Making use of equity sensitive QALYs: a case study on identifying the worse off across diseases

Appraising Drugs Based on Cost-effectiveness and Severity of Disease in Norwegian Drug Coverage Decisions

IMPORTANCE

Rising health care costs are a major health policy challenge globally. Norway has implemented a priority-setting system intended to balance cost-effectiveness and concerns for fair distribution, but little is known about this strategy and whether it works in practice.

OBJECTIVE

To present and evaluate a systematic drug appraisal method that uses the severity of disease to account for a fair distribution of health in cost-effectiveness analysis, forming the basis for price negotiations and coverage decisions.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study uses confidential drug price information and publicly available data from health technology assessments and logistic and linear regression analyses to evaluate drug coverage decisions for the Norwegian specialized health care sector from 2014 to 2019.

MAIN OUTCOMES AND MEASURES

Drug coverage decisions by Norwegian authorities and incremental cost-effectiveness and severity of disease measured as absolute shortfall of quality adjusted life years.

RESULTS

Between 2014 and 2019, a total of 188 drugs were appraised, of which 113 were cancer drugs. The overall coverage rate was 73% (138 of 188). The number of annual appraisals increased during the observation period. Based on 83 chosen decisions, regression analysis showed that incremental cost-effectiveness ratios (ICER) based on negotiated drug prices, adjusted for severity-differentiated cost-effectiveness thresholds, was the variable that best projected drug approvals (OR, 0.60; 95% CI, 0.42-0.86). An increase in the ICER by $10 000 was associated with a reduction in the odds for approval of 40% for drugs assessed from 2018 to 2019.

CONCLUSIONS AND RELEVANCE

This cross-sectional study demonstrated how concerns for efficiency and fair distribution of health can be implemented systematically into drug appraisals and reimbursement decisions. New, expensive drugs are expected to escalate health care costs in the years to come, and it may be feasible to control costs by negotiating the prices of new drugs while appraising both their cost-effectiveness and how their health benefits are distributed.

Attitudes towards priority setting in the norwegian health care system: a general population survey

BACKGROUND

In an ideal world, everyone would receive medical resources in accordance with their needs. In reality, resources are often scarce and have an alternative use. Thus, we are forced to prioritize. Although Norway is one of the leading countries in normative priority setting work, few descriptive studies have been conducted in the country. To increase legitimacy in priority setting, knowledge about laypeople's attitudes is central. The aim of the study is therefore to assess the general population's attitudes towards a broad spectrum of issues pertinent to priority setting in the Norwegian publicly financed health care system.

METHODS

We developed an electronic questionnaire that was distributed to a representative sample of 2 540 Norwegians regarding their attitudes towards priority setting in Norway. A total of 1 035 responded (response rate 40.7%). Data were analyzed with descriptive statistics and binary logistic regression.

RESULTS

A majority (73.0%) of respondents preferred increased funding of publicly financed health services at the expense of other sectors in society. Moreover, a larger share of the respondents suggested either increased taxes (37.0%) or drawing from the Government Pension Fund Global (31.0%) as sources of funding. However, the respondents were divided on whether it was acceptable to say "no" to new cancer drugs when the effect is low and the price is high: 38.6% somewhat or fully disagreed that this was acceptable, while 46.5% somewhat or fully agreed. Lastly, 84.0% of the respondents did not find it acceptable that the Norwegian municipalities have different standards for providing care services.

CONCLUSION

Although the survey suggests support for priority setting among Norwegian laypeople, it has also revealed that a significant minority are reluctant to accept it.

A flexible formula for incorporating distributive concerns into cost-effectiveness analyses: Priority weights

Background

Cost effectiveness analyses (CEAs) are widely used to evaluate the opportunity cost of health care investments. However, few functions that take equity concerns into account are available for such CEA methods, and these concerns are therefore at risk of being disregarded. Among the functions that have been developed, most focus on the distribution of health gains, as opposed to the distribution of lifetime health. This is despite the fact that there are good reasons to give higher priority to individuals and groups with a low quality adjusted life expectancy from birth (QALE). Also, an even distribution of health gains may imply an uneven distribution of lifetime health.

Methods

We develop a systematic and explicit approach that allows for the inclusion of lifetime health concerns in CEAs, by creating a new priority weight function, PW = α+(t-γ)·C·e^-β·(t-γ), where t is the health measure. PW has several desirable properties. First, it is continuous and smooth, ensuring that people with similar health characteristics are treated alike. For example, those who achieve 50 QALE should be treated similarly to those who achieve 49.9 QALE. Second, it is flexible regarding shape and outcome measure (i.e., caters to other measures than QALE), so that a broad range of values may be modelled. Third, the coefficients have distinct roles. This allows for the easy manipulation of the PW’s shape. In order to demonstrate how PW may be applied, we use data from a previous study and estimated the coefficients of PW based on two approaches.

Conclusions

Equity concerns are important when conducting CEAs, which means that suitable PWs should be developed. We do not intend to determine which PW is the most appropriate, but to illustrate how a flexible general PW can be estimated based on empirical data.

Quality of Life and Cost-Effectiveness of Cochlear Implants: A Narrative Review

OBJECTIVES

To review evidence regarding the health-related quality of life (HRQoL) and cost-effectiveness of unilateral and bilateral cochlear implantation (CI) among children and adults with severe-to-profound hearing loss.

STUDY DESIGN

Narrative review.

METHODS

Publications related to quality of life (QoL) and costs of care in CI were acquired through searches in English-language databases. Studies were included if they had identified the HRQoL attainment, cost of care, cost-utility, or cost-effectiveness associated with CI.

RESULTS

57 studies were critically reviewed. The QoL outcome metrics used in these articles were divided into 2 categories - generic and condition specific. In studies investigating children, many reported no significant difference in QoL attainment between CI recipients and normal-hearing peers. In adults, significant improvements in QoL after implantation and higher QoL than in their nonimplanted (hearing-aided) peers were frequently reported. Studies involving an older adult cohort reported significant improvement in QoL after implantation, which was often independent of audiological performance. Overall, the calculated cost-utility ratios consistently met the threshold of cost acceptance, indicating acceptable values for expenditures on CI.

CONCLUSIONS

Considerable work has been done on the QoL attainment and health economic implications of CI. Unilateral CI across all age groups leads to reported sustained benefits in the recipients' overall and disease-specific QoL. With increased cost associated with bilateral CI, further study is needed to characterize its costs and benefits with respect to the recipients' health, well-being, and contributions to society.

Distribution-Weighted Cost-Effectiveness Analysis Using Lifetime Health Loss

BACKGROUND

It is widely acknowledged that concerns for the worse off need to be integrated with the concern for cost effectiveness in priority setting, and several countries are seeking to do so. In Norway, a comprehensive framework for priority setting was recently proposed to specify the worse off in terms of lifetime loss of quality-adjusted life-years (QALYs). However, few studies have shown how to calculate such health losses, how to integrate health loss into cost-effectiveness analyses (CEAs) and how such integration impacts the incremental cost-effectiveness ratios (ICERs). The aim of this study was to do so.

METHODS

The proposed framework was applied to data from 15 recent economic evaluations of drugs. Available data were used to calculate the lifetime health loss of the target groups, and the proposed marginal weighting function was employed to adjust standard ICERs according to the size of this loss. Standard and weighted ICERs were compared to a threshold of US$35,000 per QALY gained.

RESULTS

Lifetime health loss can be calculated with the use of available data and integrated by a marginal weighting function with CEAs. Such integration affected standard ICERs to a varying degree and changed the number of interventions considered cost effective from three to eight.

CONCLUSION

Calculation of lifetime health loss and its integration with CEA is feasible and can influence the reimbursement and ranking of interventions. To facilitate regular integration, guidelines for economic evaluations could require (i) adjustment according to distributional concerns and (ii) that data on health loss are extracted directly from the models and reported. Generic databases on health loss could be developed alongside such efforts.

Using Cost-Effectiveness Analysis to Address Health Equity Concerns

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.