Considering the societal perspective in economic evaluations: a systematic review in the case of depression

Exploring the cost-effectiveness of EBV vaccination to prevent multiple sclerosis in an Australian setting

BACKGROUND

Increasing evidence suggests the potential of Epstein-Barr virus (EBV) vaccination in preventing multiple sclerosis (MS). We aimed to explore the cost-effectiveness of a hypothetical EBV vaccination to prevent MS in an Australian setting.

METHODS

A five-state Markov model was developed to simulate the incidence and subsequent progression of MS in a general Australian population. The model inputs were derived from published Australian sources. Hypothetical vaccination costs, efficacy and strategies were derived from literature. Total lifetime costs, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) were estimated for two hypothetical prevention strategies versus no prevention from the societal and health system payer perspectives. Costs and QALYs were discounted at 5% annually. One-way, two-way and probabilistic sensitivity analyses were performed.

RESULTS

From societal perspective, EBV vaccination targeted at aged 0 and aged 12 both dominated no prevention (ie, cost saving and increasing QALYs). However, vaccinating at age 12 was more cost-effective (total lifetime costs reduced by $A452/person, QALYs gained=0.007, ICER=-$A64 571/QALY gained) than vaccinating at age 0 (total lifetime costs reduced by $A40/person, QALYs gained=0.003, ICER=-$A13 333/QALY gained). The probabilities of being cost-effective under $A50 000/QALY gained threshold for vaccinating at ages 0 and 12 were 66% and 90%, respectively. From health system payer perspective, the EBV vaccination was cost-effective at age 12 only. Sensitivity analyses demonstrated the cost-effectiveness of EBV vaccination to prevent MS under a wide range of plausible scenarios.

CONCLUSIONS

MS prevention using future EBV vaccinations, particularly targeted at adolescence population, is highly likely to be cost-effective.

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

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

Costs of major depression covered / not covered in British Columbia, Canada

BACKGROUND

Major depressive disorder (MDD) is one of the world's leading causes of disability. Our purpose was to characterize the total costs of MDD and evaluate the degree to which the British Columbia provincial health system meets its objective to protect people from the financial impact of illness.

METHODS

We performed a population-based cohort study of adults newly diagnosed with MDD between 2015 and 2020 and followed their health system costs over two years. The expenditure proportion of MDD-related, patient paid costs relative to non-subsistence income was estimated, incidences of financial hardship were identified and the slope index of inequality (SII) between the highest and lowest income groups compared across regions.

RESULTS

There were 250,855 individuals diagnosed with MDD in British Columbia over the observation period. Costs to the health system totalled >$1.5 billion (2020 CDN), averaging $138/week for the first 12 weeks following a new diagnosis and $65/week to week 52 and $55/week for weeks 53-104 unless MDD was refractory to treatment ($125/week between week 12-52 and $101/week over weeks 53-104). The proportion of MDD-attributable costs not covered by the health system was 2-15x greater than costs covered by the health system, exceeding $700/week for patients with severe MDD or MDD that was refractory to treatment. Population members in lower-income groups and urban homeowners had disadvantages in the distribution of financial protection received by the health system (SII reached - 8.47 and 15.25, respectively); however, financial hardship and inequities were mitigated province-wide if MDD went into remission (SII - 0.07 to 0.6).

CONCLUSIONS

MDD-attributable costs to health systems and patients are highest in the first 12 weeks after a new diagnosis. During this time, lower income groups and homeowners in urban areas run the risk of financial hardship.

One-year direct and indirect costs of ischaemic stroke in China

BACKGROUND

This is the first real-world study to estimate the direct costs and indirect costs of first-ever ischaemic stroke with 1-year follow-up in China, based on a nationally representative sample.

METHODS

Patients were chosen from 20 geographically diverse sites from the nationally representative database China National Stroke Registry-III (CNSR-III). The inclusion criteria were surviving patients who were hospitalised with first-ever ischaemic stroke from February 2017 to February 2018 (the index event); aged 18-80 during the index event; no history of other stroke types. The primary endpoints were direct medical costs, direct non-medical costs, indirect costs and total cost (ie, the sum of all cost components). Patient characteristics and clinical data were extracted from CNSR-III. Stroke-related in-hospital direct medical costs were collected from hospital electronic medical records. The patient survey collected data related to out-of-hospital direct medical costs, direct non-medical costs and indirect costs. The secondary objective was to explore clinical factors associated with cost outcomes through univariate analysis and multiple regression.

RESULTS

The study enrolled 520 patients. The total cost was 57 567.48 CNY, with 26 612.67 CNY direct medical costs, 2 787.56 CNY direct non-medical costs and 28 167.25 CNY indirect costs. Univariate analysis showed that longer lengths of stay during the index event, higher National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale scores were associated with higher costs in all categories. Conversely, EuroQol 5 Dimension utility scores were associated with decreased costs except direct non-medical costs. Multiple regressions showed that higher admission NIHSS scores were independently associated with higher direct medical costs, indirect costs and total cost. Higher 3-month utilities were associated with lower total cost.

CONCLUSION

This real-world study showed substantial 1-year economic burden following first-ever ischaemic stroke in China, and that indirect costs are a non-negligible driver of costs.

Societal costs and health related quality of life in adult atopic dermatitis

BACKGROUND

Cost-of-illness studies are widely used for healthcare decision-making in chronic conditions. Our aim was to assess the cost-of-illness of adult atopic dermatitis (AD) from the societal perspective in Hungary.

METHODS

We conducted a multicentre, cross-sectional questionnaire survey between February 2018 and January 2021. Data was collected from consecutive AD patients aged ≥ 18 years and their physicians at dermatology departments in Hungary. We calculated direct and indirect costs, including costs for treatments, outpatient visits, hospital admissions, informal care, travel costs and productivity loss. To assess indirect costs, the Work Productivity and Activity Impairment (WPAI) questionnaire was used to collect data, and costs were estimated with the human capital approach. Generalized linear model was used to analyse predictors of total, direct and indirect costs.

RESULTS

Altogether 218 patients completed the survey (57.8% female) with an average age of 31.3 (SD = 11.7). Patients' average Dermatology Life Quality Index (DLQI) score was 13.5 (SD = 8.5). According to Eczema Area and Severity Index (EASI) score, 2.3% (n = 5), 21.2% (n = 46), 54.4% (n = 118) and 22.1% (n = 48) had clear, mild, moderate, and severe AD, respectively. We found that the average total, direct medical, direct non-medical and indirect annual costs per patients were €4,331, €1,136, €747, and €2450, respectively, with absenteeism and presenteeism being the main cost drivers, accounting for 24% and 29% of the total cost of AD. A one-year longer disease duration led to, on average, 1.6%, and 4.2% increase in total and direct non-medical costs, respectively. Patients with worse health-related quality of life (higher DLQI score) had significantly higher total, direct medical, direct non-medical costs, and indirect costs.

CONCLUSIONS

Our results indicate a substantial economic burden of AD from a societal perspective, mainly driven by productivity losses.

Does the inclusion of societal costs change the economic evaluations recommendations? A systematic review for multiple sclerosis disease

BACKGROUND

Multiple sclerosis imposes a heavy burden on the person who suffers from it and on the relatives, due to the caregiving load involved. The objective was to analyse whether the inclusion of social costs in economic evaluations of multiple sclerosis-related interventions changed results and/or conclusions.

METHODS

A systematic review was launched using Medline and the Cost-Effectiveness Analysis Registry of Tufts University (2000-2019). Included studies should: (1) be an original study published in a scientific journal, (2) be an economic evaluation of any multiple sclerosis-related intervention, (3) include productivity losses and/or informal care costs (social costs), (4) be written in English, (5) use quality-adjusted life years as outcome, and (6) separate the results according to the perspective applied.

RESULTS

Twenty-nine articles were selected, resulting in 67 economic evaluation estimations. Social costs were included in 47% of the studies. Productivity losses were assessed in 90% of the estimations (the human capital approach was the most frequently used method), whereas informal care costs were included in nearly two-thirds of the estimations (applying the opportunity and the replacement-cost methods equally). The inclusion of social costs modified the figures for incremental costs in 15 estimations, leading to a change in the conclusions in 10 estimations, 6 of them changing from not recommended from the healthcare perspective to implemented from the societal perspective. The inclusion of social costs also altered the results from cost-effective to dominant in five additional estimations.

CONCLUSIONS

The inclusion of social costs affected the results/conclusions in multiple sclerosis-related interventions, helping to identify the most appropriate interventions for reducing its economic burden from a broader perspective.

Partially different? The importance of general equilibrium in health economic evaluations: An application to nocturia

Both the human capital approach and the friction cost approach are frequently used to quantify the productivity costs associated with illness, disability or death in health economic evaluations. In this paper we argue that these approaches have one major, but common shortcoming: they only capture partial equilibrium (PE) effects and therefore underestimate the true potential productivity costs associated with health conditions. They neglect the sizable, indirect, ripple effects in the economy captured by general equilibrium (GE) models. To demonstrate our point, we compare a traditional PE with a GE approach for the application to nocturia, a condition characterized by the need to frequently wake up at night to urinate. Nocturia is associated with substantial impairment of daytime functioning and work productivity. We employ large-scale United Kingdom (UK) employer-employee survey data to estimate the prevalence and productivity loss. These estimates are then used as shared inputs to drive both approaches. We find that the traditional PE approach underestimates the annual productivity cost of clinically relevant nocturia by around 16%. We propose a generalized GE/PE multiplier to approximate the GE effect for other health conditions. Our findings stress the importance of accounting for sizable GE effects when conducting health economic evaluations.

Incorporating productivity loss in health economic evaluations: a review of guidelines and practices worldwide for research agenda in China

Introduction

Productivity loss may contribute to a large proportion of costs of health conditions in an economic evaluation from a societal perspective, but there is currently a lack of methodological consensus on how productivity loss should be measured and valued. Despite the research progress surrounding this issue in other countries, it has been rarely discussed in China.

Methods

We reviewed the official guidelines on economic evaluations in different countries and regions and screened the literature to summarise the extent to which productivity loss was incorporated in economic evaluations and the underlying methodological challenges.

Results

A total of 48 guidelines from 46 countries/regions were included. Although 32 (67%) guidelines recommend excluding productivity loss in the base case analysis, 23 (48%) guidelines recommend including productivity loss in the base case or additional analyses. Through a review of systematic reviews and the economic evaluation studies included in these reviews, we found that the average probability of incorporating productivity loss in an economic evaluation was 10.2%. Among the economic evaluations (n=478) that explicitly considered productivity loss, most (n=455) considered losses from paid work, while only a few studies (n=23) considered unpaid work losses. Recognising the existing methodological challenges and the specific context of China, we proposed a practical research agenda and a disease list for progress on this topic, including the development of the disease list comprehensively consisting of health conditions where the productivity loss should be incorporated into economic evaluations.

Conclusion

An increasing number of guidelines recommend the inclusion of productivity loss in the base case or additional analyses of economic evaluation. We optimistically expect that more Chinese researchers notice the importance of incorporating productivity loss in economic evaluations and anticipate guidelines that may be suitable for Chinese practitioners and decision-makers that facilitate the advancement of research on productivity loss measurement and valuation.

Range of invasive meningococcal disease sequelae and health economic application - a systematic and clinical review

Background

Invasive meningococcal disease (IMD) is uncommon, life-threatening, with many diverse sequelae. The aims were to: 1) comprehensively characterise the sequelae; 2) have a systematic application for sequelae impact in economic evaluation (EE).

Methods

Sequelae categorised as physical/neurological or psychological/behavioural were identified from a systematic review of IMD observational studies (OS) and EEs in high-income countries (published 2001–2020). A comprehensive map and EE-relevant list, respectively, included physical/neurological sequelae reported in ≥2OS and ≥ 2OS + 2EE (≥1OS and ≥ 1OS + 1EE for psychological/behavioural). Sequelae proportions were selected from the highest quality studies reporting most sequelae. Three medical experts independently evaluated the clinical impact of findings.

Results

Sixty-Six OS and 34 EE reported IMD sequelae. The comprehensive map included 44 sequelae (30 physical/neurological, 14 psychological/behavioural), of which 18 (14 physical/neurological and 4 psychological/behavioural) were EE-relevant. Experts validated the study and identified gaps due to limited evidence, underreporting of psychological/behavioural sequelae in survivors/their families, and occurrence of multiple sequelae in the acute phase and long-term.

Conclusions

The considerable burden of IMD sequelae on survivors and their families is potentially underestimated in EE, due to underreporting and poorly-defined subtle sequelae. When assessing IMD burden and potential interventions e.g., vaccination, sequelae range and duration, underreporting, and indirect burden on dependents should be considered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13342-2.

Invasive meningococcal disease survivors frequently suffer from variable sequelae.

A broad sequelae map plus those relevant to economic evaluation (EE) were defined.

Forty-four sequelae were selected: 30 physical/neurological and 14 psychological/behavioural.

Eighteen EE-relevant sequelae included 14 physical/neurological and 4 psychological/behavioural

Underreporting, family impact and multiple sequelae cases were critical gaps.

A video summary linked to this article can be found on Figshare: 10.6084/m9.figshare.19753840.

Using social and sexual networking mobile applications to promote HIV testing, medical care and prevention services among Latino men who have sex with men in Los Angeles County, California, USA

HIV disproportionately affects Latinos versus Whites, with Latinos having higher rates of HIV. Additionally, many HIV-positive Latinos are unaware of their infection. Proyecto Protégete, an HIV prevention intervention developed for Latino men who have sex with men (MSM), used social and sexual networking mobile applications (apps) to recruit individuals for HIV testing and linkage to medical care and prevention services. This study occurred in Los Angeles County, California, USA from December 18, 2015 to April 22, 2017. The study’s primary aim was to assess Proyecto Protégete‘s ability to successfully recruit Latino MSM involved in high-risk sexual activities. A secondary aim was to evaluate its capacity to promote HIV testing and linkage to HIV medical care and prevention services among this population by comparing it to two programs with similar samples. Comparisons using Fisher’s Exact Test were conducted between Proyecto Protégete and the HIV testing program of the agency in which Proyecto Protégete was located and the County-funded HIV testing programs to compare the samples’ rates of HIV-positive Latino MSM identified through HIV testing and linked to HIV medical care and prevention services. Participants were recruited through seven apps. In Proyecto Protégete, 9,573 individuals completed the screener, 4,657 were eligible, and 359 (7.7% of those eligible) enrolled. Among those enrolled, 79% reported anal sex without a condom in the previous twelve months; 51% reported anal sex under the influence of alcohol. The HIV positivity rates were as follows: Proyecto Protégete, 1.71%; the agency, 1.25% (p = .293, compared to Proyecto Protégete); and the County, 1.09% (p = .172, compared to Proyecto Protégete). The rates of those confirmed as new HIV-positives and linked to medical care within 30 days were as follows: Proyecto Protégete, 71.4%; the agency, 81.5% (p = .450, compared to Proyecto Protégete); and the County, 77.3% (p = .503, compared to Proyecto Protégete). Proyecto Protégete had a higher rate of linked referrals to prevention services than the agency’s testing program (19.5% versus 8.3%, p < .001). Proyecto Protégete experienced successes in some areas but not in others. Future research should build on Proyecto Protégete’s experiences to promote HIV-related services among Latino MSM.

Out of Date or Best Before? A Commentary on the Relevance of Economic Evaluations Over Time

The impact of time on the applicability and relevance of historical economic evaluations can be considerable. Ignoring this may lead to the use of weak or invalid evidence to inform important research questions or resource allocation decisions, as historical economic evaluations may have reached different conclusions compared to if a similar study had been conducted more recently. There are multiple factors that contribute towards evidence becoming outdated including changes to the relevant decision problem (e.g. comparators), changes to parameters (such as costs, utilities and resource use) and methodological updates (e.g. recommendations on uncertainty analysis). Researchers reviewing economic evaluations need to consider whether changes over time would influence the study design and results if the evaluation were repeated, to the extent that it is no longer helpful or informative. In this paper, we summarise these key issues and make recommendations about how and whether researchers can future proof their economic evaluations.

Systematic Literature Review of the Use of Productivity Losses/Gains in Cost-Effectiveness Analyses of Immune-Mediated Disorders

INTRODUCTION

In light of the lack of an agreed international standard for how to conduct cost-effectiveness analyses (CEAs), including cost-utility analyses (CUAs) from a societal perspective, there is uncertainty regarding to what extent the inclusion of productivity losses/gains in economic evaluations can affect cost-effectiveness results and subsequently decisions on whether to recommend new health technologies. To investigate this, we conducted a systematic review of CEAs and CUAs of drug-based therapies for a set of chronic immune-mediated disorders to understand how cost elements and calculation methods related to productivity losses/gains are used, examine the impact on the incremental cost-effectiveness ratio (ICER) of including productivity costs, and explore factors that affect the inclusion of productivity loss.

METHODS

Databases (MEDLINE^® In-process, MEDLINE, Embase and Cochrane Library) were searched from January 2010 to October 2020 by two independent reviewers for all CEAs and CUAs in adults with any of the following conditions: ankylosing spondylitis, chronic idiopathic urticaria, Crohn's disease, fibromyalgia, juvenile idiopathic arthritis, psoriasis, rheumatoid arthritis, systemic lupus erythematosus and ulcerative colitis. Relevant study data were extracted and evidence was synthesized for both qualitative and quantitative analysis. Productivity cost elements including absenteeism, presenteeism, unemployment/early retirement, premature mortality and informal care were extracted, along with the method used to determine them. A multivariate analysis was performed to identify factors associated with the inclusion of productivity loss.

RESULTS

Our searches identified 5016 records, culminating in 198 unique studies from 234 publications following screening. Most of the studies investigated rheumatoid arthritis (37.0%) or psoriasis (32.0%). The majority were CUAs, with some including both a CEA and a CUA (73.0%). Most studies used a payer perspective only (28.5%) or a societal perspective only (21.0%). Of the 49 studies incorporating productivity losses/gains, 42 reported the type of cost element used; all of these used patient absenteeism, either alone or in addition with other elements. Only 16 studies reported the method used to value productivity changes, of which eight used a human capital approach, four used a friction cost approach and four used both approaches. Twenty-eight of the 49 studies (57.1%) reported inclusion of productivity losses/gains as contributing to more favourable cost-effectiveness outcomes and ICERs, while 12 (24.5%) reported no substantial impact. On the basis of a multivariate analysis, rheumatoid arthritis as the target disease had a statistically significant association with the inclusion of productivity loss compared with psoriasis and inflammatory bowel disease.

CONCLUSIONS

The results of our review suggest that incorporating productivity cost elements may positively affect cost-effectiveness outcomes in evaluations of therapeutics for immune-mediated disorders. Our work highlights the continued need for clarity when reporting how CEAs and CUAs in this disease area are conducted, in order to better inform healthcare decision-making.

Principles of Economic Evaluation in a Pandemic Setting: An Expert Panel Discussion on Value Assessment During the Coronavirus Disease 2019 Pandemic

As the coronavirus disease 2019 (COVID-19) pandemic continues to generate significant morbidity and mortality as well as economic and societal impacts, the landscape of potential treatments has slowly begun to broaden. In the case of a novel disease with widespread consequences, society is more likely to place significant value on interventions that reduce the outsized economic burden of COVID-19. Treatments for severe disease will have a different value profile to that of large-scale vaccines because of their application in targeted and potentially small subsets of those with symptomatic disease vs broad deployment as a preventative measure. Where vaccines reduce transmissibility of COVID-19, use of therapeutics will target symptoms, up to and including death for infected individuals. This paper describes discussions from a virtual expert panel that met to attempt a consensus on how existing principles of economic evaluation should be applied to therapeutics that emerge in a pandemic setting, with specific focus on severe hospitalised cases of COVID-19. The panel concluded that the core principles of economic evaluation do not need to be drastically overhauled to meet the challenges of a pandemic, but that there are several additional elements of value such as equity, disease severity, insurance value, and scientific and family spillover effects that should be considered when presenting results to decision makers. The panel also highlighted the persistent challenges on how society should value novel therapies, such as the appropriate cost-effectiveness threshold to apply, which are particularly salient during a pandemic.

Scaling-up a new socio-mental health service model in Iran to reduce burden of neuropsychiatric disorders: an economic evaluation study

BACKGROUND

The integration of core packages of mental health care into routine primary health care has been introduced as an effective way to achieve universal health coverage in mental health care. Based on the transition of mental health care in Iran, from introducing basic mental health care in PHC to the experience of community-based mental health centers for urban areas, a new socio-mental health service model has been so far proposed. This study aimed to estimate the impact of scaling-up the new socio-mental health model at the national level as well as its associated costs.

METHODS

This study was a cost-consequence analysis following One Health Tool methodology. The data required for the study were collected in the first quarter of the year 2020 with a time horizon from 2020 to 2030. The selected metric for summarizing health effects is healthy life years gained. Resources used in terms of drug and supply, staff salaries and outpatient visits were documented and associated costs were subsequently estimated in order to estimate the average cost of each intervention per case.

RESULTS

The health impacts are calculated in terms of healthy life years gained for 2020-2030, after adjusting the prevalence and incidence rates for each disorder. In total, 1,702,755 healthy life years were expected to be gained. Considering total 1,363,581,654 US dollars cost in base case scenario, each healthy life years gained will cost around 801 US dollars. Based on the WHO criteria for cost-effectiveness threshold, all of the values ranged from 724 to 1119 US dollars obtained through eight different scenarios were considered as cost-effective given the GDP per capita of 5550 US dollars for Iran in 2018.

CONCLUSIONS

Mental health budget in Iran equals to about three percent of total health expenditure while the mental health cost per capita is estimated to be 1.73 US dollar which are relatively low considering the share of the MNS disorders in the national burden of diseases. The results of current study showing the cost of 16.4 US dollar per capita for scaling up this comprehensive mental health service model can convince high-level policy-makers to increase the share of mental health budget accordingly. The present study demonstrated that the cost in this new socio-mental services model is not substantial compared with GDP per capita of Iran.

Assessing the Effect of Including Social Costs in Economic Evaluations of Diabetes-Related Interventions: A Systematic Review

Background

The economic burden of diabetes from a societal perspective is well documented in the cost-of-illness literature. However, the effect of considering social costs in the results and conclusions of economic evaluations of diabetes-related interventions remains unknown.

Objective

To investigate whether the inclusion of social costs (productivity losses and/or informal care) might change the results and conclusions of economic evaluations of diabetes-related interventions.

Methods

A systematic review was designed and launched on Medline and the Cost-Effectiveness Analysis Registry from the University of Tufts, from the year 2000 until 2018. Included studies had to fulfil the following criteria: i) being an original study published in a scientific journal, ii) being an economic evaluation of an intervention on diabetes, iii) including social costs, iv) being written in English, v) using quality-adjusted life years as outcome, and vi) separating the results according to the perspective applied.

Results

From the 691 records identified, 47 studies (6.8%) were selected. Productivity losses were included in 45 of the selected articles (73% used the human capital approach) whereas informal care costs in only 13 (when stated, the opportunity cost method was used in seven studies and the replacement cost in one). The 47 studies resulted in 110 economic evaluation estimations. The inclusion of social costs changed the conclusions in 8 estimations (17%), 6 of them switching from not cost-effective from the healthcare perspective to cost-effective or dominant from the societal perspective. Considering social costs altered the results from cost-effective to dominant in 9 estimations (19%).

Conclusion

When social costs are considered, the results and conclusions of economic evaluations performed in diabetes-related interventions can alter. Wide methodological variations have been observed, which limit the comparability of studies and advocate for the inclusion of a wider perspective via the consideration of social costs in economic evaluations and methodological guidelines relating to their estimation and valuation.