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.

Aims

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