A welfare economic approach to measure outcomes in stuttering: Comparing willingness to pay and quality adjusted life years

Estimating a WTP-based value of a QALY: The ‘chained’ approach

Measuring utilities of severe facial disfigurement and composite tissue allotransplantation of the face in patients with severe face and neck burns from the perspectives of the general public, medical experts and patients

Quality-adjusted life years was a poor predictor of women's willingness to pay in acute and chronic conditions: results of a survey

We report the results of several contingent valuation (CV) surveys to elicit willingness-to-pay values from the general public for risk reductions associated with decreases in exposure to a chemical, PCBs, in the environment. We also develop Quality Adjusted Life Years (QALYs) from the survey using both standard gamble and time-tradeoff elicitation methods to explore the relationship between QALYs and willingness-to-pay (WTP), and to develop QALY weights for subtle developmental effects. The results of the CV surveys are designed for incorporation into a case study of an integrated risk model to monetize the benefits of predicted risk reductions. Respondents showed a nearly proportional, positive relationship between decreasing the risk of a 6-point reduction in IQ (a standard measure of “intelligence”) and WTP, but showed a negative relationship between risk reduction and WTP for reading comprehension as an outcome. The range of mortality risks that respondents would accept on behalf of their (hypothetical) 10-year-old child is 2 in 10,000 to 9 in 1,000 per IQ point, and WTP per IQ point is $466 ($380, $520). QALY weights elicited via time tradeoff (reduction in life expectancy) were significantly different from QALY weights elicited via a standard gamble (p = 0.001). Respondents who answered questions about ecological endpoints first were willing to pay a small additional amount when asked about human health effects, but those respondents who answered questions about human health endpoints first were not willing to pay any additional amount when subsequently asked about ecological effects.

BackgroundEconomic valuations of health care programs often require using patients as subjects, implying that research methodology should conform to the surrounding social, cultural and ethical context. The significance of patients' opinions in health care decisions has been well defined but in Greece, and perhaps elsewhere, clinicians remain skeptical. The purpose of this study was to investigate, for the first time in Greece, the feasibility of measuring preference-based health-state utilities and willingness to pay and to determine the context-based adaptations required to overcome inherent elicitation problems.MethodsA survey including a time trade-off (TTO), a standard gamble (SG), and two willingness-to-pay (WTP) questions was self-administered to a homogenous group of 606 end stage renal disease patients in 24 dialysis facilities throughout Greece and the overall response rate was 78.5%. Typical elicitation methods were adapted to overcome methodological problems such as subjective life expectancy and question framing. Spearman's correlation coefficients were calculated between utilities and WTP and parametric tests (independent samples t-test and ANOVA) examined score differences as a result of demographic and clinical factors.ResultsMean health-state utilities were 72.56 (TTO) and 91.06 (SG) and these were statistically significantly different (P < 0.0005). Significant correlations, in the expected directions, were observed between TTO – SG, TTO – WTP and SG – WTP (P < 0.01). High ceiling effects were observed in the TTO and SG methods indicating patients' adversity to risk and unwillingness to trade-off life years. Higher WTP was observed from younger patients (P < 0.0005), males (P < 0.05), higher education levels (P < 0.01), single (P < 0.0005) and employed (P < 0.005).ConclusionThis study demonstrated, to a fair extent, that adapting research methods to context-based particularities does not necessarily compromise results and should be considered in situations where standard methods cannot be applied. On the other hand, it is emphasized that the results from this study are preliminary and should be interpreted cautiously until further research demonstrates the practicality, reliability and validity of alternative measurement approaches.

It is well established that the underlying theoretical assumptions needed to obtain a constant proportional trade-off between a quality adjusted life year (QALY) and willingness to pay (WTP) are restrictive and often empirically violated. In this paper, we set out to investigate whether the proportionality conditions (in terms of scope insensitivity and severity independence) can be satisfied when data is restricted to include only respondents who pass certain consistency criteria. We hypothesize that the more we restrict the data, the better the compliance with the requirement of constant proportional trade-off between WTP and QALY. We revisit the Danish data from the European Value of a QALY survey eliciting individual WTP for a QALY (WTP-Q). Using a "chained approach" respondents were first asked to value a specified health state using the standard gamble (SG) or the time-trade-off (TTO) approach and subsequently asked their WTP for QALY gains of 0.05 and 0.1 (tailored according to the respondent's SG/TTO valuation). Analyzing the impact of the different exclusion criteria on the two proportionality conditions, we find strong evidence against a constant WTP-Q. Restricting our data to include only respondents who pass the most stringent consistency criteria does not impact on the performance of the proportionality conditions for WTP-Q.

Pelayanan kesehatan di Indonesia masih belum maksimal dalam memenuhi kebutuhan pasien dengan penyakit moderate. Cost utility analysis (CUA) adalah pendekatan farmakoekonomi yang direkomendasikan dalam rangka mengendalikan mutu dan biaya terhadap program kesehatan. Cost effectiveness threshold diperlukan untuk interpretasi terhadap nilai rasio efektivitas biaya dalam menentukan suatu teknologi kesehatan bersifat costeffective atau tidak. Salah satu pendekatan yang dapat dilakukan adalah dengan estimasi nilai willingness to pay per quality adjusted life years (WTP per QALY). Penelitian ini bertujuan untuk mengetahui perbandingan pengukuran nilai estimasi willingness to pay per quality adjusted life year untuk penyakit moderate pada masyarakat di Kota Banjarmasin berdasarkan pendapatan. Desain penelitian ini menggunakan pendekatan cross-sectional. Metode stated preference dengan pendekatan contingent valuation digunakan dalam survei yang dilakukan pada populasi umum di Kota Banjarmasin Jumlah sampel sebanyak 100 responden dan yang bersedia membayar adalah 64 responden. Instrumen penelitian berupa kuesioner yang terdiri dari pengukuran nilai willingness to pay (WTP) menggunakan metode dichotomous bidding game, pengukuran utility menggunakan visual analogscale (VAS) dan EuroQoL 5-Dimensions (EQ-5D) yang berdasarkan skenario hipotetik nilai utility pada penyakit moderate. Pengukuran WTP Per QALY menggunakan formula perbandingan antara WTP maksimal dan QALY gained. Hasil penelitian menunjukan dari 100 responden yang bersedia membayar sebesar 64 orang. Nilai utility gained EQ-5D adalah 0,544 dan utility gained VAS adalah 0,169. Berdasarkan pendapatan masyarakat di Kota Banjarmasin adapun perbandingan pengukuran nilai estimasi willingness to pay per quality adjusted life year adalah Rp. 23.594.155 untuk pendapatan rendah dan Rp. 79.265.583 untuk pendapatan tinggi. Temuan penelitian ini diharapkan dapat memberi masukan terhadap CE-Threshold berdasarkan preferensi masyarakat berdasarkan pendapatannya.

BackgroundLittle information is available regarding medical residents' perceptions of patients' health-related quality of life. Patients cared for by residents have been shown to receive differing patterns of care at Veterans Affairs facilities than at community or university settings. We therefore examined: 1) how resident physicians value the health of patients; 2) whether values differ if the patient is described as a veteran; and 3) whether residency-associated variables impact values.MethodsAll medicine residents in a teaching hospital were asked to watch a digital video of an actor depicting a 72-year-old patient with mild-moderate congestive heart failure. Residents were randomized to 2 groups: in one group, the patient was described as a veteran of the Korean War, and in the other, he was referred to only as a male. The respondents assessed the patient's health state using 4 measures: rating scale (RS), time tradeoff (TTO), standard gamble (SG), and willingness to pay (WTP). We also ascertained residents' demographics, risk attitudes, residency program type, post-graduate year level, current rotation, experience in a Veterans Affairs hospital, and how many days it had been since they were last on call. We performed univariate and multivariable analyses using the RS, TTO, SG and WTP as dependent variables.ResultsEighty-one residents (89.0% of eligible) participated, with 36 (44.4%) viewing the video of the veteran and 45 (55.6%) viewing the video of the non-veteran. Their mean (SD) age was 28.7 (3.1) years; 51.3% were female; and 67.5% were white. There were no differences in residents' characteristics or in RS, TTO, SG and WTP scores between the veteran and non-veteran groups. The mean RS score was 0.60 (0.14); the mean TTO score was 0.80 (0.20); the mean SG score was 0.91 (0.10); and the median (25th, 75th percentile) WTP was $10,000 ($7600, $20,000) per year. In multivariable analyses, being a resident in the categorical program was associated with assigning higher RS scores, but no residency-associated variables were associated with the TTO, SG or WTP scores.ConclusionPhysicians in training appear not to be biased either in favor of or against military veterans when judging the value of a patient's health.

OP0280 Step-Down Strategy of Spacing TNF-Blockers Injections for Established Rheumatoid Arthritis in Remission: A Cost-Utility Analysis Based on the Strass Trial

Funding Acknowledgements Type of funding sources: None. Background Nurse-led self-care interventions (NLSCI) in heart failure (HF), defined as the nurse education delivered to improve the daily patient self-management, are not widely adopted by the health-care systems, even though they are effective to improve outcomes (e.g., mortality, readmission). Moreover, few studies have evaluated whether NLSCI are also cost-effective. Purpose To determine the cost-effectiveness of NLSCI in the context of HF care compared with standard care (care delivered by general practitioner and/or cardiologist). Methods We performed a cost-effectiveness analysis, with a 20-year time horizon, from the perspective of the Italian National Health Service. We developed a Markov model to simulate the progression of a cohort of 1,000 HF patients aged 70 years, who were assumed to alternatively receive a NLSCI after hospital discharge, or usual care. Effectiveness on mortality and on hospitalizations of NLSCI and usual care were extrapolated from a review of randomized control trials. Health-care costs were derived from literature and national formularies. The differences in costs and the differences in Quality Adjusted Life Years (QALY) between the NLSCI and usual care were estimated to present an incremental cost-effectiveness ratio (ICER). A willingness to pay (WTP) threshold of €40,000 per QALY was considered. Probabilistic sensitivity analyses were conducted to test the robustness of results and to estimate a cost-effectiveness acceptability curve. Results Over the 20-year time horizon, NLSCI implied an extra cost of € 1.3 million and a gain of 247 QALYs compared to usual care. This resulted in an ICER of € 5,490/QALY, which is far below the €40,000/QALY WTP threshold. Sensitivity analysis showed that the ICER remains below the WTP threshold in 100% of simulations. Moreover, the cost-effectiveness acceptability curve showed a probability of 80% of being under € 7,500/QALY. Conclusions This study demonstrated that NLSCI represent an affordable solution to support patients with HF as the related extra costs of € 1.3 million is justified by the reduction in mortality and improvement in quality of life. This finding supports the promotion of NLSCI as part of routine care, in order to pursue an optimal allocation of public health expenditures.

ABSTRACTObjectives: Published estimates of willingness to pay (WTP) for quality adjusted life years (QALYs) based on elicited preferences vary widely, especially across health procedures. The study evaluated the revealed WTP for QALYs by older adult patients who paid fully out-of-pocket for common inpatient procedures in the United States.Methods: Patient-level discharge data were from academic medical center members of the University Health System Consortium Clinical Data Base from 2005 to 2015 (now Vizient) for patients who paid ‘cash-in-full.’ The median, 25th percentile, and 75th percentile of charges, payments, and payment to charge ratio were examined and combined with available measures on QALYs by procedure.Results: Among patients over age 50 from 22 academic medical centers there were 846 self-pay patients, and the majority were international. The mean out-of-pocket payment was $57731 and the payment to charge ratio was 0.53. For the five procedures with available QALYs, the lower bound median payment based estimates of WTP ranged from $2949 for PTCA to $15441 for replacement or repair of aortic valve.Conclusions: The study was designed to provide lower bound estimates of revealed preferences for QALYs. WTP and how it should intersect with payment policy remains an important area for future research.

In this paper we empirically investigate how to appropriately model utility of wealth and health. We use a recently proposed alternative approach to value willingness to pay (WTP) for health, making use of trade-offs between income and life years or quality of life, which we extend to allow for a more realistic multiplicative utility function over health and money. Moreover, we show how reference-dependency can be incorporated into this model and derive its predictions for WTP elicitation. We propose three experimental elicitation procedures and test these in a feasibility study, analysing the responses under different assumptions about the discount rate. Several interesting results are reported: first, the data are highly skewed, but if we trim the 5% lowest and highest values, we obtain plausible WTP estimates. Second, the results differ considerably between procedures, indicating that WTP estimates are sensitive to the assumed utility function. Third, respondents appear to be loss averse for both health and money, which is consistent with assumptions from prospect theory. Finally, our results also indicate that respondents are more willing to trade quality of life than life years.

BackgroundTo date no one has examined the quality of life and direct costs of care in treating early stage breast cancer with adjunct intraoperative radiation therapy (IORT) versus external beam radiation therapy (EBRT) over the life of the patient. As well no one has examined the effects of radiation exposure with both therapies on the longer term sequelae. The purpose of this analysis was to examine the cost-effectiveness of IORT vs. EBRT over the life of the patient.MethodsA Markov decision-analytic model evaluated these treatment strategies in terms of the direct costs in treating patients over their lifetime (including the downstream costs associated with radiation exposure) and the resultant quality of life of these patients. Medicare reimbursement amounts in treating patients were used for acute, steady state, recurrent cancer(s), and complications associated with radiation exposure. Quality adjusted life years (QALYs) derived from the medical literature were assessed with each of these states. Life expectancies as well were derived from the medical literature. Cost-effectiveness was evaluated for dominance and net monetary benefit [at a willingness to pay (WTP)] of $50,000/QALY. Sensitivity analysis was also performed.ResultsIORT was the dominant (least costly with greater QALYs) versus EBRT: total costs over the life of the patient = $53,179 (IORT) vs. $63,828 (EBRT) and total QALYs: 17.86 (IORT) vs. 17.06 (EBRT). At a willingness to pay of $50,000 for each additional QALY, the net monetary benefit demonstrated that IORT was the most cost effective option: $839,815 vs. $789,092. The model was most sensitive to the probabilities of recurrent cancer and death for both IORT and EBRT.ConclusionIORT is the more valuable (lower cost with improved QALYs) strategy for use in patients presenting with early stage ER+ breast cancer. It should be used preferentially in these patients.

Previous studies have reported higher quality of life in patients who receive home nocturnal hemodialysis (HNHD) than conventional in-center hemodialysis (IHD). The optimal method for eliciting preferences from dialysis patients remains undefined, and there may be unique methodologic concerns in this population. Patients' preferences for IHD (n = 20) and HNHD (n = 24) were studied using the standard gamble (SG), time trade-off (TTO), and modified willingness to pay (WTP) methods. This report describes experience with operationalizing these three techniques in this population. A higher preference for HNHD was found with all measures, with significant differences observed with the SG (HNHD: median 0.79 [interquartile range (IQR) 0.67 to 0.95]; IHD: median 0.60 [IQR 0.20 to 0.82]; P = 0.031) and WTP (HNHD: median 0.50 [IQR 0.40 to 0.68]; IHD: median 0.20 [IQR 0.20 to 0.38]; P < 0.001). SG and TTO scores were moderately correlated but not with WTP. In addition, qualitative issues arose during TTO and WTP interviews that seemed to influence the interpretation of these preference scores. In the TTO, time willing to trade became oriented toward the next pivotal life event, with a failure of the requirement for a constant proportional time trade-off. WTP preferences were oriented toward the smallest survival stipend. These issues represent range restriction biases. No significant issues arose during the SG interviews. HNHD patients expressed a greater preference for current health than IHD patients. The operational performance of SG was good in this study, whereas biases and methodologic concerns were identified with the TTO and WTP in this population.

Patients with facial paralysis are perceived negatively by society in a number of domains. Society's perception of the health utility of varying degrees of facial paralysis and the value society places on reconstructive surgery for facial reanimation need to be quantified. To measure health state utility of varying degrees of facial paralysis, willingness to pay (WTP) for a repair, and the subsequent value of facial reanimation surgery as perceived by society. This prospective observational study conducted in an academic tertiary referral center evaluated a group of 348 casual observers who viewed images of faces with unilateral facial paralysis of 3 severity levels (low, medium, and high) categorized by House-Brackmann grade. Structural equation modeling was performed to understand associations among health utility metrics, WTP, and facial perception domains. Data were collected from July 16 to September 26, 2015. Observer-rated (1) quality of life (QOL) using established health utility metrics (standard gamble, time trade-off, and a visual analog scale) and (2) their WTP for surgical repair. Among the 348 observers (248 women [71.3%]; 100 men [28.7%]; mean [SD] age, 29.3 [11.6] years), mixed-effects linear regression showed that WTP increased nonlinearly with increasing severity of paralysis. Participants were willing to pay $3487 (95% CI, $2362-$4961) to repair low-grade paralysis, $8571 (95% CI, $6401-$11 234) for medium-grade paralysis, and $20 431 (95% CI, $16 273-$25 317) for high-grade paralysis. The dominant factor affecting the participants' WTP was perceived QOL. Modeling showed that perceived QOL decreased with paralysis severity (regression coefficient, -0.004; 95% CI, -0.005 to -0.004; P < .001) and increased with attractiveness (regression coefficient, 0.002; 95% CI, 0.002 to 0.003; P < .001). Mean (SD) health utility scores calculated by the standard gamble metric for low- and high-grade paralysis were 0.98 (0.09) and 0.77 (0.25), respectively. Time trade-off and visual analog scale measures were highly correlated. We calculated mean (SD) WTP per quality-adjusted life-year, which ranged from $10 167 ($14 565) to $17 008 ($38 288) for low- to high-grade paralysis, respectively. Society perceives the repair of facial paralysis to be a high-value intervention. Societal WTP increases and perceived health state utility decreases with increasing House-Brackmann grade. This study demonstrates the usefulness of WTP as an objective measure to inform dimensions of disease severity and signal the value society places on proper facial function. NA.