Economic Evaluation
QALY maximisation and people's preferences: a methodological review of the literature
Paul Dolan,
Rebecca Shaw, Aki Tsuchiya,
Alan Williams,
Corresponding Author
Paul Dolan
Sheffield Health Economics Group, School of Health and Related Research, University of Sheffield, UK
Health Economics Research Programme, University of Oslo, Norway
Sheffield Health Economics Group, School of Health and Related Research, University of Sheffield, 30 Regent Street, Sheffield S1 4DA, UK===Search for more papers by this authorAki Tsuchiya
Sheffield Health Economics Group, University of Sheffield, UK
Search for more papers by this authorAlan Williams
Centre for Health Economics, University of York, UK
Search for more papers by this authorPaul Dolan,
Rebecca Shaw, Aki Tsuchiya,
Alan Williams,
Corresponding Author
Paul Dolan
Sheffield Health Economics Group, School of Health and Related Research, University of Sheffield, UK
Health Economics Research Programme, University of Oslo, Norway
Sheffield Health Economics Group, School of Health and Related Research, University of Sheffield, 30 Regent Street, Sheffield S1 4DA, UK===Search for more papers by this authorAki Tsuchiya
Sheffield Health Economics Group, University of Sheffield, UK
Search for more papers by this authorAlan Williams
Centre for Health Economics, University of York, UK
Search for more papers by this authorAbstract
In cost-utility analysis, the numbers of quality-adjusted life years (QALYs) gained are aggregated according to the sum-ranking (or QALY maximisation) rule. This requires that the social value from health improvements is a simple product of gains in quality of life, length of life and the number of persons treated. The results from a systematic review of the literature suggest that QALY maximisation is descriptively flawed. Rather than being linear in quality and length of life, it would seem that social value diminishes in marginal increments of both. And rather than being neutral to the characteristics of people other than their propensity to generate QALYs, the social value of a health improvement seems to be higher if the person has worse lifetime health prospects and higher if that person has dependents. In addition, there is a desire to reduce inequalities in health. However, there are some uncertainties surrounding the results, particularly in relation to what might be affecting the responses, and there is the need for more studies of the general public that attempt to highlight the relative importance of various key factors. Copyright © 2004 John Wiley & Sons, Ltd.
References
- 1 Hartley RJ et al. Online Searching: Principles and Practice. BowkerSaur: Epping, UK, 1990.
- 2 Sassi F, Archard L, Le Grand J. Equity and the economic evaluation of healthcare. Health Technol Assess 2001; 5(3).
- 3 Harris J. Unprincipled Qalys—a response to Cubbon. J Med Ethics 1991; 17(4): 185–188.
- 4 Olsen J. Theories of justice and their implications for priority setting in health care. J Health Econ 1997; 17: 625–640.
- 5 Nord E. The trade-off between severity of illness and treatment effect in cost-value analysis of health-care. Health Policy 1993; 24(3): 227–238.
- 6 Ubel PA, Spranca MD, Dekay ML, Hershey JC, Asch DA. Public preferences for prevention versus cure: what if an ounce of prevention is worth only an ounce of cure? Med Decision Making 1998; 18(2): 141–148.
- 7 Cookson R, Dolan P. Public views on health care rationing: a group discussion study. Health Policy 1999; 49(1–2): 63–74.
- 8 Nord E. The person-trade-off approach to valuing health-care programs. Med Decision Making 1995; 15(3): 201–208.
- 9 Dolan P. The measurement of individual utility and social welfare. J Health Econ 1998; 17(1): 39–52.
- 10 Ubel PA. How stable are people's preferences for giving priority to severely ill patients? Social Sci Med 1999; 49(7): 895–903.
- 11 Ubel PA, Loewenstein G. The efficacy and equity of retransplantation—an experimental survey of public attitudes. Health Policy 1995; 34(2): 145–151.
- 12 Ubel PA, Loewenstein G. Distributing scarce livers: the moral reasoning of the general public. Social Sci Med 1996; 42(7): 1049–1055.
- 13 Ubel PA, Loewenstein G. Public perceptions of the importance of prognosis in allocating transplantable livers to children. Med Decision Making 1996; 16(3): 234–241.
- 14 Ubel PA, Richardson J, Pinto Prades JL. Life-saving treatments and disabilities—are all QALYs created equal? Int J Technol Assess Health Care 1999; 15(4): 738–748.
- 15 Abellan-Perpinan JM, Pinto Prades JL. Health state after treatment: a reason for discrimination? Health Econ 1999; 8(8): 701–707.
10.1002/(SICI)1099-1050(199912)8:8<701::AID-HEC473>3.0.CO;2-M CAS PubMed Web of Science® Google Scholar
- 16 Nord E. The relevance of health state after treatment in prioritizing between different patients. J Med Ethics 1993; 19(1): 37–42.
- 17 Nord E, Pinto JL, Richardson J, Menzel P, Ubel P. Incorporating societal concerns for fairness in numerical valuations of health programmes. Health Econ 1999; 8(1): 25–39.
10.1002/(SICI)1099-1050(199902)8:1<25::AID-HEC398>3.0.CO;2-H CAS PubMed Web of Science® Google Scholar
- 18 Roberts T, Bryan S, Heinbotham C. Public involvement in health care priority setting: an economic perspective. Health Expectations 1997; 2: 235–244.
10.1046/j.1369-6513.1999.00061.x Google Scholar
- 19 Dolan P, Green C. Using the person trade-off approach to examine differences between individual and social values. Health Econ 1998; 7(4): 307–312.
10.1002/(SICI)1099-1050(199806)7:4<307::AID-HEC345>3.0.CO;2-N CAS PubMed Web of Science® Google Scholar
- 20 Dolan P, Cookson R. A qualitative study of the extent to which health gains matter when choosing between groups of patients. Health Pol 2000; 51(1): 19–30.
- 21 Shmueli A. Survival vs. quality of life: a study of the Israeli public priorities in medical care. Social Sci Med 1999; 49(3): 297–302.
- 22 Tsuchiya A. Age-related preferences and age weighting health benefits. Social Sci Med 1999; 48(2): 267–276.
- 23 Kappel K, Sandøe P. QALYS, age and fairness. Bioethics 1992; 6(4): 297–316.
- 24 Williams A. Intergenerational equity: an exploration of the ‘fair innings’ argument. Health Econ 1997; 6(2): 117–132.
10.1002/(SICI)1099-1050(199703)6:2<117::AID-HEC256>3.0.CO;2-B CAS PubMed Web of Science® Google Scholar
- 25 Harris J. Does justice require that we be ageist. Bioethics 1994; 8(1): 74–83.
- 26 Murray C, Acharya A. Understanding DALYs. J Health Econ 1997; 16: 703–730.
- 27 Anand P, Wailoo A. Utilities versus rights to publicly provided goods: arguments and evidence from health care rationing. Economica 2000; 67(268): 543–577.
- 28 Kuder LB, Roeder PW. Attitudes toward age-based health-care rationing – a qualitative assessment. J Aging Health 1995; 7(2): 301–327.
- 29 Zweibel NR, Cassel CK, Karrison T. Public attitudes about the use of chronological age as a criterion for allocating health care resources. Gerontologist 1993; 33: 74–80.
- 30 Bowling A. Health care rationing: the public's debate. Br Med J 1996; 312(7032): 670–674.
- 31 Busschbach JJV, Hessing DJ, Decharro FT. The utility of health at different stages in life – a quantitative approach. Social Sci Med 1993; 37(2): 153–158.
- 32 Charny MC, Lewis PA, Farrow SC. Choosing who shall not be treated in the NHS. Social Sci Med 1989; 28(12): 1331–1338.
- 33 Mooney G, Jan S, Wiseman V. Examining preferences for allocating health-care gains. Health Care Anal 1995; 3(3): 261–265.
- 34 Rodriguez E, Pinto JL. The social value of health programmes: is age a relevant factor? Health Econ 2000; 9(7): 611–621.
- 35 Tsuchiya, A. The value of health at different ages. Discussion Paper 184, York, Centre for Health Economics, University of York, 2001.
- 36 Williams A. Ethics and efficiency in the provision of health care. In Philosophy and Medical Welfare, M Bell, S Mendus (eds). Cambridge University Press: Cambridge, 1988.
- 37 Browning CJ, Thomas SA. Community values and preferences in transplantation organ allocation decisions. Social Sci Med 2001; 52(6): 853–861.
- 38 Cropper ML, Aydede SK, Portney PR. Preferences for life saving programs – how the public discounts time and age. J Risk Uncertainty 1994; 8(3): 243–265.
- 39 Johannesson M, Johansson PO. The economics of ageing: on the attitude of Swedish people to the distribution of health care resources between the young and the old. Health Policy 1996; 37(3): 153–161.
- 40 Johannesson M, Johansson PO. Is the valuation of a QALY gained independent of age? Some empirical evidence. J Health Econ 1997; 16(5): 589–599.
- 41 Lewis PA, Charny M. Which of 2 individuals do you treat when only their ages are different and you can't treat both. J Med Ethics 1989; 15(1): 28–32.
- 42 Nord E, Richardson J, Street A, Kuhse H, Singer P. Maximizing health benefits vs. egalitarianism – an Australian survey of health issues. Social Sci Med 1995; 41(10): 1429–1437.
- 43 Nord E, Street A, Richardson J, Kuhse H, Singer P. The significance of age and duration of effect in social evaluation of health care. Health Care Anal 1996; 4(2): 103–111.
- 44 Varekamp I, Krol LJ, Danse JAC. Age rationing for renal transplantation? The role of age in decisions regarding scarce life extending medical resources. Social Sci Med 1998; 47(1): 113–120.
- 45 LeGrand J. Equity, health and health care. Social Just Res 1987; 1: 257–274.
10.1007/BF01047663 Google Scholar
- 46 Dolan P, Olsen JA. Equity in health: the importance of different health streams. J Health Econ 2001; 20(5): 823–834.
- 47 Labelle RJ, Hurley JE. Implications of basing health-care resource allocations on cost-utility analysis in the presence of externalities. J Health Econ 1992; 11(3): 259–277.
- 48 Ratcliffe J. Public preferences for the allocation of donor liver grafts for transplantation. Health Econ 2000; 9(2): 137–148.
10.1002/(SICI)1099-1050(200003)9:2<137::AID-HEC489>3.0.CO;2-1 CAS PubMed Web of Science® Google Scholar
- 49 Kneeshaw J. What does the public think about rationing?: a review of the evidence. In Rationing: Talking and Action in Health Care, B New (ed.). BMJ: London, 1999.
- 50 Skitka LJ, Tetlock PE. Allocating scarce resources – a contingency-model of distributive justice. J Exper Social Psychol 1992; 28(6): 491–522.
- 51 Neuberger J, Adams D, MacMaster P, Maidment A, Speed M. Assessing priorities for allocation of donor liver grafts: survey of public and clinicians. Bri Med J 1998; 317(7152): 172–175.
- 52 Ubel PA, Baron J, Asch DA. Social responsibility, personal responsibility, and prognosis in public judgments about transplant allocation. Bioethics 1999; 13(1): 57–68.
- 53 Ubel PA, Jepson C, Baron J, Mohr T, McMorrow S, Asch DA. Allocation of transplantable organs: do people want to punish patients for causing their illness? Liver Transplant 2001; 7(7): 600–607.
- 54 Furnham A, Simmons K, McClelland A. Decisions concerning the allocation of scarce medical resources. J Social Behav Personality 2000; 15(2): 185–200.
- 55 Dolan P, Tsuchiya A. Individual Choice and the Social Welfare Function: Some Theoretical Issues and Empirical Evidence from Health. Paper Series 2003. Ref 03/1. The University of Sheffield, Sheffield.
- 56 Dolan P, Cookson R, Ferguson B. Effect of discussion and deliberation on the public's views of priority setting in health care: focus group study. Br Med J 1999; 318(7188): 916–919.
- 57 Edwards RT, Boland A, Wilkinson C, Cohen D, Williams J. Choosing explicit criteria for the prioritisation of elective NHS waiting lists: survey evidence of clinical and lay preferences from Wales. In Proceedings of the Health Economists' Study Group Meeting, Birmingham, 1999.
- 58 Holmes AM. A method to elicit utilities for interpersonal comparisons. Med Decision Making 1997; 17(1): 10–20.
- 59 Dolan P, Tsuchiya A, Smith P, Shaw R, Williams A. Determining the parameters in a social welfare function using stated preference data: an application to health. Sheffield Health Economics Group Discussion Paper Series. 2002. Ref 02/2. The University of Sheffield: Sheffield.
- 60 Ubel PA, Dekay M, Baron J, Asch DA. Public preferences for efficiency and racial equity in kidney transplant allocation decisions. Transplant Proc 1996; 28(5): 2997–3002.
- 61 Block MAG, Sandiford P, Ruiz JA, Rovira J. Beyond health gain: the range of health system benefits expressed by social groups in Mexico and Central America. Social Sci Med 2001; 52(10): 1537–1550.
- 62 Culyer AJ, Wagstaff A. Equity and equality in health and health-care. J Health Econ 1993; 12(4): 431–457.
- 63 Wagstaff A. QALYs and the equity-efficiency trade-off. In Cost–Benefit Analysis, A Layard, S Glaister (eds). Cambridge University Press: Cambridge (reprinted from J Health Econ 1991; 10: 21–41, with corrections).
- 64 Johannesson M. Should we aggregate relative or absolute changes in QALYs? Health Econ 2001; 10(7): 573–577.
- 65 Lindholm L, Rosen M. On the measurement of the nation's equity adjusted health. Health Econ 1998; 7(7): 621–628.
10.1002/(SICI)1099-1050(1998110)7:7<621::AID-HEC370>3.0.CO;2-Y CAS PubMed Web of Science® Google Scholar
- 66 Lindholm L, Rosen M, Emmelin M. An epidemiological approach towards measuring the trade-off between equity and efficiency in health policy. Health Policy 1996; 35(3): 205–216.
- 67 Emmelin MAC, Lindholm LA, Stenlund HC, Dahlgren LG. Pol-ethical considerations in public health – the views of Swedish health care politicians. Eur J Public Health 1999; 9(2): 124–130.
- 68 Lindholm LA, Emmelin MA, Rosen ME. Health maximization rejected—the view of Swedish politicians. Eur J Public Health 1997; 7(4): 405–410.
- 69 Lindholm L, Rosen M, Emmelin M. How many lives is equity worth? A proposal for equity adjusted years of life saved. J Epidemiol Community Health 1998; 52(12): 808–811.
- 70 Andersson F, Lyttkens CH. Preferences for equity in health behind a veil of ignorance. Health Econ 1999; 8(5): 369–378.
10.1002/(SICI)1099-1050(199908)8:5<369::AID-HEC456>3.0.CO;2-Q CAS PubMed Web of Science® Google Scholar
- 71 Johannesson M, Gerdtham UG. A note on the estimation of the equity-efficiency trade-off for QALYs. J Health Econ 1996; 15: 359–368.
- 72 Dolan P, Robinson A. The measurement of preferences over the distribution of benefits: the importance of the reference point. Eur Econ Rev 2001; 45(9): 1697–1709.
- 73 Cuadras-Morato X, Pinto-Prades JL, Abellan-Perpinan JM. Equity considerations in health care: the relevance of claims. Health Econ 2001; 10(3): 187–205.
- 74 Olsen JA. A note on eliciting distributive preferences for health. J Health Econ 2000; 19(4): 541–550.
- 75 Choudhry N, Slaughter P, Sykora K, Naylor D. Distributional dilemmas in health policy: large benefits for a few or smaller benefits for many? J Health Serv Res Policy 1997; 2: 212–216.
- 76 Olsen JA. Persons vs years—2 ways of eliciting implicit weights. Health Econ 1994; 3(1): 39–46.
- 77 Rodriguez-Miguez E, Pinto-Prades JL. Measuring the social importance of concentration or dispersion of individual health benefits. Health Econ 2002; 11: 43–53.
- 78 Ubel PA, Dekay ML, Baron J, Asch DA. Cost-effectiveness analysis in a setting of budget constraints—is it equitable? New Engl J Med 1996; 334(18): 1174–1177.
- 79 Ubel PA, Baron J, Nash B, Asch DA. Are preferences for equity over efficiency in health care allocation ‘all or nothing’? Med Care 2000; 38(4): 366–373.
- 80 Tsuchiya A, Dolan P, Shaw R. Measuring people's preferences regarding ageism in health: some methodological issues and some fresh evidence. Social Sci Med 2003; 57(4): 687–696.
