Examining the potential for links between NICE decision modifiers for health inequality and severity of disease
Examining the potential for links between NICE decision modifiers for health inequality and severity of disease
Theme 3: Inequalities
When NICE evaluates a new medicine, committees apply additional weight to quality-adjusted life year (QALY) benefits if the medicine is indicated for a condition with a high degree of severity. This is known as the ‘severity modifier’. In this case, severity is measured in terms of absolute and proportional QALY shortfall, both of which capture the difference in future expected health for people with the condition under current care compared to the general population of the same age and sex.
In parallel, NICE technology appraisals committees are being asked to consider what adjustments they can make in their deliberations when distributional analyses show that the eligible population under evaluation experiences health inequalities, and the technology reduces or mitigates inequalities. However, NICE does not apply a quantitative health inequalities modifier.
It is possible that positive recommendations arising from use of the severity modifier (intended to help improve access to care for those experiencing very poor health) may also improve outcomes for people experiencing health inequalities where there are inequalities in populations with diseases that meet specific severity thresholds. For example, NICE recently recommended bulevirtide for treating chronic hepatitis D (TA896) after applying the severity modifier in the cost-effectiveness analysis. The committee noted that hepatitis D disproportionately affects people from a Black African family background and that migrant infections are increasing, and there is potential for bulevirtide to help mitigate these issues.
Similarly, current evaluations of treatments for Duchenne muscular dystrophy and spinal muscular atrophy (both deemed eligible for the severity modifier) have relevant health inequality considerations relating to access to care for the most deprived groups. This presents challenges to NICE committees in terms of how much additional value, if any, they place on any potential reductions to health inequalities. However, the overlap between severe disease and population characteristics relevant to health inequalities (e.g. socioeconomic status) is unknown.
The overall aim is to add to understanding of the conceptual and quantitative relationship between disease severity and health inequalities and to illuminate the potential implications of this relationship for NICE decision modifiers and committee decision making.
To consider the practical implications of the current decision modifiers, including the potential for ‘double counting’ for technologies/interventions that both meet the cut-off for NICE’s severity modifier and that are expected to meaningfully impact health inequalities.
To inform research recommendations on further work aimed at improving decision making on guidance where there are multiple related factors for committees to consider.
Susan Griffin - susan.griffin@york.ac.uk