I recently read an article with the tag-line;”With every case being so different, economics should not dominate intervention policy for premature babies’ survival”. Naturally I thought “this can’t be true” and felt the need to analyse this further.
The article discusses a BBC programme, which I unfortunately missed, about babies born 23 weeks premature. To quote the article: “an NHS commissioner, Dr Daphne Austin, argued that keeping babies alive at 23 weeks does more harm than good and that the money, £10m a year for about 350 babies, would be better spent elsewhere.” Time to look at the numbers.
According to these figures, each 23 week premature baby costs just over £28,500 to keep alive. The article refers to a study that finds that 11% of these babies survive, half of which are free of significant disability. The cost per surviving baby is therefore just under £260,000. Now, let’s add some EQ-5D scores. Let’s say that the half with serious disability have an EQ-5D score of just 0.2, and those without have an EQ-5D score of 0.5. Let’s say they all survive for 20 years. Saving the babies therefore represents an expected QALY gain of 7 QALYs. That gives us a cost-per-QALY of just over £37,000; not so inefficient. I don’t know the clinical literature in this field, but I would suspect that these children live for an average of over 20 years, and that they possibly have a better quality of life than assumed here.
So, if these children live for an average of 40 years we are looking at a cost-per-QALY of just over £18,000; a bargain. Non-economists tend to confuse our field with accountancy and book-balancing. I hope that this brief analysis will help show how we really should be allowing economics to dominate intervention policy for premature babies! I only hope that this area will see more economic analysis in the future.
Please share your views and knowledge on this area in the comment box below.
It is a pity that people who believe themselves as scientists do not try to think about the consequences of what they say in terms of democracy. Ethics is not only about an agency who monitor your surveys, it is also about us being responsible.
I feel like you are not doing a great job as a defender of health economics if at the same time you tend to harm democracy. I actually think that economics as a whole does not have a good image among citizens, I find the conclusions of your comments arrogant and they do not help economics to be well perceived. A bit of modesty would be welcomed among economists.
Thank you for letting me express my views on this blog.
You’re welcome! I’m pleased for you to express your views on here.
Firstly, I don’t think the free expression of my ideas is a harm to democracy, but a clear exercise in it! Secondly, please don’t see anything I post on here as a ‘conclusion’. I will not be coming to any ‘conclusions’ as I will not be carrying out thorough enough analyses to justify this. I am not on a health economics PR mission, nor am I waging war on democracy. Please just see my blog posts as thinking aloud!
Economics certainly doesn’t have a great reputation in the wider community. Not suprising the given the multitude of assumptions that get made. Also I suspect that people dislike the way in which economics prioritises wealth/money/resources in analyses and neglects many of the finer more subjective aspects of policy.
I think health economics is different from mainstream economics for two reasons. One, health economics does not assume that money or wealth is the measure of individual welfare (even though willingness-to-pay thresholds might imply this). Second, willingness-to-pay thresholds (should) reflect a real budget constraint – There is a real budget constraint that governments face, so prioritising health care expenditure can result in the achievement of greater health in society. It can be ugly to see a monetary value decide someones fate – but that money is an instrument which must be used to its best advantage and does not suggest that a life is worth X amount.
Ultimately it is a very imperfect science (it is more like a social science than a physical science), and should be used as a factor in decision making – not the decision rule. Unfortuntately it is an easy crutch to lean on when justifying decisions.
Jusy my opinion anyway.
I am sorry to come back to my previous comments on one of your previous post (http://aheblog.com/2011/03/11/falling-on-deaf-ears-the-governments-disregard-for-empirical-evidence/) but here again are some undemocratic conclusions of an economic analysis. If I may highlight what you wrote “we really should be allowing economics to dominate intervention policy”; dominating? is that the democratic world you talked about in the comments of the previous post (link above) which is led by science? it is about science (and here economics) dominating intervention policy. I do not wish to be led by politicians as they are nowadays, (I do not think politician should be a job, anyway) but I do not wish to be dominated by economics. The political debate if dominate by science is hijacked by experts, that is not what I call democracy.
Cheers,
I’m afraid you’ll be coming back to this point repeatedly, as I have no intention of defending democracy on this blog. I do intend to defend health economics.
I expect that the majority of the costs here are accrued early on – therefore not discounted much. But the QALYs will face substantial discounting – ie. 40 years when discounted at 5% is equal to about 18 years.
Plus should also factor in future health care costs for the 50% that have serious disability.
ICER going up….
I wonder if there is some sort of societal preference multiplier that would be appropriate here – one would (intuitively) expect the ICER threshold for an infant to be higher than someone much older. Perhaps the multiplier could be related to potential vs observed productivity (ie. what we imagine the infant is capable of may exceed what we know an older person can or has done). Lots of value judgements I know, but trying to make these explicit (regardless of how uncomfortable they make us) is important to drive policy that reflects societal preference.
A great topic to tease out all these value judgements.
Without getting in to a debate about valuing QALYs for children, I believe you’re right. I think your comment further supports the idea that economic evaluation would be a good way to come up with a decision rule about the earliest a premature baby should be kept alive. Even if it will be contested for all eternity, surely a contested economics-based rule is better than a contested arbitrary one!?