QALYS and ethics: a health economist's perspective

Addressing the needs of Ethiopia's street homeless women of reproductive age in the health and social protection policy: a qualitative study

INTRODUCTION

Globally, homelessness is a growing concern, and homeless women of reproductive age are particularly vulnerable to adverse physical, mental, and reproductive health conditions, including violence. Although Ethiopia has many homeless individuals, the topic has received little attention in the policy arena. Therefore, we aimed to understand the reason for the lack of attention, with particular emphasis on women of reproductive age.

METHODS

This is a qualitative study; 34 participants from governmental and non-governmental organisations responsible for addressing homeless individuals' needs participated in in-depth interviews. A deductive analysis of the interview materials was applied using Shiffman and Smith's political prioritisation framework.

RESULTS

Several factors contributed to the underrepresentation of homeless women's health and well-being needs in the policy context. Although many governmental and non-governmental organisations contributed to the homeless-focused programme, there was little collaboration and no unifying leadership. Moreover, there was insufficient advocacy and mobilisation to pressure national leaders. Concerning ideas, there was no consensus regarding the definition of and solution to homeless women's health and social protection issues. Regarding political contexts and issue characteristics, a lack of a well-established structure, a paucity of information on the number of homeless women and the severity of their health situations relative to other problems, and the lack of clear indicators prevented this issue from gaining political priority.

CONCLUSIONS

To prioritise the health and well-being of homeless women, the government should form a unifying collaboration and a governance structure that addresses the unmet needs of these women. It is imperative to divide responsibilities and explicitly include homeless people and services targeted for them in the national health and social protection implementation documents. Further, generating consensus on framing the problems and solutions and establishing indicators for assessing the situation is vital.

Expanding health technology assessment towards broader value: Ireland as a case study

Healthcare innovations often represent important improvements in population welfare, but at what cost, and to whom? Health technology assessment (HTA) is a multidisciplinary process to inform resource allocation. HTA is conventionally anchored on health maximization as the only relevant output of health services. If we accept the proposition that health technologies can generate value outside the healthcare system, resource allocation decisions could be suboptimal from a societal perspective. Incorporating "broader value" in HTA as derived from social values and patient experience could provide a richer evaluative space for informing resource allocation decisions. This article considers how HTA is practiced and what its current context implies for adopting "broader value" to evaluating health technologies. Methodological challenges are highlighted, as is a future research agenda. Ireland serves as an example of a healthcare system that both has an explicit role for HTA and is evolving under a current program of reform to offer universal, single-tier access to public services. There are various ways in which HTA processes could move beyond health, including considering the processes of care delivery and/or expanding the evaluative space to some broader concept of well-being. Methods to facilitate the latter exist, but their adaptation to HTA is still emerging. We recommend a multi-stakeholder working group to develop and advance an international agenda for HTA that captures welfare/benefit beyond health.

Conceptualising 'Benefits Beyond Health' in the Context of the Quality-Adjusted Life-Year: A Critical Interpretive Synthesis

There is growing interest in extending the evaluative space of the quality-adjusted life-year framework beyond health. Using a critical interpretive synthesis approach, the objective was to review peer-reviewed literature that has discussed non-health outcomes within the context of quality-adjusted life-years and synthesise information into a thematic framework. Papers were identified through searches conducted in Web of Science, using forward citation searching. A critical interpretive synthesis allows for the development of interpretations (synthetic constructs) that go beyond those offered in the original sources. The final output of a critical interpretive synthesis is the synthesising argument, which integrates evidence from across studies into a coherent thematic framework. A concept map was developed to show the relationships between different types of non-health benefits. The critical interpretive synthesis was based on 99 papers. The thematic framework was constructed around four themes: (1) benefits affecting well-being (subjective well-being, psychological well-being, capability and empowerment); (2) benefits derived from the process of healthcare delivery; (3) benefits beyond the recipient of care (spillover effects, externalities, option value and distributional benefits); and (4) benefits beyond the healthcare sector. There is a wealth of research concerning non-health benefits and the evaluative space of the quality-adjusted life-year. Further dialogue and debate are necessary to address conceptual and normative challenges, to explore the societal willingness to sacrifice health for benefits beyond health and to consider the equity implications of different courses of action.

Veil-of-ignorance reasoning mitigates self-serving bias in resource allocation during the COVID-19 crisis

The COVID-19 crisis has forced healthcare professionals to make tragic decisions concerning which patients to save. Furthermore, The COVID-19 crisis has foregrounded the influence of self-serving bias in debates on how to allocate scarce resources. A utilitarian principle favors allocating scarce resources such as ventilators toward younger patients, as this is expected to save more years of life. Some view this as ageist, instead favoring age-neutral principles, such as “first come, first served”. Which approach is fairer? The “veil of ignorance” is a moral reasoning device designed to promote impartial decision-making by reducing decision-makers’ use of potentially biasing information about who will benefit most or least from the available options. Veil-of-ignorance reasoning was originally applied by philosophers and economists to foundational questions concerning the overall organization of society. Here we apply veil-of-ignorance reasoning to the COVID-19 ventilator dilemma, asking participants which policy they would prefer if they did not know whether they were younger or older. Two studies (pre-registered; online samples; Study 1, N=414; Study 2 replication, N=1,276) show that veil-of-ignorance reasoning shifts preferences toward saving younger patients. The effect on older participants is dramatic, reversing their opposition toward favoring the young, thereby eliminating self-serving bias. These findings provide guidance on how to remove self-serving biases to healthcare policymakers and frontline personnel charged with allocating scarce medical resources during times of crisis.

Orphan Drugs Offer Larger Health Gains but Less Favorable Cost-effectiveness than Non-orphan Drugs

BACKGROUND

Orphan drugs offer important therapeutic options to patients suffering from rare conditions, but are typically considerably more expensive than non-orphan drugs, leading to questions about their cost-effectiveness.

OBJECTIVE

To compare the value of orphan and non-orphan drugs approved by the FDA from 1999 through 2015.

DESIGN

We searched the PubMed database to identify estimates of incremental health gains (measured in quality-adjusted life-years, or QALYs) and incremental costs that were associated with orphan and non-orphan drugs compared with preexisting care. We excluded pharmaceutical industry-funded studies from the dataset. When a drug was approved for multiple indications, we considered each drug-indication pair separately. We then compared incremental QALY gains, incremental costs, and incremental cost-effectiveness ratios for orphan and non-orphan drugs using the Mann-Whitney U (MWU) test (to compare median values of the different distributions) and the Kolmogorov-Smirnov (KS) test (to compare the shape of different distributions).

RESULTS

We identified estimates for 49 orphan drug-indication pairs, and for 169 non-orphan drug-indication pairs. We found that orphan drug-indication pairs offered larger median incremental health gains than non-orphan drug-indication pairs (0.25 vs. 0.05 QALYs; MWU p = 0.0093, KS p = 0.02), but were associated with substantially higher costs ($47,652 vs. $2870; MWU p < 0.001, KS p < 0.001) and less favorable cost-effectiveness ($276,288 vs. $100,360 per QALY gained; MWU p = 0.0068, KS p = 0.009).

CONCLUSIONS

Our study suggests that orphan drugs often offer larger health gains than non-orphan drugs, but due to their substantially higher costs they tend to be less cost-effective than non-orphan drugs. Our findings highlight the challenge faced by health care payers to provide patients appropriate access to orphan drugs while achieving value from drug spending.

Does moral reasoning influence public values for health care priority setting?: A population-based randomized stated preference survey

OBJECTIVE

Preferences of members of the public are recognized as important inputs into health care priority-setting, though knowledge of such preferences is scant. We sought to generate evidence of public preferences related to healthcare resource allocation among adults and children.

METHODS

We conducted an experimental stated preference survey in a national sample of Canadian adults. Preferences were elicited across a range of scenarios and scored on a visual analogue scale. Intervention group participants were randomized to a moral reasoning exercise prior to each choice task. The main outcomes were the differences in mean preference scores by group, scenario, and demographics.

RESULTS

Our results demonstrate a consistent preference by participants to allocate scarce health system resources to children. Exposure to the moral reasoning exercise weakened but did not eliminate this preference. Younger respondent age and parenthood were associated with greater preference for children. The top principles guiding participants' allocative decisions were treat equally, relieve suffering, and rescue those at risk of dying.

CONCLUSIONS

Our study affirms the relevance of age in public preferences for the allocation of scarce health care resources, demonstrating a significant preference by participants to allocate healthcare resources to children. However, this preference diminishes when challenged by exposure to a range of moral principles, revealing a strong public endorsement of equality of access. Definitions of value in healthcare based on clinical benefit and cost-effectiveness may exclude moral considerations that the public values, such as equality and humanitarianism, highlighting opportunities to enrich healthcare priority-setting through public engagement.

Challenges to generating political prioritization for adolescent sexual and reproductive health in Kenya: A qualitative study

Background

Despite the high burden of adverse adolescent sexual and reproductive health (SRH) outcomes, it has remained a low political priority in Kenya. We examined factors that have shaped the lack of current political prioritization of adolescent SRH service provision.

Methods

We used the Shiffman and Smith policy framework consisting of four categories—actor power, ideas, political contexts, and issue characteristics—to analyse factors that have shaped political prioritization of adolescent SRH. We undertook semi-structured interviews with 14 members of adolescent SRH networks between February and April 2019 at the national level and conducted thematic analysis of the interviews.

Findings

Several factors hinder the attainment of political priority for adolescent SRH in Kenya. On actor power, the adolescent SRH community was diverse and united in adoption of international norms and policies, but lacked policy entrepreneurs to provide strong leadership, and policy windows were often missed. Regarding ideas, community members lacked consensus on a cohesive public positioning of the problem. On issue characteristics, the perception of adolescents as lacking political power made politicians reluctant to act on the existing data on the severity of adolescent SRH. There was also a lack of consensus on the nature of interventions to be implemented. Pertaining to political contexts, sectoral funding by donors and government treasury brought about tension within the different government ministries resulting in siloed approaches, lack of coordination and overall inefficiency. However, the SRH community has several strengths that augur well for future political support. These include the diverse multi-sectoral background of its members, commitment to improving adolescent SRH, and the potential to link with other health priorities such as maternal health and HIV/AIDS.

Conclusion

In order to increase political attention to adolescent SRH in Kenya, there is an urgent need for policy actors to: 1) create a more cohesive community of advocates across sectors, 2) develop a clearer public positioning of adolescent SRH, 3) agree on a set of precise approaches that will resonate with the political system, and 4) identify and nurture policy entrepreneurs to facilitate the coupling of adolescent SRH with potential solutions when windows of opportunity arise.

Estimation of Quality-Adjusted Life Expectancy of Patients With Oral Cancer: Integration of Lifetime Survival With Repeated Quality-of-Life Measurements

BACKGROUND

Quality-adjusted life year is widely applied nowadays, which consider both survival and quality of life (QoL). When most diseases are becoming chronic, it is imperative to quantify the overall health impact of a disease in lifetime perspective.

OBJECTIVE

The purpose of this study is to introduce methods for estimating quality-adjusted life expectancy (QALE) and loss of QALE in patients with a disease or specific conditions.

METHODS

The QALE of an index cohort can be represented as the integration of the product of lifetime survival function and mean QoL function. We introduce a robust extrapolation approach for estimating lifetime survival function and propose an approach for estimating lifetime mean QoL function for studies with limited follow-up. The best part of the proposed method is that the survival data and QoL data can be collected separately. A cohort of patients with a specific condition can be identified by databases that regularly collect data for the control of diseases, and their survival status is verified by linking to a mortality registry. Although nationwide QoL data are not available, researchers can implement a relative short-term follow-up interview on a random sample of patients to collect QoL data. For demonstration, we applied the proposed methods to estimate QALE and loss of QALE of oral cancer patients.

RESULTS

The estimates (95% confidence interval) of QALE for oral cancer patients were 11.0 (10.5-11.6) and 14.2 (12.7-15.5) quality-adjusted life years (QALYs) for men and women, respectively. The estimates of loss of QALE for the male and female patients with oral cancer were 14.4 (13.8-14.9) and 7.5 (6.2-9.0) QALYs, respectively.

CONCLUSIONS

The methods for estimating QALE and loss of QALE can be applied to economic evaluation of cancer control, including screening.

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.

Drugs Cleared Through The FDA's Expedited Review Offer Greater Gains Than Drugs Approved By Conventional Process

We investigated whether drugs approved by the Food and Drug Administration (FDA) through expedited review have offered larger health gains, compared to drugs approved through conventional review processes. We identified published estimates of additional health gains (measured in quality-adjusted life-years, or QALYs) associated with drugs approved in the period 1999-2012 through expedited (seventy-six drugs) versus conventional (fifty-nine) review processes. We found that drugs in at least one expedited review program offered greater gains than drugs reviewed through conventional processes (0.182 versus 0.003 QALYs). We also found that, compared to drugs not included in the same program, greater gains were provided by drugs in the priority review (0.175 versus 0.007 QALYs), accelerated approval (0.370 versus 0.031 QALYs), and fast track (0.254 versus 0.014 QALYs) programs. Our analysis suggests that the FDA has prioritized drugs that offer the largest health gains.

Estimating Population Health Benefits Associated with Specialty and Traditional Drugs in the Year Following Product Approval

OBJECTIVE

Compared to traditional drugs, specialty drugs tend to be indicated for lower prevalence diseases. Our objective was to compare the potential population health benefits associated with specialty and traditional drugs in the year following product approval.

METHODS

First, we created a dataset of estimates of incremental quality-adjusted life-year (QALY) gains and incremental life-year (LY) gains for US FDA-approved drugs (1999-2011) compared to standard of care at the time of approval identified from a literature search. Second, we categorized each drug as specialty or traditional. Third, for each drug we identified estimates of US disease prevalence for each pertinent indication. Fourth, in order to conservatively estimate the potential population health gains associated with each new drug in the year following its approval we multiplied the health gain estimate by 10% of the identified prevalence. Fifth, we used Mann-Whitney U tests to compare the population health gains for specialty and traditional drugs.

RESULTS

We identified QALY gain estimates for 101 drugs, including 56 specialty drugs, and LY gain estimates for 50 drugs, including 34 specialty drugs. The median estimated population QALY gain in the year following approval for specialty drugs was 4200 (IQR = 27,000) and for traditional drugs was 694 (IQR = 24,400) (p = 0.245). The median estimated population LY gain in the year following approval for specialty drugs was 7250 (IQR = 39,200) and for traditional drugs was 2500 (IQR = 58,200) (p = 0.752).

CONCLUSIONS

Despite often being indicated for diseases of lower prevalence, we found a trend towards specialty drugs offering larger potential population health gains than traditional drugs, particularly when measured in terms of QALYs.

Health-state utility estimates for health technology assessment: a review of the manufacturers' submissions to the French National Authority for Health

BACKGROUND

Our aim was to review the selection and methods used for deriving health state utility (HSU) estimates included in the cost-utility analyses (CUA) submitted by manufacturers to the National Authority for Health (HAS) during the first 2 years after the introduction of the economic evaluation for price setting in France.

METHODS

We reviewed all manufacturers' submissions that included a CUA and were assessed by HAS by the end of October 2015 (N = 34). We reviewed the identification, selection, and methods used to estimate HSU and compared them with those recommended by HAS.

RESULTS

A literature review to identify HSU was reported in only 13 (38%) submissions. The instruments for describing HSU were a preference-based generic instrument in 20 (59%) submissions; vignettes in five (15%); a condition-specific instrument in three (9%); and a combination of instruments in six (18%). The valuation perspective was the general population in 26 (76%) submissions; in only nine (26%) submissions, the valuation set was derived from the French general population.

CONCLUSIONS

We identified numerous concerns in the selection, valuation and use of HSU, as well as a frequent lack of clarity in the methods used. Most submissions (79%) included HSU that did not meet HAS recommendations.

Despite high costs, specialty drugs may offer value for money comparable to that of traditional drugs

Specialty drugs are often many times more expensive than traditional drugs, which raises questions of affordability and value. We compared the value of specialty and traditional drugs approved by the Food and Drug Administration (FDA) in the period 1999-2011. To do this, we identified published estimates of additional health gains (measured in quality-adjusted life-years, or QALYs) and increased costs of drug and health care resource use that were associated with fifty-eight specialty drugs and forty-four traditional drugs, compared to preexisting care. We found that specialty drugs offered greater QALY gains (0.183 versus 0.002 QALYs) but were associated with greater additional costs ($12,238 versus $784), compared to traditional drugs. The two types of drugs had comparable cost-effectiveness. However, the distributions across the two types differed, with 26 percent of specialty drugs--but only 9 percent of traditional drugs--associated with incremental cost-effectiveness ratios of greater than $150,000 per QALY. Our study suggests that although specialty drugs often have higher costs than traditional drugs, they also tend to confer greater benefits and hence may still offer reasonable value for money.

The quality of economic evaluations of ultra-orphan drugs in Europe - a systematic review

An orphan disease is defined in the EU as a disorder affecting less than 1 in 2 000 individuals. The concept of ultra-orphan has been proposed for diseases with a prevalence of less than 1:50 000. Drugs for ultra-orphan diseases are amongst the most expensive medicines on a cost-per-patient basis. The extremely high prices have prompted initiatives to evaluate cost-effectiveness and cost-utility in EU-member states. The objective of this review was to evaluate the quality of cost-effectiveness and cost-utility studies on ultra-orphan drugs. We searched 2 databases and the reference lists of relevant systematic reviews. Studies reporting on full economic evaluations, or at least aiming at such evaluation, were eligible for inclusion. Quality was assessed with the use of the Consensus on Health Economic Criteria (CHEC)-list. Two-hundred-fifty-one studies were identified. Of these, 16 fitted our inclusion criteria. A study on enzyme replacement and substrate reduction therapies for lysosomal storage disorders did not perform a full economic evaluation due to the high drug costs and the lack of a measurable effect on either clinical or health-related quality of life outcomes. Likewise, a cost-effectiveness analysis of laronidase for mucopolysaccharidosis type 1 was considered unfeasible due to lack of clinical effectiveness data, while in the same study a crude model was used to estimate cost-utility of enzyme replacement therapy (ERT) for Fabry disease. Three additional studies, one on ERT for Fabry disease, one on ERT for Gaucher disease and one on eculizumab for paroxysmal nocturnal haemoglobinuria, used an approach that was too simplistic to lead to a realistic estimate of the incremental cost-effectiveness (ICER) or cost-utility ratio (ICUR). In all other studies (N = 11) more sophisticated pharmacoeconomic models were used to estimate cost-effectiveness and cost-utility of the specific drug, mostly ERT or drugs indicated for pulmonary arterial hypertension (PAH). Seven studies used a Markov-state-transition model. Other models used were patient-level simulation models (N = 3) and decision trees (N = 1). Only 4 studies adopted a societal perspective. All but 2 studies discounted costs and effects appropriately. Drugs for metabolic diseases appeared to be significantly less cost-effective than drugs indicated for PAH, with ICERs ranging from €43 532 (Gaucher disease) to €3 282 252 (Fabry disease). Quality of studies using a Markov-state-transition or patient-level simulation model is in general good with 14–19 points on the CHEC-list. We therefore conclude that economic evaluations of ultra-orphan drugs are feasible if pharmacoeconomic modelling is used. Considering the need for modelling of several disease states and the small patient groups, a Markov-state-transition model seems to be most suitable type of model. However, it should be realised that ultra-orphan drugs will usually not meet the conventional criteria for cost-effectiveness. Nevertheless, ultra-orphan drugs are often reimbursed. Further discussion on the use of economic evaluations and their consequences in case of ultra-orphan drugs is therefore warranted.

Validation of the underlying assumptions of the quality-adjusted life-years outcome: results from the ECHOUTCOME European project

BACKGROUND

Quality-adjusted life-years (QALYs) have been used since the 1980s as a standard health outcome measure for conducting cost-utility analyses, which are often inadequately labeled as 'cost-effectiveness analyses'. This synthetic outcome, which combines the quantity of life lived with its quality expressed as a preference score, is currently recommended as reference case by some health technology assessment (HTA) agencies. While critics of the QALY approach have expressed concerns about equity and ethical issues, surprisingly, very few have tested the basic methodological assumptions supporting the QALY equation so as to establish its scientific validity.

OBJECTIVES

The main objective of the ECHOUTCOME European project was to test the validity of the underlying assumptions of the QALY outcome and its relevance in health decision making.

METHODS

An experiment has been conducted with 1,361 subjects from Belgium, France, Italy, and the UK. The subjects were asked to express their preferences regarding various hypothetical health states derived from combining different health states with time durations in order to compare observed utility values of the couples (health state, time) and calculated utility values using the QALY formula.

RESULTS

Observed and calculated utility values of the couples (health state, time) were significantly different, confirming that preferences expressed by the respondents were not consistent with the QALY theoretical assumptions.

CONCLUSIONS

This European study contributes to establishing that the QALY multiplicative model is an invalid measure. This explains why costs/QALY estimates may vary greatly, leading to inconsistent recommendations relevant to providing access to innovative medicines and health technologies. HTA agencies should consider other more robust methodological approaches to guide reimbursement decisions.

Cost utility analyses in international disaster responses-where are they?

International health care providers have flocked to Haiti and other disaster-affected countries in record numbers. Anecdotal articles often give "body counts" to describe what was accomplished, followed months later by articles suggesting outcomes could have been better. Mention will be made that various interventions were "expensive," or not the best use of limited funds. But there is very little science to post-intervention evaluations, especially with regard to the value for the money spent. This is surprising, because a large body of literature exists with regard to the Cost Utility Analysis (CUA) of health care interventions. Applying reproducible metrics to disaster interventions will help improve performance.This study will: (1) introduce and explain basic CUA; (2) review why the application of CUA is difficult in disaster settings; (3) consider how disasters may be unique with regard to CUA; (4) demonstrate past and theoretical utilization of CUA in disaster settings; and (5) suggest future utilization of CUA by healthcare providers in Disaster Response.

Deriving distributional weights for QALYs through discrete choice experiments

This paper presents the first attempt to use a discrete choice experiment to derive distributional weights for quality adjusted life years (QALYs), based on characteristics (age and severity) of the beneficiaries. A novel approach using the Hicksian compensating variation is applied. Advantages include derivation of weights for QALYs, not just for life or life years saved, and investigation of the impact of the size of the health gain by allowing the gain to be traded against other characteristics. Results suggest one would generally not weight QALYs, except in a small number of specific cases and in those cases the weights are relatively small. Methodological challenges are highlighted as is a future research agenda.

[Hazards, tactics and constraints of evaluation of health care in low income countries]

Unless a large, new, financial contribution comes from the international community, health indicators are far from good in low income countries. However, even if health financing is still insufficient, better health care in these countries could be produced with their present resources. It requires an improvement in the health system performance, as well as efficacy and efficiency of health programs. As a tool, evaluation allows one firstly to check this performance and efficiency, and then to assess the impact of different programs. This article is organising in three sections. The first presents the different (economic, ethical and social) stakes of an evaluation system. The second section describes its methods and the third analyses its constraints.

Ethics in American health 2: an ethical framework for health system reform

I argue that an ethical vision resting on explicitly articulated values and norms is critical to ensuring comprehensive health reform. Reform requires a consensus on the public good transcending self-interest and narrow agendas and underpinning collective action for universal coverage. In what I call shared health governance, individuals, providers, and institutions all have essential roles in achieving health goals and work together to create a positive environment for health. This ethical paradigm provides (1) reasoned consensus through a joint scientific and deliberative approach to judge the value of a health care intervention; (2) a method for achieving consensus that differs from aggregate tools such as a strict majority vote; (3) combined technical and ethical rationality for collective choice; (4) a joint clinical and economic approach combining efficiency with equity, but with economic solutions following and complementing clinical progress; and (5) protection for disabled individuals from discrimination.

Estimating health effects in quality-of-life terms: health losses following road crashes

Currently, measures of disability and health-related quality of life are becoming important, even essential, parameters in the evaluation of treatment and prevention strategies for reducing the burden of injury. The estimation of the 'health effect' induced by these policies should incorporate several important aspects: the proper definition of health effect, at individual and aggregate levels; the correct selection of a health metric; the accurate estimation of the short-term effect (direct health gain/loss) and long-term effect (total of health gain/loss throughout the life of the individual) that injuries may produce; and the suitable selection and management of databases. This review article focuses on the particular topic of road crashes, but the analysis can be extended to any sort of injury.

The impact of anchor point on utilities for 5 common ophthalmic diseases

PURPOSE

To elicit utilities on a perfect health and perfect vision scale for 5 common eye diseases.

DESIGN

Cross-sectional observational preference study.

PARTICIPANTS

We included 434 patients: 58 with diabetic retinopathy, 99 with glaucoma, 44 with age-related macular degeneration (AMD), 124 with cataract; 109 with refractive error.

TESTING

Standard gamble utilities were estimated using a computer-based preference assessment interview platform.

MAIN OUTCOME MEASURES

Standard gamble utilities, a quality-of-life measure that examines the willingness to accept a risk of death or unilateral blindness in return for perfect health or perfect vision.

RESULTS

Using the standard policy scale, where health equivalent to death is 0 and perfect health is 1, participants with asymptomatic diabetic retinopathy had a utility of 0.93. By comparison, symptomatic diabetics had a further utility loss of 0.14. Asymptomatic glaucoma participants had a utility of 0.92 with a decrease of 0.03 for early field loss and a further decrease of 0.03 with central field loss. Participants with AMD who had > or =20/100 better-eye visual acuity reported a utility of 0.89, whereas those with more severe AMD reported 0.76. However, neither clinical cataract opacity score nor refractive error correlated with utility. Adjustment for age and comorbidity did not alter these relationships. For the same participants, utilities measured with different anchor points-monocular blindness as 0 and perfect vision as 1-were lower, especially among participants with increased disease severity. The difference between utility assessed on this perfect vision-blindness scale and the perfect health-death scale ranged from 0.04 for those with severe refractive error to 0.19 for symptomatic diabetics and 0.37 for those with severe AMD.

CONCLUSIONS

This paper elicits utilities with different anchor points from a previously unreported sample of 434 patients. Lower utility scores normally imply greater benefit with successful treatment or prevention of disease, but switching from the conventional policy scale to the perfect vision scale also consistently results in lower scores. Because most previous ophthalmic studies have used perfect vision as the upper anchor, the resulting utilities may not have been accurate.

Economic evaluation of services for a National Health scheme: the case for a fairness-based framework

In this paper we argue that the usual framework for evaluating health services may need modification in the context of a National Health Scheme (NHS). Some costs and benefits may need to be ignored or discounted, others included at face value, and some transfer payments included in the decision algorithm. In contrast with the standard framework, we argue that economic evaluation in the context of an NHS should focus on 'social transfers' between taxpayers and beneficiaries, and that the nature and scope of these transfers is determined by the level of social generosity. Some of the implications of a modified framework are illustrated with a re-examination of (i) costs and transfer payments, (ii) unrelated future costs, (iii) moral hazard, and (iv) the rule that marginal costs should equal marginal benefits. We argue that an explicitly 'fairness-based' framework is needed for the evaluation of services in an NHS. In contrast, the usual welfare economic theoretic framework facilitates the sidelining of issues of fairness.

Responsibility, fairness and rationing in health care

OBJECTIVE

People make different choices about how to live their life and these choices have a significant effect on their health, the risks they face and their need for treatment in the future. The objective of this article is, drawing on normative political theory, to sketch an argument that assigns a limited but significant role to individual responsibility in the design of the health-care system.

METHOD

In developing our argument, we proceed in five steps. First, we review the literature on criteria for priority setting. Second, we explore the most prominent contemporary tradition in normative theory, liberal egalitarian ethics, with the aim to clarify the role of responsibility for choice. In particular, we discuss where liberal egalitarian theories would draw the 'cut' between the responsibility of the state (which is extensive) and the responsibility of the individuals (which is limited but significant). In the third step, we identify a priority setting dilemma where the commonly advocated criteria would assign equal priority. Finally, we develop a simple model in order to examine the implications of introducing a well-defined notion of responsibility for choice in a priority-setting dilemma of this kind.

RESULTS

Liberal egalitarianism holds individuals responsible for choices that affect their health, given that (i) the illness is completely or partly a result of individual behaviour and choice; (ii) the illness is not life-threatening; (iii) the illness does not limit the use of political rights or the exercise of fundamental capabilities; and (iv) the cost of treatment is low relative to the income of the patients. The paper shows how this type of considerations can be used to determine an optimal level of co-payments for diseases even when individual choices cannot be observed directly.

CONCLUSIONS

It is possible to assign a limited but significant role to individual responsibility in the rationing of health-care resources. The liberal egalitarian argument captures a concern that is not captured by traditional criteria for priorities in health care. It can thus help policy makers in situations where the cost-effectiveness of different alternatives and the severity of the illnesses are approximately the same, or if the society wants to assign some weight to responsibility for choice. It can easily be linked to a system of graduated co-payments, but need not be.

Economic evaluation: what does a nurse manager need to know?

This paper considers how health economists can assist nurse managers, using the concepts and tools of economic evaluation. We aim to clarify these and also explode some of the myths about economic evaluation and its role in health care decision-making. Economic evaluation techniques compare alternative courses of action in terms of their costs and consequences. There are four principal methods; cost-minimization, cost-effectiveness, cost-utility and cost-benefit analysis, all of which synthesize costs and outcomes, at different levels of outcome. Economic evaluation is an intrinsic part of national decision-making about the efficient provision of effective treatments and services, and increasingly, organizational matters. In the UK, such technology evaluation is disseminated in guidelines from the National Institute for Clinical Effectiveness (NICE), having a top-down impact on the nurse manager. But economic evaluation is increasingly relevant to the nurse manager at local level, through newer techniques such as Programme Budgeting Marginal Analysis (PBMA), which facilitates explicit, transparent decisions, from the bottom-up. Nurse managers need to weigh up competing demands on resources and decide in ways which maximize health gain. Economic evaluation can help here because it presents evidence to challenge or support existing allocations, and provides a systematic framework to analyse health care decisions. In the current context of competition for scarce resources, we suggest that nurse managers need to embrace these techniques, or be marginalized from the resource allocation process.

Using burden of disease information for health planning in developing countries: the experience from Uganda

Given the growing interest in both the use of evidence in planning and in using the burden of disease measure (BOD) and cost-effectiveness analysis, we explored health planners' perception of the usefulness of the BOD in priority setting and planning in developing countries, using Uganda as an example. An exploratory qualitative approach involving in-depth interviews with key policy makers in health at district and national levels was employed. Interviews were supplemented with a review of relevant documents. Analysis involved identification of key concepts from the interviews. Concepts were grouped into categories, namely, the appeal of quantitative data, data limitations, opaque methodology, planning as a political process and opportunity costs. These form the basis of this article. We found that the BOD study results have been used as the basis for the national health policy and in defining the contents of the national essential health care package. The quantification and ranking of disease burden is appreciated by politicians and used for advocacy, resource mobilization and re-allocation. The results have also provided information for priority setting and strategic planning. Limitations to its use included poor understanding of the methodology, poor quality of data in-puts, low involvement of stakeholders, inability of the methodology to capture key non-economic issues, and the costs of carrying out the study. There is commitment, by Ugandan planners to using evidence in priority setting. Since this was an exploratory study, there is a need for more studies in developing countries to document their experiences with the use of evidence, and specifically, the BOD approach in planning and priority setting. Such information would contribute to further synthesis of the approach.

The rule of rescue

Jonsen coined the term "Rule of Rescue"(RR) to describe the imperative people feel to rescue identifiable individuals facing avoidable death. In this paper we attempt to draw a more detailed picture of the RR, identifying its conflict with cost-effectiveness analysis, the preference it entails for identifiable over statistical lives, the shock-horror response it elicits, the preference it entails for lifesaving over non-lifesaving measures, its extension to non-life-threatening conditions, and whether it is motivated by duty or sympathy. We also consider the measurement problems it raises, and argue that quantifying the RR would probably require a two-stage procedure. In the first stage the size of the individual utility gain from a health intervention would be assessed using a technique such as the Standard Gamble or the Time Trade-Off, and in the second the social benefits arising from the RR would be quantified employing the Person Trade-Off. We also consider the normative status of the RR. We argue that it can be defended from a utilitarian point of view, on the ground that rescues increase well-being by reinforcing people's belief that they live in a community that places great value upon life. However, utilitarianism has long been criticised for failing to take sufficient account of fairness, and the case is no different here: fairness requires that we do not discriminate between individuals on morally irrelevant grounds, whereas being "identifiable" does not seem to be a morally relevant ground for discrimination.

HALYS and QALYS and DALYS, Oh My: similarities and differences in summary measures of population Health

Health-adjusted life years (HALYs) are population health measures permitting morbidity and mortality to be simultaneously described within a single number. They are useful for overall estimates of burden of disease, comparisons of the relative impact of specific illnesses and conditions on communities, and in economic analyses. Quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs) are types of HALYs whose original purposes were at variance. Their growing importance and the varied uptake of the methodology by different U.S. and international entities makes it useful to understand their differences as well as their similarities. A brief history of both measures is presented and methods for calculating them are reviewed. Methodological and ethical issues that have been raised in association with HALYs more generally are presented. Finally, we raise concerns about the practice of using different types of HALYs within different decision-making contexts and urge action that builds and clarifies this useful measurement field.

Selecting human health metrics for environmental decision-support tools

Environmental decision-support tools often predict a multitude of different human health effects due to environmental stressors. The accounting and aggregating of these morbidity and mortality outcomes is key to support decision making and can be accomplished by different methods that we call human health metrics. This article attempts to answer two questions: Does it matter which metric is chosen? and What are the relevant characteristics of these metrics in environmental applications? Three metrics (quality adjusted life years (QALYs), disability adjusted life years (DALYs), and willingness to pay (WTP)) have been applied to the same diverse set of health effects due to environmental impacts. In this example, the choice of metric mattered for the ranking of these environmental impacts and it was found for this example that WTP was dominated by mortality outcomes. Further, QALYs and DALYs are sensitive to mild illnesses that affect large numbers of people and the severity of these mild illnesses are difficult to assess. Eight guiding questions are provided in order to help select human health metrics for environmental decision-support tools. Since health metrics tend to follow the paradigm of utility maximization, these metrics may be supplemented with a semi-quantitative discussion of distributional and ethical aspects. Finally, the magnitude of age-dependent disutility due to mortality for both monetary and nonmonetary metrics may bear the largest practical relevance for future research.

Staking a claim for claims: a case study of resource allocation in Australian Aboriginal health care

There have been numerous ways in which the notion of equity has been put forward in the literature. This reflects the fact that equity is essentially driven by values and is therefore subject to individual interpretation and preferences. Deciding between these various value judgements is however outside the scope of economic analysis, as conventionally defined. This poses a problem for the examination of issues of resource allocation in Aboriginal health services in Australia, where equity, very clearly, has a role to play. One possibility for moving forward on this issue is the adoption of a 'claims' approach where the emphasis is on the explicit recognition of the values to be employed in the 'equitable' allocation of resources. This involves teasing out the principles by which, under various approaches, resources are allocated differentially across groups (e.g. under resource allocation formulae, the criterion of 'need' as measured by SMRs can be viewed to be a basis for a 'claim' over resources). The commonly cited 'basic needs approach' is then used in the paper as a case in point to illustrate how such underlying principles may be identified and then assessed. In relation to the issue of equity in Aboriginal health services, there are a number of possible standards for equity which seem to have a significant degree of community acceptance. The paper discusses ways in which they can be applied to the problem of deciding how to allocate resources in Aboriginal health.

Guidelines for appropriate care: the importance of empirical normative analysis

The Royal Dutch Medical Association recently completed a research project aimed at investigating how guidelines for 'appropriate medical care' should be construed. The project took as a starting point that explicit attention should be given to ethical and political considerations in addition to data about costs and effectiveness. In the project, two research groups set out to design guidelines and cost-effectiveness analyses (CEAs) for two circumscribed medical areas (angina pectoris and major depression). Our third group was responsible for the normative analysis. We undertook an explorative, qualitative pilot study of the normative considerations that played a role in constructing the guidelines and CEAs, and simultaneously interviewed specialists about the normative considerations that guided their diagnostic and treatment decisions. Explicating normative considerations, we argue, is important democratically: the issues at stake should not be left to decision analysts and guideline developers to decide. Moreover, it is a necessary condition for a successful implementation of such tools: those who draw upon these tools will only accept them when they can recognize themselves in the considerations implied. Empirical normative analysis, we argue, is a crucial tool in developing guidelines for appropriate medical care.

Resource allocation within Australian indigenous communities: a program for implementing vertical equity

Given the significant disparities in health and health related disadvantage between Aboriginal and non-Aboriginal Australians, the application of some notion of equity has a role to play in the formulation of policy with respect to Aboriginal health. Aboriginal and Torres Strait Islander has been abbreviated to Aboriginal. There has been considerable debate in Australia as to what the principles of equity should be. This paper discusses the relevance of the principle of vertical equity (the unequal, but equitable, treatment of unequals) to Aboriginal health funding. In particular, the paper advocates pursuing procedural justice as the basis for vertical equity where the focus is on the fairness of how things are done rather than on the distribution of outcomes per se (i.e. distributive justice). Particular attention is paid to how the principle of vertical equity might be handled at a practical level. Details of the approach used in a number of Australian indigenous communities are discussed. It is concluded that there are strong arguments for pursuing procedural justice under vertical equity particularly when there are cultural differences in the way health is defined and when there is importance attached to indigenous involvement in the health care decision making process.

On individual preferences and aggregation in economic evaluation in healthcare

For practical reasons, in order to carry out economic evaluations of collective decisions, total costs will generally be compared with total benefits; hence, individuals' willingness to pay (WTP) or quality-adjusted life-years (QALYs) have to be estimated at an aggregate level. So far, aggregation has usually been done by taking the individuals' mean WTP or the unweighted number of QALYs. Since the aggregation process is closely related to the way that income, health and/or utility of different individuals are compared and weighted, it also has significant equity implications. Thus. the explicit (or, more often, implicit) assumptions behind the aggregation process will largely affect how health and welfare are distributed is society. The aggregation problem in economic evaluation is certainly not trivial, but is seldom addressed in current practice. This paper shows the underlying assumptions of aggregate cost-benefit analysis (CBA) and cost-effectiveness analysis/cost-utility analysis (CEA/CUA), and it emphasises the particularly strong assumptions which have to be made when QALYs are interpreted as utilities in the welfare economics sense. Naturally, the appropriate method to choose depends on what is to be maximised: welfare or health. If decisions of resource allocation are to be based on economic welfare theory, then CBA should be preferred. However, if QALYs are interpreted as measures of health, rather than as utilities, then CEA/CUA would be appropriate.

O conceito de saúde: ponto-cego da epidemiologia?

O trabalho faz uma avaliação da proposição de que o conceito de 'saúde' constitui um ponto-cego para a ciência epidemiológica, postulando que não há base lógica para uma definição negativa da Saúde, tanto no nível individual quanto no coletivo. Também analisa brevemente as tentativas de produzir uma "epidemiologia da saúde" em bases simétricas à epidemiologia dos riscos, bem como as abordagens econométricas que reforçam e complementam o repertório epidemiológico destinado à medida da saúde. Focaliza em mais detalhe a abordagem denominada DALY, considerada como protótipo da nova geração de indicadores de saúde, face à sua atualidade e crescente importância na definição de políticas de financiamento em saúde. Finalmente, constatando o fracasso das propostas metodológicas de avaliação direta dos níveis coletivos de saúde através de indicadores unificados, conclui com uma avaliação das perspectivas atuais da Epidemiologia no sentido da incorporação do objeto complexo da saúde na sua pauta teórica e metodológica.

A new perspective on economic analysis in health care? A critical review of 'The Economics of Health Reconsidered' by Tom Rice

A recently published book, 'The Economics of Health Reconsidered' by Tom Rice, provides a strong critique of the role of markets in health care. Many of the issues of 'market failure' raised by Rice, however, have been, to varying extents, recognised previously in the health economics literature (at least outside the U.S.). What perhaps sets Rice's book apart from previous attempts to document such issues is its elegance and the methodical manner in which this critique is delivered. Significantly the critique is based solely on conventional economic arguments. There has, however, been an emerging strand of the health economics literature not acknowledged in Rice's book which has approached some of these issues of market failure from a different perspective. Notably this research has involved, in part, borrowing from the ideas and methodological traditions of other disciplines. The emphasis in this work has been to expand the scope and the concerns of economic analysis in health care.

The relation between funding by the National Institutes of Health and the burden of disease

BACKGROUND

The Institute of Medicine has proposed that the amount of disease-specific research funding provided by the National Institutes of Health (NIH) be systematically and consistently compared with the burden of disease for society.

METHODS

We performed a cross-sectional study comparing estimates of disease-specific funding in 1996 with data on six measures of the burden of disease. The measures were total mortality, years of life lost, and number of hospital days in 1994 and incidence, prevalence, and disability-adjusted life-years (one disability-adjusted life-year is defined as the loss of one year of healthy life to disease) in 1990. With the use of these measures as explanatory variables in a regression analysis, predicted funding was calculated and compared with actual funding.

RESULTS

There was no relation between the amount of NIH funding and the incidence, prevalence, or number of hospital days attributed to each condition or disease (P=0.82, P=0.23, and P=0.21, respectively). The numbers of deaths (r=0.40, P=0.03) and years of life lost (r=0.42, P=0.02) were weakly associated with funding, whereas the number of disability-adjusted life-years was strongly predictive of funding (r=0.62, P<0.001). When the latter three measures were used to predict expected funding, the conclusions about the appropriateness of funding for some diseases varied according to the measure used. However, the acquired immunodeficiency syndrome, breast cancer, diabetes mellitus, and dementia all received relatively generous funding, regardless of which measure was used as the basis for calculating support. Research on chronic obstructive pulmonary disease, perinatal conditions, and peptic ulcer was relatively underfunded.

CONCLUSIONS

The amount of NIH funding for research on a disease is associated with the burden of the disease; however, different measures of the burden of disease may yield different conclusions about the appropriateness of disease-specific funding levels.

Incorporating societal concerns for fairness in numerical valuations of health programmes

The paper addresses some limitations of the QALY approach and outlines a valuation procedure that may overcome these limitations. In particular, we focus on the following issues: the distinction between assessing individual utility and assessing societal value of health care; the need to incorporate concerns for severity of illness as an independent factor in a numerical model of societal valuations of health outcomes; similarly, the need to incorporate reluctance to discriminate against patients that happen to have lesser potentials for health than others; and finally, the need to combine measurements of health-related quality of life obtained from actual patients (or former patients) with measurements of distributive preferences in the general population when estimating societal value. We show how equity weights may serve to incorporate concerns for severity and potentials for health in QALY calculations. We also suggest that for chronically ill or disabled people a life year gained should count as one and no less than one as long as the year is considered preferable to being dead by the person concerned. We call our approach 'cost-value analysis'.

Where are we now in British health economics?

Health economics took off in 1970 or thereabouts, just after the take-off date for the economics of education. Although early health economics made use of human capital theory as did the economics of education, it soon took a different route inspired by Arrow's work on medical insurance. The economics of education failed to live up to its promising start in the 1960s and gradually ran out of steam. The economics of health, however, has made steady theoretical and empirical progress since 1970, principally in coming to grips with the implications of supplier-induced demand and the difficulties of evaluating health care outcomes. Some of the best work on British health economics has been in the area of normative welfare economics, defining more precisely what is meant by equity in the delivery of health care and measuring the degree of success in achieving equity. Recent efforts to reform the NHS by the introduction of 'quasi markets' have improved the quantity and quality of health care in Britain. In short, British health economics has been characterised by the use of Pigovian piecemeal rather than Paretian global welfare economics, retaining a distinctive style that sets it apart from American health economics.