Trading people versus trading time: what is the difference?

How Much Does the US Public Value Equity in Health? A Systematic Review

OBJECTIVES

This systematic review aims to summarize and qualitatively assess published evaluations on the US public's preferences for health equity and their willingness to trade-off efficiency for equity.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses literature search extension guidelines, we searched MEDLINE and Embase for relevant peer-reviewed publications on this topic before February 2021. We included English-language articles that solicited US preferences regarding efficiency-equity trade-offs and prioritizing healthcare resources based on socioeconomic status, race, disability, or burden of disease. Quantitative and qualitative data captured were decided a priori and iteratively adapted as themes emerged.

RESULTS

Fourteen studies were found over a 25-year span. Only 4 focused on resource allocation across social groups. Three distinct notions of fairness were studied: equal distribution of resources, priority to the worse-off, and equal health achieved. We found modest support for equal distribution of resources and willingness to sacrifice efficiency for equity in the United States. Prioritizing the underserved was relatively less studied and received less support and was more preferred when resources were scarce, when allocating resources between social groups, or when participants were informed about the fundamental origins of health inequities. Equal health was the least studied, but received nontrivial support.

CONCLUSIONS

The existing literature evaluating the US public's understanding and preferences toward equity was severely limited by the lack of rigorous quantitative studies and heterogeneous attribute selection and fairness definitions. High-quality studies that clearly define fairness, focus on social groups, and apply rigorous methods to quantify equity preferences are needed to integrate the public's value on equity into healthcare decisions.

Evaluating Discrete Choice Experiment Willingness to Pay [DCE-WTP] analysis, and Relative Social Willingness to Pay [RS-WTP] analysis in a Health Technology Assessment of a treatment for an ultra-rare childhood disease [CLN2]

BACKGROUND

: Conventional cost-effectiveness analysis [CEA] using cost per QALY thresholds may counteract other incentives introduced to foster development of treatments for rare and ultra-rare diseases. Therefore, alternative economic evaluation methods were explored, namely Discrete Choice Experiment Willingness to Pay (DCE-WTP) and Relative Social Willingness to Pay (RS-WTP), to value interventions for an ultra-rare childhood disease, Neuronal Ceroid Lipofuscinosis type 2 (CLN2).

RESEARCH DESIGN AND METHODS

Treatment for CLN2 was valued from a citizen's ("social") perspective using DCE-WTP and RS-WTP in a survey of 4,009 United Kingdom [UK] adults. Three attributes (initial quality of life, treatment effect, and life expectancy) were used in both analyses. For DCE-WTP a cost attribute (marginal income tax increase) was also included. Optimal econometric models were identified.

RESULTS

DCE-WTP indicated that UK adults are willing to pay incremental increases through taxation for improvements in CLN2 attributes. RS-WTP identified a willingness to allocate >40% of a pre-assigned healthcare budget to prevent child mortality and approximately 15% for improved health status.

CONCLUSIONS

Both techniques illustrated substantive social WTP for CLN2 interventions, despite the small number of children benefitting. This highlights a gap between UK citizens' willingness to spend on rare disease interventions and current funding policies.

Effect of Reflection and Deliberation on Health State Values: A Mixed-Methods Study

BACKGROUND

Health economists ask members of the general public to value health states, but it is recognized that individuals construct their preferences during the valuation tasks. Conventional methods rely on one-off interviews that do not give participants time to reflect and deliberate on their preferences.

OBJECTIVE

This study investigates the effect of reflection and deliberation on health state preferences using the EQ-5D questionnaire and time trade-off valuation method.

METHODS

A novel concurrent explanatory mixed-methods design is used to investigate the explanation for the quantitative findings.

RESULTS

A total of 57 participants in the United Kingdom valued health states before and after a group-based deliberation exercise. There were large changes in health state values at the individual level, but the changes canceled out at the aggregate level. The mixed-methods findings suggest deliberation did not reveal new information or reduce inconsistencies in reasoning but rather focused on an exchange of personal subjective beliefs. In cases of disagreement, the participants accepted but did not adopt other participants' opinions. Participants remained uncertain about the relevance of their experiences and about their values.

CONCLUSIONS

The evidence suggests that reflection and deliberation, as designed in this study, are unlikely to result in large systematic changes of health state values. The uncertainties expressed by participants means future research should investigate whether preferences are informed or whether providing participants with more information helps them construct their preferences with more certainty. The mixed-methods design used is a promising design to help elucidate the reasons for quantitative findings.

Acceptability and potential impact of brief preconception health risk assessment and counseling in the WIC setting

PURPOSE

To determine the reproductive risks of women using the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the acceptability of delivering preconception screening and counseling with the WIC encounter.

DESIGN

A mixed methods approach to include quantitative analysis of reproductive risks and qualitative analysis of post-counseling interviews.

SETTING

A WIC clinic in Clayton County, Georgia.

PARTICIPANTS

A quota sample of 150 African-American women 18 to 44 years of age recruited from the attendees of WIC nutrition classes for postpartum and breastfeeding women and mothers of children under 5. Intervention. A brief individual counseling based upon identified risks.

METHOD

Participants were administered a risk assessment questionnaire by a member of the study team to determine topics for brief counseling. Following standardized brief counseling, participants completed an individual semistructured interview. The risk assessment questionnaire was analyzed quantitatively; transcripts from the post-counseling interviews were analyzed thematically.

RESULTS

Reproductive risks were prevalent among women of reproductive age seeking WIC services: unintended pregnancy (27%), history of sexually transmitted infection (49%), inadequate folic acid supplementation (66%), intimate partner violence (47%), tobacco use (21%), binge drinking (10%), and illicit drug use (5%). The vast majority of WIC clients found the preconception risk assessment and brief counseling to be acceptable and important.

CONCLUSION

WIC constitutes a suitable location for identifying low-income African-American women in need of preconception and reproductive health services and at risk for poor reproductive health outcomes.

Underlying Rationale and Approach to Treat Hypertension in Adolescents by Physicians of Different Specialty

OBJECTIVE

To describe the underlying clinical decision-making rationale among general pediatricians, family physicians, pediatric cardiologists and pediatric nephrologists in their approach to an adolescent with hypertension.

METHODS

We conducted semi-structured phone interviews with a convenience sample of physicians from the above-mentioned 4 specialties. Each participant was asked to "think aloud" regarding their approach to a hypothetical patient - 12 year old boy with persistent hypertension for 6 months. Standardized open-ended questions about potential factors that could affect physicians' diagnosis and treatment strategies (e.g., patient age) were used. Interviews were audio-recorded; transcribed verbatim; transcripts were independently coded by 2 investigators; emergent themes identified and inter-coder agreement achieved. Thematic analysis was performed based on grounded theory.

RESULTS

Nineteen participants included 5 general pediatricians, 5 pediatric cardiologists, 5 pediatric nephrologists and 4 family physicians. Five themes emerged: 1) Accuracy of blood pressure measurement and hypertension diagnosis, 2) Shift in the epidemiology of pediatric hypertension from secondary to primary hypertension, 3) Patient characteristics considered in the decision to initiate workup, 4) Obesity-centered choice of diagnostic tests and lifestyle modifications, and 5) Variable threshold for initiating antihypertensive pharmacotherapy vs. referral to hypertension specialists.

CONCLUSIONS

There is variation across primary care and specialty physicians who provide care for children and adolescents with hypertension. Key areas of variability include the willingness to initiate antihypertensive medications, the use of diagnostic tests (e.g., ambulatory blood pressure monitoring), and the perceived need for specialty referral. Further study is needed to assess whether different treatment paradigms result in differential patient outcomes.

Using surveys to calculate disability-adjusted life-years

Mapping a certain disease into a system of disabling attributes allows researchers to compare diseases within a common framework. To quantify the total burden of morbidity (e.g., morbidity attributable to alcohol use), so-called disability weights (DWs) must be generated. General-population surveys can be used to derive DWs from health valuation tasks. This article describes the application of three psychometric methods (i.e., pairwise comparisons, ranking tasks, and visual analog scales) in general-population surveys and outlines their strengths and weaknesses. A recently proposed health valuation framework also is presented, which highlights the underlying cognitive processes from a social-judgment perspective and presents a structured data-collection procedure that seems promising in deriving DWs from general-population surveys.

Does responsibility affect the public's valuation of health care interventions? A relative valuation approach to health care safety

OBJECTIVE

Health services often spend more on safety interventions than seems cost-effective. This study investigates whether the public value safety-related health care improvements more highly than the same improvements in contexts where the health care system is not responsible.

METHOD

An online survey was conducted to elicit the relative importance placed on preventing harms caused by 1) health care (hospital-acquired infections, drug administration errors, injuries to health care staff), 2) individuals (personal lifestyle choices, sports-related injuries), and 3) nature (genetic disorders). Direct valuations were obtained from members of the public by using a person trade-off or "matching" method. Participants were asked to choose between two preventative interventions of equal cost and equal health benefit per person for the same number of people, but differing in causation. If participants indicated a preference, their strength of preference was measured by using person trade-off.

RESULTS

Responses were obtained from 1030 people, reflecting the sociodemographic mix of the UK population. Participants valued interventions preventing hospital-acquired infections (1.31) more highly than genetic disorders (1.0), although drug errors were valued similarly to genetic disorders (1.07), and interventions to prevent injury to health care staff were given less weight than genetic disorders (0.71). Less weight was also given to interventions related to lifestyle (0.65) and sports injuries (0.41).

CONCLUSION

Our results suggest that people do not attach a simple fixed premium to "safety-related" interventions but that preferences depend more subtly on context. The use of the results of such public preference surveys to directly inform policy would therefore be premature.

Preconsent education about research processes improved African Americans' willingness to participate in clinical research

OBJECTIVE

To determine whether preconsent education about research processes and protections affects the willingness of African Americans to participate.

STUDY DESIGN AND SETTING

This study examined the willingness of 192 African American outpatients (stratified by age, gender, and education) to participate in a hypothetical clinical study under varying consent conditions: phase I participants underwent a typical informed consent process and were asked to indicate whether they would be willing to participate in the hypothetical clinical study and the reasons for their decision; their responses were used to develop a preconsent educational digital video disk (DVD). Phase II participants viewed the DVD before the consent process. We compared the proportion of those who stated they were willing to participate in the clinical study using Fisher's exact tests and used qualitative methods to analyze open-ended responses.

RESULTS

When the consent process included education about research processes and protections, significantly more patients reported willingness to participate in the hypothetical clinical study (43% vs. 27%; P=0.002). Patients receiving preconsent education were significantly less likely to cite mistrust, fear of side effects, lack of perceived benefits, and privacy as reasons for not participating.

CONCLUSION

Preconsent education may improve the willingness of African Americans to participate in clinical research and may address important concerns about research participation.

Valuation of health states in the US study to establish disability weights: lessons from the literature

The metric of disability-adjusted life years (DALYs) has become the global standard of measuring burden of disease. DALYs are comprised of years of life lost due to premature mortality and years of healthy life lost due to living with disability. In order to calculate the second part of the DALY equation, disease specific disability weights have to be established, i.e. measures for the decline of health associated with these disease states, which vary between zero for perfect health and one for death. Although these disability weights are key for estimating DALYs, there have not been many comprehensive studies with empirical determinations of them. This article describes a systematic review on the state of the art with respect to empirically determining disability weights. Based on this review, a multi-method approach is outlined, which has also been implemented in a US study to measure burden of disease. This approach involves the use of psychometric methodology as well as economic trade-off methods for determining the value of health states. It is conceptualized as a disaggregated approach, where the disability weight of any health state can be calculated if the attributes of this health state are known. The US study received the collaboration of experts from more than 20 institutes of the National Institutes of Health and of the Centers for Disease Control and Prevention. First results will be available by the end of this year.

Integrating reproductive planning with primary health care: an exploration among low-income, minority women and men

INTRODUCTION

Despite recommendations to integrate reproductive and preconception health care services with primary health care, integration of such services is uncommon. The purpose of this study was to explore the acceptability and utility of integrating an assessment of reproductive plans into primary care encounters.

METHODOLOGY

Using a purposive sampling strategy, we purposively selected 144 African-American and Hispanic females and males from publicly-funded clinics. We assessed their desire for a child and contraceptive practices via a reproductive plans questionnaire. Patients' written responses were attached to the medical record for provider use. After the encounter, we administered semi-structured interviews to elicit patients' opinions about the questionnaire. We audio-recorded and transcribed verbatim responses and qualitatively analyzed them by content analysis.

RESULTS

Overall, 58/72 (81%) of females and 30/72 (42%) of males reported the reproductive plans assessment was important to their encounter, with variation in the reason according to reported desire for a child. According to reported contraceptive practices, >45% who reported never wanting a child or not wanting a child for at least one year were 'at-risk for unintended pregnancy.' A substantial proportion of patients reported uncertainty about desiring a child, and a minority of these reported consistent contraception use.

DISCUSSION

Questions to assess patients' reproductive plans were viewed as important by the majority of female and a substantial proportion of male primary care patients, and a substantial proportion were at-risk for unintended pregnancy. Primary care practices should consider implementing a reproductive plans assessment to facilitate linkage of patients to appropriate family planning, preconception, and sexually-transmitted infection services.

When are person tradeoffs valid?

The person tradeoff (PTO) is commonly used in health economic applications. However, to date it has no theoretical basis. The purpose of this paper is to provide this basis from a set of assumptions that together justify the most common applications of the PTO method. Our analysis identifies the central assumptions in PTO measurements. We test these assumptions in an experiment, but find only limited support for the validity of the PTO.

The impact of HIPAA authorization on willingness to participate in clinical research

PURPOSE

This study systematically examined the impact of inclusion of Health Insurance Portability and Accountability Act (HIPAA) authorization on the willingness of African Americans of diverse sociodemographic characteristics to participate in a clinical research study and explored reasons for nonparticipation.

METHODS

For a purposive sample of 384 African American outpatients at four metropolitan primary care clinics from August 2005 through May 2006, willingness to participate in a hypothetic clinical research study of an antihypertensive medication under one of two experimental conditions was compared. Interviewees were randomly assigned to undergo informed consent alone (control group) or informed consent with HIPAA authorization (HIPAA group). They were asked whether they would participate and reasons for their decisions.

RESULTS

A smaller proportion of interviewees in the HIPAA group were willing to enroll in the study (27% vs. 39%; p = 0.02), with an adjusted odds ratio of 0.56 (95% confidence interval = 0.36-0.91). Those in the HIPAA group were more likely to give reasons related to privacy (p < 0.001), poor understanding of the form (p = 0.01), and mistrust or fear of research (p = 0.04) for nonparticipation.

CONCLUSIONS

The inclusion of HIPAA authorization within the informed consent process may adversely affect the willingness of African Americans to participate in clinical research and may raise concerns about privacy, understanding the forms, and mistrust or fear of research.

Why people refuse to make tradeoffs in person tradeoff elicitations: a matter of perspective?

OBJECTIVE

Person tradeoff (PTO) elicitations assess people's values for health states by asking them to compare the value of treatment programs. For example, people might be asked how many patients need to be cured of health condition X to equal the benefit of curing 100 people of condition Y. However, when faced with PTO elicitations, people frequently refuse to make quantifiable tradeoffs, exhibiting 2 kinds of refusals: 1) They say that 2 treatment programs have equal value, that curing 100 of X is just as good as curing 100 of Y, even if X is a less serious condition than Y, or 2) they say that the 2 programs are incomparable, that millions of people need to be cured of X to be as good as curing 100 of Y. The authors explore whether people would be more willing to make tradeoffs if the focus was changed from trading off groups of patients to choosing the best decision or evaluating treatment benefits.

DESIGN

. Two randomized trials used diverse samples (N=2400) via the Internet to test for the effect of perspective on refusal rates. The authors predicted that perspectives that removed people from decision-making roles would increase their willingness make tradeoffs.

RESULTS

Contrary to expectations, refusal rates increased when people were removed from decision-making roles. In fact, the more pressure put on people to make a decision, the less likely they were to refuse to make tradeoffs.

CONCLUSION

To reduce PTO refusals, it is best to adopt a decision-maker perspective.