Are all health gains equally important? An exploration of acceptable health as a reference point in health care priority setting
Wouters et al. Health and Quality of Life Outcomes
Are all health gains equally important? An exploration of acceptable health as a reference point in health care priority setting
S. Wouters 0
N.J.A. van Exel 0
K.I.M. Rohde 1
W.B.F. Brouwer 0
0 Institute of Health Policy & Management, Erasmus University Rotterdam , 3000 DR, Rotterdam , The Netherlands
1 Erasmus School of Economics, Erasmus University Rotterdam , 3000 DR, Rotterdam , The Netherlands
Background: Accumulating evidence suggests that members of society prefer some QALY gains over others. In this paper, we explore the notion of acceptable health as a reference point in assessing the value of health gains. The value of health benefits may be assessed in terms of their position relative to this reference level, benefits above the level of acceptable health being valued differently from benefits below this level. In this paper we focus on assessing the level of acceptable health at different ages and associations with background variables. Methods: We recruited a sample of the adult population from the Netherlands (n = 1067) to investigate which level of health problems they consider to be acceptable for people aged 40 to 90, using 10-year intervals. We constructed acceptable health curves and associated acceptable health with background characteristics using linear regressions. Results: The results of this study indicate that the level of health problems considered acceptable increases with age. This level was associated with respondents' age, age of death of next of kin, health and health behaviour. Conclusions: Our results suggest that people are capable of indicating acceptable levels of health at different ages, implying that a reference point of acceptable health may exist. While more investigation into the measurement of acceptable health remains necessary, future studies may also focus on how health gains may be valued relative to this reference level. Gains below the reference point may receive higher weight than those above this level since the former improve unacceptable health states while the latter improve acceptable health states.
Acceptable health; Reference point; Resource allocation; Ageing; 'Normal' functioning
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Background
Scarcity of health care resources makes priority setting
inevitable. An increasingly used tool to inform such
decision-making is cost-utility analysis, which assesses the
incremental costs and health benefits of a new
intervention relative to some relevant alternative (like an old
intervention, doing nothing or care as usual). The results of a
cost-utility analysis are typically summarized in an
incremental cost-utility ratio (ICUR), expressing the
incremental costs per unit of health gain [1]. Costs are expressed in
monetary terms while health gains are generally expressed
in terms of quality-adjusted life years (QALYs), i.e. the
amount of life time gained by the intervention corrected
for the quality of life (QoL) during that time, with a QoL
score of 1 representing perfect health and a QoL score of
0 representing the state of being dead [2]. An intervention
may be considered to offer value for money and hence be
considered for reimbursement when its costs per QALY
are lower than some relevant threshold [1]. The nature
and height of this threshold are a matter of ongoing
discussion (e.g. [3, 4]).
In calculating the cost-utility of interventions in health
care, each QALY is usually weighted equally, regardless
of whom it accrues to or under which circumstances it
is gained. This means that in calculating QALY gains, it
does not matter whether, for example, a QALY is gained
in the context of a severe or mild illness or whether the
beneficiary is 10 or 80 years old. However, accumulating
evidence (from the literature and policy practice)
suggests that members of society do prefer some QALY
gains over others. Disease and patient characteristics
such as the severity of the treated illness and the age of
the beneficiaries have been found to be important in the
valuation of health gains [5–7]. This means that priority
setting based on QALY maximization is unlikely to
reflect societal preferences for the just distribution of
health and health care, and that weighting QALYs
according to particular equity principles may improve the
societal support for health care decisions.
Two prominent equity principles that may justify and
guide the process of empirically deriving such equity
weights are the fair innings principle [8] and the severity
of illness argument [9–11]. Fair inning aims to promote
equality in lifetime health, assigning higher priority to
people who have not had their ‘fair share’ of lifetime
health than to people who have, and therefore live on
‘borrowed time’. The severity argument aims to promote
equality in people’s prospective health, therefore
assigning higher priority to those people whose health status
or expectations are worse [7].
Notwithstanding the increasing focus on equity
considerati (...truncated)