Abstract: In order to allocate health care resources more efficiently, it is necessary to relate health improvements provided by new medicines to their cost. It is necessary to ascertain when the additional cost of introducing a new health technology is justified by the additional health gain produced. Eplerenone is a new medicine that reduces the risk of death after myocardial infarction (MI) but produces additional cost to the health system. The contingent valuation approach can be used to measure the monetary value of this risk reduction and to estimate society's willingness to pay (WTP) for a new medicine that reduces the risk of death after MI by 2% points. We used a contingent valuation approach to evaluate WTP amongst members of the general population. We used the ex-ante and the ex-post approach. In the ex-ante approach, subjects are asked if they would accept an increase in their taxes in order to have access to eplerenone should they need it in the future. In the ex-post approach, subjects are asked if they would pay a certain amount of money as co-payment per month during 5 years if they suffered an MI. We used the dichotomous choice method, using five bids in each approach. The WTP was estimated using both single-bound and double-bound dichotomous choice (SBDC, DBDC). Extensive piloting (n = 187) preceded the final survey (n = 350). The WTP in the ex-ante case was <euro>58 per year under both SBDC and DBDC. In the ex-post case, monthly WTP was <euro>141 for the SBDC and <euro>85 for the DBDC. Subjects with higher income and subjects with a higher perception of risk showed a higher WTP (P < 0.05). Society is willing to pay an additional amount of money in order to give eplerenone to present and future patients. We estimate that <euro>85 per month is a conservative estimate of the monetary value of a 2% risk reduction in mortality after MI and to spend this additional amount of money in Eplerenone can be considered an efficient policy.
Abstract: OBJECTIVES: To estimate and compare citizen preferences regarding patient prioritization for cataract surgery. METHOD: A conjoint analysis was performed. Priority criteria were identified and selected using 4 focus/nominal groups consisting of the general public, patients/relatives, allied health-professionals and specialists from Catalonia (n=36). Preferences elicitation (score of criteria): representative sample survey of the above mentioned groups (n=771) and rank-ordered logit model application. Differences were assessed by group analysis and their comparison. RESULTS: The criteria selected and their relative importance were: visual impairment (45%), difficulty in performing activities of daily living (ADL) (15%), limitation of ability to work (14%), being looked after by someone (11%), being a caregiver (8%), and recovery probability (7%). Differences in scores were observed among groups. Visual impairment was scored more highly by the general public and patients/relatives than by other groups (p<0.001). These two groups also assigned less importance to difficulty in performing ADL (p<0.001). The probability of recovery was the least scored criterion by most groups. Correlations among the order of hypothetical patient scenarios were high (r>0.9). However, the final order of patients on the waiting list could differ by up to 27 positions when different group scores were applied. CONCLUSIONS: Social and clinical criteria were considered important. The observed differences among citizens regarding how to prioritize patients on the waiting lists indicates the need to take into account the preferences of all groups of citizens.
Abstract: This paper presents a test of the predictive validity of various classes of QALY models (i.e. linear, power and exponential models). We first estimated TTO utilities for 43 EQ-5D chronic health states and next these states were embedded in nonchronic health profiles. The chronic TTO utilities were then used to predict the responses to TTO questions with nonchronic health profiles. We find that the power QALY model clearly outperforms linear and exponential QALY models. Optimal power coefficient is 0.65. Our results suggest that TTO-based QALY calculations may be biased. This bias can be corrected using a power QALY model.
Abstract: We report the results from two surveys designed to explore whether an application of Harsanyi's principle of choice form behind a veil of ignorance (VEI) can be used in order to measure the health of populations. This approach was tentatively recommended by Murray et al. (Bull. World Health Organ 2000; 78: 981-994; Summary Measures of population health: Concepts, Ethics, Measurement and Applications, WHO, 2002.) as an appropriate way of constructing summary measures of population health (SMPH) for comparative purposes. The operationalization of the VEI approach used in this paper was suggested by Nord (Summary Measures of Population Health: Concepts, Ethics, Measurement and Applications, WHO, 2002.). We test if VEI and person trade-off (PTO) methods generate similar quality-of-life weights. In addition, we compare VEI and PTO weights with individual utilities estimated by means of the conventional standard gamble (SG) and a variation of it we call double gamble. Finally, psychometric properties like feasibility, reliability, and consistency are examined. Our main findings are next: (1) VEI and PTO approaches generate very different weights; (2) it seems that differences between PTO and VEI are not due to the 'rule of rescue'; (3) the VEI resembled more a DG than a classical SG; (4) PTO, VEI, and DG exhibited good feasibility, reliability and consistency.
Abstract: In the management of waiting lists, point systems could be a useful mechanism to establish priorities amongst patients. In this paper we explore the possibility of using Conjoint Analysis (CA) in order to implement a point system based on social preferences. We conducted an experiment for the specific case of cataract extraction. In spite of the pilot nature of the study the results seems to suggest that CA is a feasible method in order to estimate a point system.
Abstract: This paper tests the internal consistency of time trade-off utilities. We find significant violations of consistency in the direction predicted by loss aversion. The violations disappear for higher gauge durations. We show that loss aversion can also explain that for short gauge durations time trade-off utilities exceed standard gamble utilities. Our results suggest that time trade-off measurements that use relatively short gauge durations, like the widely used EuroQol algorithm, are affected by loss aversion and lead to utilities that are too high.
Abstract: In cost-utility analysis it is assumed that health state valuations are directly comparable across individuals. Instead, health state valuations may be relative and related to people's expectations and abilities. Then health state valuations are not fully comparable across people and, consequently, cost utility analysis cannot be applied in full. The present paper analyzes this comparability problem and proposes a method to solve it.
Abstract: In this paper we address the importance of distributive preferences in the social valuation of quality-adjusted life years (QALYs). We propose a social welfare function that generalises the functions traditionally used in the health economic literature. The novelty is that, depending on the individual health gains, this function can represent either preferences for concentrating or preferences for spreading total gain or both together, an issue which has not been addressed until now. Based on an experiment, we observe that this generalisation provides a suitable approximation to the sampled social preferences.
Abstract: INTRODUCTION: Despite the growing recognition of the potential applications of cost-effectiveness assessments, a criterion to establish what is an efficient health technology does not exist in Spain. The objective of this work is to describe the limits and the criteria used in Spain to recommend the adoption of health interventions. METHOD: A review of the economic evaluations of health technologies published in Spain from 1990 to 2001 was conducted. Complete economic assessments in which the cost-effectiveness ratio was expressed as cost per life-year gained (LYG), cost per quality-adjusted-life-year (QALY) or cost per saved live were selected. Those interventions in which the authors established recommendations (adoption or rejection) and the criteria used were analyzed. RESULTS: Twenty (20%) of the 100 complete economic evaluations fulfilled the selection criteria. In16 studies, the results were expressed as cost per LYG, in 6 studies as cost per QALY and in 1 as cost per saved live. A total of 82 health interventions were assessed and some kind of recommendation was established in 44 of them. All technologies with a cost-effectiveness ratio lower than 30,000 euros (5 million pesetas) per LYG were recommended for adoption by the authors. Up to that limit there was no a clear tendency. CONCLUSIONS: Although the results must be interpreted with much precaution, given the limitations of the study, the limits of cost-effectiveness presented in this work could be a first reference to which would be an efficient health intervention in Spain.
Abstract: The general issues of equity and efficiency are central to the analysis of resource allocation problems in health care. We examine them using axiomatic bargaining theory. We study different solutions that have been proposed and relate them to previous literature on health care allocation. In particular, we focus on the solutions based on axiomatic bargaining with claims, and show that they are appealing as distributive criteria in health policy. Finally, we present the results of a survey that tries to elicit moral intuitions of people about resource allocation problems and their different solutions.
Abstract: In cost-effectiveness analysis (CEA) it is usually assumed that a quality-adjusted life-year (QALY) is of equal value to everybody, irrespective of the patient's age. However, it is possible that society assigns different social values to a QALY, according to who gets it. In this paper, we discuss the possibility of weighting health benefits for age in CEA. We also examine the possibility that age-related preferences depend on the size of the health gain. An experiment was performed to test these hypotheses. The assessment of results suggests that the patient's age is a relevant factor when assessing health gains.
Abstract: In this paper the issue of discrimination between patients based on the health improvement that each can achieve is addressed. Previous research in this area by Nord has shown that, in this context, society's preferences may be quite opposite to the principle of health maximization present in cost utility analysis. Using a different experimental design from that used by Nord, some results are achieved which suggest that social preferences may be somewhere in between two opposite extremes, which are that discrimination based on the degree of health improvement is never acceptable and that discrimination based on the degree of health improvement is always acceptable.
Abstract: The purpose of this study was to test the existence of the plateau effect at the social level. The authors tried to confirm the preliminary conclusion that people may not be willing to trade off any longevity to improve the health state of a large number of people if the health states are mild enough. They tested this assumption using the person-tradeoff technique. They also used a parametric approach and a nonparametric approach to study the relationship between individual and social values. Results show the existence of the plateau effect in the context of resource allocation. Furthermore, with the nonparametric approach, a plateau effect in the middle part of the scale was also observed, suggesting that social preference may not be directly predicted from individual utilities. The authors caution against the possible framing effects that may be present in these kinds of questions.
Abstract: The Person Trade-Off (PTO) is a methodology aimed at measuring the social value of health states. It is claimed that other methods measure individual utility and are less appropriate for taking resource allocation decisions. However, few studies have been conducted to test the apparent superiority of the method for this particular kind of decision. We present a pilot study to this end. The study is based on the results of interviewing 30 undergraduate students in economics. We compare two well known techniques, the Standard Gamble and the Visual Analogue Scale, with the PTO. The criterion against which the performance of the methods is assessed is the directly obtained preference about how to establish priorities among hypothetical patients waiting for treatment. Apparently the PTO performed better than the others. We also compare three different frames for the PTO. One of them seems to predict people's preferences.
