Abstract
ObjectivesDecision-making frameworks that draw on economic evaluations increasingly use equity weights to facilitate a more equitable and fair allocation of healthcare resources. These weights can be attached to health gains or reflected in the monetary threshold against which the incremental cost-effectiveness ratios of (new) health technologies are evaluated. Currently applied weights are based on different definitions of disease severity and do not account for age-related preferences in society. However, age has been shown to be an important equity-relevant characteristic. This study examines the willingness to pay (WTP) for health-related quality of life (QOL) gains in relation to the disease severity and age of patients, and the outcome of the disease. MethodsWe obtained WTP estimates by applying contingent-valuation tasks in a representative sample of the public in The Netherlands (n = 2023). We applied random-effects generalized least squares regression models to estimate the effect of patients’ disease severity and age, size of QOL gains, disease outcome (full recovery/death 1 year after falling ill), and respondent characteristics on the WTP. ResultsRespondents’ WTP was higher for more severely ill and younger patients and for larger-sized QOL gains, but lower for patients who died. However, the relations were nonlinear and context dependent. Respondents with a lower age, who were male, had a higher household income, and a higher QOL stated a higher WTP for QOL gains. ConclusionsOur results suggest that—if the aim is to align resource-allocation decisions in healthcare with societal preferences—currently applied equity weights do not suffice.
Highlights
An important objective of publicly financed healthcare systems is to maximize population health given a certain budget constraint.[1]
Health gains are often expressed in terms of quality-adjusted life-years (QALYs), comprising gains in both health-related quality of life (QOL) and life expectancy (LE).[2,3]
The incremental cost-effectiveness ratio (ICER) of a technology is evaluated against a monetary threshold that represents the maximum societal willingness to pay (WTP) for a QALY or the opportunity costs of spending within the healthcare sector.[4,5,6]
Summary
An important objective of publicly financed healthcare systems is to maximize population health given a certain budget constraint.[1] To meet this objective, economic evaluations can be used to inform decision makers about whether reimbursing a (new) health technology can be considered good value for money. Health gains are often expressed in terms of quality-adjusted life-years (QALYs), comprising gains in both health-related quality of life (QOL) and life expectancy (LE).[2,3] The incremental cost-effectiveness ratio (ICER) of a technology is evaluated against a monetary threshold that represents the maximum societal willingness to pay (WTP) for a QALY or the opportunity costs of spending within the healthcare sector.[4,5,6]. Equity weights can be attached to health gains or reflected in the monetary threshold to facilitate a more equitable and fair allocation of healthcare resources.[1,8,9,10,11,12] In the former case, the equity-adjusted ICER of a technology is evaluated against a fixed monetary threshold and in the latter case, the (unadjusted) ICER of a technology is evaluated against a flexible, equity-adjusted monetary threshold.[1,10] These weights can be based on a range of equity considerations that, for example, are related to characteristics of the patients, disease, or technology.[1,12,13,14,15,16,17,18,19,20] To facilitate consistent and accountable decision making, it has been advocated to explicitly and transparently integrate such considerations into the decision-making framework.[21,22,23,24] many countries (eg, France, Germany, Sweden, and Australia) do this in an ad hoc, implicit manner,[25,26,27] Norway, The Netherlands, and England do this in an explicit manner by applying equity weights.[28,29,30,31] Text Box 1 includes a brief overview of how the weights are applied in these countries
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