Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.
Individualised and personalised QALYs in exceptional treatment decisions. Journal of Medical Ethics [PubMed] Published 22nd July 2016
I’ve written previously about the notion of individualised cost-effectiveness analysis – or iCEA. With the rise of personalised medicine it will become an increasingly important idea. But it’s one that needs more consideration and research. So I was very pleased to see this essay in JME. The starting point for the author’s argument is that – in some cases – people will be denied treatment that would be cost-effective for them, because it has not been judged to be cost-effective for the target population on average. The author’s focus is upon people at the extremes of the distribution in terms of treatment effectiveness or costs: exceptional cases. There are two features to the argument. First, cost-effectiveness should be individualised in the sense that we should be providing treatment according to the costs and effects for that individual. Second, QALYs should be ‘personalised’ in the sense that individual’s own (health) preferences should be used to determine whether or not treatment is cost-effective. The author argues that ‘individual funding requests’ (where patients apply for eligibility for treatment that is not normally approved) represent an ideal context in which to use individualised and personalised QALYs. Unfortunately there are a lot of problems with the arguments presented in this essay, both in terms of their formulation and their practical implications. Some of the ideas are a bit dangerous. That there is no discussion of uncertainty or expectations is telling. If I can find the time I’ll write a full response to the journal. Nevertheless, it’s good to see discussion around this issue.
The value of medicines: a crucial but vague concept. PharmacoEconomics [PubMed] Published 21st July 2016
That we can’t define value is perhaps why the practice of value-based pricing has floundered in the UK. Yes, there’s cost-per-QALY, but none of us really think that’s the end of the value story. This article reports on a systematic review to try and identify how value has been defined in a number of European countries. Apparently none of the identified articles in the published literature included an explicit definition of value. This may not come as a surprise – value is in the eye of the beholder, and analysts defer to decision makers. Some vague definitions were found in the grey literature. The paper highlights a number of studies that demonstrate the ways in which different stakeholders might define value. In the countries that consider costs in reimbursement decisions, QALYs were (unsurprisingly) the most common way of measuring “the value of healthcare products”. But the authors note that most also take into account wider societal benefits and broader aspects of value. The review also identifies safety as being important. The authors seem to long for a universal definition of value, but acknowledge that it cannot be a fixed target. Value is heavily dependent on the context of a decision, so it makes sense to me that there should be inconsistencies. We just need to make sure we know what these inconsistencies are, and that we feel they are just.
The value of mortality risk reductions. Pure altruism – a confounder? Journal of Health Economics Published 19th July 2016
Only the most belligerent of old-school economists would argue that all human choices can be accounted for in purely selfish terms. There’s been much economic research into altruistic preferences. Pure altruism is the idea that people might be concerned with the general welfare of others, rather than just specific factors. In the context of tax-funded initiatives it can be either positive or negative, as people could either be willing to pay more for benefits to other people or less due to a reluctance to enforce higher costs (say nothing of sadism). This study reports on a discrete choice experiment regarding mortality reductions through traffic safety. Pure altruism is tested by the randomised inclusion of a statement about the amount paid by other people. An additional question about what the individual thinks the average citizen would choose is used to identify the importance of pure altruism (if it exists). The findings are both heartening and disappointing. People are considerate of other people’s preferences, but unfortunately they think that other people don’t value mortality reductions as highly as them. Therefore, individuals reduce their own willingness to pay, resulting in negative altruism. Furthermore, the analysis suggests that this is due to (negative) pure altruism because the stated values increase when the notion of coercive taxation is removed.
Realism and resources: towards more explanatory economic evaluation. Evaluation Published July 2016
This paper was doing the rounds on Twitter, having piqued people’s interest with an apparently alternative approach to economic evaluation. Realist evaluation – we are told – is expressed primarily as a means of answering the question ‘what works for whom, under what circumstances and why?’ Economic evaluation, on the other hand, might be characterised as ‘does this work for these people under these circumstances?’ We’re not really bothered why. Realist evaluation is concerned with the theory underlying the effectiveness of an intervention – it is seen as necessary to identify the cause of the benefit. This paper argues for more use of realist evaluation approaches in economic evaluation, providing an overview of the two approaches. The authors present an example of shared care and review literature relating to cost-effectiveness-specific ‘programme theories’: the mechanisms affecting resource use. The findings are vague and inconclusive, and for me this is a problem – I’m not sure what we’ve learned. I am somewhat on the fence. I agree with the people who think we need more data to help us identify causality and support theories. I agree with the people who say we need to better recognise context and complexity. But alternative approaches to economic evaluation like PBMA could handle this better without any express use of ‘realist evaluation’. And I agree that we could learn a lot from more qualitative analysis. I agree with most of what this article’s authors’ say. But I still don’t see how realist evaluation helps us get there any more than us just doing economic evaluation better. If understanding the causal pathways is relevant to decision-making (i.e., understanding it could change decisions in certain contexts) then we ought to be considering it in economic evaluation. If it isn’t then why would we bother? This article demonstrates that it is possible to carry out realist evaluation to support cost-effectiveness analysis, but it isn’t clear why we should. But then, that might just be because I don’t understand realist evaluation.
Photo credit: Antony Theobald (CC BY-NC-ND 2.0)