Valuing Healthcare Goods and Services: A Systematic Review and Meta-Analysis on the WTA-WTP Disparity

Time value of informal care of people with alzheimer's disease in Spain: a population-based analysis

The aims of this paper are to estimate the monetary value of informal care for people with Alzheimer's disease (AD) in Spain, to compare results with those obtained in 2008 and to analyse the main determinants of the time of the value of informal care. The Survey on Disabilities, Autonomy and Dependency carried out in Spain in 2020/21 was used to obtain information about disabled individuals with AD and their informal caregivers. Assessment of informal care time was carried out using two alternative approaches: the replacement method, and the contingent valuation method (willingness to pay & willingness to accept). The number of people with AD residing in Spanish households and receiving informal care rose to more than 200,000, representing an increase of 43% compared with 2008. The average number of hours of informal care per week ranged from 86 to 101 h, with an estimated value of between €31,584 - €37,019 per year per caregiver (willingness to accept) or €71,653 - €83,984 per year (replacement). The annual total number of caregiving hours ranged between 896 and 1,061 million hours, representing between 0.52 and 0.62 of GDP in 2021 (willingness to accept) or 1.19-1.40 of GDP (replacement). The level of care needs plays a central role in explaining heterogeneity in estimates. These results should be taken into account by decision-makers for long-term care planning in the coming years.

The global, regional, and national burden and quality of care index of kidney cancer; a global burden of disease systematic analysis 1990-2019

Kidney cancer (KC) is a prevalent cancer worldwide. The incidence and mortality rates of KC have risen in recent decades. The quality of care provided to KC patients is a concern for public health. Considering the importance of KC, in this study, we aim to assess the burden of the disease, gender and age disparities globally, regionally, and nationally to evaluate the quality and inequities of KC care. The 2019 Global Burden of Disease study provides data on the burden of the KC. The secondary indices, including mortality-to-incidence ratio, disability-adjusted life years -to-prevalence ratio, prevalence-to-incidence ratio, and years of life lost-to-years lived with disability ratio, were utilized. These four newly merged indices were converted to the quality-of-care index (QCI) as a summary measure using principal component analysis. QCI ranged between 0 and 100, and higher amounts of QCI indicate higher quality of care. Gender disparity ratio was calculated by dividing QCI for females by males to show gender inequity. The global age-standardized incidence and mortality rates of KC increased by 29.1% (95% uncertainty interval 18.7-40.7) and 11.6% (4.6-20.0) between 1990 and 2019, respectively. Globally, the QCI score for KC increased by 14.6% during 30 years, from 71.3 to 81.6. From 1990 to 2019, the QCI score has increased in all socio-demographic index (SDI) quintiles. By 2019, the highest QCI score was in regions with a high SDI (93.0), and the lowest was in low SDI quintiles (38.2). Based on the World Health Organization regions, the QCI score was highest in the region of America, with Canada having the highest score (99.6) and the lowest in the African Region, where the Central African Republic scored the lowest (17.2). In 1990, the gender disparity ratio was 0.98, and in 2019, it was 0.97 showing an almost similar QCI score for females and males. Although the quality of care for KC has improved from 1990 to 2019, there is a significant gap between nations and different socioeconomic levels. This study provides clinicians and health authorities with a global perspective on the quality of care for KC and identifies the existing disparities.

Simulations of Multifocal Vision in Patients With Previous Monofocal Intraocular Lens Implantation

PURPOSE

To evaluate the effectiveness and patient acceptance of multifocal vision simulation in patients with previous monofocal intraocular lens (IOL) implantation, and to explore their willingness-to-pay (WTP) and willingness-to-accept (WTA) based on the perceived advantages and disadvantages of multifocal vision.

METHODS

Seventeen patients with previous monofocal IOL implantation participated in this cross-sectional study. The SimVis Gekko device (2EyesVision SL) was used to simulate monofocal (Evaluation B) and multifocal (Evaluation C) visual experiences, compared to their existing vision (Evaluation A). Visual acuity at three distances and defocus curves were measured. Patients responded to inquiries about visual quality in each evaluation, bothersomeness of photic phenomena, probability to select the visual experience, and the monetary value they associated with enhanced WTP or diminished WTA visual quality.

RESULTS

The simulations underestimated the visual acuity reported for the IOL in existing literature by one or two lines, depending on the testing distance. This underestimation was more pronounced in defocus curves. However, 70.6% of patients were likely or very likely to opt for multifocal vision, indicating they perceived the benefits of multifocality. The WTP for multifocal vision was twice that of monofocal vision, and the WTP/WTA ratio exceeded 1, suggesting the perceived vision benefits outweighed potential drawbacks.

CONCLUSIONS

Despite underestimating the expected postoperative visual performance, the multifocal simulation enabled patients to perceive the benefits of multifocal vision to some extent. This system could be beneficial in avoiding potential postoperative complaints, but the possible rise in false-positive results should be considered and evaluated in future research. [J Refract Surg. 2023;39(12):831-839.].

Cost-utility analysis of tapering strategies of biologicals in rheumatoid arthritis patients in the Netherlands

OBJECTIVES

Current guidelines recommend tapering biological disease-modifying antirheumatoid drugs (bDMARDs) in rheumatoid arthritis (RA) if the disease is under control. However, guidelines on tapering are lacking. Assessing cost-effectiveness of different tapering strategies might provide broader input for creating guidelines on how to taper bDMARDs in patients with RA. The aim of this study is to evaluate the long-term cost-effectiveness from a societal perspective of bDMARD tapering strategies in Dutch patients with RA, namely 50% dose reduction (tapering), discontinuation and a 50% dose reduction followed by discontinuation (de-escalation).

METHODS

Using a societal perspective, a Markov model with a life-time horizon of 30 years was used to simulate 3-monthly transitions between Disease Activity 28 (DAS28)-defined health states of remission (<2.6), low disease activity (2.63.2). Transition probabilities were estimated through literature search and random effects pooling. Incremental costs, incremental quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs) and incremental net monetary benefits for each tapering strategy were compared with continuation. Deterministic, probabilistic sensitivity analyses and multiple scenario analyses were performed.

RESULTS

After 30 years, the ICERs were €115 157/QALY lost, €74 226/QALY lost and €67 137/QALY lost for tapering, de-escalation and discontinuation, respectively; mainly driven by bDMARD cost savings and a 72.8% probability of a loss in quality of life. This corresponds to a 76.1%, 64.3% and 60.1% probability of tapering, de-escalation and discontinuation being cost-effective, provided a willingness-to-accept threshold of €50 000/QALY lost.

CONCLUSIONS

Based on these analyses, the 50% tapering approach saved the highest cost per QALY lost.

Financial compensation for natural forest logging ban: Standard calculation based on willingness to accept

To alleviate the deteriorating environment and protect biodiversity, China has implemented a natural forest protection system, demonstrating the importance of sustainable forest management for ecological conservation and socio-economic development, including the complete cessation of commercial logging of natural forests. Financial compensation is adopted to increase farmers' enthusiasm within the commercial Logging Ban of Natural Forests framework. This study used the contingent valuation method and the Heckman two-stage model to explore farmers' willingness to participate in the Logging Ban of Natural Forests and the willingness to accept by survey data on 486 farming households. 72% of farmers are willing to join the Logging Ban of Natural Forests. Their willingness to accept is 517.95 yuan/ha per year, higher than the current state subsidy standard (225 yuan/ha per year). The key factors influencing willingness to accept include the education and degree of fragmentation of woodland and village collective willingness to accept. The age of the rural household head, the fragmentation of the forest, and the evaluation of the Logging Ban of Natural Forests policies have inhibited the increase of farmers' compensation. Farmers' assessment of the Logging Ban of Natural Forests policy only impacts the medium level of compensation. The age and the degree of forest fragmentation would affect the higher compensation amount. The results from this study suggest more financial sources and increased compensation standards are needed. The government should also strengthen ecological awareness and adopt different compensation standards for other groups to achieve sustainable forestry.

Determinants of willingness to pay for health services: a systematic review of contingent valuation studies

INTRODUCTION

Stated preference studies are a valuable tool to elicit respondents' willingness to pay (WTP) for goods or services, especially in situations where no market valuation exists. Contingent valuation (CV) is a widely used approach among stated-preference techniques for eliciting WTP if prices do not exist or do not reflect actual costs, for example, when services are covered by insurance. This review aimed to provide an overview of relevant factors determining WTP for health services to support variable selection.

METHODS

A comprehensive systematic literature search and review of CV studies assessing determinants of WTP for health services was conducted, including 11 electronic databases. Two of the authors made independent decisions on the eligibility of studies. We extracted all determinants used and related p values for the effect sizes (e.g. reported in regression models with WTP for a health service as outcome variable). Determinants were summarised in systematic evidence tables and structured by thematic domains.

RESULTS

We identified 2082 publications, of which 202 full texts were checked for eligibility. We included 62 publications on 61 studies in the review. Across all studies, we identified 22 WTP determinants and other factors from 5 thematic domains: sociodemographic characteristics, perceived threat, perceived benefit, perceived barriers, and other information.

CONCLUSION

Our review provides evidence on 22 relevant determinants of WTP for health services, which may be used for variable selection and as guidance for planning CV surveys. Endogeneity should be carefully considered before interpreting these determinants as causal factors and potential intervention targets.

Cost-effectiveness of the implementation of [68Ga]Ga-PSMA-11 PET/CT at initial prostate cancer staging

Background

Despite its high specificity, PSMA PET/CT has a moderate to low sensitivity of 40–50% for pelvic lymph node detection, implicating that a negative PSMA PET/CT cannot rule out lymph node metastases. This study investigates a strategy of implementing PSMA PET/CT for initial prostate cancer staging and treatment planning compared to conventional diagnostics. In this PSMA PET/CT strategy, a bilateral extended pelvic lymph node dissection (ePLND) is only performed in case of a negative PSMA PET/CT; in case of a positive scan treatment planning is solely based on PSMA PET/CT results.

Method

A decision table and lifetime state transition model were created. Quality-adjusted life years and health care costs were modelled over lifetime.

Results

The PSMA PET/CT strategy of treatment planning based on initial staging with [⁶⁸Ga]Ga-PSMA-11 PET/CT results in cost-savings of €674 and a small loss in quality of life (QoL), 0.011 QALY per patient. The positive effect of [⁶⁸Ga]Ga-PSMA-11 PET/CT was caused by abandoning both an ePLND and unnecessary treatment in iM1 patients, saving costs and resulting in higher QoL. The negative effect was caused by lower QoL and high costs in the false palliative state, due to pN1_lim patients (≤ 4 pelvic lymph node metastases) being falsely diagnosed as iN1_ext (> 4 pelvic lymph node metastases). These patients received subsequently palliative treatment instead of potentially curative therapy.

Conclusion

Initial staging and treatment planning based on [⁶⁸Ga]Ga-PSMA-11 PET/CT saves cost but results in small QALY loss due to the rate of false positive findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13244-022-01265-w.

Cost-effectiveness of an educational intervention to reduce potentially inappropriate medication

Background

Educational interventions can reduce potentially inappropriate medication (PIM) use in older people. Their effectiveness has been measured mainly as changes in PIM use. In this economic evaluation, we analyse the impact of an educational intervention in terms of costs and quality-adjusted life years (QALYs).

Methods

The educational intervention consisted of activating and interactive training sessions for nursing staff and consulting physicians, and was compared with treatment as usual (TAU). Participants (n = 227) in a cluster randomised trial (cRCT) were residents living permanently in assisted living facilities (n = 20 wards). For economic evaluation, participants’ healthcare service use costs and costs for the intervention were estimated for a 12 month period.

Incremental cost-effectiveness ratios (ICERs) were estimated for QALYs per participant. Cost-effectiveness analysis was conducted from a healthcare perspective. A bootstrapped cost-effectiveness plane and one-way sensitivity analysis were undertaken to analyse the uncertainty surrounding the estimates.

Results

The educational intervention was estimated to be less costly and less effective in terms of QALYs than TAU at the 12 month follow-up [incremental costs –€1,629, confidence interval (CI) –€5,489 to €2,240; incremental effect −0.02, CI –0.06 to 0.02]. The base case ICER was >€80,000/QALY.

Conclusion

The educational intervention was estimated to be less costly and less effective in terms of QALYs compared with TAU, but the results are subject to some uncertainties. Reduction in PIM use or benefits in quality of life did not seem to translate into improvements in QALYs. Our findings emphasise the need for better understanding of the impact of decreasing PIM use on health outcomes.

Willingness to bear economic costs of measures against SARS-CoV-2 in Germany

Background

The aim of this study was to assess the willingness of the general population in Germany to bear the economic costs of measures against the spread of SARS-CoV-2.

Methods

Repeated cross-sectional data were taken from three waves of a nationally representative survey of individuals aged 18 to 74 years (wave 8: 21–22 April 2020, N = 976; wave 16: 7–8 July 2020, N = 977; wave 38: 9–10 March 2021). The willingness to accept a reduction of annual household income in order to bear the economic costs of the measures against SARS-CoV-2 served as outcome measure. Two-part models were used including explanatory variables on sociodemographic and (subjectively assessed) potential health hazard caused by COVID-19.

Results

65.5% (61.6%; 56.9%) of respondents in wave 8 (wave 16; wave 38) were willing to accept a reduction of income, with the likelihood for accepting a reduction of income being positively associated with higher affect (i.e. emotional reaction) and presumed severity regarding COVID-19 in all three waves. The mean maximum percentage of income participants were willing to give up was 3.3% (95% CI: 2.9 to 3.7%) in wave 8, 2.9% (95% CI: 2.5 to 3.3%) in wave 16 and 4.3% (95% CI: 3.6 to 5.0%) in wave 38, with presumed severity of COVID-19 being positively associated with this percentage in all three waves.

Conclusions

The majority of respondents indicated willingness to sacrifice income in order to bear the costs of measures against the spread of SARS-CoV-2, with the potential health hazard caused by COVID-19 being consistently associated with this willingness. However, the proportion of individuals who were willing to give up income slightly decreased throughout the pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11734-4.

Prevalence of Missing Values and Protest Zeros in Contingent Valuation in Dental Medicine

Background: The number of contingent valuation (CV) studies in dental medicine using willingness-to-pay (WTP) methodology has substantially increased in recent years. Missing values due to absent information (i.e., missingness) or false information (i.e., protest zeros) are a common problem in WTP studies. The objective of this study is to evaluate the prevalence of missing values in CV studies in dental medicine, to assess how these have been dealt with, and to suggest recommendations for future research. Methods: We systematically searched electronic databases (MEDLINE, Web of Science, Cochrane Library, PROSPERO) on 8 June 2021, and hand-searched references of selected reviews. CV studies in clinical dentistry using WTP for valuing a good or service were included. Results: We included 49 WTP studies in our review. Out of these, 19 (38.8%) reported missing values due to absent information, and 28 (57.1%) reported zero values (i.e., WTP valued at zero). Zero values were further classified into true zeros (i.e., representing the underlying preference of the respondent) or protest zeros (i.e., false information as a protest behavior) in only 9 studies. Most studies used a complete case analysis to address missingness while only one study used multiple imputation. Conclusions: There is uncertainty in the dental literature on how to address missing values and zero values in CV studies. Zero values need to be classified as true zeros versus protest zeros with follow-up questions after the WTP elicitation procedure, and then need to be handled differently. Advanced statistical methods are available to address both missing values due to missingness and due to protest zeros but these are currently underused in dental medicine. Failing to appropriately address missing values in CV studies may lead to biased WTP estimates of dental interventions.

Risk aversion, trust in institutions and contingent valuation of healthcare services: trying to explain the WTA-WTP gap in the Dutch population

Background

The preferences of citizens are a basic element to incorporate into the decision-making process when planning health policies. Contingent valuation (CV) is a common method for calculating the value for citizens that new technologies, interventions, and the provision of services or policies have. However, choosing the correct CV tool may not be a neutral decision. This work aims to assess the substitution of a healthcare service by comparing valuation differences between the willingness to pay (WTP) for the maintenance of the service versus the willingness to accept compensation (WTA) for its substitution, both of which are related to subject characteristics, with a particular focus on trust in institutions and risk aversion.

Methods

A CV study was designed to study Dutch population preferences when physician assistants replace anaesthesiologists. Differences between the distributions of WTA and WTP were compared through full decomposition methods, and conditional quantile regression was performed.

Results

Nearly two-thirds of surveyed citizens expressed null values for WTA and WTP. The other third systematically reported a value of WTA higher than that of WTP, which increased further with lower income and the possible presence of a strategic bias. In contrast, being more than 65 years old, having trust in government, and preferring anaesthesiologists decreased the WTA-WTP difference. Risk aversion had no clear association with the WTA-WTP gap.

Conclusions

Known differences between the perceived value of health services from the perspective of gains and losses could be related to people’s characteristics. Trust in government but not aversion to risk was related to the WTA-WTP differences. Identifying a profile of citizens who are averse to losing health services should be considered when designing and implementing health services or interventions or making disinvestment decisions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12962-021-00281-9.

Dealing with Bad Risk in Cost-Effectiveness Analysis: The Cost-Effectiveness Risk-Aversion Curve

Cost-effectiveness analysis has been advocated and is widely used to inform policy and decision makers in setting priorities for resource allocation. Since the costs and effects of health care interventions are uncertain, much research interest has focused on handling uncertainty in cost-effectiveness analysis. The most widely used method to summarize uncertainty in cost-effectiveness analysis is the cost-effectiveness acceptability curve, which estimates the probability that an intervention is cost effective for a wide range of threshold ratios. However, by estimating the uncertainty associated with incremental costs and effects, information about the uncertainty associated with the costs and effects of the individual programs is lost, which may be important to inform risk-averse decision makers. In the present paper, we suggest to penalize the expected net monetary benefit (NMB) of a program for its downside risk (i.e. bad risk), which preserves the uncertainty of the individual programs and rank orders programs according to their risk-adjusted NMB. The cost-effectiveness risk-aversion curve (CERAC) is introduced, which estimates the net benefit-to-risk ratio for a wide range of threshold rations. The CERAC is a helpful additional tool to inform decision and policy makers who are risk averse, and can easily be constructed using the results of a cost-effectiveness analysis.

A Systematic Review of WTA-WTP Disparity for Dental Interventions and Implications for Cost-Effectiveness Analysis

Cost-effectiveness analysis is widely adopted as an analytical framework to evaluate whether health care interventions represent value for money, and its use in dentistry is increasing. Traditionally, in cost-effectiveness analysis, one assumes that the decision maker's maximum willingness to pay (WTP) for health gain is equivalent to his minimum willingness to accept (WTA) monetary compensation for health loss. It has been documented in the literature that losses are weighted higher than equivalent gains, i.e., that WTA exceeds WTP for the same health condition, resulting in a WTA/WTP ratio greater than 1. There is a knowledge gap of published WTA/WTP ratios for dental interventions in the literature. We therefore conducted a (i) systematic review of published WTA-WTP estimates in dentistry (MEDLINE, Web of Science, Cochrane Library, London, UK) and (ii) a patient-level analysis of WTA/WTP ratios of included studies, and (iii) we demonstrate the impact of a WTA-WTP disparity on cost-effectiveness analysis. Out of 55 eligible studies, two studies were included in our review. The WTA/WTP ratio ranged from 2.58 for discontinuing water fluoridation to 5.12 for mandibular implant overdentures, indicating a higher disparity for implant rehabilitations than for dental public health interventions. A WTA-WTP disparity inflates the cost-effectiveness of dental interventions when there is a substantial risk of both lower costs and health outcomes. We therefore recommend that in these cases the results of cost-effectiveness analyses are reported using different WTA/WTP ratios in a sensitivity analysis.