MCDA-based deliberation to value health states: lessons learned from a pilot study

"It is not a scientific number it is just a feeling": Populating a multi-dimensional end-of-life decision framework using deliberative methods

The capability approach is potentially valuable for economic evaluation at the end of life because of its conceptualization of wellbeing as freedom and the potential for capturing outcomes for those at end of life and those close to persons at the end of life. For decision making, however, this information needs to be integrated into current evaluation paradigms. This research explored weights for an integrated economic evaluation framework using a deliberative approach. Twelve focus groups were held (38 members of the public, 29 "policy makers," seven hospice volunteers); budget pie tasks were completed to generate weights. Constant comparison was used to analyze qualitative data, exploring principles behind individuals' weightings. Average weights elicited from members of the general population and policy makers for the importance that should be given to close persons (vs. patients) were very similar, at around 30%. A "sliding scale" of weights between health gain and the capability for a good death resulted from the policy maker and volunteer groups, with increasing weight given to the capability for a good death as the trajectory got closer to death. These weights can be used in developing a more comprehensive framework for economic evaluation at end of life.

Social tariffs and democratic choice-Do population-based health state values reflect the will of the people?

In economic evaluations of health technologies, health outcomes are commonly measured in terms of quality-adjusted life years (QALYs). QALYs are the product of time and health-related quality of life. Health-related quality of life, in turn, is determined by a social tariff, which is supposed to reflect the public's preference over health states. This study argues that, because of the tariff's role in the societal decision-making process, it should not be understood as merely an operational (statistical) definition of health, but as a major instrument of democratic participation. I outline what implications this might have for both the method used to aggregate individual preferences, and the set of individuals whose preferences should count. Alternative tariff specifications and decision rules are explored, and future research directions are proposed.

HTA methodology and value frameworks for evaluation and policy making for cell and gene therapies

This last decade has been marked by significant advances in the development of cell and gene (C&G) therapies, such as gene targeting or stem cell-based therapies. C&G therapies offer transformative benefits to patients but present a challenge to current health technology decision-making systems because they are typically reviewed when clinical efficacy data are very limited and when there is uncertainty about the long-term durability of outcomes. These challenges are not unique to C&G therapies, but they face more of these barriers, reflecting the need for adapting existing value assessment frameworks. Still, C&G therapies have the potential to be cost-effective even at very high price points. The impact on healthcare budgets will depend on the success rate of pipeline assets and on the extent to which C&G therapies will expand to wider pathologies beyond rare or ultra-rare diseases. Getting pricing and reimbursement models right is important for incentivising research and development investment while not jeopardising the sustainability of healthcare systems. Payers and manufacturers therefore need to acknowledge each other's constraints-limitations in the evidence generation on the manufacturer side, budget considerations on the payer side-and embrace innovative thinking and approaches to ensure timely delivery of therapies to patients. Several experts in health technology assessment and clinical experts have worked together to produce this publication and identify methodological and policy options to improve the assessment of C&G therapies, and make it happen better, faster and sustainably in the coming years.

Reasoning in the valuation of health-related quality of life: A qualitative content analysis of deliberations in a pilot study

BACKGROUND

Group deliberation can be a pathway to understanding reasons behind judgement decisions. This pilot study implemented a deliberative process to elicit public values about health-related quality of life. In this study, participants deliberated scales and weights for a German adaption of the Short-Form Six-Dimension (SF-6D) Version 2 from a public perspective.

OBJECTIVE

This article examines the reasons participants stated for health state valuations and investigates the feasibility of eliciting public reasons for judgement decisions in a deliberative setting.

METHODS

The 1-day deliberation was guided by MACBETH as a method of multi-criteria decision analysis and involved qualitative comparisons of SF-6D health states and dimensions. Participants deliberated in parallel small groups and a subsequent plenary assembly. A qualitative content analysis was conducted to assess the value judgements and reasons behind them.

RESULTS

A total of 34 students participated in the study. Common reasoning was the level of impairment, marginal benefit, possibility of adjustment and expectation satisfaction. While the small groups agreed on scales for the SF-6D dimensions, the plenary assembly did not reach consensus on one scale and dimension weights. When dimensions were prioritized, these were pain and mental health.

CONCLUSIONS

While no consented value set was derived, this pilot study presents a promising approach for eliciting public reasoning behind judgements on health state values. Furthermore, it demonstrates that participants consider diverse motives when valuing health-related quality of life.