Quality-of-life effects of screening mammography in Norway

Mammography screening may save women from dying of breast cancer, although it has not been shown to reduce all-cause mortality. Screening also leads to overdiagnosis and many false positive mammograms aggravating women's quality-of-life. Quality adjusted life years (QALY) analyses of mammography screening have so far, calculated life years gained assuming that all prevented breast cancer deaths translate into a reduction in all-cause mortality. We calculated net QALYs in two hypothesized cohorts of 100,000 Norwegian women; one screened biennially from age 50 to 69 years and one not screened. We followed both cohorts to age 85 years. We used EQ-5D and an alternative equity weighted QALY instrument to estimate utility losses. In the screening cohort, we assumed 20% false positive tests during screening, different levels of overdiagnosis (20-75%) and different levels of breast cancer mortality reduction (10-30%). We assumed that reductions in breast cancer mortality only to a limited extent (20, 50 or 80%), resulted in reductions in all-cause mortality. We calculated both undiscounted and discounted (4%) QALYs. Assuming that 50% of the reduction in breast cancer mortality translated to a reduction in all-cause mortality and using estimated levels of benefits and harms in modern screening programs (50-75% overdiagnosis and 10% reduction in breast cancer mortality), undiscounted equity weighted QALY loss varied from 437 to 875 per 100,000 women. Using the levels of benefit and harms as reported in 30-40 years old randomized trials (30% overdiagnosis and 15% reduction in breast cancer mortality), undiscounted equity weighted QALY gain was 535 per 100,000. Net QALY in modern mammography screening in Norway is negative. Results could also be representative for Sweden, Denmark, UK and the US.

Determining Value in Health Technology Assessment: Stay the Course or Tack Away?

The economic evaluation of new health technologies to assess whether the value of the expected health benefits warrants the proposed additional costs has become an essential step in making novel interventions available to patients. This assessment of value is problematic because there exists no natural means to measure it. One approach is to assume that society wishes to maximize aggregate health, measured in terms of quality-adjusted life-years (QALYs). Commonly, a single 'cost-effectiveness' threshold is used to gauge whether the intervention is sufficiently efficient in doing so. This approach has come under fire for failing to account for societal values that favor treating more severe illness and ensuring equal access to resources, regardless of pre-existing conditions or capacity to benefit. Alternatives involving expansion of the measure of benefit or adjusting the threshold have been proposed and some have advocated tacking away from the cost per QALY entirely to implement therapeutic area-specific efficiency frontiers, multicriteria decision analysis or other approaches that keep the dimensions of benefit distinct and value them separately. In this paper, each of these alternative courses is considered, based on the experiences of the authors, with a view to clarifying their implications.

Beyond QALYs: Multi-criteria based estimation of maximum willingness to pay for health technologies

The QALY is a useful outcome measure in cost-effectiveness analysis. But in determining the overall value of and societal willingness to pay for health technologies, gains in quality of life and length of life are prima facie separate criteria that need not be put together in a single concept. A focus on costs per QALY can also be counterproductive. One reason is that the QALY does not capture well the value of interventions in patients with reduced potentials for health and thus different reference points. Another reason is a need to separate losses of length of life and losses of quality of life when it comes to judging the strength of moral claims on resources in patients of different ages. An alternative to the cost-per-QALY approach is outlined, consisting in the development of two bivariate value tables that may be used in combination to estimate maximum cost acceptance for given units of treatment-for instance a surgical procedure, or 1 year of medication-rather than for 'obtaining one QALY.' The approach is a follow-up of earlier work on 'cost value analysis.' It draws on work in the QALY field insofar as it uses health state values established in that field. But it does not use these values to weight life years and thus avoids devaluing gained life years in people with chronic illness or disability. Real tables of the kind proposed could be developed in deliberative processes among policy makers and serve as guidance for decision makers involved in health technology assessment and appraisal.

8th European Conference on Rare Diseases & Orphan Products (ECRD 2016)

O1 The European Social Preferences Measurement (ESPM) study project: social cost value analysis, budget impact, commercial life cycle revenue management, and the economics of biopharmaceutical Research & Development (R&D)

Michael Schlander, Søren Holm, Erik Nord, Jeff Richardson, Silvio Garattini, Peter Kolominsky-Rabas, Deborah Marshall, Ulf Persson, Maarten Postma, Steven Simoens, Oriol de Solà Morales, Keith Tolley, Mondher Toumi, Harry Telser

O2 Newborn Screening: the potential and the challenges

James R Bonham

O3 Untreatable disease outcomes - how would we measure them?

Helmut Hintner, Anja Diem, Martin Laimer

O4 Taking Integrated Care Forward: Experiences from Canada to inspire service provision for people living with rare disease in Europe

Réjean Hébert

O5 Listening to the patient’s voice: social media listening for safety and benefits in rare diseases

Nabarun Dasgupta, Carrie E. Pierce, Melissa Jordan

O6 Via Opta: Mobile apps making visually impaired patients’ lives easier

Barbara Bori, Mohanad Fors, Emilie Prazakova

O7 A report of the IRDiRC “Small Population Clinical Trial” Task Force

Simon Day

O8 HAE patient identification and diagnosis: An innovative, ‘game changing’ collaboration

Thomas J. Croce Jr.

O9 Co-creating with the community: primary packaging & administration for people with haemophilia

Jonas Fransson, Philip Wood

O10 Go with Gaucher, taking forward the next generation. How to involve young people to create a new generation of patient advocates

Anne-Grethe Lauridsen, Joanne Higgs, Vesna Stojmirova Aleksovska

P1 ODAK – Orphan Drug for Acanthamoeba Keratitis

Christina Olsen, Ritchie Head, Antonio Asero, Vincenzo Papa, Christa van Kan, Loic Favennec, Silvana Venturella, Michela Salvador, Alan Krol

P5 Rare Navigators help people living with rare diseases to manage the social – and healthcare systems Stephanie J. Nielsen, Birthe B. Holm

P6 The eAcademy for Tay-Sachs & Sandhoff disease app

Daniel Lewi, Patricia Durão

P10 The role of a patient organisation in driving the research agenda in a rare disease

Heather Band, Andrea West

P13 Expertise for rare diseases mapped

Marinda J.A. Hammann, Marije C. Effing-Boele, Hanka K. Dekker

P14 The hidden costs of rare diseases: a feasibility study

Amy Hunter, Amy Simpson

P15 FDA’s new natural history grant program: support to build a solid foundation for development of products for rare diseases

Gumei Liu, Katherine Needleman, Debra Lewis, Gayatri Rao

P17 Understanding the wider impact of adrenal insufficiency: patient organisation involvement in the TAIN project

Amy Simpson, Amy Hunter, Martin J Whitaker

P20 Bridging the gaps between medical and social care for people living with a rare disease

Raquel Castro

Determining the value of medical technologies to treat ultra-rare disorders: a consensus statement

BACKGROUND

In most jurisdictions, policies have been adopted to encourage the development of treatments for rare or orphan diseases. While successful as assessed against their primary objective, these policies have prompted concerns among payers about the economic burden that might be caused by an annual cost per patient in some cases exceeding 100,000 Euro. At the same time, many drugs for rare disorders do not meet conventional standards for cost-effectiveness or 'value for money'. Owing to the fixed (volume-independent) cost of research and development, this issue is becoming increasingly serious with decreasing prevalence of a given disorder.

METHODS

In order to critically appraise the problems posed by the systematic valuation of interventions for ultra-rare disorders (URDs), an international group of clinical and health economic experts was convened in conjunction with the Annual European ISPOR Congress in Berlin, Germany, in November 2012. Following this meeting and during subsequent deliberations, the group achieved a consensus on the specific challenges and potential ways forward.

RESULTS

The group concluded that the complexities of research and development for new treatments for URDs may require conditional approval and reimbursement policies, such as managed entry schemes and coverage with evidence development agreements, but should not use as justification surrogate end point improvement only. As a prerequisite for value assessment, the demonstration of a minimum significant clinical benefit should be expected within a reasonable time frame. As to the health economic evaluation of interventions for URDs, the currently prevailing logic of cost-effectiveness (using benchmarks for the maximum allowable incremental cost per quality-adjusted life year gained) was considered deficient as it does not capture well-established social preferences regarding health care resource allocation.

CONCLUSION

Modified approaches or alternative paradigms to establish the 'value for money' conferred by interventions for URDs should be developed with high priority.

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

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

Transforming EQ-5D utilities for use in cost–value analysis of health programs

In a number of jurisdictions there is increasing interest in incorporating concerns for fairness in models for economic evaluation of health interventions. Cost–value analysis is a name for evaluations with such a broader aim. The most widely held concern for fairness is a concern for the worse off, i.e. the idea that severity of illness should count in determining priorities. In economic evaluations of improvements in health-related quality of life this concern may be taken into account by replacing conventional health state utilities with societal values for health states that are characterised by strong upper end compression and decreasing marginal value of utility gains. We review evidence on the strength of concerns for the worse off--measured at the cardinal level--in 15 articles published in peer-reviewed journals in the time period 1978–2010, with reports from altogether 20 individual studies in nine different countries. We report 116 individual observations of paired comparisons of utility improvements with different start levels. Concerns for severity show up quite strongly across countries, sample types and question framings. By means of regression analyses we fit a societal value function to the data that has the property of decreasing marginal value of utility gains. Using the central tendency in the data we present two plausible transformations of EQ-5D utilities into societal values that reflect concerns for the worse off.

Cost-value analysis of health interventions: introduction and update on methods and preference data

According to the consensus statement from the International Society for Pharmacoeconomics and Outcomes Research Quality-Adjusted Life-Year (QALY) workshop in Philadelphia in 2007 "concerns for fairness may cause social resource allocation preferences to deviate considerably from the ranking that consideration of costs per QALY would suggest." Salient concerns for fairness include the view that priority should be given to the severely ill over the less severely ill, that people have a right to realize their potential for health even if their capacity to benefit from treatment is moderate, and that everybody has the same right to treatment that averts premature death, even if their health and functional level is less than perfect. Cost-value analysis incorporates these concerns in formal economic evaluation of health interventions and programs and thus has a potential for ranking interventions and programs in a way that is more consistent with societal values. Data on the strength of public concerns for fairness are now sufficient to be useful in formal economic evaluation. The data may, within a context of fair and open deliberations, help societal decision makers to roughly indicate the societal value of a QALY in different circumstances and thus determine a tentative grading of willingness to pay for a QALY.

Guidance on priority setting in health care (GPS-Health): the inclusion of equity criteria not captured by cost-effectiveness analysis

This Guidance for Priority Setting in Health Care (GPS-Health), initiated by the World Health Organization, offers a comprehensive map of equity criteria that are relevant to health care priority setting and should be considered in addition to cost-effectiveness analysis. The guidance, in the form of a checklist, is especially targeted at decision makers who set priorities at national and sub-national levels, and those who interpret findings from cost-effectiveness analysis. It is also targeted at researchers conducting cost-effectiveness analysis to improve reporting of their results in the light of these other criteria. THE GUIDANCE WAS DEVELOP THROUGH A SERIES OF EXPERT CONSULTATION MEETINGS AND INVOLVED THREE STEPS: i) methods and normative concepts were identified through a systematic review; ii) the review findings were critically assessed in the expert consultation meetings which resulted in a draft checklist of normative criteria; iii) the checklist was validated though an extensive hearing process with input from a range of relevant stakeholders. The GPS-Health incorporates criteria related to the disease an intervention targets (severity of disease, capacity to benefit, and past health loss); characteristics of social groups an intervention targets (socioeconomic status, area of living, gender; race, ethnicity, religion and sexual orientation); and non-health consequences of an intervention (financial protection, economic productivity, and care for others).

Disability weights in the Global Burden of Disease 2010: unclear meaning and overstatement of international agreement

The Global Burden of Disease Project (GBD) is a huge international enterprise that provides vast amounts of valuable data on (a) the prevalence of different diseases in the world as a whole, in regions and in individual countries, (b) their causes (risk factors), and (c) their burden on populations in terms of Disability Adjusted Life Years (DALYs). However, the methods used for disability weighting of life years are problematic. After a long history of changing concepts and methods the GBD in its 2010 version has landed on 'health' as a unidimensional construct to be used for weighing multi-dimensional non-fatal health problems against each other and against death. The unidimensional health construct does not have a clear meaning. It likely also leads to biases in assessments of conditions that in everyday language are associated with 'being ill' as opposed to conditions which are not associated with 'being ill' (states of physical disability and the state dead). Furthermore, the transformation of ordinal data from paired comparisons into disability weights with purported ratio scale properties is not validated nor explained in a way that allows judgements of face validity. There are also issues related to the way in which different health problems were described to respondents. Lastly, international agreement on disability weights is clearly overstated. Policy makers at national and international levels should understand the GBD 2010 methods properly and carefully consider their validity before deciding to implement the methods, or the disability weights estimated so far by means of them, in further projects and studies. Considerable local adjustments of the weights offered presently are a likely outcome of such methodological scrutiny.

A randomized controlled trial of a senior centre group programme for increasing social support and preventing depression in elderly people living at home in Norway

BACKGROUND

Late-life depression is a common condition and a challenging public health problem. A lack of social support is strongly associated with psychological distress. Senior centres seem to be suitable arenas for community-based health promotion interventions, although few studies have addressed this subject. The objectives were to examine the effect of a preventive senior centre group programme consisting of weekly meetings, on social support, depression and quality of life.

METHODS

A questionnaire was sent to a random sample of 4,000 persons over 65 in Oslo, and a total of 2,387 completed questionnaires were obtained. These subjects served as a basis for recruitment of participants for a trial, with scores on HSCL-10 being used as a main inclusion criterion. A total of 138 persons were randomized into an intervention group (N = 77) and control group (N = 61). Final analyses included 92 persons. Social support (OSS-3), depression (BDI), life satisfaction and health were measured in interviews at baseline and after 12 months (at the end of the intervention programme). Perceptions of benefits from the intervention were also measured. Mean scores, SD, SE and CI were used to describe the changes in outcomes. Effect sizes were calculated based on the original scales and as Cohen's d. Paired sample tests and ANOVA were used to test group differences.

RESULTS

There was an increase in social support in both groups, but greatest in the intervention group. The level of depression increased for both groups, but more so in the control than the intervention group. There was a decrease in life satisfaction, although the decrease was largest among controls. There were almost no differences in reported health between groups. However, effect sizes were small and differences were not statistically significant. In contrast, most of the participants said the intervention meant much to them and led to increased use of the centre.

CONCLUSIONS

In all probability, the intervention failed to meet optimistic targets, but possibly met quite modest ones. Since intention-to-treat analysis was not possible, we do not know the effect on the intervention group as a whole. A further evaluation of these programmes is necessary to expand the group programme. For the depressed, more specialized programmes to cope with depression may be a more appropriate intervention.

TRIAL REGISTRATION

DRKS00003120 on DRKS.

Undervisningsprogram i videregående skoler om psykiske plager: Effekter på elevers hjelpsøking og psykiske helse

Det primærforebyggende programmet ”VIP” – Veiledning og Informasjon om Psykisk helse – gjennomføres overfor elever i første klasse i videregående skoler. VIPs mål er å fremme psykisk helse ved å øke elevenes kunnskapsgrunnlag om psykiske helse, å forbedre de unges evne til gjenkjennelse av signaler på psykiske lidelser og å senke terskelen for å søke hjelp. Vi evaluerer VIP ved å sammenlikne elever i et utvalg av skoler i Akershus der intervensjonen ble gjennomført (intervensjonsgruppe), med elever i et utvalg av skoler i Vestfold som ikke fikk intervensjonen (kontrollgruppe). Vi har tidligere funnet at programmet på helt kort sikt har effekter både på generelle kunnskaper om psykisk helse og på kunnskaper om hjelpeapparatet. I denne artikkelen har vi vist at det etter 6 og 12 måneder synes å være en liten effekt på hjelpsøking. Innvirkningen på dagliglivet blant de som faktisk har problemer er positiv (12% bedre utvikling etter 12 måneder) men ikke statistisk signifikant. Derimot har vi funnet statistisk signifikante effekter på totalskåren i SDQ-Nor (Cohens d = 0,15), problemnivå med jevnaldrende (d = 0,31) og angst etter 12 måneder (d = 0,37). Vi finner dette bemerkelsesverdig gitt VIP-intervensjonens moderate omfang og den store sammenhengen som VIP-programmet forekommer i. Effektene er ikke veldig store, men selv moderate eller små bidrag til økt kunnskap og bedre mestring gjennom VIP-programmet vil være forsvarlig hvis det oppnås med tilsvarende lave kostnader. En nærmere analyse av programmets kostnader vil således være av interesse.

Discounting future health benefits: the poverty of consistency arguments

In economic evaluation of health care, main stream practice is to discount benefits at the same rate as costs. But main papers in which this practice is advocated have missed a distinction between two quite different evaluation problems: (1) How much does the time of program occurrence matter for value and (2) how much do delays in health benefits from programs implemented at a given time matter? The papers have furthermore focused on logical and arithmetic arguments rather than on real value considerations. These 'consistency arguments' are at best trivial, at worst logically flawed. At the end of the day, there is a sensible argument for equal discounting of costs and benefits rooted in microeconomic theory of rational, utility maximising consumers' saving behaviour. But even this argument is problematic, first because the model is not clearly supported by empirical observations of individuals' time preferences for health, second because it relates only to evaluation in terms of overall individual utility. It does not provide grounds for claiming that decision makers with a wider societal perspective, which may include concerns for fair distribution, need to discount Copyright © 2010 John Wiley & Sons, Ltd.

The efficiency frontier approach to economic evaluation of health-care interventions

BACKGROUND

IQWiG commissioned an international panel of experts to develop methods for the assessment of the relation of benefits to costs in the German statutory health-care system.

PROPOSED METHODS

The panel recommended that IQWiG inform German decision makers of the net costs and value of additional benefits of an intervention in the context of relevant other interventions in that indication. To facilitate guidance regarding maximum reimbursement, this information is presented in an efficiency plot with costs on the horizontal axis and value of benefits on the vertical. The efficiency frontier links the interventions that are not dominated and provides guidance. A technology that places on the frontier or to the left is reasonably efficient, while one falling to the right requires further justification for reimbursement at that price. This information does not automatically give the maximum reimbursement, as other considerations may be relevant. Given that the estimates are for a specific indication, they do not address priority setting across the health-care system.

CONCLUSION

This approach informs decision makers about efficiency of interventions, conforms to the mandate and is consistent with basic economic principles. Empirical testing of its feasibility and usefulness is required.

Severity of illness versus expected benefit in societal evaluation of healthcare interventions

Society's valuation of a healthcare outcome depends not only on the size of the gain in well-being (utility), but also on the severity of the initial condition. This seems to be a major problem with the conventional utility-based QALY approach to outcome evaluation. In particular, QALY calculations based on utilities from multiattribute utility instruments assign too high value to interventions for people with mild and moderate health problems compared with interventions for people with severe and life threatening diseases. Analysts should somehow make corrections for this bias in economic evaluations of healthcare programs.

Socio-demographic, psychosocial and health characteristics of Norwegian senior centre users: a cross-sectional study

AIMS

The senior centre is the only welfare service in Norwegian elder care serving both fit and less functional pensioners over 65 years. The aim of the study was to determine the socio-demographic, psychosocial and health characteristics of users of the senior centres in relation to non-users in order to find out who can benefit from the senior centre service.

METHODS

Data was collected from the Population Register for all persons living at home over 65 years in two municipal districts in Oslo. A random sample was drawn limited to 4,000 of the total number of residents over 65 years, 2,000 from each district. Questionnaires were sent by post. The response rate was 64% (n = 2,387). Psychological ailments were assessed using Hopkins Symptom Checklist-10 and social support with Oslo-3 Social Support Scale.

RESULTS

The percentage of users was 44 among the survey respondents. Age was the most significant variable explaining use of the senior centre; increased age led to greater use. Single women used the senior centre more than married women while single men used it less than married men. Other predictors for women included osteoporosis, memory impairment and participation/interest from others. Memory impairment was a predictor for men.

CONCLUSIONS

High age and specific health problems led to increased use. Living alone predicted greater use among women but less use among men. The association with age could not be explained through socio-demographic, psychosocial or health variables.

QALYs: is the value of treatment proportional to the size of the health gain?

In societal priority setting between health programs for different patient groups, many people are reluctant to discriminate too strongly between those who can benefit much from treatment and those who can benefit moderately. We suggest that this view of distributive fairness has a counterpart in personal valuations of gains in health. Such valuations may be influenced by psychological reference points and diminishing marginal utility such that the individual utility of care in patient groups with different potentials may be more similar than what conventional QALY estimates suggest. In interviews in three convenience samples, there is some support for the hypothesis. Most respondents do not think that desire for treatment is significantly less in those who stand to gain only moderately compared with those who stand to gain much - even when the treatment is associated with a mortality risk. When stating insurance preferences, a majority of subjects express a greater concern for avoiding the worst states in question than for maximising expected value for money in terms of treatment effects. The tendency applies to outcomes in terms of both quality and quantity of life. Choices between prefixed response options fit well with oral explanations of these choices.

[Economic evaluation of a course in coping with depression]

BACKGROUND

A course in coping with depression was reported to have documented effects in terms of shortening periods of depression. An economic evaluation of the course was conducted.

MATERIALS AND METHODS

The estimate of medical effect derives from a randomized controlled trial in 155 subjects with depression. On average subjects in the intervention group improved 3-4 points more on the Beck Depression Inventory than subjects in the control group. A value estimate is provided for this effect given what is known about the weight that society places on severity of illness and effect of treatment when prioritising among patient groups. The value estimate is compared with the costs of the course.

RESULTS AND INTERPRETATION

It is estimated that if 200 people take the course, the improvements in quality of life for all these people taken together may be regarded as equally valuable and worthy of priority as an intervention that provides an extra life year to one person. The cost of giving the course to 200 people is estimated at USD 45,000-60,000. This is within the limits of what society is generally willing to pay in order to gain life years. Because of possible reductions in sick leave, societal net costs may be modest.

Multi-method approach to valuing health states: problems with meaning

In an earlier article in Health Economics, Salomon and Murray argue that by applying maximum likelihood techniques to predetermined functional forms and to a data set where a number of health states are valued by means of four standard valuation techniques, underlying 'pure' valuations of health may be teased out, together with estimates of parametric relationships between these 'pure' valuations and valuations based on the four standard techniques. We argue below that 'pure' valuations of health are ordinal rather than cardinal and that the 'pure' values that result from the multi-method approach give a false impression of being cardinal. They are therefore not usable as weights for life years. In the unlikely event that the authors should be able to demonstrate cardinality in 'pure' valuations of health, it must be possible to have subjects express these valuations directly, in which case there seems to be no need for the indirect multi-method approach.

Towards cost-value analysis in health care?

By describing societal value judgements in health care in numerical terms one may in theory increase the precision of guidelines for priority setting and allow decision makers to judge more accurately the degree to which different health care programs provide societal value for money. However, valuing health programs in terms of QALYs disregards salient societal concerns for fairness in resource allocation. A different kind of numerical valuation of medical interventions, that incorporates concerns for fairness, is described. The usefulness to decision makers of such numerical information remains to be tested.

Concerns for the worse off: fair innings versus severity

The original fair innings argument is about claims on length of life. Alan Williams has suggested that the argument also should apply to quality of life. His 'generalised fair innings approach' on the one hand, and the severity approach on the other, are two ways of incorporating concerns for fairness in economic evaluation of health care. They are based on different ethical arguments and therefore partly lead to different results. Both approaches incorporate concerns for current and future severity. There is strong support for this in formal theories of justice and government guidelines, and a number of public surveys even indicate the strength of these concerns. The generalised fair innings approach additionally incorporates concerns for past suffering. Intuitively, this is not unreasonable, but there is at this point little ethical theory or empirical evidence to suggest the strength of such concerns. The fair innings argument can be decomposed in an 'equal innings argument' and a 'sufficient innings argument'. When the fair innings argument is applied to quality of life, its sufficient innings component implies that young people should have priority over old people when it comes to functional improvements and symptom relief for non-fatal conditions. This runs counter to both moral intuitions and official goverment guidelines in Norway and Sweden.

Lack of multiplicative transitivity in person trade-off responses

BACKGROUND

The person trade-off (PTO) is a technique for eliciting preferences for resource allocation across patient groups. In principle PTO responses should satisfy a requirement of multiplicative transitivity, i.e. that if people consider treatment of 1 in state A to be equivalent to treating 10 in state B, and 1 in state B to be equivalent to 10 in state C, then they should find 1 in state A equivalent to 100 in state C. Earlier studies addressing labelled diseases (specific diagnoses), have shown multiplicative intransitivity of the PTO responses. Our purpose was to test multiplicative transitivity in the case of health states described with the EuroQol instrument only and to find a possible framing effect such as the number of persons in the reference intervention.

METHODS

Forty-four master degree students were asked to fill in a questionnaire addressing four chronic health states. Their task consisted in (1). ranking the states by severity, (2). valuing each of them by the means of the time trade-off, and (3). doing the PTO for all the 10 possible pairwise combinations of the four chronic states plus a fatal one. In a subsequent questionnaire the number of persons in the reference intervention in the PTO was increased from 10 to 100. Multiplicative transitivity was studied in subjects who demonstrated a willingness to trade off and consistency in ranking individual values.

RESULTS

None of the 39 subjects included satisfied a minimum multiplicative transitivity requirement in PTO responses. Internal consistency was not improved when the PTO involved health states close to each other in terms of severity, nor when the prevention of death was not the reference intervention. For the 22 subjects having answered both types of questionnaire, increasing the number of persons in the reference intervention did not improve multiplicative transitivity.

CONCLUSIONS

The PTO holds promise as a useful method for determining social preferences for priority setting, inasmuch as it captures distributive concerns that individual utility techniques such as the time trade-off do not address. But the lack of multiplicative transitivity in PTO responses is unsatisfactory, and ways to reduce this problem need to be explored.

Cross-national agreement on disability weights: the European Disability Weights Project

Background

Disability weights represent the relative severity of disease stages to be incorporated in summary measures of population health. The level of agreement on disability weights in Western European countries was investigated with different valuation methods.

Methods

Disability weights for fifteen disease stages were elicited empirically in panels of health care professionals or non-health care professionals with an academic background following a strictly standardised procedure. Three valuation methods were used: a visual analogue scale (VAS); the time trade-off technique (TTO); and the person trade-off technique (PTO). Agreement among England, France, the Netherlands, Spain, and Sweden on the three disability weight sets was analysed by means of an intraclass correlation coefficient (ICC) in the framework of generalisability theory. Agreement among the two types of panels was similarly assessed.

Results

A total of 232 participants were included. Similar rankings of disease stages across countries were found with all valuation methods. The ICC of country agreement on disability weights ranged from 0.56 [95% CI, 0.52–0.62] with PTO to 0.72 [0.70–0.74] with VAS and 0.72 [0.69–0.75] with TTO. The ICC of agreement between health care professionals and non-health care professionals ranged from 0.64 [0.58–0.68] with PTO to 0.73 [0.71–0.75] with VAS and 0.74 [0.72–0.77] with TTO.

Conclusions

Overall, the study supports a reasonably high level of agreement on disability weights in Western European countries with VAS and TTO methods, which focus on individual preferences, but a lower level of agreement with the PTO method, which focuses more on societal values in resource allocation.

The value of life: individual preferences and social choice. A comment to Magnus Johannesson

In order to avoid undue discrimination of disabled people, we have suggested that all life years gained by the disabled should count as 1 in QALY calculations as long as the health states in question are preferred to being dead by those concerned. Johannesson noted that such a convention could lead to inconsistencies between societal and individual preferences. We believe the problem derives from the structure of preferences in the real world, rather than from our specific choice of model. The inconsistency is at any rate a much smaller practical problem than Johannesson suggests. Johannesson's alternative model has some virtues, but it does not resolve the inconsistency problem. It also leads to counter intuitive results.

Evidence-based medicine: excessive attraction to efficiency and certainty?

Advocates of EBM deserve much credit for their efforts to increase the use of scientific evidence and economic evaluation in medical decision making. But EBM advocates' rigid requirements of certainty in the estimation of intervention effects may run counter to society's interest in maximising the expected benefits from resource use in health care. Also, their dedication to efficiency may lead some to overlook societal concerns for fairness in resource allocation.

Insulin lispro therapy in pregnancies complicated by type 1 diabetes mellitus

OBJECTIVE

To compare the efficacy and safety of preprandial administration of rapid-acting lispro analogue with regular short-acting insulin to pregnant women with type 1 diabetes.

STUDY DESIGN

Open randomised multicentre study. Women were treated with multiple insulin injections aiming at normoglycaemia. Blood glucose was determined six times daily, HbA(1c) every 4 weeks. Diurnal profiles of blood glucose were analysed at gestational week 14 and during the study period at weeks 21, 28 and 34.

PARTICIPANTS

33 pregnant women with type 1 DM were randomised to treatment with lispro insulin (n=16) or regular insulin (n=17).

RESULTS

Blood glucose was significantly lower (P<0.01) after breakfast in the lispro group, while there were no significant group differences in glycemic control during the rest of the day. Severe hypoglycaemia occurred in two patients in the regular group but biochemical hypoglycaemia (blood glucose <3.0 mmol/l) was more frequent in the lispro than in the regular group (5.5 vs. 3.9%, respectively). HbA(1c) values at inclusion were 6.5 and 6.6% in the lispro and regular group respectively. HbA(1c) values declined during the study period and were similar in both groups. There was no perinatal mortality. Complications during pregnancy, route of delivery and foetal outcome did not differ between the groups. Retinopathy progressed in both groups, one patient in the regular group developed proliferative retinopathy.

CONCLUSION

The results suggest that it is possible to achieve at least as adequate glycemic control with lispro as with regular insulin therapy in type 1 diabetic pregnancies.

Measures of goal attainment and performance in the World Health Report 2000: a brief, critical consumer guide

The World Health Report 2000 presents a set of indicators and global indices by which different countries' goal attainment and performance in health care may be compared. The paper explains the methods employed in some detail and raises a number of critical points. The WHO has gone too far in compressing the results of potentially useful primary measurements in summary indices with unclear meaning, dubious validity and little practical relevance to decision makers facing specific tasks and problems. The WHO has also gone too far in applying the same measuring rods to countries with different histories and values and different stages of development, and in encouraging international comparisons that are of little use to policy makers. The WHO needs to add an indicator of equality in access to its present indicator of fairness in financing.

The desirability of a condition versus the well being and worth of a person

The desirability of a condition to people who are not in it themselves is only moderately correlated to the experienced well being of people with the condition and hardly correlated at all to the worth of those people. A single score for a health state, of the kind used in QALY calculations, cannot express all these three types of value. The history and current practice of health economics is highly problematic in this respect.

Health state values from multiattribute utility instruments need correction

Cost-utility analysis uses the quality-adjusted life year (QALY) as a measure of the benefit of health interventions. It presupposes the assignment of utility scores to different states of health on a scale from zero (dead) to unity (healthy). A number of so-called multiattribute utility (MAU) instruments are available for this purpose. Analysts who wish to use MAU instruments in economic evaluations of health programmes and technologies may improve their performance by conducting two different analyses: the first is a conventional cost-utility study, in which the utilities from MAU instruments are used as they stand, and the second is a study in which the utilities are transformed into numbers that also encapsulate concerns for giving priority to the worst off. The term 'cost-value analysis' is used for the latter, broader approach. A figure is offered as a preliminary tool to help conduct the required transformations.

Cost-utility analysis of high-dose melphalan with autologous blood stem cell support vs. melphalan plus prednisone in patients younger than 60 years with multiple myeloma

We evaluated the costs and the cost utility of high-dose melphalan and autologous stem cell support followed by interferon maintenance relative to conventional treatment with melphalan and prednisone, in patients less than 60 yr of age with multiple myeloma. From March 1994 to July 1997, 274 patients with newly diagnosed, symptomatic multiple myeloma were enrolled in a prospective, non-randomized, population-based, multicenter study to evaluate the treatment with high-dose melphalan and autologous blood stem cell support. Health-related quality-of-life was measured prior to treatment and during follow-up, using the EORTC QLQ-C30 questionnaire. Resource consumption was also recorded prospectively. The intensive treatment yielded a significant increase in median survival time from 44 to 62 months compared to conventionally treated patients. The corresponding gain in quality-adjusted life years (QALY) was found to be 1.2. Cost per QALY gained by the treatment with high-dose melphalan and autologous blood stem cell support was estimated at NOK 249,000 (USD 27,000).