QALYs, age and fairness

Healthcare Priorities: The "Young" and the "Old"

Some philosophers and segments of the public think age is relevant to healthcare priority-setting. One argument for this is based in equity: "Old" patients have had either more of a relevant good than "young" patients or enough of that good and so have weaker claims to treatment. This article first notes that some discussions of age-based priority that focus in this way on old and young patients exhibit an ambiguity between two claims: that patients classified as old should have a low priority, and that patients classified as young should have high priority. The author next argues, drawing on a problem raised by Christine Overall, that equity cannot justify giving "old" patients low priority, since there is wide variety in the total lifetime experiences of older people, partly influenced by gender, race, class, and disability injustice. Finally, the author suggests that there might be a limited role for age-based prioritization in the context of infant and childhood death, since those who die in childhood are always and uncontroversially among the worst-off.

Explaining rule of rescue obligations in healthcare allocation: allowing the patient to tell the right kind of story about their life

I consider various principles which might explain our intuitive obligation to rescue people from imminent death at great cost, even when the same resources could produce more benefit elsewhere. Our obligation to rescue is commonly explained in terms of the identifiability of the rescuee, but I reject this account. Instead, I offer two considerations which may come into play. Firstly, I explain the seeming importance of identifiability in terms of an intuitive obligation to prioritise life-extending interventions for people who face a high risk of an early death, and I explain this in turn with a fair innings-style principle which prioritises life-extending interventions for people expected to die young. However, this account is incomplete. It does not explain why we would devote the same resources to rescuing miners stuck down a mine even if they are elderly. We are averse to letting people die suddenly, or separated from friends and family. And so, secondly, I give a new account that explains this in terms of narrative considerations. We value life stories that follow certain patterns, classic patterns which are reflected in many popular myths and stories. We are particularly averse to depriving people of the opportunity to follow some such pattern as they approach death. This means allowing them to sort out their affairs, say goodbyes to family and friends, review their life, or come to terms with death itself. Such activities carry a lot of meaning as ways of closing our life story in the right way. So, for someone who has not been given much notice of their death, an extra month is worth much more than for other patients. Finally, I review the UK National Health Service's end of life premium, which gives priority to patients with short life expectancy. I suggest it falls short in terms of such considerations. For example, the NHS defines its timings in terms of how long the patient can expect to live as at the time of the treatment decision, whereas the timings should be specified in terms of time from diagnosis.

The application of the QALY measure in the assessment of the effects of health interventions on an older population: a systematic scoping review

Background

One of the most commonly used types of evaluation methods is cost-utility analysis (CUA), using the Quality Adjusted Life Year (QALY) indicator as a preference-based measure for assessing effects of a given programme. Such assessments are often translated into health-care provision priorities; therefore, effectively choosing the method of outcome evaluation is crucial for ensuring the best possible allocation of scarce resources. The main objective of this scoping review is to identify what kinds of problems and limitations may occur when the QALY indicator is used to assess the effects of health interventions in the older population.

Methods

To identify literature in a scoping review, the databases MEDLINE via PubMed and Scopus were searched. A manual search on relevant organizations’ and associations’ websites was also conducted (EUnetHTA, ISPOR and national governmental agencies responsible for allocation decisions). No limits concerning publication dates were set. All relevant data were extracted and analyzed, then a narrative summary was prepared.

Results

The database search identified 10,832 relevant items, finally 32 studies were included in the analysis. The main types of issues indicated in the studies were as follows: (1) lower life expectancy in the older population causes lower QALY gains; (2) an equal value of one QALY is used regardless of age; (3) poorer average health state causes lower QALY gains; (4) inadequate instruments to measure quality of life (QoL); (5) attributes of QoL used regardless of age; and (6) no beyond-health QoL aspects taken into account.

Conclusions

This review shows clearly that many problems of different types are connected with using QALY for the older population, but there is no consensus as to whether QALY discriminates against the older population or not – an opinion regarding this issue depends strongly on accepted principles, particularly the approach to equity and how one understands fairness. Health care resources should not be allocated solely on the basis of the health maximization rule because this can lead to discrimination against certain groups (e.g., older, disabled, and/or chronically ill people). To maintain the balance between efficiency and equity, the issues connected with age-based rationing should be widely discussed.

How to Value Orphan Drugs? A Review of European Value Assessment Frameworks

Background: Decision-makers have implemented a variety of value assessment frameworks (VAFs) for orphan drugs in European jurisdictions, which has contributed to variations in access for rare disease patients. This review provides an overview of the strengths and limitations of VAFs for the reimbursement of orphan drugs in Europe, and may serve as a guide for decision-makers.

Methods: A narrative literature review was conducted using the databases Pubmed, Scopus and Web of Science. Only publications in English were included. Publications known to the authors were added, as well as conference or research papers, or information published on the website of reimbursement and health technology assessment (HTA) agencies. Additionally, publications were included through snowballing or focused searches.

Results: Although a VAF that applies a standard economic evaluation treats both orphan drugs and non-orphan drugs equally, its focus on cost-effectiveness discards the impact of disease rarity on data uncertainty, which influences an accurate estimation of an orphan drug’s health benefit in terms of quality-adjusted life-years (QALYs). A VAF that weighs QALYs or applies a variable incremental cost-effectiveness (ICER) threshold, allows the inclusion of value factors beyond the QALY, although their methodologies are flawed. Multi-criteria decision analysis (MCDA) incorporates a flexible set of value factors and involves multiple stakeholders’ perspectives. Nevertheless, its successful implementation relies on decision-makers’ openness toward transparency and a pragmatic approach, while allowing the flexibility for continuous improvement.

Conclusion: The frameworks listed above each have multiple strengths and weaknesses. We advocate that decision-makers apply the concept of accountability for reasonableness (A4R) to justify their choice for a specific VAF for orphan drugs and to strive for maximum transparency concerning the decision-making process. Also, in order to manage uncertainty and feasibility of funding, decision-makers may consider using managed-entry agreements rather than implementing a separate VAF for orphan drugs.

Severity as a Priority Setting Criterion: Setting a Challenging Research Agenda

Priority setting in health care is ubiquitous and health authorities are increasingly recognising the need for priority setting guidelines to ensure efficient, fair, and equitable resource allocation. While cost-effectiveness concerns seem to dominate many policies, the tension between utilitarian and deontological concerns is salient to many, and various severity criteria appear to fill this gap. Severity, then, must be subjected to rigorous ethical and philosophical analysis. Here we first give a brief history of the path to today’s severity criteria in Norway and Sweden. The Scandinavian perspective on severity might be conducive to the international discussion, given its long-standing use as a priority setting criterion, despite having reached rather different conclusions so far. We then argue that severity can be viewed as a multidimensional concept, drawing on accounts of need, urgency, fairness, duty to save lives, and human dignity. Such concerns will often be relative to local mores, and the weighting placed on the various dimensions cannot be expected to be fixed. Thirdly, we present what we think are the most pertinent questions to answer about severity in order to facilitate decision making in the coming years of increased scarcity, and to further the understanding of underlying assumptions and values that go into these decisions. We conclude that severity is poorly understood, and that the topic needs substantial further inquiry; thus we hope this article may set a challenging and important research agenda.

HEALTH(CARE) AND THE TEMPORAL SUBJECT

Many assume that theories of distributive justice must obviously take people’s lifetimes, and only their lifetimes, as the relevant period across which we distribute. Although the question of the temporal subject has risen in prominence, it is still relatively underdeveloped, particularly in the sphere of health and healthcare. This paper defends a particular view, “momentary sufficientarianism,” as being an important element of healthcare justice. At the heart of the argument is a commitment to pluralism about justice, where theorizing about just principles demands paying attention to the role particular goods play in our lives. This means that different approaches to the temporal subject—as well as other relevant issues—may be appropriate for different goods, including different goods within healthcare. In particular, the paper discusses two central goods targeted by healthcare: life-saving and pain relief. The view is offered as complementary to, rather than competitive with, lifetime approaches. As such, the paper finishes by considering how a pluralist approach, which engages both with people’s lives as a whole and with their states at particular moments, can reconcile the potentially competing claims in healthcare that emerge from these two perspectives.

Rationing costly treatments: can it be fair?

Healthcare resources are finite and rationing is common. Fair distribution assumes that equals are treated equally and unequals are treated unequally, based on morally relevant differences such as the needs of and likely benefits to the patients. Applying these considerations in practice is complex. A case is described to illustrate the ethical issues raised by patients’ requests to pay for an expensive drug treatment.

Accounting for Attribute-Level Non-Attendance in a Health Choice Experiment: Does it Matter?

An extensive literature has established that it is common for respondents to ignore attributes of the alternatives within choice experiments. In most of the studies on attribute non-attendance, it is assumed that respondents consciously (or unconsciously) ignore one or more attributes of the alternatives, regardless of their levels. In this paper, we present a new line of enquiry and approach for modelling non-attendance in the context of investigating preferences for health service innovations. This approach recognises that non-attendance may not just be associated with attributes but may also apply to the attribute's levels. Our results show that respondents process each level of an attribute differently: while attending to the attribute, they ignore a subset of the attribute's levels. In such cases, the usual approach of assuming that respondents either attend to the attribute or not, irrespective of its levels, is erroneous and could lead to misguided policy recommendations. Our results indicate that allowing for attribute-level non-attendance leads to substantial improvements in the model fit and has an impact on estimated marginal willingness to pay and choice predictions.

Prioritising health service innovation investments using public preferences: a discrete choice experiment

BACKGROUND

Prioritising scarce resources for investment in innovation by publically funded health systems is unavoidable. Many healthcare systems wish to foster transparency and accountability in the decisions they make by incorporating the public in decision-making processes. This paper presents a unique conceptual approach exploring the public's preferences for health service innovations by viewing healthcare innovations as 'bundles' of characteristics. This decompositional approach allows policy-makers to compare numerous competing health service innovations without repeatedly administering surveys for specific innovation choices.

METHODS

A Discrete Choice Experiment (DCE) was used to elicit preferences. Individuals chose from presented innovation options that they believe the UK National Health Service (NHS) should invest the most in. Innovations differed according to: (i) target population; (ii) target age; (iii) implementation time; (iv) uncertainty associated with their likely effects; (v) potential health benefits; and, (vi) cost to a taxpayer. This approach fosters multidimensional decision-making, rather than imposing a single decision criterion (e.g., cost, target age) in prioritisation. Choice data was then analysed using scale-adjusted Latent Class models to investigate variability in preferences and scale and valuations amongst respondents.

RESULTS

Three latent classes with considerable heterogeneity in the preferences were present. Each latent class is composed of two consumer subgroups varying in the level of certainty in their choices. All groups preferred scientifically proven innovations, those with potential health benefits that cost less. There were, however, some important differences in their preferences for innovation investment choices: Class-1 (54%) prefers innovations benefitting adults and young people and does not prefer innovations targeting people with 'drug addiction' and 'obesity'. Class- 2 (34%) prefers innovations targeting 'cancer' patients only and has negative preferences for innovations targeting elderly, and Class-3 (12%) prefers spending on elderly and cancer patients the most.

CONCLUSIONS

DCE can help policy-makers incorporate public preferences for health service innovation investment choices into decision making. The findings provide useful information on the public's valuation and acceptability of potential health service innovations. Such information can be used to guide innovation prioritisation decisions by comparing competing innovation options. The approach in this paper makes, these often implicit and opaque decisions, more transparent and explicit.

Is the QALY blind, deaf and dumb to equity? NICE's considerations over equity

INTRODUCTION/BACKGROUND

The quality-adjusted life year (QALY) is the preferred measure of health outcome used to inform decisions over the use of health care interventions in the UK NHS. This measure considers the overall impact of alternative interventions on both the quantity and quality of life.

SOURCES OF DATA

Review of the relevant literature. Areas of agreement The QALY assumes that health improvement is equally valued between individuals. Areas of controversy Some can perceive as equitable, that is fair, the assumption that health improvement is equally valued between individuals in the QALY. However, others may believe that this assumption leaves no space for alternative views over equity to be explicitly considered in societal decision making.

GROWING POINTS

The role of equity in decision making in the UK has been subject of intense debate, and controversy, and to-date there is no consensus on whether, or how, should NICE should change their general process.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further examination of the issues needs to be debated and researched.

Principles for allocation of scarce medical interventions

Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and disability-adjusted life-years. We recommend an alternative system-the complete lives system-which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles.

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.

QALY maximisation and people's preferences: a methodological review of the literature

In cost-utility analysis, the numbers of quality-adjusted life years (QALYs) gained are aggregated according to the sum-ranking (or QALY maximisation) rule. This requires that the social value from health improvements is a simple product of gains in quality of life, length of life and the number of persons treated. The results from a systematic review of the literature suggest that QALY maximisation is descriptively flawed. Rather than being linear in quality and length of life, it would seem that social value diminishes in marginal increments of both. And rather than being neutral to the characteristics of people other than their propensity to generate QALYs, the social value of a health improvement seems to be higher if the person has worse lifetime health prospects and higher if that person has dependents. In addition, there is a desire to reduce inequalities in health. However, there are some uncertainties surrounding the results, particularly in relation to what might be affecting the responses, and there is the need for more studies of the general public that attempt to highlight the relative importance of various key factors.

Academic freedom, analysis, and the Code of Professional Conduct

Despite nursing's move into higher education, academic freedom has received little attention within the literature. After discussing the concept of academic freedom, this paper argues that there is a potential tension between academic freedom and the requirement to educate student nurses who are fit for practice. One way in which this tension might be revealed is in the marking of student assignments. We ask the question--how should nurse educators mark an essay which is sufficiently analytical but reaches moral conclusions that lie outside the Code of Professional Conduct? We argue that despite an understandable temptation to penalise such an essay, invoking the Code of Professional Conduct to do so, no penalty should be applied, and academic freedom for students within higher education should be encouraged. This is because first, academic freedom is a good in itself especially as it allows unconventional and unpalatable conclusions to be discussed and rebutted, and second, applying a penalty on these grounds is necessarily inconsistent.

QALYs and ageism: philosophical theories and age weighting

QALY maximization is sometimes criticized for being 'ageist', because, other things being equal, the elderly, with a shorter life expectancy, will be given lower priority. On the other hand, there are philosophical arguments that, for different reasons, advocate rationing health care to the elderly, even when the size of the expected benefits in QALY terms is the same across older and younger patients. This paper examines six proposals, both from the philosophical and the health economics literature, that will lead to such conclusions. These are: two variants of the so-called fair innings argument, the fair innings weights, the Disability Adjusted Life Year (DALY) age weighting, the biographical life span, and the prudential lifetime account. Two questions are addressed with regard to each of these. First, what is the reason for choosing the younger patient when the QALY gains are equal; second, will the younger patient continue to be chosen even when the QALY gains to the older patient are larger. The paper studies the relationship between the six proposals and explores their possible implications for QALY maximization.

QALYS and ethics: a health economist's perspective

Objectors on ethical grounds to the use of QALYs in priority-setting in public health care systems are here categorised as (1) those who reject all collective priority-setting as unethical; (2) those who accept the need for collective priority-setting but believe that it is contrary to medical ethics; (3) those who accept the need for collective priority-setting and do not believe that it is contrary to medical ethics, but reject the role of QALYs in it on other ethical grounds; and (4) those who accept the need for collective priority-setting in principle, but are unwilling to specify how it should be done in practice. It is argued that the first two groups of objectors are simply wrong, if distributive justice is a proper ethical concern in this context. The third group is of more interest, as this group appears to believe that QALYs are unethical because it is unethical to regard QALY maximisation as the sole objective of the health care system. This paper argues that QALYs are relevant to a much wider range of objectives than QALY maximisation, and that they can accommodate a wide variety of health dimensions and sources of valuation. They can also accommodate the differential weighting of benefits according to who gets them, so they do not commit their users to any particular notion of distributive justice. What they do commit their users to is the notion that the health of people is a central concept in priority-setting, and that it is desirable, for reasons of accountability, to have the bases for such priority-setting made as precise and explicit as possible. The fourth group of objectors needs to acknowledge that there is no perfect system on offer, and since priority-setting does and will proceed willy-nilly we cannot wait until there is. It would be more constructive to set up the desiderata that a priority-setting system should ideally fulfil, and then appraise all feasible alternatives (including the status quo) even-handedly by those criteria. None will be perfect, but this author predicts that QALYs would emerge from such an appraisal with a significant role to play.

Allocating healthcare by QALYs: the relevance of age

What proportion of available healthcare funds should be allocated to hip replacement operations and what proportion to psychiatric care? What proportion should go to cardiac patients and what to newborns in intensive care? What proportion should go to preventative medicine and what to treating existing conditions? In general, how should limited healthcare resources (people, facilities, equipment, drugs…) be distributed If not all demands can be met?