FREE ELECTRONIC LIBRARY - Dissertations, online materials

Pages:     | 1 |   ...   | 21 | 22 || 24 | 25 |   ...   | 27 |

«Edited by ANNE MASON Research Fellow, Centre for Health Economics University of York and ADRIAN TOWSE Director, Office of Health Economics Radcliffe ...»

-- [ Page 23 ] --

At the end of the 1980s, Dutch policy makers were searching for ways to limit the growth of expenditure on health care. Reports were published with titles such as ‘Limits to growth’ (of the insurance package), and a national debate was fought over ‘Dunning’s filter’ (named after a professor of cardiology), a system devised to stop inefficient, costly and unnecessary technologies from receiving reimbursement. All this activity implied that choices had to be made about funding health care: choices about what should and should not be reimbursed and for whom and under what conditions. Moreover, the mechanisms by which such choices were made needed to be transparent, because explicit choices are open to debate. At the same time, the Dutch government initiated a number of large studies, fashionably called ‘technology assessments’, to evaluate heart transplantation, liver transplantation and in vitro fertilisation. At the centre of these studies was the assessment of costs and effects. In those days, methods to assess the cost-effectiveness of public programmes could be found in the text books of Mishan (1982), Dasgupta and Pearce (1978) and Sugden and Williams (1978). They offered researchers a frame of reference in which changes were assessed using concepts such as ‘opportunity costs’ ‘equivalent variation’ and ‘compensating variation’.

‘Compensating variation’ refers to the amount of money that one has to give a person to make him as happy after a change as he was before that change. In 1978, Broome pointed out that it is somewhat difficult to establish


the amount of money needed to make dead people as happy as when they were alive and that ‘the attempt to value life in terms of money is more or less doomed to failure’ (Broome, 1978). A lively debate followed in which Alan Williams (Williams, 1979) was one of several famous economists (JonesLee, 1979; Mishan, 1981) who wrote replies to Broome’s critique. Mishan’s offer to help ‘to clear the cobwebs from his [Broome’s] mind and to restore perspective’ illustrates that the economists were not persuaded by Broome’s arguments. However, an atmosphere was created in which it seemed politically incorrect to value the effects of medical treatments in monetary terms. It is possible that this catalysed Alan Williams’s efforts to try to develop a less controversial measure that could be used without the accusation of applying a single-minded, short-sighted, internally inconsistent pseudo-science.


Researchers in York were not the only ones searching for a scale to enable the comparison of treatment effects in different therapeutic areas for the sole purpose of the application in economic analyses. Dutch researchers were facing the same questions, and the contact between York and Rotterdam was also mediated via Brunel where Martin Buxton was sharing similar experiences concerning the evaluation of heart and liver transplantation. In my view, the central problem posed by the founding members of the EuroQol group was not – as Kind states – whether values for health differ between countries, but rather an economic one: to devise a metric that could be used in economic evaluations that would facilitate the decision-making process for policy makers. The presence of psychologists in the group was – from the perspective of the economists – instrumental. They didn’t share the same problem, but they did hold most of the solution. And while the landmark publication about the cost-effectiveness of bypass surgery (Williams, 1985) could never have been written without the work of Rosser and Kind, it should be noted that QALYs have always been designed as a solution to an economic problem: the allocation of scarce resources within health care based on the assessment of costs and effects.

QALY The ‘best’ way to derive the values which inform the Q element of the QALY may remain the subject of debate for many years to come. This process may be prolonged if the same system is also expected to be used for decisions other than those to do with resource allocation. One reason for this is that it is often very unclear what people mean by ‘best’. When the goal is to support decision making it is indeed the extent to which the public remains convinced of the probity of the process and its outcomes. And indeed, when harsh decisions are taken there will always be groups who are disadvantaged and who will DISCUSSION OF ‘PUTTING THE “Q” IN QALYS’ 129 challenge the methods that were used. However, as Kind notes, the occasions where QALY calculations have been crucial, are limited. From a decision maker’s perspective, the calculation of the balance between cost and effects is like a diagnostic test. Sometimes an intervention is clearly not cost-effective, sometimes it clearly is cost-effective but often one has to do some additional work. This may be in the form of additional research, additional considerations or both. The balance between costs and effects is assessed to define whether we are in a white, a black or in a grey area. Thresholds, such as say £30 000 per QALY gained, may be a trigger for doubts and for further thoughts. Such doubts are usually more about whether the threshold is correct, whether there are sufficient numbers of patients, whether the trial data are generalisable or whether there should be certain restrictions, than about the valuation technique used to calculate the QALY weights. This leads to a more pragmatic approach, or what may be termed ‘a decision-maker’s approach’. Such a view is probably quite close to the one held by Alan Williams, and one wonders whether he was one of the purist health economists Kind refers to. Alan’s decisions to transform the values under 0 to a limit of –1, and to use means instead of medians (something he later seemed to regret), suggested that he was not. For him, political acceptability seemed to score more highly than scientific rigour. Additionally, Alan was also very aware of Joan Robinson’s view that ‘Utility is a metaphysical concept of impregnable circularity; utility is the quality in commodities that makes individuals want to buy them, and the fact that individuals want to buy them shows that they have utility’ (Robinson, 1962). In other words ‘real economists’ know that they can’t measure utility, but can only derive it by observing real behaviour, something that in health care is rarely done. Instead, economists are asked to ‘prescribe’ what a society should decide rather than ‘describe’ what ‘typical’ people do decide. Moreover, they do not really have any experience with doing this. Given that the whole question is about choices, and given that it has to be done on a collective basis, it may be best to derive the answers by asking people to decide in imaginary situations. Whatever the method, the concept of choice is eminently present.


The fact that decision makers might be less worried about the theoretical underpinnings of their value sets than purist economists (whoever these are) does not mean that they do not have any preferences about the ideal attributes for a value set. A good start might be a scale that puts 1 at perfect health, dead at 0, non-perfect states that are better than dead between 0 and 1, and states worse than dead below 0. Additionally, the scale would ideally have cardinal properties such that a year in a state of 0.50 is about equal to two years in

0.25. The latter is a harsh requirement whatever the technique used to derive the scale. As Kind points out, time trade-off and standard gamble seem to be the preferred methods, with visual analogue scaling, category rating and


some discrete choice models following at a respectable distance. According to Kind, this distance was created by NICE and not by theory. Unfortunately, nobody will ever know whether he is right or wrong. There is no gold standard, and the fact that discrete choice models are often used in other areas does not mean that they give the right scale, either in their existing applications or in health.

When the aim is to value and compare a number of life years gained in states x, y and z, TTO seems to be the method that most closely reflects the question, in that it explicitly asks for the value of a given number of years in these health states. In contrast, standard gamble requires one to imagine a risk-taking situation. Visual analogue scaling and category rating only have an implicit choice element. Furthermore, all the discrete-choice methods need additional heroic assumptions before being able to derive a meaningful scale.

Research has shown that each method produces a slightly different scale.

All methods seem to have their pros and cons. In order to decide whether one is better than any other, one has to define ‘better’. Better – in light of the use in economic evaluations (the beginning of the EuroQol group) should be concerned with whether a different method would lead to decisions that better reflect what the majority of society prefers. At this point one may also wonder whether a different method would lead to any change in the decisions that are currently being taken. In addition, the decisions have to be defended in public and, in the absence of a gold standard, basing them on a method that seems intuitively closest to the original question seems as good as any other.

There are a number of different value functions for EQ-5D available, based on different sets of data. The so called ‘A1 tariff’, as derived from the TTO questions in the MVH study, is probably most often used. This is not only in the UK but also in the Netherlands where the logical preference for a Dutch tariff does not always prevail. The perceived effect on the probability of an international publication often outweighs any other argument. Indeed it is questionable whether using other value sets leads to different orderings of therapies which should be reimbursed. And indeed it may be suggested – as Kind does – that it is a scientific duty to keep on checking whether we are still on the right path. However, there is also something of a scientific duty to focus one’s brain-power where it is most needed. This may be what Claxton (1999) refers to when considering the value of perfect information. And one may wonder whether Alan Williams wasn’t one of the first to apply this concept when allocating his research activities away from QALYs, towards other issues such as those about equity weights?


Each valuation method has its own advantages and disadvantages, and one may never get to a gold standard in the sense of a perfect diagnostic test. The DISCUSSION OF ‘PUTTING THE “Q” IN QALYS’ 131 word ‘gold standard’ however may apply in its more traditional meaning. Just as in the late 19th century gold was arbitrarily chosen above silver after years of attempts to maintain a bimetallic standard, TTO might just be accepted as the standard. Maybe one should just accept that Alan Williams – or the MVH study for that matter – has defined TTO as the gold standard, just like the Germans decided in favour of gold when they wanted to be paid after the 100-year war.

ABOUT TTO That TTO may be identified as the ‘reasonable’ Alan Williams way and thus as the way to go, does not imply that it is beyond improvement. For example TTO was used to estimate the impact of various degrees of erectile dysfunction and estimated the QALY weight for a complete dysfunctional state at 0.74 (Stolk et al., 2000). This led to a very favourable cost-effectiveness ratio for Viagra.

But the Dutch government decided not to reimburse it. This suggests that the valuation was not accepted to really reflect the disease burden. And indeed, taking a chance of 25% to die on an operating table, or to be in coma for almost two days a week just to be perfectly ‘erectile ready’ for the rest of the week, may seem rather high. This is especially so considering that medications that have to be injected into the penis – and that offer effective relief of the problem – are hardly ever used. This type of revealed preference suggests that maybe this isn’t as serious a health problem as Stolk’s work implies.

Does this study mean that we should use a different method to TTO? Not necessarily, but is does suggest that maybe one should be careful applying TTO in a disease-specific context.

Defining TTO as the gold standard does not mean that one should stop exploring alternatives. However, it would be foolish not to anchor that work within the rich experience that is already available. Additionally, it would be rather foolish to step away from the face-validity that TTO brings with it.

Any discrete-choice study aiming to establish value sets could be improved if informed by TTO values for a number of the states being evaluated. Analyses are needed in which times are traded off without using ‘perfect health’ as a comparator. Additionally, a deeper understanding of the values elicited using TTO is needed. The observation that respondents especially disagree about the positioning of ‘death’ (Macran and Kind, 2001) warrants further research.


I think that knowing Alan Williams personally – talking to him at conferences – increased my scientific ‘street cred’ among other Dutch researchers. Knowing Alan was ‘cool’. Moreover he has helped us, less talented health economists, so often. Whenever some ethicist stood up to challenge the fruits of our research, he was the first to take up the challenge and did so with a flair that many can


only aspire to ever reach. He led an international battle, not just a personal or a UK one.

Alan Williams made an impact on many, and those who met him or read his work will easily remember him. There are parts of the world where one is not really dead as long as one is still remembered. This may imply that one is ‘more dead’ when remembered by only one person than when remembered by thousands; perhaps this might be scored on a type of ‘scale’, measuring how much someone lives on in other people’s memories. On this scale – assuming that health economists count too – he might be close to being alive. I like that thought.

ACKNOWLEDGEMENTSI would like to thank Susan Macran for very helpful comments.

Pages:     | 1 |   ...   | 21 | 22 || 24 | 25 |   ...   | 27 |

Similar works:

«University of Szeged Faculty of Economics and Business Administration Doctoral School in Economics Zoltán Bajmócy The Theory of Technology Business Incubation and Opportunities of Application in the Less Favoured Regions of Hungary Theses of PhD Dissertation Supervisor: Prof. Dr. Lengyel Imre, DSc Head of department University of Szeged Faculty of Economics and Business Administration Institute of Economics and Economic Development Szeged, 2007. The Theory of Technology Business Incubation...»

«Vol. 2 Spring 2011 Dear Friends of EMU Department of Economics, Last year has been an exciting and challenging, yet energetic time for the department. It has been exciting to witness students’ success, faculty development, and the return of our alumni and their families. It has been challenging to move the department out of Pray-Harrold for the renovation, which will be completed in August 2011. It has been an energetic time as so many people worked hard to have a successful and great year. I...»

«3 December 2012 CABLE & WIRELESS COMMUNICATIONS PLC Agreement on Monaco & Islands Disposal Cable & Wireless Communications Plc (CWC or “the Company”) today announces that it has agreed with Batelco Group (Batelco) the sale of the majority of the businesses within its Monaco & Islands division for an enterprise value of US$680 million (the “Disposal”). CWC will divest its entire shareholdings in its businesses in the Maldives, Channel Islands and Isle of Man, the Seychelles, South...»

«The impact of high and volatile commodity prices on public finances: Evidence from developing countries Hélène Ehrhart*and Samuel Guérineau† Abstract The recent boom and bust in commodity prices has renewed the policymakers’ interest in three complementary issues: i) characteristics and determinants of commodity price instability, ii) its macroeconomic effects and, iii) the optimal policy responses to this instability. This work falls within the scope of studies dedicated to the...»

«Structural Times Series Modelling of Energy Demand Zafer Dilaver Surrey Energy Economics Centre (SEEC) School of Economics Faculty of Business, Economics and Law University of Surrey Guildford UK A Thesis Submitted to University of Surrey For the Degree of Doctor of Philosophy in Economics October 2012 TABLE OF CONTENTS Table of Contents List of Tables List of Figures Glossary Abstract Declaration...xv Acknowledgements...xvi CHAPTER 1: Introduction 1.1 Introduction 1.2 Research Questions 1.3...»

«15.2.2014 1. Curriculum Vita Name: Nissim Ben-David )‫(נסים בן דוד‬ Place of Birth: Israel Marital Status: Married + 3 Academic Degree: Professor (Ph.D.) Electronic Address: nissimB@yvc.ac.il, nissim11@matav.net.il Internet web site: www.ofekmodels.co.il Phone: 9724-6398847, 97250-7314999 Fax Number: 97246291452 2. Academic Degrees Date Institution Degree Department Field of Study Period Granted Tel-Aviv B. A 1984 Economics Economics 1981-1984 University Tel-Aviv M. A 1986...»

«This PDF is a selection from a published volume from the National Bureau of Economic Research Volume Title: Corruption and Reform: Lessons from America's Economic History Volume Author/Editor: Edward L. Glaeser and Claudia Goldin, editors Volume Publisher: University of Chicago Press Volume ISBN: 0-226-29957-0 Volume URL: http://www.nber.org/books/glae06-1 Conference Date: July 30-31, 2004 Publication Date: March 2006 Title: Bank Chartering and Political Corruption in Antebellum New York. Free...»

«DRAFT Adelphi Friends Meeting Meeting for Worship for the Conduct of Business First Month, Eleventh Day, 2004 (January 11, 2004) Meeting began with a period of silent worship. The Clerk read the queries for the first month from Baltimore Yearly Meeting's Faith & Practice: Are meetings for worship held in expectant waiting for Divine guidance? Are Friends encouraged to share spiritual insights? Are special gifts of ministry recognized and encouraged? Do you come to meeting with heart and mind...»

«LISA K. MEULBROEK Claremont McKenna College Phone: 909-607-7363 500 E. Ninth St. Fax: 909-621-8249 Claremont, MA 91711 E-mail: lmeulbroek@mckenna.edu Experience Claremont McKenna College Claremont, CA Fritz B. Burns Associate Professor of Economics, Fall 2003 Massachusetts Institute of Technology Cambridge, MA Sloan School of Management Visiting Associate Professor, 2002 Harvard Business School Boston, MA Associate Professor, Finance, 1996-2002 Assistant Professor, Finance, 1991-1996 Securities...»

«Journal of Advertising Research Digital First, February 2015 www.journalofadvertisingresearch.com E-Word of Mouth: Early Predictor Of Audience Engagement — How Pre-Release E-WOM Drives Box-Office Outcomes of Movies C. Samuel Craig and William H. Greene Stern School of Business Anthony Versaci AIG INTRODUCTION Few industries are helped (or harmed) more by off-line and online word of mouth (WOM) than the movie business. The results are immediate and either can doom a film to early failure or...»

«Conference Towards implementing European Public Sector Accounting Standards 29-30 May 2013 Room Alcide de Gasperi Charlemagne Rue de la Loi 170, 1040 Brussels EUROPEAN COMMISSION EUROSTAT Directorate D Government Finance Statistics (GFS) Unit D-4: GFS quality management and government accounting 2 Aim of the conference This conference, hosted by Eurostat and Mr Algirdas Šemeta, Commissioner for Taxation, Customs, Statistics, Audit and Anti-fraud, will bring together high-level stakeholders and...»

«PART FIVE JUDAIC SOCIAL THOUGHT www.fraserinstitute.org www.fraserinstitute.org Chapter 10 Judaism's Historical Response to Economic, Social and Political Systems Ellis Rivkin It is pointless to ask a critically minded scholar what Judaism teaches about economic, social, and political systems. The biblical beginnings The Jewish people had their beginnings as semi-nomads sojourning in the land of Canaan. Their society was patriarchal, and their God was pictured as an eternal patriarch who had...»

<<  HOME   |    CONTACTS
2016 www.dissertation.xlibx.info - Dissertations, online materials

Materials of this site are available for review, all rights belong to their respective owners.
If you do not agree with the fact that your material is placed on this site, please, email us, we will within 1-2 business days delete him.