Aversion to health inequalities and priority setting in health care

Computing individual and collective ethical utility for optimally planning phase III trials

A quantitative evaluation of individual and collective ethics is proposed here, with the aim of providing a tool for sample size determination/estimation that goes further than the standard power setting of 80-90%. Individual ethics deal with issues that concern the patients enrolled in the trial, where collective ones concern the patients not enrolled in the trial, and who might benefit from a positive result. The global ethical utility (GEU) of a phase III trial is introduced here, being the summation of individual and collective ethical utilities, and can be viewed as a function of the sample size. The GEU model is based on the extent of the efficacy of the treatments in study, of the quality of life of the patients being treated, of the effects of potential adverse reactions, it accounts for the duration of the periods of interest and for the size of population groups, and also embeds the experimental power. This work aims at arguing the case for GEU adoption for sample size determination. The sample size that maximizes GEU can be adopted for planning the trial, even when providing a power value out of the classical range [.8,.9]. Alternatively, among the sample sizes based on power values of 80% and 90%, the one providing the highest GEU can be adopted. Intuitively, when a treatment is assumed to work well, to have few adverse effects, and is expected to improve the QoL of the ill population for a considerable amount of time, collective ethics may prevail giving ethically optimal sample sizes larger than usual, and consequent quite high power values (e.g. 99%). Instead, medium, though still clinically meaningful, levels of effect, considerable adverse reactions, and limited life expectation and QoL improvement, might shift the ethical balance on individual ethics and give an ethically optimal sample size providing a power lower than standard values (e.g. 70%). Some examples and an application in the cardiovascular area, including sensitivity analyses of the results based on the so-called Bayesian "assurance" technique, are also discussed. Several possible extensions of the model related to particular clinical frameworks are also presented.

Incremental cost per quality-adjusted life year gained? The need for alternative methods to evaluate medical interventions for ultra-rare disorders

Drugs for ultra-rare disorders (URDs) rank prominently among the most expensive medicines on a cost-per-patient basis. Many of them do not meet conventional standards for cost-effectiveness. In light of the high fixed cost of R&D, this challenge is inversely related to the prevalence of URDs. The present paper sets out to explain the rationale underlying a recent expert consensus on these issues, recommending a more rigorous assessment of the clinical effectiveness of URDs, applying established standards of evidence-based medicine. This may include conditional approval and reimbursement policies, which should be combined with a firm expectation of proof of a minimum significant clinical benefit within a reasonable time. In contrast, current health economic evaluation paradigms fail to adequately reflect normative and empirical concerns (i.e., morally defensible 'social preferences') regarding healthcare resource allocation. Hence there is a strong need for alternative economic evaluation models for URDs.

Priority setting in health care: disentangling risk aversion from inequality aversion

In this paper, we introduce a tractable social welfare function that is rich enough to disentangle attitudes towards risk in health outcomes from attitudes towards health inequalities across individuals. Given this preference specification, we evaluate how the introduction of uncertainty over the severity of illness and over the effectiveness of treatments affects the optimal allocation of healthcare resources. We show that the way in which uncertainty affects the optimal allocation within our proposed specification may differ sharply from that in the standard expected utility framework.

Priority setting in health care and higher order degree change in risk

This paper examines how priority setting in health care expenditures is influenced by the presence of uncertainty about the severity of the illness and the effectiveness of medical treatment. We provide necessary and sufficient conditions on social preferences under which a social planner will allocate more health care resources to populations at higher risk. Changes in risk are defined by the concept of stochastic dominance up to order n. The shape of the social utility function and an equity weighting function are used to model the inequality aversion of the social planner. We show that for higher order risk changes, the usual conditions on preferences such as prudence or relative risk aversion are not necessarily required to prioritise health care when there are different levels of uncertainty associated with otherwise similar patient groups.

Bridging the gap: health equality and the deficit framing of health

The analyst tasked with measuring population health, with appraising healthcare investments, or allocating healthcare resources, may frame their task in one of two possible ways: either as being concerned with health assets (e.g. health expectancy or stock of QALYs), or with health deficits (a 'health gap', analogous to the poverty gap). In this paper, we discuss the consequences of taking the asset or the deficit concept as one's basic building block in developing a health measurement system when one has concerns about equitable distribution. We conclude that building metrics from a primitive health gap concept is possible and indeed may offer insights not otherwise easily accessible.

A cost-based equity weight for use in the economic evaluation of primary health care interventions: case study of the Australian Indigenous population

Background

Efficiency and equity are both important policy objectives in resource allocation. The discipline of health economics has traditionally focused on maximising efficiency, however addressing inequities in health also requires consideration. Methods to incorporate equity within economic evaluation techniques range from qualitative judgements to quantitative outcomes-based equity weights. Yet, due to definitional uncertainties and other inherent limitations, no method has been universally adopted to date. This paper proposes an alternative cost-based equity weight for use in the economic evaluation of interventions delivered from primary health care services.

Methods

Equity is defined in terms of 'access' to health services, with the vertical equity objective to achieve 'equitable access for unequal need'. Using the Australian Indigenous population as an illustrative case study, the magnitude of the equity weight is constructed using the ratio of the costs of providing specific interventions via Indigenous primary health care services compared with the costs of the same interventions delivered via mainstream services. Applying this weight to the costs of subsequent interventions deflates the costs of provision via Indigenous health services, and thus makes comparisons with mainstream more equitable when applied during economic evaluation.

Results

Based on achieving 'equitable access', existing measures of health inequity are suitable for establishing 'need', however the magnitude of health inequity is not necessarily proportional to the magnitude of resources required to redress it. Rather, equitable access may be better measured using appropriate methods of health service delivery for the target group. 'Equity of access' also suggests a focus on the processes of providing equitable health care rather than on outcomes, and therefore supports application of equity weights to the cost side rather than the outcomes side of the economic equation.

Conclusion

Cost-based weights have the potential to provide a pragmatic method of equity weight construction which is both understandable to policy makers and sensitive to the needs of target groups. It could improve the evidence base for resource allocation decisions, and be generalised to other disadvantaged groups who share similar concepts of equity. Development of this decision-making tool represents a potentially important avenue for further health economics research.

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.

Challenges of translating genetic tests into clinical and public health practice

Research in genetics and genomics has led to an expanding list of molecular genetic tests, which are increasingly entering health care systems. However, the evidence surrounding the benefits and harms of these tests is frequently weak. Here we present the main challenges to the successful translation of new research findings about genotype-phenotype associations into clinical practice. We discuss the means to achieve an accelerated translation research agenda that is conducted in a reasonable, fair and efficient manner.