Allocation of scarce resources in health care: values and concepts

In many countries, a gap exists between the population's need for health care and available resources. These nations have attempted to eliminate or reduce the gap through such activities as improving efficiency and narrowing responsibilities. Since these measures have proven insufficient, decisions must be made regarding how to best use the scarce resources. The priority-setting and rationing processes involve key decisions in the sense that they have consequences for people's health and quality of life and they should therefore be rational and based on solid grounds. This means that the decisions involve three issues: facts, concepts and values. In this presentation the focus is on the conceptual and value issues. A basic ethical platform as a guide for decision-making will be presented. The ethical principles that constitute the platform contain central concepts like health care need, cost-effectiveness, health and goal. A short presentation of these concepts will be carried out. This will end with the concept of a goal and its importance for decision-making.

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Goals of palliative cancer therapy.

Journal of Clinical Oncology ◽

10.1200/jco.1993.11.2.378 ◽

1993 ◽

Vol 11 (2) ◽

pp. 378-381 ◽

Cited By ~ 53

Author(s):

F Porzsolt ◽

I Tannock

Keyword(s):

Quality Of Life ◽

Decision Making ◽

Cost Effectiveness ◽

Cancer Therapy ◽

Health Professionals ◽

Palliative Treatment ◽

Clinical Decision Making ◽

Clinical Decision ◽

Oncology Practice

The major conclusions of the Workshop on Goals of Palliative Cancer Therapy are as follows: 1. The goals of any cancer therapy should be stated explicitly. 2. If the goal of treatment is palliation, this should be documented according to one of the established and validated methods for assessment of quality of life. Several validated methods are available, and although imperfect, have been shown to give reliable information. 3. The use of simple measures of quality of life (eg, symptom checklists, pain assessment cards) should become routine in oncology practice. The act of introducing such measures improves palliation. 4. Measures of cost-effectiveness should be used more widely in clinical decision making to ensure the appropriate deployment of resources. 5. There must be improved education of all health professionals with regard to the multiple methods for provision of palliative treatment to cancer patients and the assessment of palliation.

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Cost-effectiveness analysis: role and implications

Phlebology The Journal of Venous Disease ◽

10.1177/0268355512475119 ◽

2013 ◽

Vol 28 (1_suppl) ◽

pp. 135-140 ◽

Cited By ~ 5

Author(s):

G Marsden ◽

D Wonderling

Keyword(s):

Quality Of Life ◽

Health Care ◽

Cost Effectiveness ◽

Varicose Vein ◽

Varicose Veins ◽

Health Gain ◽

Cost Effectiveness Analysis ◽

Effectiveness Analysis ◽

The Cost

Background: Cost-effectiveness analysis (CEA) is often misperceived to be a cost-cutting exercise. The intention of CEA is not to identify and implement cheap technologies, but rather those which offer maximum health gain, subject to available funds. Such analysis is crucial for decision making in health care, as tight budget constraints mean spending in one area of healthcare displaces spending elsewhere. Therefore in order to achieve the greatest health gain for the overall population, treatments must be selected which provide the greatest health gain within the available funds. Summary: The relevance of CEA in health care systems is explained, using varicose vein treatment in the UK NHS as an example. Treatment for varicose veins is often not commissioned to at a local level, most likely because it is misperceived to be a cosmetic problem. However, this view does not take into account the impact of quality of life. CEA balances costs against a quantitative measure of health related quality of life, and could therefore be used to determine whether it is cost-effective to provide varicose vein treatment. The current literature on the cost-effectiveness of varicose vein treatment is reviewed, and an overview of cost-effectiveness principles is provided. Concepts such as economic modelling, incremental cost-effectiveness ratios (ICERs), net monetary benefit (NMB) and sensitivity analysis are explained, using examples relevant to varicose veins where appropriate. Conclusion: This article explains how, far from cutting costs and sacrificing patient health, CEA provides a useful tool to maximise the health of the population in the face of ever tightening budget constraints. CEA could be used to compare the cost-effectiveness of the various treatment options for varicose veins, and efficiencies realised.

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Toward a Centralized, Systematic Approach to the Identification, Appraisal, and Use of Health State Utility Values for Reimbursement Decision Making: Introducing the Health Utility Book (HUB)

Medical Decision Making ◽

10.1177/0272989x19837969 ◽

2019 ◽

Vol 39 (4) ◽

pp. 371-379 ◽

Cited By ~ 3

Author(s):

Feng Xie ◽

Michael Zoratti ◽

Kelvin Chan ◽

Don Husereau ◽

Murray Krahn ◽

...

Keyword(s):

Health Care ◽

Decision Making ◽

Cost Effectiveness ◽

Systematic Approach ◽

Health Utility ◽

Reimbursement Decision ◽

Health State ◽

Life Years ◽

Health State Utility Values

Cost-utility analysis (CUA) is a widely recommended form of health economic evaluation worldwide. The outcome measure in CUA is quality-adjusted life-years (QALYs), which are calculated using health state utility values (HSUVs) and corresponding life-years. Therefore, HSUVs play a significant role in determining cost-effectiveness. Formal adoption and endorsement of CUAs by reimbursement authorities motivates methodological advancement in HSUV measurement and application. A large body of evidence exploring various methods in measuring HSUVs has accumulated, imposing challenges for investigators in identifying and applying HSUVs to CUAs. First, large variations in HSUVs between studies are often reported, and these may lead to different cost-effectiveness conclusions. Second, issues concerning the quality of studies that generate HSUVs are increasingly highlighted in the literature. This issue is compounded by the limited published guidance and methodological standards for assessing the quality of these studies. Third, reimbursement decision making is a context-specific process. Therefore, while an HSUV study may be of high quality, it is not necessarily appropriate for use in all reimbursement jurisdictions. To address these issues, by promoting a systematic approach to study identification, critical appraisal, and appropriate use, we are developing the Health Utility Book (HUB). The HUB consists of an HSUV registry, a quality assessment tool for health utility studies, and a checklist for interpreting their use in CUAs. We anticipate that the HUB will make a timely and important contribution to the rigorous conduct and proper use of health utility studies for reimbursement decision making. In this way, health care resource allocation informed by HSUVs may reflect the preferences of the public, improve health outcomes of patients, and maintain the efficiency of health care systems.

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Economic evaluation alongside a randomised controlled trial to assess the effectiveness and cost-effectiveness of acupuncture in the management of chemotherapy-induced peripheral neuropathy

Acupuncture in Medicine ◽

10.1177/0964528420920285 ◽

2020 ◽

pp. 096452842092028

Author(s):

Alex Molassiotis ◽

Bryony Dawkins ◽

Roberta Longo ◽

Lorna KP Suen ◽

Hui Lin Cheng ◽

...

Keyword(s):

Quality Of Life ◽

Health Care ◽

Economic Evaluation ◽

Cost Effectiveness ◽

Peripheral Neuropathy ◽

Usual Care ◽

Base Case ◽

Cost Effective Treatment ◽

The Cost

Objective To assess the cost-effectiveness of acupuncture in the management of chemotherapy-induced peripheral neuropathy (CIPN) in Hong Kong. Methods A within trial cost-utility analysis with the primary endpoint for the economic evaluation being the Quality Adjusted Life Year (QALY) and associated Incremental Cost Effectiveness Ratio (ICER) over 14 weeks of treatment. A secondary cost-effectiveness analysis was undertaken with the endpoint being change in pain as measured on the Brief Pain Inventory (BPI). Results Eighty-seven patients were randomised to acupuncture or usual care. Acupuncture resulted in significant improvements in pain intensity (8- and 14-week mean changes compared to usual care of −1.8 and −1.8, respectively), pain interference (8- and 14-week mean changes compared to usual care of −1.5 and −0.9, respectively) and indicators of quality of life and neurotoxicity-related symptoms. However, in the economic evaluation there was little difference in QALYs between the two arms (mean change 0.209 and 0.200 in the acupuncture and usual care arms, respectively). Also, costs yielded deterministic ICERs of HK$616,965.62, HK$824,083.44 and HK$540,727.56 per QALY gained from the health care provider perspective, the societal perspective and the patient perspective, respectively. These costs are significantly higher than the cost-effectiveness threshold of HK$180,450 that was used for the base case analysis. Conclusion While acupuncture can improve symptoms and quality of life indicators related to CIPN, it is unlikely to be a cost-effective treatment for CIPN-related pain in health care systems with limited resources. Trial registration number NCT02553863 (ClinicalTrials.gov) post-results.

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Effectiveness, cost-utility and implementation of a decision aid for patients with localised prostate cancer and their partners: study protocol of a stepped-wedge cluster randomised controlled trial

BMJ Open ◽

10.1136/bmjopen-2016-015154 ◽

2017 ◽

Vol 7 (9) ◽

pp. e015154 ◽

Cited By ~ 3

Author(s):

Hoda H M Al-Itejawi ◽

Cornelia F van Uden-Kraan ◽

Peter M van de Ven ◽

Veerle M H Coupé ◽

André N Vis ◽

...

Keyword(s):

Quality Of Life ◽

Prostate Cancer ◽

Health Care ◽

Decision Making ◽

The Netherlands ◽

Cost Utility ◽

Treatment Preferences ◽

Stepped Wedge ◽

Cluster Randomised

IntroductionPatient decision aids (PDAs) have been developed to help patients make an informed choice for a treatment option. Despite proven benefits, structural implementation falls short of expectations. The present study aims to assess the effectiveness and cost-utility of the PDA among newly diagnosed patients with localised prostate cancer and their partners, alongside implementation of the PDA in routine care.Methods/analysisA stepped-wedge cluster randomised trial will be conducted. The PDA will be sequentially implemented in 18 hospitals in the Netherlands, over a period of 24 months. Every 3 or 6 months, a new cluster of hospitals will switch from usual care to care including a PDA.The primary outcome measure is decisional conflict experienced by the patient. Secondary outcomes comprise the patient’s quality of life, treatment preferences, role in the decision making, expectations of treatment, knowledge, need for supportive care and decision regret. Furthermore, societal cost-utility will be valued. Other outcome measures considered are the partner’s treatment preferences, experienced participation to decision making, quality of life, communication between patient, partner and health care professional, and the effect of prostate cancer on the relationship, social contacts and their role as caregiver. Patients and partners receiving the PDA will also be asked about their satisfaction with the PDA.Baseline assessment takes place after the treatment choice and before the start of a treatment, with follow-up assessments at 3, 6 and 12 months following the end of treatment or the day after deciding on active surveillance. Outcome measures on implementation include the implementation rate (defined as the proportion of all eligible patients who will receive a PDA) and a questionnaire for health care professionals on determinants of implementing an innovation.Ethics and disseminationThis study will be conducted in accordance with local laws and regulations of the Medical Ethics Committee of VU University Medical Center, Amsterdam, The Netherlands. The results from this stepped-wedge trial will be presented at scientific meetings and published in peer-reviewed journals.Trial registrationNederlands Trial Register NTR TC5177, registration date: May 28th2015.Pre-results.

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Measuring cost-effectiveness of secondary health care: Feasibility and potential utilization of results

International Journal of Technology Assessment in Health Care ◽

10.1017/s0266462305050038 ◽

2005 ◽

Vol 21 (1) ◽

pp. 22-31 ◽

Cited By ~ 13

Author(s):

Pirjo Räsänen ◽

Harri Sintonen ◽

Olli-Pekka Ryynänen ◽

Marja Blom ◽

Virpi Semberg-Konttinen ◽

...

Keyword(s):

Quality Of Life ◽

Health Care ◽

Cost Effectiveness ◽

Data Collection ◽

Treatment Effectiveness ◽

Life Data ◽

Secondary Health Care ◽

Related Quality ◽

Health Related

Objectives: Whether cost-effectiveness of secondary health care can be measured in a simple, yet commensurate way was studied.Methods: Approximately 4,900 patients' health-related quality of life scores before and after treatment were measured. Used were a combination of quality of life data with diagnostic and financial indicators routinely collected in the hospital.Results: Seventy percent of patients returned the first questionnaire and the informed written consent to participate. Of these patients, 80 percent also returned the second questionnaire sent out 3 to 12 months after treatment, depending on clinical specialty and diagnostic category. The routine of sending out questionnaires could be automated in such a way that data collection required only a limited amount of extra work. Patients were generally satisfied with the fact that the hospital was interested in their well-being also after treatment. No physician offered the chance to participate refused data collection in the patient group he or she was responsible for. The attitudes of the nursing staff were generally positive toward data collection, although it caused some extra work for some of them. The possibility of relating already routinely collected financial performance indicators with a relevant measure of treatment effectiveness, opened prospects for refined analysis of cost-effectiveness of secondary health care.Conclusions: Routine collection of health-related quality of life data as an indicator of treatment effectiveness is feasible, requires only a small amount of extra work, and is potentially very useful when combined with existing measures of hospital performance.

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A randomised comparison of the effect of haemodynamic monitoring with CardioMEMS in addition to standard care on quality of life and hospitalisations in patients with chronic heart failure

Netherlands Heart Journal ◽

10.1007/s12471-019-01341-9 ◽

2019 ◽

Vol 28 (1) ◽

pp. 16-26 ◽

Cited By ~ 4

Author(s):

J. J. Brugts ◽

J. F. Veenis ◽

S. P. Radhoe ◽

G. C. M. Linssen ◽

M. van Gent ◽

...

Keyword(s):

Quality Of Life ◽

Heart Failure ◽

Health Care ◽

Clinical Trial ◽

Cost Effectiveness ◽

Remote Monitoring ◽

Hospital Admissions ◽

Haemodynamic Monitoring ◽

Western European

Abstract Background Assessing haemodynamic congestion based on filling pressures instead of clinical congestion can be a way to further improve quality of life (QoL) and clinical outcome by intervening before symptoms or weight gain occur in heart failure (HF) patients. The clinical efficacy of remote monitoring of pulmonary artery (PA) pressures (CardioMEMS; Abbott Inc., Atlanta, GA, USA) has been demonstrated in the USA. Currently, the PA sensor is not reimbursed in the European Union as its benefit when applied in addition to standard HF care is unknown in Western European countries, including the Netherlands. Aims To demonstrate the efficacy and cost-effectiveness of haemodynamic PA monitoring in addition to contemporary standard HF care in a high-quality Western European health care system. Methods The current study is a prospective, multi-centre, randomised clinical trial in 340 patients with chronic HF (New York Heart Association functional class III) randomised to HF care including remote monitoring with the CardioMEMS PA sensor or standard HF care alone. Eligible patients have at least one hospitalisation for HF in 12 months before enrolment and will be randomised in a 1:1 ratio. Minimum follow-up will be 1 year. The primary endpoint is the change in QoL as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ). Secondary endpoints are the number of HF hospital admissions and changes in health status assessed by EQ-5D-5L questionnaire including health care utilisation and formal cost-effectiveness analysis. Conclusion The MONITOR HF trial will evaluate the efficacy and cost-effectiveness of haemodynamic monitoring by CardioMEMS in addition to standard HF care in patients with chronic HF. Clinical Trial Registration number NTR7672.

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The Effects of Preventive Home Visits on Older People’s Use of Health Care and Social Services and Related Costs

The Journals of Gerontology Series A ◽

10.1093/gerona/glz139 ◽

2019 ◽

Vol 75 (8) ◽

pp. 1586-1593

Author(s):

Heini A Liimatta ◽

Pekka Lampela ◽

Hannu Kautiainen ◽

Pirjo Laitinen-Parkkonen ◽

Kaisu H Pitkala

Keyword(s):

Quality Of Life ◽

Health Care ◽

Cost Effectiveness ◽

Social Services ◽

Health Related Quality ◽

Quality Adjusted Life Years ◽

Related Quality ◽

Health Related ◽

Quality Adjusted Life

Abstract Background We use data from a randomized controlled trial on preventive home visits exploring effectiveness on health-related quality of life. In this article, we examine the intervention’s cost-effectiveness and effects on quality-adjusted life years in older home-dwelling adults. Methods There were 422 independently home-dwelling participants in the randomized, controlled trial, all aged more than 75 years, with equal numbers in the control and intervention groups. The intervention took place in a municipality in Finland and consisted of multiprofessional preventive home visits. We gathered the data on health care and social services use from central registers and medical records during 1 year before the intervention and 2 years after the intervention. We analyzed the total health care and social services use and costs per person-years and the difference in change in health-related quality of life as measured using the 15D measure. We calculated quality-adjusted life years and incremental cost-effectiveness ratios. Results There was no significant difference in baseline use of services or in the total use and costs of health care and social services during the 2-year follow-up between the two groups. In the intervention group, health-related quality of life declined significantly more slowly compared with the control group (–0.015), but there was no significant difference in quality-adjusted life years gained between the groups. The cost-effectiveness plane showed 60% of incremental cost-effectiveness ratios lying in the dominant quadrant, representing additional effects with lower costs. Conclusions This multiprofessional preventive home visit intervention appears to have positive effects on health-related quality of life without accruing additional costs. The clinical trial registration number ACTRN12616001411437.

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Individualized quality of life benefit and cost-effectiveness estimates of proton therapy for patients with oropharyngeal cancer

Radiation Oncology ◽

10.1186/s13014-021-01745-1 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

N. Patrik Brodin ◽

Rafi Kabarriti ◽

Clyde B. Schechter ◽

Mark Pankuch ◽

Vinai Gondi ◽

...

Keyword(s):

Quality Of Life ◽

Decision Making ◽

Cost Effectiveness ◽

Proton Therapy ◽

Oropharyngeal Cancer ◽

Normal Tissue ◽

Cost Effective ◽

Intensity Modulated ◽

The Cost

Abstract Background Proton therapy is a promising advancement in radiation oncology especially in terms of reducing normal tissue toxicity, although it is currently expensive and of limited availability. Here we estimated the individual quality of life benefit and cost-effectiveness of proton therapy in patients with oropharyngeal cancer treated with definitive radiation therapy (RT), as a decision-making tool for treatment individualization. Methods and materials Normal tissue complication probability models were used to estimate the risk of dysphagia, esophagitis, hypothyroidism, xerostomia and oral mucositis for 33 patients, comparing delivered photon intensity-modulated RT (IMRT) plans to intensity-modulated proton therapy (IMPT) plans. Quality-adjusted life years (QALYs) lost were calculated for each complication while accounting for patient-specific conditional survival probability and assigning quality-adjustment factors based on complication severity. Cost-effectiveness was modeled based on upfront costs of IMPT and IMRT, and the cost of acute and/or long-term management of treatment complications. Uncertainties in all model parameters and sensitivity analyses were included through Monte Carlo sampling. Results The incremental cost-effectiveness ratios (ICERs) showed considerable variability in the cost of QALYs spared between patients, with median $361,405/QALY for all patients, varying from $54,477/QALY to $1,508,845/QALY between individual patients. Proton therapy was more likely to be cost-effective for patients with p16-positive tumors ($234,201/QALY), compared to p16-negative tumors ($516,297/QALY). For patients with p16-positive tumors treated with comprehensive nodal irradiation, proton therapy is estimated to be cost-effective in ≥ 50% of sampled cases for 8/9 patients at $500,000/QALY, compared to 6/24 patients who either have p16-negative tumors or receive unilateral neck irradiation. Conclusions Proton therapy cost-effectiveness varies greatly among oropharyngeal cancer patients, and highlights the importance of individualized decision-making. Although the upfront cost, societal willingness to pay and healthcare administration can vary greatly among different countries, identifying patients for whom proton therapy will have the greatest benefit can optimize resource allocation and inform prospective clinical trial design.

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