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Stenmarck MS, Whitehurst DG, Lurås H, Rugkåsa J. "It's hard to say anything definitive about what severity really is": lay conceptualisations of severity in a healthcare context. BMC Health Serv Res 2024; 24:490. [PMID: 38641590 PMCID: PMC11031975 DOI: 10.1186/s12913-024-10892-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 03/22/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Demand for healthcare outweighs available resources, making priority setting a critical issue. 'Severity' is a priority-setting criterion in many healthcare systems, including in Norway, Sweden, the Netherlands, and the United Kingdom. However, there is a lack of consensus on what severity means in a healthcare context, both in the academic literature and in policy. Further, while public preference elicitation studies demonstrate support for severity as a relevant concern in priority setting, there is a paucity of research on what severity is taken to mean for the public. The purpose of this study is to explore how severity is conceptualised by members of the general public. METHODS Semi-structured group interviews were conducted from February to July 2021 with members of the Norwegian adult public (n = 59). These were transcribed verbatim and subjected to thematic analysis, incorporating inductive and deductive elements. RESULTS Through the analysis we arrived at three interrelated main themes. Severity as subjective experience included perceptions of severity as inherently subjective and personal. Emphasis was on the individual's unique insight into their illness, and there was a concern that the assessment of severity should be fair for the individual. The second theme, Severity as objective fact, included perceptions of severity as something determined by objective criteria, so that a severe condition is equally severe for any person. Here, there was a concern for determining severity fairly within and across patient groups. The third theme, Severity as situation dependent, included perceptions of severity centered on second-order effects of illness. These included effects on the individual, such as their ability to work and enjoy their hobbies, effects on those surrounding the patient, such as next of kin, and effects at a societal level, such as production loss. We also identified a concern for determining severity fairly at a societal level. CONCLUSIONS Our findings suggest that severity is a polyvalent notion with different meanings attached to it. There seems to be a dissonance between lay conceptualisations of severity and policy operationalisations of the term, which may lead to miscommunications between members of the public and policymakers.
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Affiliation(s)
- Mille Sofie Stenmarck
- The Health Services Research Unit- HØKH, Akershus University Hospital HF, Lørenskog, Norway.
- Faculty of Medicine, University of Oslo, Oslo, Norway.
| | | | - Hilde Lurås
- The Health Services Research Unit- HØKH, Akershus University Hospital HF, Lørenskog, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jorun Rugkåsa
- The Health Services Research Unit- HØKH, Akershus University Hospital HF, Lørenskog, Norway
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
- Faculty of Health and Social Sciences, University of South-Eastern Norway, Porsgrunn, Norway
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Stenmarck MS, Whitehurst DG, Baker R, Barra M. Charting public views on the meaning of illness severity. Soc Sci Med 2024; 347:116760. [PMID: 38489961 DOI: 10.1016/j.socscimed.2024.116760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/05/2024] [Accepted: 03/05/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Illness severity is a central principle in multiple priority-setting frameworks, yet there is a paucity of research on public views regarding the meaning of illness severity. This study builds on the findings of a Q methodology study with members of the public that identified four general viewpoints on the meaning of illness severity. Here, we investigate the support for those viewpoints among the Norwegian population. METHODS Following piloting, the online survey was distributed to a broadly representative sample of the population (March to April 2023). The viewpoints from the earlier Q study were converted into vignettes: Lifespan, Subjective, Objective, and Functioning and Quality of Life (FQoL). The main task in the survey comprised ranking the vignettes and scoring them on a 0-10 visual analogue scale. We describe vignette alignment (from weak to strong) based on four categorisations (C1 to C4). C1 placed all respondents on their top scored vignette(s); C2 required a score of ≥7; C3 was designed to resolve ties; and C4 (which describes vignette membership) required a score of ≥7, a gap of two between vignettes scored ≥7, and did not allow ties. RESULTS The survey was completed by 1174 individuals; those who completed in ≤3.5 min were excluded. Of the final sample (n = 1094), 98.1% scored at least one vignette ≥7. In C1, 40.2% were aligned with Lifespan, 32.4% with FQoL, 28.9% with Objective, and 16.3% with Subjective. Using the C4 criteria, 55.4% did not have vignette membership, 13.6% had membership with Lifespan, 13.1% with Objective, 11.4% with FQoL, and 6.5% with Subjective. CONCLUSIONS Severity is an ambiguous term among members of the public. Decisionmakers ought to bear this plurality of meanings in mind, and perhaps reconsider whether using a term as multifaceted as 'severity' is helpful in formulating precise and transparent priority-setting criteria.
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Affiliation(s)
- Mille Sofie Stenmarck
- The Health Services Research Unit - HØKH, Akershus University Hospital HF, Lørenskog, Norway; Faculty of Medicine, University of Oslo, Norway.
| | | | - Rachel Baker
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Scotland, UK
| | - Mathias Barra
- The Health Services Research Unit - HØKH, Akershus University Hospital HF, Lørenskog, Norway
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Smeele NVR, Chorus CG, Schermer MHN, de Bekker-Grob EW. Towards machine learning for moral choice analysis in health economics: A literature review and research agenda. Soc Sci Med 2023; 326:115910. [PMID: 37121066 DOI: 10.1016/j.socscimed.2023.115910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 04/06/2023] [Accepted: 04/13/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Discrete choice models (DCMs) for moral choice analysis will likely lead to erroneous model outcomes and misguided policy recommendations, as only some characteristics of moral decision-making are considered. Machine learning (ML) is recently gaining interest in the field of discrete choice modelling. This paper explores the potential of combining DCMs and ML to study moral decision-making more accurately and better inform policy decisions in healthcare. METHODS An interdisciplinary literature search across four databases - PubMed, Scopus, Web of Science, and Arxiv - was conducted to gather papers. Based on the Preferred Reporting Items for Systematic and Meta-analyses (PRISMA) guideline, studies were screened for eligibility on inclusion criteria and extracted attributes from eligible papers. Of the 6285 articles, we included 277 studies. RESULTS DCMs have shortcomings in studying moral decision-making. Whilst the DCMs' mathematical elegance and behavioural appeal hold clear interpretations, the models do not account for the 'moral' cost and benefit in an individual's utility calculation. The literature showed that ML obtains higher predictive power, model flexibility, and ability to handle large and unstructured datasets. Combining the strengths of ML methods with DCMs has the potential for studying moral decision-making. CONCLUSIONS By providing a research agenda, this paper highlights that ML has clear potential to i) find and deepen the utility specification of DCMs, and ii) enrich the insights extracted from DCMs by considering the intrapersonal determinants of moral decision-making.
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Affiliation(s)
- Nicholas V R Smeele
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus Choice Modelling Centre, Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus Centre for Health Economics Rotterdam, Erasmus University Rotterdam, Rotterdam, the Netherlands.
| | - Caspar G Chorus
- Department of Engineering Systems and Services, Delft University of Technology, Delft, the Netherlands; Faculty of Industrial Design Engineering, Delft University of Technology, Delft, the Netherlands
| | - Maartje H N Schermer
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Esther W de Bekker-Grob
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus Choice Modelling Centre, Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus Centre for Health Economics Rotterdam, Erasmus University Rotterdam, Rotterdam, the Netherlands
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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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Who should be given priority for public funding? Health Policy 2020; 124:1108-1114. [PMID: 32651005 DOI: 10.1016/j.healthpol.2020.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 06/12/2020] [Accepted: 06/19/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND This study explored if Koreans consider the type of disease, rarity, and availability of alternative treatments as priority criteria in limited healthcare resource allocation. MATERIALS AND METHODS A web-based survey was conducted with a representative sample of 3,482 Korean adults. Participants were divided into six cohorts, differing in terms of the disease being compared and the cost and benefits of the treatments. Each cohort was asked two questions: 1) How to allocate a fixed budget into each of the two groups (cancer vs non-cancer, rare vs common, no other treatments available vs several treatments available), all else being equal; 2) allocation choices when conditions of two groups differed. The McNemar test was used to assess changes in responses between the two questions. RESULTS Under the control condition, the majority chose to treat an even number of patients with cancer and non-cancer diseases, and preferred to treat common diseases and those with no alternative treatments. However, when the treatment effects or costs of two comparison groups changed, choice shifted toward more effective or less costly treatment. CONCLUSIONS While Koreans generally support the principle of health maximization, they also believe that priority should be given to diseases that previously did not have any treatments. However, no priority was given to cancer or rare diseases.
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Barra M, Broqvist M, Gustavsson E, Henriksson M, Juth N, Sandman L, Solberg CT. Severity as a Priority Setting Criterion: Setting a Challenging Research Agenda. HEALTH CARE ANALYSIS 2020; 28:25-44. [PMID: 31119609 PMCID: PMC7045747 DOI: 10.1007/s10728-019-00371-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Priority setting in health care is ubiquitous and health authorities are increasingly recognising the need for priority setting guidelines to ensure efficient, fair, and equitable resource allocation. While cost-effectiveness concerns seem to dominate many policies, the tension between utilitarian and deontological concerns is salient to many, and various severity criteria appear to fill this gap. Severity, then, must be subjected to rigorous ethical and philosophical analysis. Here we first give a brief history of the path to today's severity criteria in Norway and Sweden. The Scandinavian perspective on severity might be conducive to the international discussion, given its long-standing use as a priority setting criterion, despite having reached rather different conclusions so far. We then argue that severity can be viewed as a multidimensional concept, drawing on accounts of need, urgency, fairness, duty to save lives, and human dignity. Such concerns will often be relative to local mores, and the weighting placed on the various dimensions cannot be expected to be fixed. Thirdly, we present what we think are the most pertinent questions to answer about severity in order to facilitate decision making in the coming years of increased scarcity, and to further the understanding of underlying assumptions and values that go into these decisions. We conclude that severity is poorly understood, and that the topic needs substantial further inquiry; thus we hope this article may set a challenging and important research agenda.
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Affiliation(s)
- Mathias Barra
- The Health Services Research Unit - HØKH, Akershus University Hospital, Sykehusveien 25, Postboks 1000, 1473, Lørenskog, Norway.
| | - Mari Broqvist
- Department of Medical and Health Sciences, The National Centre for Priorities in Health, Linköping University, Linköping, Sweden
| | - Erik Gustavsson
- Department of Culture and Communication, Centre for Applied Ethics, Linköping University, Linköping, Sweden
- Division of Health Care Analysis, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Martin Henriksson
- Department of Medical and Health Sciences, Center for Medical Technology Assessment, Linköping University, Linköping, Sweden
| | - Niklas Juth
- Stockholm Centre for Healthcare Ethics (CHE), LIME, Karolinska Institutet, Solna, Sweden
| | - Lars Sandman
- Department of Medical and Health Sciences, The National Centre for Priorities in Health, Linköping University, Linköping, Sweden
| | - Carl Tollef Solberg
- The Health Services Research Unit - HØKH, Akershus University Hospital, Sykehusveien 25, Postboks 1000, 1473, Lørenskog, Norway
- Global Health Priorities, Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
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Reckers-Droog V, Jansen M, Bijlmakers L, Baltussen R, Brouwer W, van Exel J. How does participating in a deliberative citizens panel on healthcare priority setting influence the views of participants? Health Policy 2019; 124:143-151. [PMID: 31839335 DOI: 10.1016/j.healthpol.2019.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 10/14/2019] [Accepted: 11/28/2019] [Indexed: 11/25/2022]
Abstract
A deliberative citizens panel was held to obtain insight into criteria considered relevant for healthcare priority setting in the Netherlands. Our aim was to examine whether and how panel participation influenced participants' views on this topic. Participants (n = 24) deliberated on eight reimbursement cases in September and October, 2017. Using Q methodology, we identified three distinct viewpoints before (T0) and after (T1) panel participation. At T0, viewpoint 1 emphasised that access to healthcare is a right and that prioritisation should be based solely on patients' needs. Viewpoint 2 acknowledged scarcity of resources and emphasised the importance of treatment-related health gains. Viewpoint 3 focused on helping those in need, favouring younger patients, patients with a family, and treating diseases that heavily burden the families of patients. At T1, viewpoint 1 had become less opposed to prioritisation and more considerate of costs. Viewpoint 2 supported out-of-pocket payments more strongly. A new viewpoint 3 emerged that emphasised the importance of cost-effectiveness and that prioritisation should consider patient characteristics, such as their age. Participants' views partly remained stable, specifically regarding equal access and prioritisation based on need and health gains. Notable changes concerned increased support for prioritisation, consideration of costs, and cost-effectiveness. Further research into the effects of deliberative methods is required to better understand how they may contribute to the legitimacy of and public support for allocation decisions in healthcare.
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Affiliation(s)
- Vivian Reckers-Droog
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, the Netherlands.
| | - Maarten Jansen
- Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Leon Bijlmakers
- Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Rob Baltussen
- Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Werner Brouwer
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, the Netherlands; Erasmus School of Economics, Erasmus University Rotterdam, the Netherlands
| | - Job van Exel
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, the Netherlands; Erasmus School of Economics, Erasmus University Rotterdam, the Netherlands
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Reckers-Droog V, van Exel J, Brouwer W. Equity Weights for Priority Setting in Healthcare: Severity, Age, or Both? VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1441-1449. [PMID: 31806201 DOI: 10.1016/j.jval.2019.07.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 07/21/2019] [Accepted: 07/24/2019] [Indexed: 05/19/2023]
Abstract
BACKGROUND Priority setting in healthcare can be guided by both efficiency and equity principles. The latter principle is often explicated in terms of disease severity and, for example, defined as absolute or proportional shortfall. These severity operationalizations do not explicitly consider patients' age, even though age may be inextricably related to severity and an equity-relevant characteristic. OBJECTIVE This study examines the relative strength of societal preferences for severity and age for informing allocation decisions in healthcare. METHODS We elicited preferences for severity and age in a representative sample of the public in The Netherlands (N = 1025) by applying choice tasks and person-trade-off tasks in a design in which severity levels and ages varied both separately and simultaneously between patient groups. We calculated person trade-off ratios and, in addition, applied ordinary least squares regression models to aid interpretation of the ratios when both severity and age varied. RESULTS Respondents attached a higher weight (median of ratios: 2.46-3.50) to reimbursing treatment for relatively more severely ill and younger patients when preferences for both were elicited separately. When preferences were elicited simultaneously, respondents attached a higher weight (median of ratios: 1.98 and 2.42) to reimbursing treatment for relatively younger patients, irrespective of patients' severity levels. Ratios varied depending on severity level and age and were generally higher when the difference in severity and age was larger between groups. CONCLUSIONS Our results suggest that severity operationalizations and equity weights based on severity alone may not align with societal preferences. Adjusting decision-making frameworks to reflect age-related societal preferences should be considered.
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Affiliation(s)
- Vivian Reckers-Droog
- Erasmus University Rotterdam, Erasmus School of Health Policy & Management, Rotterdam, The Netherlands.
| | - Job van Exel
- Erasmus University Rotterdam, Erasmus School of Health Policy & Management, Rotterdam, The Netherlands; Erasmus University Rotterdam, Erasmus School of Economics, Rotterdam, The Netherlands
| | - Werner Brouwer
- Erasmus University Rotterdam, Erasmus School of Health Policy & Management, Rotterdam, The Netherlands; Erasmus University Rotterdam, Erasmus School of Economics, Rotterdam, The Netherlands
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A flexible formula for incorporating distributive concerns into cost-effectiveness analyses: Priority weights. PLoS One 2019; 14:e0223866. [PMID: 31600342 PMCID: PMC6786599 DOI: 10.1371/journal.pone.0223866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/29/2019] [Indexed: 01/06/2023] Open
Abstract
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.
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Zrubka Z, Hermann Z, Gulácsi L, Brodszky V, Rencz F, Péntek M. Determinants of the acceptability of health problems in different ages: exploring a new application of the EQ VAS. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:31-41. [PMID: 31111401 DOI: 10.1007/s10198-10019-01060-10193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 04/15/2019] [Indexed: 05/25/2023]
Abstract
BACKGROUND We aimed to determine the acceptability of non-perfect health states with age using the EQ VAS and analyse the influencing factors. METHODS We conducted a cross-sectional survey on a convenience sample from the general population (N = 200). Respondents were asked to indicate on the EQ VAS the health states that are still acceptable for ages between 30 and 80 years in 10-year intervals (VAS acceptable health curve, AHCvas). We recorded respondents' current health, health-related lifestyle, demographic background and explored the reference person they imagined when evaluating acceptable health states. We evaluated the AHCvas by estimating linear multilevel models including a random intercept (estimated at age 30) and a random slope for age. RESULTS AHCvas scores were available for 194 respondents (mean age = 42.8 years, range 19-93, 58% female). For ages of 30, 40, 50, 60, 70 and 80 years, mean AHCvas scores were 93, 87, 80, 73, 65 and 57, respectively. The decline of AHCvas was linear with age. Respondents' age, health status, lifestyle and health-related experiences, as well as their reference point taken (e.g. imagining themselves, others or both during the valuation task) influenced significantly the acceptability of health problems. CONCLUSIONS When measured with the EQ VAS, health problems were increasingly acceptable with age. Capturing well the individual variability in the assessment of acceptable health states at different ages, the EQ VAS is a useful addition to EQ-5D-3L descriptive system-based measures of acceptable health.
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Affiliation(s)
- Zsombor Zrubka
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary.
- Doctoral School of Management, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary.
| | - Zoltán Hermann
- Centre for Economic and Regional Studies, Hungarian Academy of Sciences, Tóth Kálmán u. 4, 1097, Budapest, Hungary
- Centre for Labour Economics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary
| | - László Gulácsi
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary
| | - Valentin Brodszky
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary
| | - Fanni Rencz
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary
- Premium Postdoctoral Research Program, Hungarian Academy of Sciences, Nádor u. 7, 1051, Budapest, Hungary
| | - Márta Péntek
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary
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Zrubka Z, Hermann Z, Gulácsi L, Brodszky V, Rencz F, Péntek M. Determinants of the acceptability of health problems in different ages: exploring a new application of the EQ VAS. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:31-41. [PMID: 31111401 PMCID: PMC6544591 DOI: 10.1007/s10198-019-01060-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 04/15/2019] [Indexed: 05/16/2023]
Abstract
BACKGROUND We aimed to determine the acceptability of non-perfect health states with age using the EQ VAS and analyse the influencing factors. METHODS We conducted a cross-sectional survey on a convenience sample from the general population (N = 200). Respondents were asked to indicate on the EQ VAS the health states that are still acceptable for ages between 30 and 80 years in 10-year intervals (VAS acceptable health curve, AHCvas). We recorded respondents' current health, health-related lifestyle, demographic background and explored the reference person they imagined when evaluating acceptable health states. We evaluated the AHCvas by estimating linear multilevel models including a random intercept (estimated at age 30) and a random slope for age. RESULTS AHCvas scores were available for 194 respondents (mean age = 42.8 years, range 19-93, 58% female). For ages of 30, 40, 50, 60, 70 and 80 years, mean AHCvas scores were 93, 87, 80, 73, 65 and 57, respectively. The decline of AHCvas was linear with age. Respondents' age, health status, lifestyle and health-related experiences, as well as their reference point taken (e.g. imagining themselves, others or both during the valuation task) influenced significantly the acceptability of health problems. CONCLUSIONS When measured with the EQ VAS, health problems were increasingly acceptable with age. Capturing well the individual variability in the assessment of acceptable health states at different ages, the EQ VAS is a useful addition to EQ-5D-3L descriptive system-based measures of acceptable health.
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Affiliation(s)
- Zsombor Zrubka
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary.
- Doctoral School of Management, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary.
| | - Zoltán Hermann
- Centre for Economic and Regional Studies, Hungarian Academy of Sciences, Tóth Kálmán u. 4, 1097, Budapest, Hungary
- Centre for Labour Economics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary
| | - László Gulácsi
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary
| | - Valentin Brodszky
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary
| | - Fanni Rencz
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary
- Premium Postdoctoral Research Program, Hungarian Academy of Sciences, Nádor u. 7, 1051, Budapest, Hungary
| | - Márta Péntek
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary
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Berhane Defaye F, Danis M, Wakim P, Berhane Y, Norheim OF, Miljeteig I. Bedside Rationing Under Resource Constraints-A National Survey of Ethiopian Physicians' Use of Criteria for Priority Setting. AJOB Empir Bioeth 2019; 10:125-135. [PMID: 31002289 DOI: 10.1080/23294515.2019.1583691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In low-income settings resource constraints force clinicians to make harsh choices. We examine the criteria Ethiopian physicians use in their bedside rationing decisions through a national survey at 49 public hospitals in Ethiopia. Substantial variation in weight given to different criteria were reported by the 587 participating physicians (response rate 91.7%). Young age, primary prevention, or the patient being the family's economic provider increased likelihood of offering treatment to a patient, while small expected benefit or low chance of success diminished likelihood. More than 50% of responding physicians were indifferent to patient's position in society, unhealthy behavior, and residence, while they varied widely in weight they gave to patient's poverty, ability to work, and old age. While the majority of Ethiopian physicians reported allocation of resources that was compatible with national priorities, more contested criteria were also frequently reported. This might affect distributional justice and equity in health care access.
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Affiliation(s)
- Frehiwot Berhane Defaye
- a Research Group in Global Health Priorities, Department of Global Public Health and Primary Care , University of Bergen , Norway.,b Center for Medical Ethics and Priority Setting , Addis Ababa University , Ethiopia
| | - Marion Danis
- c Department of Bioethics , National Institutes of Health , USA
| | - Paul Wakim
- d Biostatistics and Clinical Epidemiology Service, Clinical Center , National Institutes of Health , USA
| | - Yemane Berhane
- e Addis Continental Institute of Public Health , Ethiopia
| | - Ole Frithjof Norheim
- a Research Group in Global Health Priorities, Department of Global Public Health and Primary Care , University of Bergen , Norway.,b Center for Medical Ethics and Priority Setting , Addis Ababa University , Ethiopia
| | - Ingrid Miljeteig
- a Research Group in Global Health Priorities, Department of Global Public Health and Primary Care , University of Bergen , Norway.,b Center for Medical Ethics and Priority Setting , Addis Ababa University , Ethiopia
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Herlitz A. Health, priority to the worse off, and time. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2018; 21:517-527. [PMID: 29350341 PMCID: PMC6267230 DOI: 10.1007/s11019-018-9825-2] [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] [Indexed: 06/07/2023]
Abstract
It is a common view that benefits to the worse off should be given priority when health benefits are distributed. This paper addresses how to understand who is worse off in this context when individuals are differently well off at different times. The paper argues that the view that this judgment about who is worse off should be based solely on how well off individuals are when their complete lives are considered (i.e. 'the complete lives view') is implausible in this context. Instead, it is argued that a pluralistic stance toward this issue should be accepted. This pluralistic stance recognizes that also the view that only focuses on how well off individuals are now and in the future (i.e. 'the forward-looking view') is relevant. The argument is based on appeals to intuitive judgments concerning who is worse off in different cases and reference to various underlying reasons why priority to benefits to the worse off is justified.
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Affiliation(s)
- Anders Herlitz
- Department of Philosophy, Linguistics and Theory of Science, University of Gothenburg, Box 200, 405 30, Gothenburg, Sweden.
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA.
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Social preferences for prioritising the treatment of disabled and chronically ill patients: beyond the order effect. HEALTH ECONOMICS POLICY AND LAW 2018; 14:443-467. [PMID: 29734969 DOI: 10.1017/s1744133118000154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Previous evidence suggests that members of the public value life saving services differently when they are for patients with a pre-existing permanent disability and when they are for patients who become disabled at the onset of treatment - for example, as a result of treatment that is not entirely effective. However, the valuation of services in these two cases has also been found to differ with the order in which they are presented in a population survey. This casts doubt upon the validity of the results and leaves unresolved the nature of the public's true preferences. The study reported here had three main objectives: (i) to determine the considered, underlying preferences of a sample of the Australian public with respect to the treatment of the permanently disabled and chronically ill, (ii) to gain insight into the reasons for respondent's distributive preferences and (iii) to eliminate or significantly reduce the order effect. Eight semi-structured, small-group discussions were held with 66 members of the public in Victoria, Australia. Order effects were effectively eliminated. The study found substantial support among participants for the equal treatment of the permanently disabled and chronically ill regardless of when the problem commenced.
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Herlitz A. Against lifetime QALY prioritarianism. JOURNAL OF MEDICAL ETHICS 2018; 44:109-113. [PMID: 28993423 DOI: 10.1136/medethics-2017-104250] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 09/11/2017] [Accepted: 09/24/2017] [Indexed: 06/07/2023]
Abstract
Lifetime quality-adjusted life-year (QALY) prioritarianism has recently been defended as a reasonable specification of the prioritarian view that benefits to the worse off should be given priority in health-related priority setting. This paper argues against this view with reference to how it relies on implausible assumptions. By referring to lifetime QALY as the basis for judgments about who is worse off lifetime QALY prioritarianism relies on assumptions of strict additivity, atomism and intertemporal separability of sublifetime attributes. These assumptions entail that a health state at some period in time contributes with the same amount to how well off someone is regardless of intrapersonal and interpersonal distributions of health states. The paper argues that this is implausible and that prioritarians should take both intrapersonal and interpersonal distributions of goods into account when they establish who is worse off. They should therefore not accept that lifetime QALY is a reasonable ground for ascribing priority and reject lifetime QALY prioritarianism.
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Affiliation(s)
- Anders Herlitz
- Department of Philosophy, Linguistics and Theory of Science, University of Gothenburg, Gothenburg, Sweden
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
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Hernæs UJV, Johansson KA, Ottersen T, Norheim OF. Distribution-Weighted Cost-Effectiveness Analysis Using Lifetime Health Loss. PHARMACOECONOMICS 2017. [PMID: 28625004 DOI: 10.1007/s40273-017-0524-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
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.
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Affiliation(s)
- Ulrikke J V Hernæs
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway.
| | - Kjell A Johansson
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Trygve Ottersen
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Ole F Norheim
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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McKie J, Richardson J. Social preferences for prioritizing the treatment of severely ill patients: The relevance of severity, expected benefit, past health and lifetime health. Health Policy 2017. [DOI: 10.1016/j.healthpol.2017.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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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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