Using Stated Preferences to Guide Health Care Resource Allocation Decisions
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The document discusses the role of economic evaluation in healthcare resource allocation, particularly focusing on the use of Quality-Adjusted Life Years (QALYs) to measure health benefits. It highlights how QALYs influence cost-effectiveness decisions regarding treatment reimbursements while addressing the complexities of prioritizing healthcare resources based on societal values and preferences. Additionally, it presents empirical studies reflecting public opinions on end-of-life treatments and the associated premium values which vary across different contexts.
Using Stated Preferences to Guide Health Care Resource Allocation Decisions
- 1. Using Stated Preferences to Guide Health Care Resource Allocation Decisions Koonal Shah UK Departmentof Health, NHS Group ‘Speakeasy’ Series London • 10 October 2014
- 2. Presentation to the DH 10/10/14 2 • Economic evaluation is used to: • Estimate the efficiency of health care technologies • Inform decisions about whether those technologies should be reimbursed • Common approach is to measure the health benefits of a given intervention in terms of quality-adjusted life years (QALYs) • Cost-effectiveness expressed in terms of 'cost-per-QALY' • Decisions about reimbursement can be made by comparing cost-effectiveness of a technology to the cost-effectiveness of other technologies, or to some threshold that represents displaced activities Introduction
- 3. Presentation to the DH 10/10/14 3 How the QALY works Quality of life 1 0 Life expectancy Life extension
- 4. Presentation to the DH 10/10/14 4 How the QALY works (2) Quality of life 1 0 Life expectancy Quality of life improvement
- 5. Presentation to the DH 10/10/14 5 QALY = life expectancy (yrs) * quality of life weight QALY gain = QALYs with treatment –QALYs without treatment In order to calculate QALYs, it is necessary to represent health-related quality of life on a scale where death and full health are assigned values of 0 and 1, respectively How the QALY works (3)
- 6. Presentation to the DH 10/10/14 6 Making decisions based on cost- per-QALY information +ΔQALYs +Δcost -ΔQALYs -Δcost Intervention less effectiveand more costly Intervention more effectiveand less costly x x x
- 7. Presentation to the DH 10/10/14 7 Cost per QALY gained Health care service Cumulative budget £1 Service 1 £50,000 £1.50 Service 2 £80,000 £20,000 £100 billion £30,000 £800,000 Service 32,000 £800,000 billion Cost-per- QALY of service ‘at the margin’ = NICE threshold In the absence of evidence, NICE’s threshold is simply its ‘best guess’ about what this ‘shadow price’ is Stylised model of the cost- effectiveness threshold
- 8. Presentation to the DH 10/10/14 8 Illustrative cost-effectiveness plane (pilot data) Source: Devlin N, Appleby J (2010) Getting the most out of PROMs: putting health outcomes at the heart of the NHS. London: King’s Fund/OHE.
- 9. Presentation to the DH 10/10/14 9 The Price of life • BBC documentary about health economics and NHS rationing, with particular focus on NICE’s evaluation of end-of-life drugs • Broadcast in 2009 http://www.adamwishart.info/2009/06/the-price-of-life- bbc-documentary.html
- 10. Presentation to the DH 10/10/14 10 Are all QALYs of equal value? • If it is assumed that the objective of health care is to maximise population health using available resources and that the QALY is an acceptable measure of health benefit, it follows that health care resources should be prioritised so as to maximise the total number of QALYs gained • However, maximising health may not be the only purpose of health care • The 'QALY is a QALY' approach can conflict with NHS objectives and with people’s considered moral convictions • NICE’s appraisal committees are expected to make judgements about what is acceptable and appropriate for society (social value judgements), which may involve treating QALYs differently depending on the recipient
- 11. Presentation to the DH 10/10/14 11 Examples of attributes across which the value of a QALY might vary • Age of patient • Socioeconomic background of patient • Degree of responsibility • Patient’s expected lifetime health • Rarity of condition • Availability of alternative treatment options • Severity of patient’s condition • Patient’s proximity to end of life
- 12. Presentation to the DH 10/10/14 12 Criteria that need to be satisfied for NICE’s supplementary end of life policy (issued in 2009) to apply are as follows: NICE’s end of life policy C2 The treatment is indicated for patients with a short life expectancy, normally less than 24 months There is sufficient evidence to indicate that the treatment offers an extension to life, normally of at least an additional three months, compared to current NHS treatment The treatment is licensed or otherwise indicated, for small patient populations C3 C1
- 13. Presentation to the DH 10/10/14 13 • If the criteria are met, NICE appraisal committees consider giving additional weight to the QALY gains achieved by these life-extending, end-of-life treatments • Placing additional weight on survival benefits in patients with short remaining life expectancy couldbe considered a valid representation of society's preferences • But the NICE consultation revealed concerns that there is little scientific evidence to support this premise NICE’s end of life policy (2)
- 14. Presentation to the DH 10/10/14 14 A role for stated preferences? • NICE’s position on social value judgements is that ‘advice from NICE to the NHS should embody values that are generally held by the population of the NHS’ • Empirical stated preference studies can provide meaningful information about societal values, as long as the methods used are scientifically defensible • Members of the public are taxpayers / potential users of the NHS • In line with NHS’s policy objective of ensuring public involvement in health care priority setting activities • Can form part of an ‘empirical ethics’ approach to allocating health care resources
- 15. Presentation to the DH 10/10/14 15 Examples of studies examining preferences regarding end of life denotes time in full quality of life denotes life extension (at full quality of life) achievable from treatment Time (years) 0 1 2 3 4 5 6 7 8 9 10 11 Patient A Patient B
- 16. Presentation to the DH 10/10/14 16
- 17. Presentation to the DH 10/10/14 17 Source: Abel Olsen (2013)
- 18. Presentation to the DH 10/10/14 18 Examples of studies examining preferences regarding end of life Source: Abel Olsen (2013)
- 19. Presentation to the DH 10/10/14 19 Examples Source: Linley & Hughes (2013)
- 20. Presentation to the DH 10/10/14 20 Summary of selected studies Study Country Sample size Method Mode of administration Findings relevant to end of life Abel Olsen (2013) NOR 503 Pairwise choice Web-based survey No evidence in support of a premium for life-extending end of life treatments Baker et al. (2011) UK 40 Ranking exercise Focus group Evidence in support of a premium for life-extending end of life treatments Linley and Hughes (2013) UK 4,118 Budget allocation Web-based survey No evidence in support of a premium for life-extending end of life treatments Pennington et al. (2013) Multiple 17,657 WTP Web-based survey Evidence in support of a premium for life-extending end of life treatments Pinto Prades et al. (2014) SPA 813 WTP, PTO CAPI Evidence in support of a premium for end of life treatments, but QOL-improving end of life treatments were valued more highly than life-extending end of life treatments Rowen et al. (2014) UK 3,669 DCE Web-based survey Evidence in support of a premium for life-extending end of life treatments, but responses to the follow-up attitudinal questions cast doubt on this finding Shah et al. (2014) UK 50 Pairwise choice Face-to-face interview Some evidence in support of a premium for end of life treatments, but QOL-improving end of life treatments were valued more highly than life-extending end of life treatments Shah et al. (2012) UK 3,969 DCE Web-based survey No evidence in support of a premium for life-extending end of life treatments Skedgel et al. (2014) CAN 656 DCE Web-based survey No evidence in support of a premium for life-extending end of life treatments
- 21. Presentation to the DH 10/10/14 21 For additional information, please contact Koonal Shah at kshah@ohe.org. To keep up with the latest news and research, subscribe to our blog, OHE News Follow us on Twitter @OHENews, LinkedInand SlideShare The Office of Health Economics is a research and consulting organisation that has been providing specialised research, analysis and expertise on a range of health care and life sciences issues and topics for more than 50 years. OHE’s publications may be downloaded free of charge by registered users of its website. Office of Health Economics Southside, 7th Floor105 Victoria StreetLondon SW1E 6QT United Kingdom +44 20 7747 8850 www.ohe.org ©2014 OHE About OHE