Carers' Health-Related Quality of Life in Global Health Technology Assessment: Guidance, Case Studies and Recommendations

The New Dutch Guideline for Economic Evaluations in Healthcare: Taking the Societal Perspective to the Next Level

OBJECTIVES

To promote uniform and high-quality economic evaluations, several national Health Technology Assessment (HTA) bodies have developed guidelines. Because of ongoing (methodological) developments within the field of HTA and economic evaluations, the Dutch health economic guideline needed a revision. This article briefly discusses the process of the latest revision, highlights most important changes, and presents a research agenda with topics for which more research is desired.

METHODS

An independent committee of 8 Dutch academic HTA experts was installed to advise the National Health Care Institute on this revision. A survey was sent to all relevant stakeholders to obtain input on adjustments needed. The committee discussed the results from the survey and during 4 meetings, formulated its advice accordingly.

RESULTS

The most important revisions are a lowered discount rate for costs, additional guidance concerning expert opinion and expert elicitation, the inclusion of health-related quality of life of informal caregivers, performing probabilistic analysis for the main results, indirect medical costs in life years gained, additional guidance on empirical economic evaluations and the inclusion of value of information analyses. Furthermore, the costing manual has been updated as well, including updated reference prices and additional price categories related to educational and judicial costs.

CONCLUSIONS

The revised Dutch guideline provides up-to-date guidance for conducting economic evaluations in The Netherlands that can inform health policy decisions from a broad societal perspective.

Understanding the health-related quality of life impacts of caring for children and adolescents with rare progressive life-limiting conditions: key challenges and future research priorities

The inclusion of health-related quality of life (HRQoL) impacts on informal carers in health technology assessments (HTAs) is lacking due, primarily, to a deficiency in evidence and methodological issues on how informal carer HRQoL is captured and incorporated into economic models. These issues are magnified in areas of significant burden, such as caring for children and adolescents with rare, progressive, life-limiting conditions. In this commentary we outline key challenges in measuring, and incorporating in HTA submissions, informal carer HRQoL data in rare, progressive, paediatric, life-limiting conditions and identify future research priorities in this space. We argue that: (i) a generic model of carer HRQoL is likely inadequate to characterise the HRQoL impacts in this population; (ii) the underlying evidence-base is underdeveloped, including understanding commonalities across conditions, impact beyond the primary carer, and differences over time; and (iii) methodological challenges in modelling informal carer HRQoL in cost-effectiveness analysis are inhibiting progress. A research agenda is proposed that addresses these challenges by focusing first on in-depth qualitative research to develop an appropriate, content valid 'disease-group-specific' model for understanding informal carer HRQoL in rare, progressive, paediatric, life-limiting conditions. This model can be used to inform the appropriate measurement of carer HRQoL in this population, which, alongside methodological research on addressing modelling challenges, can help to facilitate the recommended inclusion of informal carer HRQoL data in HTA submissions for children and adolescents living with rare, progressive, life-limiting conditions.

Challenges in Value Assessment for One-Time Gene Therapies for Inherited Retinal Diseases: Are We Turning a Blind Eye?

OBJECTIVES

X-linked retinitis pigmentosa (XLRP) is a rare inherited retinal disease with no available treatment. Gene therapies in clinical trials will pose challenges for health technology assessment (HTA) if found to be safe and effective. We evaluated 2 of these challenges, namely acceptability and difficulties in assessing value beyond short-term patient health and healthcare savings and discounting in economic evaluation.

METHODS

We conducted a narrative literature review on the socioeconomic burden of XLRP to identify relevant components of value for a hypothetical gene therapy from a societal perspective and to assess their relative importance. We compared the resulting value profile against the value frameworks of three European HTA agencies. We also reviewed their guidelines on discounting and potential discounting issues specific to XLRP.

RESULTS

Much of the societal value of an XLRP gene therapy is likely to originate from productivity effects, carer spillovers, and value elements related to patient uncertainty. The evidence on these effects, however, is often limited, making it difficult for HTA agencies to assess them. Cost-effectiveness results are likely to be highly sensitive to the discount rate, and discounting will compound the effects of omitting important sources of value.

CONCLUSIONS

We have identified and detailed important components of societal value, key evidence gaps, and potential discounting issues for an XLRP gene therapy, which can inform future value assessments. Many of these may apply to gene therapies in other disease areas. Revisiting existing HTA approaches is recommended to ensure these are fit for purpose for such new classes of treatment.

Food for thought: more explicit guidance for inclusion of caregiver perspectives in health technology assessment

Caregivers can play an important role in supporting and caring for people with progressive, life-threatening, or debilitating conditions. However, this supportive role can expose caregivers to various detrimental financial, physical, and psychosocial issues. When evaluating medical technologies for reimbursement decisions, health technology assessment (HTA) agencies typically focus on the treatment's impact on patients and ignore or downplay the impact on caregivers. Including caregiver impacts within a wider societal perspective may better enable health systems to maximize health benefits from available resources. However, the lack of clear guidance or methodological recommendations from decision makers on the inclusion of caregiver impacts limits the number of HTA submissions that consider these effects. We outline a conceptual framework based on intensity and duration of caregiving to guide researchers, industry, and decision makers when developing policies for the inclusion of caregiver outcomes and justify their inclusion based on expected caregiver burden in identified circumstances.

Cost-Effectiveness of Teduglutide for Pediatric Patients with Short Bowel Syndrome in Japan, Including Caregiver Burden

INTRODUCTION

Short bowel syndrome (SBS) is associated with a significant mental and physical burden for patients and caregivers. Standard of care (SOC) for SBS includes parenteral support (PS) to optimize intestinal function. Teduglutide, a recombinant human glucagon-like peptide 2 analogue, reduces the need for PS in patients with SBS. In this study, we assessed the cost-effectiveness of teduglutide in pediatric patients with SBS from multiple perspectives, considering the caregiver's burden.

METHODS

A Markov model was used to evaluate cost (Japanese yen, JPY) and effectiveness (quality-adjusted life years, QALYs) of teduglutide compared with SOC for pediatric patients with SBS in Japan. We conducted a base-case analysis and selected sensitivity and scenario analyses from three perspectives: (1) the public healthcare payer, (2) the public healthcare and long-term care payer, and (3) society.

RESULTS

In the base-case analysis, the incremental cost-effectiveness ratio (ICER) was 9,533,412 JPY per QALY from the public healthcare payer perspective, 6,335,980 JPY per QALY from the public healthcare and long-term care payer perspective, and 3,510,371 JPY per QALY from the societal perspective. The probability that cost-effectiveness of teduglutide is favorable from a societal perspective was 59.3%. In all scenario analyses, consistent with the base-case analysis, ICERs for teduglutide compared with SOC were different depending on whether caregiver utility and productivity loss were considered.

CONCLUSIONS

Incorporating the caregiver's burden in the cost-effectiveness analysis of teduglutide for pediatric patients with SBS provided a more comprehensive assessment of the value of teduglutide for patients, their families, and society. This approach enhances our understanding of the overall value of a treatment, especially for diseases with significant caregiver burden.

Including carer health-related quality of life in NICE health technology assessments in the United Kingdom

The impact of health technologies may extend beyond the patient and affect the health of people in their network, like their informal carers. The National Institute for Health and Care Excellence (NICE) methods guide explicitly allows the inclusion of health-related quality of life (HRQoL) effects on carers in economic evaluations when these effects are substantial, but the proportion of NICE appraisals that includes carer HRQoL remains small. This paper discusses when inclusion of carer HRQoL is justified, how inclusion can be substantiated, and how carer HRQoL can be measured and included in health economic models. Inclusion of HRQoL in economic evaluations can best be substantiated by data collected in (carers for) patients eligible for receiving the intervention. To facilitate combining patient and carer utilities on the benefit side of economic evaluations, using EQ-5D to measure impacts on carers seems the most successful strategy in the UK context. Alternatives to primary data collection of EQ-5D include vignette studies, using existing values, and mapping algorithms. Carer HRQoL was most often incorporated in economic models in NICE appraisals by employing (dis)utilities as a function of the patient's health state or disease severity. For consistency and comparability, economic evaluations including carer HRQoL should present analyses with and without carer HRQoL.

Development of stakeholder-informed recommendations for inclusion of family spillover effects in health technology assessment

BACKGROUND

The impacts of disease and treatment on a patient's family members and informal caregivers are known as "family spillover effects." Although many formal value frameworks call for the consideration of these effects, they are often not included in health technology assessments (HTAs) and cost-effectiveness analyses (CEAs). A formal evaluation of stakeholder perspectives may help address the disconnect for inclusion of family spillover effects observed in practice.

OBJECTIVE

To develop stakeholder-driven recommendations for the measurement and use of family spillover effects in the United States and to identify research opportunities.

METHODS

We first conducted a targeted literature review of US-based CEAs and HTA reports from the past 10 years to assess the current use of family spillover effects. We then used a purposeful sampling technique to conduct 25 qualitative interviews with outcomes researchers, patient advocates, health economists, and health policy and payer experts to gather perspectives on when and how family spillover effects should be considered in HTA processes. We conducted a thematic analysis of the interview transcripts to identify key themes and develop preliminary recommendations. Finally, we conducted an online workshop with 8 stakeholders to discuss, rate, and refine preliminary recommendations to develop final recommendations.

RESULTS

A key theme identified in the stakeholder interviews was the role that data availability, analyst preferences, and prior precedence play in limiting the inclusion of spillover effects in HTAs. Additional themes included support for the inclusion of both qualitative and quantitative spillover effects and the need to capture broad and diverse impacts across populations. We developed 15 recommendations from the consensus building workshop addressing measurement, CEA modeling, and HTA processes. Key recommendations included (1) a transparent process for deciding when family spillover effects should be included, (2) measurement of direct and indirect costs with priority based on the magnitude of impact, (3) the use of validated measures, (4) the use of proxy information and expert elicitation when quality data are unavailable, and (5) the use of a modified impact inventory table for transparency of included effects. Research opportunities included patient involvement in family spillover effect research and HTAs, mapping algorithms and non-preference-based caregiver measures to generate utilities, and consensus best practices for modeling.

CONCLUSIONS

The inconsistent inclusion of family spillover effects in HTAs and CEAs remains a persistent challenge. The stakeholder-driven recommendations and research opportunities identified in this study may help improve the transparency, measurement, and use of family spillover effects in assessing the clinical and economic value of novel medical technologies.

On spillovers in economic evaluations: definition, mapping review and research agenda

An important issue in economic evaluations is determining whether all relevant impacts are considered, given the perspective chosen for the analysis. Acknowledging that patients are not isolated individuals has important implications in this context. Increasingly, the term "spillovers" is used to label consequences of health interventions on others. However, a clear definition of spillovers is lacking, and as a result, the scope of the concept remains unclear. In this study, we aim to clarify the concept of spillovers by proposing a definition applicable in health economic evaluations. To illustrate the implications of this definition, we highlight the diversity of potential spillovers through an expanded impact inventory and conduct a mapping review that outlines the evidence base for the different types of spillovers. In the context of economic evaluations of health interventions, we define spillovers as all impacts from an intervention on all parties or entities other than the users of the intervention under evaluation. This definition encompasses a broader range of potential costs and effects, beyond informal caregivers and family members. The expanded impact inventory enables a systematic approach to identifying broader impacts of health interventions. The mapping review shows that the relevance of different types of spillovers is context-specific. Some spillovers are regularly included in economic evaluations, although not always recognised as such, while others are not. A consistent use of the term "spillovers", improved measurement of these costs and effects, and increased transparency in reporting them are still necessary. To that end, we propose a research agenda.

Examining how well economic evaluations capture the value of mental health

Health economics evidence informs health-care decision making, but the field has historically paid insufficient attention to mental health. Economic evaluations in health should define an appropriate scope for benefits and costs and how to value them. This Health Policy provides an overview of these processes and considers to what extent they capture the value of mental health. We suggest that although current practices are both transparent and justifiable, they have distinct limitations from the perspective of mental health. Most social value judgements, such as the exclusion of interindividual outcomes and intersectoral costs, diminish the value of improving mental health, and this reduction in value might be disproportionate compared with other types of health. Economic analyses might have disadvantaged interventions that improve mental health compared with physical health, but research is required to test the size of such differential effects and any subsequent effect on decision-making systems such as health technology assessment systems. Collaboration between health economics and the mental health sciences is crucial for achieving mental-physical health parity in evaluative frameworks and, ultimately, improving population mental health.

Recommendations for Emerging Good Practice and Future Research in Relation to Family and Caregiver Health Spillovers in Health Economic Evaluations: A Report of the SHEER Task Force

BACKGROUND

Omission of family and caregiver health spillovers from the economic evaluation of healthcare interventions remains common practice. When reported, a high degree of methodological inconsistency in incorporating spillovers has been observed.

AIM

To promote emerging good practice, this paper from the Spillovers in Health Economic Evaluation and Research (SHEER) task force aims to provide guidance on the incorporation of family and caregiver health spillovers in cost-effectiveness and cost-utility analysis. SHEER also seeks to inform the basis for a spillover research agenda and future practice.

METHODS

A modified nominal group technique was used to reach consensus on a set of recommendations, representative of the views of participating subject-matter experts. Through the structured discussions of the group, as well as on the basis of evidence identified during a review process, recommendations were proposed and voted upon, with voting being held over two rounds.

RESULTS

This report describes 11 consensus recommendations for emerging good practice. SHEER advocates for the incorporation of health spillovers into analyses conducted from a healthcare/health payer perspective, and more generally inclusive perspectives such as a societal perspective. Where possible, spillovers related to displaced/foregone activities should be considered, as should the distributional consequences of inclusion. Time horizons ought to be sufficient to capture all relevant impacts. Currently, the collection of primary spillover data is preferred and clear justification should be provided when using secondary data. Transparency and consistency when reporting on the incorporation of health spillovers are crucial. In addition, given that the evidence base relating to health spillovers remains limited and requires much development, 12 avenues for future research are proposed.

CONCLUSIONS

Consideration of health spillovers in economic evaluations has been called for by researchers and policymakers alike. Accordingly, it is hoped that the consensus recommendations of SHEER will motivate more widespread incorporation of health spillovers into analyses. The developing nature of spillover research necessitates that this guidance be viewed as an initial roadmap, rather than a strict checklist. Moreover, there is a need for balance between consistency in approach, where valuable in a decision making context, and variation in application, to reflect differing decision maker perspectives and to support innovation.

A Systematic Review of Methods Used by Pediatric Cost-Utility Analyses to Include Family Spillover Effects

BACKGROUND

A child's health condition affects family members' health and well-being. However, pediatric cost-utility analysis (CUA) commonly ignores these family spillover effects leading to an incomplete understanding of the cost and benefits of a child's health intervention. Methodological challenges exist in assessing, valuing, and incorporating family spillover effects.

OBJECTIVE

This study systematically reviews and compare methods used to include family spillover effects in pediatric CUAs.

METHODS

A literature search was conducted in MEDLINE, Embase, EconLit, Cochrane collection, CINAHL, INAHTA, and the Pediatric Economic Database Evaluation (PEDE) database from inception to 2020 to identify pediatric CUAs that included family spillover effects. The search was updated to 2021 using PEDE. The data describing in which family members spillover effects were measured, and how family spillover effects were measured, incorporated, and reported, were extracted. Common approaches were grouped conceptually. Further, this review identified theories or theoretical frameworks used to justify approaches for integrating family spillover effects into CUA.

RESULTS

Of 878 pediatric CUAs identified, 35 included family spillover effects. Most pediatric CUAs considered family spillover effects on one family member. Pediatric CUAs reported eight different approaches to measure the family spillover effects. The most common method was measuring the quality-adjusted life years (QALY) loss of the caregiver(s) or parent(s) due to a child's illness or disability using an isolated approach whereby family spillover effects were quantified in individual family members separately from other health effects. Studies used four approaches to integrate family spillover effects into CUA. The most common method was to sum children's and parents/caregivers' QALYs. Only two studies used a theoretical framework for incorporation of family spillover effects.

CONCLUSIONS

Few pediatric CUAs included family spillover effects and the observed variation indicated no consensus among researchers on how family spillover effects should be measured and incorporated. This heterogeneity is mirrored by a lack of practical guidelines by Health Technology Assessment (HTA) agencies or a theoretical foundation for including family spillover effects in pediatric CUA. The results from this review may encourage researchers to develop a theoretical framework and HTA agencies to develop guidelines for including family spillover effects. Such guidance may lead to more rigorous and standardized methods for including family spillover effects and better-quality evidence to inform decision-makers on the cost-effectiveness of pediatric health interventions.

Does caring for patients with advanced non-small cell lung cancer affect health-related quality of life of caregivers? A multicenter, cross-sectional study

PURPOSE

Patients with advanced non-small cell lung cancer (NSCLC) mostly receive essential routine care and support from informal caregivers, who usually experience poorer health-related quality of life (HRQoL). The study aimed to evaluate the HRQoL and its predictors among informal caregivers of patients with advanced NSCLC in China.

METHODS

We interviewed the adult caregiver population of patients with advanced NSCLC (stage IIIB~IV) in nine tertiary hospitals from multiple provinces in China between November 2020 and June 2021. The EQ-5D-5L instrument measured the HRQoL of caregivers, as analyzed by employing descriptive analysis, univariate analysis, Tobit regression, and multivariate logistic regression, and investigated the important influencing factors further.

RESULTS

A valid sample of 553 caregivers was analyzed. The mean EQ-5D-5L utility score of caregivers was 0.92 (SD = 0.14). Caregivers reported the greatest problems in mental health, with 45.39% reporting slight, moderate, severe, or extreme anxiety/depression. The potential influencing factors of HRQoL in caregivers included patients' age and cancer histology, relationship with the patients, and daily caregiving hours. Compared to other caregivers, patients' spouses had the lowest HRQoL. In addition, over six hours of caregiving per day was associated with lower HRQoL in caregivers of patients with advanced NSCLC.

CONCLUSIONS

The HRQoL of caregivers for patients with advanced NSCLC was investigated for the first time in China. The informal caregivers experience decreased HRQoL, with anxiety /depression problems being reported the most. The findings of this study would provide extensive information on the HRQoL of advanced NSCLC patients' caregivers for future health-promoting self-care.

Modelling Informal Carers' Health-Related Quality of Life: Challenges for Economic Evaluation

There has been increasing interest in including carers' health-related qualify of life (HRQoL) in decision models, but currently there is no best practice guidance as to how to do so. Models thus far have typically assumed that carers' HRQoL can be predicted from patient health states, as we illustrate with three examples of disease-modifying treatments. However, this approach limits the mechanisms that influence carers' HRQoL solely to patient health and may not accurately reflect carers' outcomes. In this article, we identify and discuss challenges associated with modelling intervention effects on carers' HRQoL: attaching carer utilities to patient disease states, the size of the caring network, aggregation of carer and patient HRQoL, patient death, and modelling longer-term carer HRQoL. We review and critique potential alternatives to modelling carers' HRQoL in decision models: trial-based analyses, qualitative consideration, cost-consequence analysis, and multicriteria decision analysis, noting that each of these also has its own challenges. We provide a framework of issues to consider when modelling carers' HRQoL and suggest how these can be addressed in current practice and future research.

Modelling Spillover Effects on Informal Carers: The Carer QALY Trap

The provision of informal (unpaid) care can impose significant 'spillover effects' on carers, and accounting for these effects is consistent with the efficiency and equity objectives of health technology assessment (HTA). Inclusion of these effects in health economic models, particularly carer health-related quality of life (QOL), can have a substantial impact on net quality-adjusted life year (QALY) gains and the relative cost effectiveness of new technologies. Typically, consideration of spillover effects improves the value of a technology, but in some circumstances, consideration of spillover effects can lead to situations whereby life-extending treatments for patients may be considered cost ineffective due to their impact on carer QOL. In this piece we revisit the classic 'QALY trap' and introduce an analogous 'carer QALY trap' which may have practical implications for economic evaluations where the inclusion of carer QOL reduces incremental QALY gains. Such results may align with a strict QALY-maximisation rule, however we consider the extent to which this principle may be at odds with the preferences of carers themselves (and possibly society more broadly), potentially leading decision makers into the carer QALY trap as a result. We subsequently reflect on potential solutions, highlighting the important (albeit limited) role that deliberation has to play in HTA.

The Feasibility and Validity of Preference-Based Quality of Life Measures With Informal Carers: A Think-Aloud Study

OBJECTIVES

A range of preference-based quality of life (QoL) measures have been proposed for use with informal carers. Qualitative evaluation of validity and feasibility of the measures is an important step in understanding whether measures will work as intended. At present, little is known about the performance of different types of preference-based QoL measures with informal carers. The objective of this study was to qualitatively assess the feasibility, content validity (including face validity), and acceptability of 5 QoL measures (the Carer Experience Scale, CarerQoL-7D, ASCOT-C, ICECAP-A, and EQ-5D-5L) with informal carers.

METHODS

A total of 24 "think-aloud" interviews were conducted with a cross-section of carers of adults in the United Kingdom. This think-aloud process was followed by semistructured discussion to probe issues of validity and feasibility in more detail. The interview data were transcribed, coded to identify the frequency of errors in completing the QoL measures and thematically analyzed to study the validity, feasibility, and acceptability of the measures.

RESULTS

Few errors (3%-7% per item) were identified in completing each of the measures with little distinct pattern. Most participants found the measures to be concise, clear, and relevant. Challenges included relevance, context, time period, missing items, multiple questions, and response options. Informal carers generally expressed a preference for using a care-related QoL measure.

CONCLUSIONS

Existing preference-based QoL measures have encouraging validity and feasibility within a mixed sample of informal carers, with minor challenges raised. These challenges ought to be considered, alongside the decision context, when administering QoL measures in this context.

Assessing the impact of grief on quality of life, work productivity, and health outcomes for parents bereaved from SMA: A study protocol

BACKGROUND

U.S. cost-effectiveness recommendations suggest that analyses should include all costs and effects relevant to the decision problem [1]. However, in many diseases, including spinal muscular atrophy (SMA), few studies have evaluated bereaved family outcomes after a child has died, neglecting potential impacts on their health-related quality of life (HRQoL), work productivity, and mental health. Additionally, grief-related outcomes are rarely included in economic evaluations. This manuscript outlines the protocol of a study that will estimate the HRQoL, work functioning, and mental health of bereaved parents of children with SMA type 1 to determine how outcomes vary based on parent's sex and the time since a child's death.

METHODS

This study will involve two phases. In Phase 1, we will conduct a literature review to identify prior research that has measured how parental grief impacts HRQoL, work productivity, and mental health. We will also interview four bereaved parents of children with SMA type 1, stratified by parent sex and time since their child's death, and analyze findings using a thematic analysis. In Phase 2, we will develop a survey draft based on Phase 1 findings. Parents bereaved from SMA type 1 will review our survey draft and we will revise the survey based on their feedback. We will send a cross-sectional survey to approximately 880 parents bereaved from SMA type 1. We will analyze findings from the survey to investigate whether the severity of grief symptoms is correlated with HRQoL, productivity, depression and anxiety symptom severity. We will also evaluate whether the mean scores of grief and each of the outcomes vary significantly when stratified by parent sex and the time since the child's death.

DISCUSSION

Our results will provide preliminary information on how parental grief can impact HRQoL, productivity, and mental health outcomes over time. Increasing the availability of family outcomes data will potentially assist organizations performing health economic evaluations, such as the Institute of Clinical and Economic Review (ICER) in the U.S. This research will also help to inform the development of future economic guidelines on this topic.

Review of economic modeling evidence from NICE appraisals of rare disease treatments for spinal muscular atrophy

INTRODUCTION

The National Institute of Health and Care Excellence (NICE) in England has appraised three treatments for spinal muscular atrophy (SMA), namely, nusinersen, onasemnogene abeparvovec, and risdiplam. As rare disease treatments (RDTs) commonly face challenges in health technology assessment (HTA) processes due to their clinical and economic uncertainties, an in-depth review of these appraisals is useful to enable a deeper understanding of economic modelling considerations for SMA.

AREAS COVERED

This review is a detailed analysis of NICE appraisals for SMA and aims to compare the economic modelling evidence of the three RDTs. This is done by examining differences and similarities and by discussing critical outstanding issues across the economic evaluations of the appraisals.

EXPERT OPINION

This article aims to contribute to the development of evidence that can be used as guidance to inform resource allocation decisions for RDTs for SMA, but also to be a resource about approaches for the generation, analysis and interpretation of economic modelling evidence for RDTs more broadly.