Simple methods for quantifying the sensitivity of cost-effectiveness estimates to distributional concerns
Simple methods for quantifying the sensitivity of cost-effectiveness estimates to distributional concerns
Theme 3: Inequalities
There is great concern from policy-makers and the public for health inequality and its relationship with socio-economic inequality.
The reduction of health inequality is a stated objective of government policy and its arms-length bodies (particularly OHID, but also NICE).
It is often assumed that health inequality is an issue mainly for prevention and public health, but inequality is also a potential consideration in cost-effectiveness evaluations of medicines, medical technologies and diagnostics in cases where the pattern of patient benefits is distributionally significant.
We see a potential value in a simple, clear and practical procedure for identifying those cost-effectiveness applications where distributional considerations are most likely to affect the outcome.
We do not aim to be prescriptive about the concept of distributional equity that is appropriate in cost-effectiveness analysis – the appropriate distributional concept is to be left to the user of the proposed procedure to judge.
The first aim is to develop a methodology for identifying “distributionally sensitive” cost-effectiveness applications, for any given concept of inequality specified by the user. The methodology would work by estimating the degree of social inequality aversion that would be necessary to make a material change to the outcome of the cost-effectiveness study (e.g. to change the decision that would be recommended to NICE).
A second aim is to gain experience of the proposed methodology in applications to a set of exemplar cost-effectiveness studies, relating to one or more conditions whose prevalence is believed to vary substantially across social groups. An example is asthma, where prevalence has been shown to be strongly related to socio-economic disadvantage, and where there have been several suitable clinical trials in recent years.
Steve Pudney, Monica Hernandez, Allan Wailoo, Aki Tsuchiya
Steve Pudney steve.pudney@sheffield.ac.uk
Background:
This project addresses concerns about health and socio-economic inequalities and their relationship. Health inequalities can be seen as those health differences between groups in society that are seen as unfair and unavoidable. Government policies which aim to reduce health inequality are often viewed as a matter for prevention and public health. However, this project suggests that concerns about fair shares (called “distributional considerations”), particularly in cost-effectiveness evaluations of medical interventions, may also play a significant role.
Aim:
This project aims to identify those settings where it is likely to be important to take distributional concerns into account because this might change policy decisions compared to those based on cost effectiveness. These may be specific disease areas, or stages of diseases, or may be defined by other characteristics either of the patients or the health intervention in question. The goal is not to specify either any particular definition of inequality, or the extent to which decision makers may care about it, but to identify how important these issues would need to be to change policy conclusions.
Methods:
To achieve this, the project plans to:
Select various case studies where cost-effectiveness analyses have been conducted
Obtain relevant survey datasets, such as the Health Survey for England and UK Household Longitudinal Survey, containing information on diagnosed medical conditions, health measures, and socio-economic factors.
Select a range of measures of inequality. These will focus on things like differences in general health or socioeconomic status between groups.
Select a range of ways of measuring inequality and ranges for how important reducing inequality is to society.
Use specialist statistical methods to examine relationships between medical conditions and chosen dimensions of inequality.
Estimate distributional sensitivity for each cost-effectiveness application based on various inequality measures and concepts.
The project aims to gain insights by applying this methodology to exemplar cost-effectiveness studies related to conditions with varying prevalence across social groups, citing asthma as an example. The initial focus is on applications where mortality is not the primary concern, with potential extensions to incorporate other factors in subsequent phases.
Policy relevance & dissemination:
This project is in its early stages but it's directly important for making decisions about when and where to consider issues related to how resources are distributed. This is becoming more important, and there are already a few examples of using methods like DCEA (Distributional Cost-Effectiveness Analysis) in specific cases.