
- Emily Lancsar
- Department of Health Services Research and Policy, Research School of Population Health, Australian National University, Australia.
| | - Yuanyuan Gu
- Centre for the Health Economy, Macquarie University, Australia
| | - Dorte Gyrd-Hansen
- Centre of Health Economics Research, Department of Public Health, University of Southern Denmark, Denmark
| | - Jim Butler
- Health Research Institute, University of Canberra, Australia
| | - Julie Ratcliffe
- Health and Social Care Economics Group, College of Nursing and Health Sciences, Flinders University, Australia
| | | | - Cam Donaldson
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, United Kingdom
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McNamara S, Holmes J, Stevely AK, Tsuchiya A. How averse are the UK general public to inequalities in health between socioeconomic groups? A systematic review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:275-285. [PMID: 31650439 PMCID: PMC7072057 DOI: 10.1007/s10198-019-01126-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 10/07/2019] [Indexed: 05/20/2023]
Abstract
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.
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Affiliation(s)
- Simon McNamara
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK.
| | - John Holmes
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
| | - Abigail K Stevely
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
| | - Aki Tsuchiya
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
- Department of Economics, University of Sheffield, Sheffield, S1 4DA, UK
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Sculpher M, Palmer S. After 20 Years of Using Economic Evaluation, Should NICE be Considered a Methods Innovator? PHARMACOECONOMICS 2020; 38:247-257. [PMID: 31930460 DOI: 10.1007/s40273-019-00882-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The National Institute for Health and Care Excellence (NICE) is only one of several organisations internationally that uses economic evaluation as part of decision making regarding funding and pricing of new medical technologies. However, it can be argued that NICE has developed a more prominent international profile than most in their use of economics. After 20 years of operation, it is timely to assess the extent of NICE's achievements, including the economic evaluation methods it has used and its willingness to adapt these as new evaluative approaches emerge and when NICE faces particular policy challenges. This paper considers some of the important policy and contextual developments in the UK over the last 20 years and how these may have shaped NICE's approach to economic evaluation. It then assesses key areas of NICE methods, including perspective, defining benefits, modelling and uncertainty. The paper concludes that NICE has provided important support for the development of new methods, in particular through its role in identifying priorities for methods research funding and its sponsorship of the NICE Decision Support Unit. However, potentially important developments in methods in a number of important areas have yet to be formally included in NICE's methods guidance and this should be addressed in the Institute's 2019/2020 methods review.
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Affiliation(s)
- Mark Sculpher
- Centre for Health Economics, University of York, York, YO10 5DD, UK.
| | - Stephen Palmer
- Centre for Health Economics, University of York, York, YO10 5DD, UK
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Exploring the relative value of end of life QALYs: Are the comparators important? Soc Sci Med 2020; 245:112660. [DOI: 10.1016/j.socscimed.2019.112660] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 10/30/2019] [Accepted: 11/01/2019] [Indexed: 11/17/2022]
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Pauwels K, Huys I, Casteels M, Denier Y, Vandebroek M, Simoens S. What Does Society Value About Cancer Medicines? A Discrete Choice Experiment in the Belgian Population. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2019; 17:895-902. [PMID: 31359269 PMCID: PMC6885509 DOI: 10.1007/s40258-019-00504-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Debate on pricing and reimbursement of cancer medicines highlights the need to establish the value of cancer medicines. OBJECTIVE This study aims to elicit the trade-offs in cancer medicine characteristics that the Belgian population is willing to make. METHODS A discrete choice experiment used six attributes with three levels each, based on literature and focus group discussions. The survey was sent to a random sample of 3500 Belgian citizens. Based on the choice of 961 respondents, individual parameters were estimated with a mixed logit model. RESULTS Societal value of cancer medicines was positively affected by a higher number of patients eligible for treatment, a high initial life expectancy and quality of life of patients, a high gain in quality of life and life expectancy due to treatment, and a low treatment cost. The value of 1-year gain in life expectancy was independent from the initial life expectancy of the patient. However, the value of one-point gain in quality of life was higher for patients with a low initial quality of life than for patients with a high initial quality of life. CONCLUSIONS This study has shown that gain in quality of life with cancer medicines is valued higher by Belgian society for patients who have lower initial quality of life before the start of treatment.
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Affiliation(s)
- Kim Pauwels
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, P.O. Box 521, Onderwijs en Navorsing 2, Herestraat 49, 3000, Leuven, Belgium
| | - Isabelle Huys
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, P.O. Box 521, Onderwijs en Navorsing 2, Herestraat 49, 3000, Leuven, Belgium
| | - Minne Casteels
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, P.O. Box 521, Onderwijs en Navorsing 2, Herestraat 49, 3000, Leuven, Belgium
| | - Yvonne Denier
- Department of Public Health and Primary Care, KU Leuven, 3000, Leuven, Belgium
| | | | - Steven Simoens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, P.O. Box 521, Onderwijs en Navorsing 2, Herestraat 49, 3000, Leuven, Belgium.
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Disentangling public preferences for health gains at end-of-life: Further evidence of no support of an end-of-life premium. Soc Sci Med 2019; 236:112375. [DOI: 10.1016/j.socscimed.2019.112375] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 05/24/2019] [Accepted: 06/17/2019] [Indexed: 11/20/2022]
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Drummond MF, Neumann PJ, Sullivan SD, Fricke FU, Tunis S, Dabbous O, Toumi M. Analytic Considerations in Applying a General Economic Evaluation Reference Case to Gene Therapy. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:661-668. [PMID: 31198183 DOI: 10.1016/j.jval.2019.03.012] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/22/2019] [Accepted: 03/25/2019] [Indexed: 05/05/2023]
Abstract
The concept of a reference case, first proposed by the US Panel on Cost-Effectiveness in Health and Medicine, has been used to specify the required methodological features of economic evaluations of healthcare interventions. In the case of gene therapy, there is a difference of opinion on whether a specific methodological reference case is required. The aim of this article was to provide a more detailed analysis of the characteristics of gene therapy and the extent to which these characteristics warrant modifications to the methods suggested in general reference cases for economic evaluation. We argue that a completely new reference case is not required, but propose a tailored checklist that can be used by analysts and decision makers to determine which aspects of economic evaluation should be considered further, given the unique nature of gene therapy.
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Affiliation(s)
| | - Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, USA
| | - Sean D Sullivan
- CHOICE Institute, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Frank-Ulrich Fricke
- Fakultät Betriebswirtschaft, Technische Hochschule Nürnberg Georg Simon Ohm, Nürnberg, Germany
| | - Sean Tunis
- Center for Medical Technology Policy, Baltimore, MD, USA
| | | | - Mondher Toumi
- Public Health Department, Aix-Marseille University, Marseille, France
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Retzler J, Davies H, Jenks M, Kiff C, Taylor M. The impact of increased post-progression survival on the cost-effectiveness of interventions in oncology. CLINICOECONOMICS AND OUTCOMES RESEARCH 2019; 11:309-324. [PMID: 31118714 PMCID: PMC6504552 DOI: 10.2147/ceor.s191382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 03/08/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose: Cost-effectiveness analyses (CEA) of new technologies typically include “background” costs (eg, all “related” health care costs other than the specific technology under evaluation) as well as drug costs. In oncology, these are often expensive. The marginal cost-effectiveness ratio (ie, the extra costs and QALYs associated with each extra period of survival) calculates the ratio of background costs to QALYs during post-progression. With high background costs, the incremental cost-effectiveness ratio (ICER) can become less favorable as survival increases and the ICER moves closer to the marginal cost-effectiveness ratio, making cost-effectiveness prohibitive. This study assessed different methods to determine whether high ICERs are caused by high drug costs, high “background costs” or a combination of both and how different approaches can alter the impact of background costs on the ICER where the marginal cost-effectiveness ratio is close to, or above, the cost-effectiveness threshold. Methods: The National Institute for Health and Care Excellence oncology technology appraisals published or updated between October 2012 and October 2017 were reviewed. A case study was selected, and the CEA was replicated. Three modeling approaches were tested on the case study model. Results: Applying one-off “transition” costs during post-progression reduced the ongoing “incremental” costs of survival, which meant that the marginal cost-effectiveness ratio was substantially reduced and problems associated with additional survival were less likely to impact the ICER. Similarly, the use of two methods of additional utility weighting for end-of-life cases meant that the marginal cost-effectiveness ratio was reduced proportionally, again lessening the impact of increased survival. Conclusion: High ICERs can be caused by factors other than the cost of the drug being assessed. The economic models should be correct and valid, reflecting the true nature of marginal survival. Further research is needed to assess how alternative approaches to the measurement and application of background costs and benefits may provide an accurate assessment of the incremental benefits of life-extending oncology drugs. If marginal survival costs are incorrectly calculated (ie, by summing total post-progressed costs and dividing by the number of baseline months in that state), then the costs of marginal survival are likely to be overstated in economic models.
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Affiliation(s)
- Jenny Retzler
- Department of Psychology, University of Huddersfield, Huddersfield, UK.,York Health Economics Consortium, University of York, York, UK
| | - Heather Davies
- York Health Economics Consortium, University of York, York, UK
| | - Michelle Jenks
- York Health Economics Consortium, University of York, York, UK
| | | | - Matthew Taylor
- York Health Economics Consortium, University of York, York, UK
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Jönsson B, Hampson G, Michaels J, Towse A, von der Schulenburg JMG, Wong O. Advanced therapy medicinal products and health technology assessment principles and practices for value-based and sustainable healthcare. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:427-438. [PMID: 30229376 PMCID: PMC6438935 DOI: 10.1007/s10198-018-1007-x] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 09/11/2018] [Indexed: 05/05/2023]
Abstract
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.
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Affiliation(s)
- Bengt Jönsson
- Department of Economics, Stockholm School of Economics, Stockholm, Sweden.
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Caro JJ, Brazier JE, Karnon J, Kolominsky-Rabas P, McGuire AJ, Nord E, Schlander M. Determining Value in Health Technology Assessment: Stay the Course or Tack Away? PHARMACOECONOMICS 2019; 37:293-299. [PMID: 30414074 PMCID: PMC6386014 DOI: 10.1007/s40273-018-0742-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
The economic evaluation of new health technologies to assess whether the value of the expected health benefits warrants the proposed additional costs has become an essential step in making novel interventions available to patients. This assessment of value is problematic because there exists no natural means to measure it. One approach is to assume that society wishes to maximize aggregate health, measured in terms of quality-adjusted life-years (QALYs). Commonly, a single 'cost-effectiveness' threshold is used to gauge whether the intervention is sufficiently efficient in doing so. This approach has come under fire for failing to account for societal values that favor treating more severe illness and ensuring equal access to resources, regardless of pre-existing conditions or capacity to benefit. Alternatives involving expansion of the measure of benefit or adjusting the threshold have been proposed and some have advocated tacking away from the cost per QALY entirely to implement therapeutic area-specific efficiency frontiers, multicriteria decision analysis or other approaches that keep the dimensions of benefit distinct and value them separately. In this paper, each of these alternative courses is considered, based on the experiences of the authors, with a view to clarifying their implications.
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Affiliation(s)
- J Jaime Caro
- London School of Economics and Political Science, London, UK.
- Evidera, Waltham, MA, USA.
- , 39 Bypass Road, Lincoln, MA, 01773, USA.
| | - John E Brazier
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jonathan Karnon
- School of Public Health, University of Adelaide, Adelaide, SA, Australia
| | - Peter Kolominsky-Rabas
- Interdisciplinary Centre for Health Technology Assessment and Public Health, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | | | - Erik Nord
- Norwegian Institute of Public Health, Oslo, Norway
| | - Michael Schlander
- Division of Health Economics, German Cancer Research Center (DKFZ), University of Heidelberg, Heidelberg, Germany
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Soekhai V, de Bekker-Grob EW, Ellis AR, Vass CM. Discrete Choice Experiments in Health Economics: Past, Present and Future. PHARMACOECONOMICS 2019; 37:201-226. [PMID: 30392040 PMCID: PMC6386055 DOI: 10.1007/s40273-018-0734-2] [Citation(s) in RCA: 393] [Impact Index Per Article: 78.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Discrete choice experiments (DCEs) are increasingly advocated as a way to quantify preferences for health. However, increasing support does not necessarily result in increasing quality. Although specific reviews have been conducted in certain contexts, there exists no recent description of the general state of the science of health-related DCEs. The aim of this paper was to update prior reviews (1990-2012), to identify all health-related DCEs and to provide a description of trends, current practice and future challenges. METHODS A systematic literature review was conducted to identify health-related empirical DCEs published between 2013 and 2017. The search strategy and data extraction replicated prior reviews to allow the reporting of trends, although additional extraction fields were incorporated. RESULTS Of the 7877 abstracts generated, 301 studies met the inclusion criteria and underwent data extraction. In general, the total number of DCEs per year continued to increase, with broader areas of application and increased geographic scope. Studies reported using more sophisticated designs (e.g. D-efficient) with associated software (e.g. Ngene). The trend towards using more sophisticated econometric models also continued. However, many studies presented sophisticated methods with insufficient detail. Qualitative research methods continued to be a popular approach for identifying attributes and levels. CONCLUSIONS The use of empirical DCEs in health economics continues to grow. However, inadequate reporting of methodological details inhibits quality assessment. This may reduce decision-makers' confidence in results and their ability to act on the findings. How and when to integrate health-related DCE outcomes into decision-making remains an important area for future research.
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Affiliation(s)
- Vikas Soekhai
- Section of Health Technology Assessment (HTA) and Erasmus Choice Modelling Centre (ECMC), Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam (EUR), P.O. Box 1738, Rotterdam, 3000 DR The Netherlands
- Department of Public Health, Erasmus MC, University Medical Center, P.O. Box 2040, Rotterdam, 3000 CA The Netherlands
| | - Esther W. de Bekker-Grob
- Section of Health Technology Assessment (HTA) and Erasmus Choice Modelling Centre (ECMC), Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam (EUR), P.O. Box 1738, Rotterdam, 3000 DR The Netherlands
| | - Alan R. Ellis
- Department of Social Work, North Carolina State University, Raleigh, NC USA
| | - Caroline M. Vass
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
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Rowen D, Mulhern B, Stevens K, Vermaire JH. Estimating a Dutch Value Set for the Pediatric Preference-Based CHU9D Using a Discrete Choice Experiment with Duration. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:1234-1242. [PMID: 30314625 DOI: 10.1016/j.jval.2018.03.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 02/13/2018] [Accepted: 03/19/2018] [Indexed: 05/20/2023]
Abstract
OBJECTIVE This article presents the development of the Dutch value set for the Child Health Utility 9D, a pediatric preference-based measure of quality of life that can be used to generate quality-adjusted life-years. METHODS A large online survey was conducted using a discrete choice experiment including a duration attribute with adult members of the Netherlands general population (N = 1276) who were representative in terms of age, gender, marital status, employment, education, and region. Respondents were asked which of two health states they prefer, where each health state was described using the nine dimensions of the Child Health Utility 9D (worried, sad, pain, tired, annoyed, school work/homework, sleep, daily routine, able to join in activities) and duration. The data were modeled using conditional logit with robust standard errors to produce utility values for every health state described by the Child Health Utility 9D. RESULTS The majority of the dimension level coefficients were monotonic, leading to a decrease in utility as severity increases. There was, however, evidence of some logical inconsistencies, particularly for the school work/homework dimension. The value set produced was based on the ordered model and ranges from -0.568 for the worst state to 1 for the best state. CONCLUSION The valuation of the Child Health Utility 9D using online discrete choice experiment with duration with adult members of the Dutch general population was feasible and produced a valid model for use in cost utility analysis. Normative questions are raised around the valuation of pediatric preference-based measures, including the appropriate perspective for imagining hypothetical pediatric health states.
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Affiliation(s)
- Donna Rowen
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK.
| | - Brendan Mulhern
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, NSW, Australia
| | - Katherine Stevens
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Jan Hendrik Vermaire
- TNO Child Health, Oral Health Division, Leiden, The Netherlands; Centrum voor Tandheelkunde en Mondzorgkunde, University of Groningen, Groningen, The Netherlands
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Reckers-Droog V, van Exel N, Brouwer W. Looking back and moving forward: On the application of proportional shortfall in healthcare priority setting in the Netherlands. Health Policy 2018; 122:621-629. [DOI: 10.1016/j.healthpol.2018.04.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 03/27/2018] [Accepted: 04/01/2018] [Indexed: 11/24/2022]
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Valuing health at the end of life: A review of stated preference studies in the social sciences literature. Soc Sci Med 2018; 204:39-50. [DOI: 10.1016/j.socscimed.2018.03.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 02/26/2018] [Accepted: 03/05/2018] [Indexed: 11/17/2022]
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Round J, Paulden M. Incorporating equity in economic evaluations: a multi-attribute equity state approach. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2018; 19:489-498. [PMID: 28573333 PMCID: PMC5913380 DOI: 10.1007/s10198-017-0897-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 05/11/2017] [Indexed: 05/29/2023]
Abstract
In publicly funded health care systems, decision makers must continually balance often conflicting priorities of efficiency and equity. Health economists have developed a set of highly sophisticated analytical methods for assessing efficiency, but less attention has been paid to formally incorporating equity considerations into analyses. As a result, where equity is considered is often informal, ad hoc and/or simplistic. This paper is a proposal for a mechanism for formally incorporating equity within the decision process. It begins with an overview of the current literature on equity weighting. It then considers the case of a single equity domain and illustrates how this is currently applied in practice by the UK's National Institute for Health and Care Excellence. It then proposes a more comprehensive method for considering the multi-attribute equity state, where a population exhibits more than one trait considered worthy of differential weighting. Finally, the paper proposes a mechanism by which this could be applied in practice, and concludes with a discussion of the challenges for applying multi-attribute equity weighting.
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Affiliation(s)
- Jeff Round
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Mike Paulden
- School of Public Health, University of Alberta, Edmonton, Canada
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Campillo-Artero C, Puig-Junoy J, Culyer AJ. Does MCDA Trump CEA? APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2018; 16:147-151. [PMID: 29468578 DOI: 10.1007/s40258-018-0373-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Carlos Campillo-Artero
- Center for Research in Health and Economics, Pompeu Fabra University, carrer Ramon Trias Fargas 25-27, 08005, Barcelona, Spain
| | - Jaume Puig-Junoy
- Center for Research in Health and Economics, Pompeu Fabra University, carrer Ramon Trias Fargas 25-27, 08005, Barcelona, Spain.
- Department of Economics and Business, Pompeu Fabra University, Ramon Trias Fargas 25-27, 08005, Barcelona, Spain.
| | - Anthony J Culyer
- Center for Health Economics, Department of Economics and Related Studies, University of York, York, YO10 5DD, UK
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Lakdawalla DN, Doshi JA, Garrison LP, Phelps CE, Basu A, Danzon PM. Defining Elements of Value in Health Care-A Health Economics Approach: An ISPOR Special Task Force Report [3]. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:131-139. [PMID: 29477390 DOI: 10.1016/j.jval.2017.12.007] [Citation(s) in RCA: 296] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 12/07/2017] [Indexed: 05/21/2023]
Abstract
The third section of our Special Task Force report identifies and defines a series of elements that warrant consideration in value assessments of medical technologies. We aim to broaden the view of what constitutes value in health care and to spur new research on incorporating additional elements of value into cost-effectiveness analysis (CEA). Twelve potential elements of value are considered. Four of them-quality-adjusted life-years, net costs, productivity, and adherence-improving factors-are conventionally included or considered in value assessments. Eight others, which would be more novel in economic assessments, are defined and discussed: reduction in uncertainty, fear of contagion, insurance value, severity of disease, value of hope, real option value, equity, and scientific spillovers. Most of these are theoretically well understood and available for inclusion in value assessments. The two exceptions are equity and scientific spillover effects, which require more theoretical development and consensus. A number of regulatory authorities around the globe have shown interest in some of these novel elements. Augmenting CEA to consider these additional elements would result in a more comprehensive CEA in line with the "impact inventory" of the Second Panel on Cost-Effectiveness in Health and Medicine. Possible approaches for valuation and inclusion of these elements include integrating them as part of a net monetary benefit calculation, including elements as attributes in health state descriptions, or using them as criteria in a multicriteria decision analysis. Further research is needed on how best to measure and include them in decision making.
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Affiliation(s)
- Darius N Lakdawalla
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA.
| | - Jalpa A Doshi
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Louis P Garrison
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA, USA
| | - Charles E Phelps
- Economics, Public Health Sciences, Political Science, University of Rochester, Gualala, CA, USA
| | - Anirban Basu
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA, USA
| | - Patricia M Danzon
- The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
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McHugh N, van Exel J, Mason H, Godwin J, Collins M, Donaldson C, Baker R. Are life-extending treatments for terminal illnesses a special case? Exploring choices and societal viewpoints. Soc Sci Med 2018; 198:61-69. [PMID: 29276987 PMCID: PMC5884317 DOI: 10.1016/j.socscimed.2017.12.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 12/12/2017] [Accepted: 12/15/2017] [Indexed: 11/13/2022]
Abstract
Criteria used by the National Institute for Health and Care Excellence (NICE) to assess life-extending, end-of-life (EoL) treatments imply that health gains from such treatments are valued more than other health gains. Despite claims that the policy is supported by societal values, evidence from preference elicitation studies is mixed and in-depth research has shown there are different societal viewpoints. Few studies elicit preferences for policies directly or combine different approaches to understand preferences. Survey questions were designed to investigate support for NICE EoL guidance at national and regional levels. These 'Decision Rule' and 'Treatment Choice' questions were administered to an online sample of 1496 UK respondents in May 2014. The same respondents answered questions designed to elicit their agreement with three viewpoints (previously identified and described) in relation to provision of EoL treatments for terminally ill patients. We report the findings of these choice questions and examine how they relate to each other and respondents' viewpoints. The Decision Rule questions described three policies: DA - a standard 'value for money' test, applied to all health technologies; DB - giving special consideration to all treatments for terminal illnesses; and DC - giving special consideration to specific categories of treatments for terminal illnesses e.g. life extension (as in NICE EoL guidance) or those that improve quality-of-life (QoL). Three Treatment Choices were presented: TA - improving QoL for patients with a non-terminal illness; TB - extending life for EoL patients; and TC - improving QoL at the EoL. DC received most support (45%) with most respondents giving special consideration to EoL only when treatments improved QoL. The most commonly preferred treatment choices were TA (51%) and TC (43%). Overall, this study challenges claims about public support for NICE's EoL guidance and the focus on life extension at EoL and substantiates existing evidence of plurality in societal values.
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Affiliation(s)
- Neil McHugh
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, United Kingdom.
| | - Job van Exel
- Institute of Health Policy & Management and Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Helen Mason
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, United Kingdom
| | - Jon Godwin
- Institutes for Applied Health Research and Society & Social Justice Research, School of Health and Life Sciences, Glasgow Caledonian University, United Kingdom
| | - Marissa Collins
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, United Kingdom
| | - Cam Donaldson
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, United Kingdom
| | - Rachel Baker
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, United Kingdom
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Gyrd-Hansen D. Is there additional value attached to health gains at the end of life? A revisit. HEALTH ECONOMICS 2018; 27:e71-e75. [PMID: 28568843 DOI: 10.1002/hec.3534] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 02/17/2017] [Accepted: 05/03/2017] [Indexed: 05/19/2023]
Abstract
Researchers have in recent years sought to establish whether the general public value treatment at the end of life (EOL) more highly than other treatments. Results are mixed, with social preferences most often exhibiting lack of preferences for EOL treatments. This null result may be driven by the often applied study design, where respondents are to choose between treatments targeting patients with varying fixed life expectancies. When remaining life is certain and salient, a rule-of-rescue sentiment may drive preferences across all scenarios. This study presents a different design, where the comparator is a preventive intervention. We study preferences from both an individual and social perspective and find no preference for an EOL premium.
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Affiliation(s)
- Dorte Gyrd-Hansen
- Department of Business and Economics & Department of Public Health, University of Southern Denmark, Odense, Denmark
- Department of Community Medicine, University of Tromsø, Norway
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Morrell L, Ii SS, Wordsworth S, Wilson R, Rees S, Barker R. Cancer as the "perfect storm"? A qualitative study of public attitudes to health conditions. Health Sci Rep 2017; 1:e16. [PMID: 30024988 PMCID: PMC6034427 DOI: 10.1002/hsr2.16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 09/14/2017] [Accepted: 09/15/2017] [Indexed: 11/06/2022] Open
Abstract
Aims Our aim is to identify important attributes of major diseases that shape how they are perceived by the public. Methods and Results Four focus groups among members of the public were recruited, in March and October 2016, and used semistructured discussion to explore important attributes of cancer, heart disease, stroke, dementia, mental illness, and infectious disease. Common themes were identified by using inductive thematic analysis.Five themes were identified: fear, impact on family and friends, hope, detection, and prevention. Fear of cancer includes not only fear of death but also of aggressive treatments. Loss of dignity is feared in dementia, while infectious disease raises fear of uncontrollable "plague"; in contrast, people with mental illness may themselves be seen as a potential threat. The impact of cancer and its treatment on family and friends was described as intense and all-consuming, even for those not involved directly in caring; with dementia and stroke, the family impact is taking on care, including funding, over the long term with little expectation of improvement. Hope is a major theme in cancer and stroke recovery, linked with the need to take action, often expressed in aggressive language of "fighting," but seen as futile in dementia. Detection difficulties for "silent" cancers mean that real treatment opportunities are missed; cardiovascular and infection risk, however, are seen as easy to identify and act on, whereas mental illness and dementia are seen as poorly diagnosed and with limited treatment options. Prevention awareness is high for cardiovascular disease and infection, lower for cancer, and limited for dementia and mental health. Conclusion Although themes overlap across diseases, the specific concerns are different and each condition has a unique profile. Quantifying the relative importance of these themes could allow their incorporation in decision-making, not only when they occur as a named disease but also in any relevant condition.
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Affiliation(s)
- Liz Morrell
- Oxford-UCL Centre for the Advancement of Sustainable Medical Innovation (CASMI), Radcliffe Department of Medicine University of Oxford Oxford UK
| | - Suzanne Sayuri Ii
- Oxford-UCL Centre for the Advancement of Sustainable Medical Innovation (CASMI), Radcliffe Department of Medicine University of Oxford Oxford UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health University of Oxford Oxford UK.,Oxford NIHR Biomedical Research Centre University of Oxford Oxford UK
| | - Roger Wilson
- National Cancer Research Institute Consumer Forum London UK
| | - Sian Rees
- Health Experiences Institute, Nuffield Department of Primary Care Health Sciences University of Oxford Oxford UK
| | - Richard Barker
- Oxford-UCL Centre for the Advancement of Sustainable Medical Innovation (CASMI), Radcliffe Department of Medicine University of Oxford Oxford UK
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Morrell L, Wordsworth S, Rees S, Barker R. Does the Public Prefer Health Gain for Cancer Patients? A Systematic Review of Public Views on Cancer and its Characteristics. PHARMACOECONOMICS 2017; 35:793-804. [PMID: 28455834 PMCID: PMC5548817 DOI: 10.1007/s40273-017-0511-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
BACKGROUND Policies such as the Cancer Drugs Fund in England assumed a societal preference to fund cancer care relative to other conditions, even if that resulted in lower health gain for the population overall. OBJECTIVE The aim of this study was to investigate the evidence for such a preference among the UK public. METHODS The MEDLINE, PubMed and Econlit electronic databases were searched for studies relating to preferences for prioritising cancer treatment, as well as studies relating to preferences for the characteristics of cancer (severity of disease, end-of-life). The searches were run in November 2015 and updated in March 2017. Empirical preference studies, studies of public views, and studies in English were included. RESULTS We identified 24 studies relating to cancer preferences. Two directly addressed health trade-offs in the UK-one showed a preference for health gain in cancer, while the other found no such preference but provided results consistent with population health maximisation. Other studies mostly showed support for cancer but did not require a direct health trade-off. Severity and end-of-life searches identified 12 and 6 papers, respectively, which were additional to existing reviews. There is consistent evidence that people give priority to severe illness, while results for end-of-life are mixed. CONCLUSION We did not find consistent support for a preference for health gains to cancer patients in the context of health maximisation. The evidence base is small and the results are highly sensitive to study design. There remains a contradiction between these findings and the popular view of cancer, and further work is required to determine the features of cancer which contribute to that view.
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Affiliation(s)
- Liz Morrell
- Centre for the Advancement of Sustainable Medical Innovation (CASMI), University of Oxford, Room 4403, Level 4, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK.
| | - Sarah Wordsworth
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
- Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Sian Rees
- Nuffield Department of Primary Care Health Sciences, Health Experiences Institute, University of Oxford, Oxford, UK
| | - Richard Barker
- Centre for the Advancement of Sustainable Medical Innovation (CASMI), University of Oxford, Room 4403, Level 4, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK
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Ali S, Tsuchiya A, Asaria M, Cookson R. How Robust Are Value Judgments of Health Inequality Aversion? Testing for Framing and Cognitive Effects. Med Decis Making 2017; 37:635-646. [PMID: 28441098 DOI: 10.1177/0272989x17700842] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Empirical studies have found that members of the public are inequality averse and value health gains for disadvantaged groups with poor health many times more highly than gains for better off groups. However, these studies typically use abstract scenarios that involve unrealistically large reductions in health inequality and face-to-face survey administration. It is not known how robust these findings are to more realistic scenarios or anonymous online survey administration. METHODS This study aimed to test the robustness of questionnaire estimates of inequality aversion by comparing the following: 1) small versus unrealistically large health inequality reductions, 2) population-level versus individual-level descriptions of health inequality reductions, 3) concrete versus abstract intervention scenarios, and 4) online versus face-to-face mode of administration. Fifty-two members of the public participated in face-to-face discussion groups, while 83 members of the public completed an online survey. Participants were given a questionnaire instrument with different scenario descriptions for eliciting aversion to social inequality in health. RESULTS The median respondent was inequality averse under all scenarios. Scenarios involving small rather than unrealistically large health gains made little difference in terms of inequality aversion, as did population-level rather than individual-level scenarios. However, the proportion expressing extreme inequality aversion fell 19 percentage points when considering a specific health intervention scenario rather than an abstract scenario and was 11 to 21 percentage points lower among online public respondents compared with the discussion group. CONCLUSIONS Our study suggests that both concrete scenarios and online administration reduce the proportion expressing extreme inequality aversion but still yield median responses that imply substantial health inequality aversion.
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Affiliation(s)
- Shehzad Ali
- Centre for Health Economics and Department of Health Sciences, University of York, York, Heslington, UK (SA)
| | - Aki Tsuchiya
- University of Sheffield School of Health and Related Research (ScHARR), and Department of Economics, University of Sheffield, Sheffield, England, UK (AT)
| | - Miqdad Asaria
- Centre for Health Economics, University of York, York, Heslington, UK (MA, RC)
| | - Richard Cookson
- Centre for Health Economics, University of York, York, Heslington, UK (MA, RC)
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Cookson R, Mirelman AJ, Griffin S, Asaria M, Dawkins B, Norheim OF, Verguet S, J Culyer A. Using Cost-Effectiveness Analysis to Address Health Equity Concerns. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:206-212. [PMID: 28237196 PMCID: PMC5340318 DOI: 10.1016/j.jval.2016.11.027] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 11/09/2016] [Accepted: 11/28/2016] [Indexed: 05/22/2023]
Abstract
This articles serves as a guide to using cost-effectiveness analysis (CEA) to address health equity concerns. We first introduce the "equity impact plane," a tool for considering trade-offs between improving total health-the objective underpinning conventional CEA-and equity objectives, such as reducing social inequality in health or prioritizing the severely ill. Improving total health may clash with reducing social inequality in health, for example, when effective delivery of services to disadvantaged communities requires additional costs. Who gains and who loses from a cost-increasing health program depends on differences among people in terms of health risks, uptake, quality, adherence, capacity to benefit, and-crucially-who bears the opportunity costs of diverting scarce resources from other uses. We describe two main ways of using CEA to address health equity concerns: 1) equity impact analysis, which quantifies the distribution of costs and effects by equity-relevant variables, such as socioeconomic status, location, ethnicity, sex, and severity of illness; and 2) equity trade-off analysis, which quantifies trade-offs between improving total health and other equity objectives. One way to analyze equity trade-offs is to count the cost of fairer but less cost-effective options in terms of health forgone. Another method is to explore how much concern for equity is required to choose fairer but less cost-effective options using equity weights or parameters. We hope this article will help the health technology assessment community navigate the practical options now available for conducting equity-informative CEA that gives policymakers a better understanding of equity impacts and trade-offs.
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Affiliation(s)
| | | | - Susan Griffin
- Centre for Health Economics, University of York, York, UK
| | - Miqdad Asaria
- Centre for Health Economics, University of York, York, UK
| | - Bryony Dawkins
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Ole Frithjof Norheim
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Stéphane Verguet
- Department of Global Health and Population, Harvard University, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Sculpher M, Claxton K, Pearson SD. Developing a Value Framework: The Need to Reflect the Opportunity Costs of Funding Decisions. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:234-239. [PMID: 28237201 DOI: 10.1016/j.jval.2016.11.021] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 11/20/2016] [Accepted: 11/22/2016] [Indexed: 05/24/2023]
Abstract
A growing number of health care systems internationally use formal economic evaluation methods to support health care funding decisions. Recently, a range of organizations have been advocating forms of analysis that have been termed "value frameworks." There has also been a push for analytical methods to reflect a fuller range of benefits of interventions through multicriteria decision analysis. A key principle that is invariably neglected in current and proposed frameworks is the need to reflect evidence on the opportunity costs that health systems face when making funding decisions. The mechanisms by which opportunity costs are realized vary depending on the system's financial arrangements, but they always mean that a decision to fund a specific intervention for a particular patient group has the potential to impose costs on others in terms of forgone benefits. These opportunity costs are rarely explicitly reflected in analysis to support decisions, but recent developments to quantify benefits forgone make more appropriate analyses feasible. Opportunity costs also need to be reflected in decisions if a broader range of attributes of benefit is considered, and opportunity costs are a key consideration in determining the appropriate level of total expenditure in a system. The principles by which opportunity costs can be reflected in analysis are illustrated in this article by using the example of the proposed methods for value-based pricing in the United Kingdom.
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Affiliation(s)
- Mark Sculpher
- Centre for Health Economics, University of York, York, UK.
| | - Karl Claxton
- Centre for Health Economics, University of York, York, UK; Department of Economics, University of York, York, UK
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Rowen D, Brazier J, Keetharuth A, Tsuchiya A, Mukuria C. Comparison of Modes of Administration and Alternative Formats for Eliciting Societal Preferences for Burden of Illness. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2016; 14:89-104. [PMID: 26445967 PMCID: PMC4740557 DOI: 10.1007/s40258-015-0197-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND Proposals for value-based assessment, made by the National Institute of Health and Care Excellence (NICE) in the UK, recommended that burden of illness (BOI) should be used to weight QALY gain. This paper explores some of the methodological issues in eliciting societal preferences for BOI. AIMS This study explores the impact of mode of administration and framing in a survey for eliciting societal preferences for BOI. METHODS A pairwise comparison survey with six arms was conducted online and via face-to-face interviews, involving two different wordings of questions and the inclusion/exclusion of pictures. Respondents were asked which of two patient groups they thought a publically funded health service should treat, where the groups varied by life expectancy without treatment, health-related quality of life (HRQOL) without treatment, survival gain from treatment, and HRQOL gain from treatment. Responses across different modes of administration, wording and use of pictures were compared using chi-squared tests and probit regression analysis controlling for respondent socio-demographic characteristics. RESULTS The sample contained 371 respondents: 69 were interviewed and 302 completed the questionnaire online. There were some differences in socio-demographic characteristics across the online and interview samples. Online respondents were less likely to choose the group with higher BOI and more likely to treat those with a higher QALY gain, but there were no statistically significant differences by wording or the inclusion of pictures for the majority of questions. Regression analysis confirmed these results. Respondents chose to treat the group with larger treatment gain, but there was little support for treating the group with higher BOI. Respondents also preferred to treat the group with treatment gains in life expectancy rather than HRQOL. CONCLUSIONS Mode of administration did impact on responses, whereas question wording and pictures did not impact on responses, even after controlling for the socio-demographic characteristics of respondents in the regression analysis.
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Affiliation(s)
- Donna Rowen
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - John Brazier
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.
| | - Anju Keetharuth
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Aki Tsuchiya
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
- Department of Economics, University of Sheffield, Sheffield, UK
| | - Clara Mukuria
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
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