Setting health priorities: the development of cost-effectiveness league tables.

Abstract

AlanWilliams’swebsitedescribeshimasa‘‘pseudo-retired professor of economics still active inpromoting more explicit priority-setting based oncost-effectivenessapproachestobothhealthmaxim-isationandthereductionofhealthinequalities’’.Heiswidely acknowledged as the most influential ofBritishhealtheconomistsandindeedthefatherofthesub-discipline in the United Kingdom, as evidencedby respondents to a survey of British healtheconomists who, when asked about the paperdeemed most influential on both the discipline andpolicy,answered‘‘anythingwrittenbyAlanWilliams’’(1) and specifically his 1985 paper reproduced here.Atfirstsightitmayappearoddthateconomistsshould choose as ‘‘most influential’’ a paper aboutcoronary artery bypass grafting (CABG), and more-over one published in a medical journal. We believethat the following features account for the seminalnatureofthepaper:thecollectionofmethodologicalaspects that were innovative at that time; the closerelationship between analysis and policy; the frankacknowledgement of the limitations in data quality;andthevisionofafutureresearchagenda.However,the active involvement of its author in proselytisingand arguing for his overall vision that ‘‘an explicitapproachbasedoncost-effectivenessreasoningisonstrongermoralgroundthananyotherapproach’’hasalso been a key reason for the paper’s success instimulating the research and policy directions ofmany others (including economists).Williams’s paper introduced four specificmethodological ideas to the context of decision-making in the UK National Health Service (NHS):application of the quality-adjusted life year (QALY)as a measure of effectiveness of interventions;calculation of ratios of cost per QALY gained frominterventions; presentation of the first ‘league table’comparingtherelativecost-effectivenessofdifferentinterventions; and recognition that sub-groups ofpatients may have differential cost-effectivenessratios. Parts of these ideas had been developed andapplied in earlier publications in the USA (2, 3)butnever in the UK. The approach of combiningquantity and quality of life across different healthinterventions in the league table was particularlyinfluentialinmovingcost-effectivenessanalysisawayfrom only piecemeal decision-making to broadersectoral planning (4).In terms of policy implications, the paperconcluded that CABG compared extremely favour-ablywithhearttransplantsandtreatmentofend-stagerenal failure, favourably with valve replacement foraortic stenosis and implantation of pacemakers forheartblock,andlessfavourablywithhipreplacements.The more severe a case of angina, the more cost-effectiveitwastotreatwithCABG,andonlythemostsevere cases were judged to be ‘‘a fairly strongclaimant’’ on any extra resources. These werecontroversialconclusionsaimedatstimulatingfurtherdebate. The paper was published at an importantpoint: a consensus conference had recommended alarge increase in CABG operations; the UK Depart-ment of Health and Social Security had just signifi-cantlyextendedthehearttransplantprogramme;andadetailed report on the costs and benefits of the hearttransplantation programme had been completed (5).The paper was the first to compare directly theefficiency of very different types of health careinterventions and, by so doing, to challenge UKgovernmentpolicy.However,itwasalsoimportantforthefutureacceptanceoftheapproachthatseveralkeypeople involved in these debates had been part of the