Project Grant (APP1047788): "Societal and decision maker preferences for priority setting in heal... more Project Grant (APP1047788): "Societal and decision maker preferences for priority setting in health care resource allocation". We would like to thank Professor Jeffrey Richardson and the participants at the 36 th Australian Health Economics Society Conference and the International Priorities Conference 2014 for their helpful and valuable comments along with Brett Doble for useful advice.
Best worst discrete choice experiments in health: Methods and an application
Social Science & Medicine, 2013
A key objective of discrete choice experiments is to obtain sufficient quantity of high quality c... more A key objective of discrete choice experiments is to obtain sufficient quantity of high quality choice data to estimate choice models to be used to explore various policy/clinically relevant issues. This paper focuses on a relatively new form of choice experiment, 'Best Worst Discrete Choice Experiments' (BWDCEs) and their relevance to health research as a new way to meet such an objective. We explain what BWDCEs are, how and when to apply them and we present several analytical approaches to model the resulting data. We demonstrate this preference elicitation approach in an empirical application exploring preferences of 898 members of the general public in Edmonton and Calgary, Canada for treatment of cardiac arrest occurring in a public place and show the gains achieved compared to traditional analysis of first best data. We suggest that BWDCEs are a valuable way to investigate preferences in the health sector and discuss implications for task design, analysis and areas for future research.
Advances in Accounting for Income Effects in the Derivation of Welfare Measures from Discrete Choice Experiments
Social Science Research Network, 2007
Monetary valuation of both health and non health outcomes using stated preference data is gaining... more Monetary valuation of both health and non health outcomes using stated preference data is gaining currency in health economics. Discrete choice experiments (DCEs) offer one form of stated preference data used for this purpose. In particular, the Hicksian compensating variation can be used to calculate willingness to pay (WTP) or willingness to accept (WTA) compensation arising from a policy change. This essentially involves a comparison of expected utility pre and post the policy change weighted by the marginal utility of income. To date in empirical applications in health, utility is usually assumed to be linear in income, or put another way, the marginal utility of income is assumed to be constant across respondents, producing constant WTP across individuals. That the marginal utility of income and WTP need not be constant across individuals was highlighted by the current authors in previous work which presented a method for calculating measures of welfare change from discrete choice random utility models allowing for non constant dependence of utility on income using evidence from a pilot study. The current paper builds on this earlier pilot work by presenting a more refined approach to esitmating WTP from choice experiments taking account of individual differences and demonstrates this in an empirical application with a larger sample size. Advantages of using this approach are outlined and further implications for the derivation of welfare measures from DCEs is discussed.
Despite the label "generic" health state utility instruments (HSUIs), empirical evidence shows th... more Despite the label "generic" health state utility instruments (HSUIs), empirical evidence shows that different HSUIs generate different estimates of Health-Related Quality of Life (HRQoL) in the same person. Once a HSUI is used to generate a QALY, the difference between HSUIs is often ignored, and decisionmakers act as if 'a QALY is a QALY is a QALY'. Complementing evidence that different generic HSUIs produce different empirical values, this study addresses an important gap by exploring how HSUIs differ, and processes that produced this difference. 15 developers of six generic HSUIs used for estimating the QOL component of QALYs: Quality of Well-Being (QWB) scale; 15 Dimension instrument (15D); Health Utilities Index (HUI); EuroQol EQ-5D; Short Form-6 Dimension (SF-6D), and the Assessment of Quality of Life (AQoL) were interviewed in 2012-2013. Principal findings: We identified key factors involved in shaping each instrument, and the rationale for similarities and differences across measures. While HSUIs have a common purpose, they are distinctly discrete constructs. Developers recalled complex developmental processes, grounded in unique histories, and these backgrounds help to explain different pathways taken at key decision points during the HSUI development. The basis for the HSUIs was commonly not equivalent conceptually: differently valued concepts and goals drove instrument design and development, according to each HSUI's defined purpose. Developers drew from different sources of knowledge to develop their measure depending on their conceptualisation of HRQoL. Major conclusions/contribution to knowledge: We generated and analysed first-hand accounts of the development of the HSUIs to provide insight, beyond face value, about how and why such instruments differ. Findings enhance our understanding of why the six instruments developed the way they did, from the perspective of key developers of those instruments. Importantly, we provide additional, original explanation for why a QALY is not a QALY is not a QALY. Quality Adjusted Life Years (QALYs) are the dominant measure of health benefit used in economic evaluation to inform health care resource allocation decisions. QALYs account for both length of life and health related quality of life (HRQoL) in a single index. Over the past four decades, a small number of generic preference-weighted health state utility instruments (HSUIs; also referred to as multi-dimension utility instruments) have been developed to measure HRQoL for use in QALYs. Health state utility measurement comprises two main elements: (a) a health state classification system: defining and describing a set of health states of interest, usually presented as a standardised questionnaire, and (b) valuation of those health states to generate the HRQoL weights used to generate QALYs. Six generic HSUIs are used most widely for estimating the quality of
Preparing for future pandemics: A multi‐national comparison of health and economic trade‐offs
Health Economics
Government investment in preparing for pandemics has never been more relevant. The COVID‐19 pande... more Government investment in preparing for pandemics has never been more relevant. The COVID‐19 pandemic has stimulated debate regarding the trade‐offs societies are prepared to make between health and economic activity. What is not known is: (1) how much the public in different countries are prepared to pay in forgone GDP to avoid mortality from future pandemics; and (2) which health and economic policies the public in different countries want their government to invest in to prepare for and respond to the next pandemic. Using a future‐focused, multi‐national discrete choice experiment, we quantify these trade‐offs and find that the tax‐paying public is prepared to pay $3.92 million USD (Canada), $4.39 million USD (UK), $5.57 million USD (US) and $7.19 million USD (Australia) in forgone GDP per death avoided in the next pandemic. We find the health policies that taxpayers want to invest in before the next pandemic and the economic policies they want activated once the next pandemic hit...
Willingness to pay (WTP) is used to generate information about value. However, when comparing 2 o... more Willingness to pay (WTP) is used to generate information about value. However, when comparing 2 or more services using standard WTP techniques, the amounts elicited from participants for the services are often similar, even when individuals state a clear preference for one service over another. An incremental approach has been suggested, in which individuals are asked to first rank interventions and provide a WTP value for their lowest-ranked intervention followed by then asking how much more they are willing to pay for their next preferred choice and so on. To date, evaluation of this approach has disregarded protest responses, which may give information on consistency between stated and implicit rankings. Methods. A representative sample of the English population (n = 790) were asked to value 5 dental services adopting a societal perspective, using a payment vehicle of additional household taxation per year. The sample was randomized to either the standard or the incremental approach. Performance for both methods is assessed on discrimination between values for interventions and consistency between implicit and stated ranks. The data analysis is the first to retain protest responses when considering consistency between ranks. Retaining protest responses reveals inconsistencies between the stated and implicit ranks are present in both approaches but much reduced in the incremental approach. Conclusion. The incremental approach does not improve discrimination between values, yet there is less inconsistency between ranks. The protest responses indicate that objections to giving values to the dental interventions are dependent on a multitude of factors beyond the elicitation process.
Background: Resources in any healthcare systems are scarce relative to need and therefore choices... more Background: Resources in any healthcare systems are scarce relative to need and therefore choices need to be made which often involve difficult decisions about the best allocation of these resources. One pragmatic and robust tool to aid resource allocation is Programme Budgeting and Marginal Analysis (PBMA), but there is mixed evidence on its uptake and effectiveness. Furthermore, there is also no evidence on the incorporation of the preferences of a large and representative sample of the general public into such a process. The study therefore aims to undertake, evaluate and refine a PBMA process within the exemplar of NHS dentistry in England whilst also using an established methodology (Willingness to Pay (WTP)) to systematically gather views from a representative sample of the public. Methods: Stakeholders including service buyers (commissioners), dentists, dental public health representatives and patient representatives will be recruited to participate in a PBMA process involving defining current spend, agreeing criteria to judge services/interventions, defining areas for investment and disinvestment, rating these areas against the criteria and making final recommendations. The process will be refined based on participatory action research principles and evaluated through semi-structured interviews, focus groups and observation of the process by the research team. In parallel a representative sample of English adults will be recruited to complete a series of four surveys including WTP valuations of programmes being considered by the PBMA panel. In addition a methodological experiment comparing two ways of eliciting WTP will be undertaken. Discussion: The project will allow the PBMA process and particularly the use of WTP within it to be investigated and developed. There will be challenges around engagement with the task by the panel undertaking it and with the outputs by stakeholders but careful relationship building will help to mitigate this. The large volume of data will be managed through careful segmenting of the analysis and the use of the well-established Framework approach to qualitative data analysis. WTP has various potential biases but the elicitation will be carefully designed to minimise these and some methodological investigation will take place.
JDR clinical and translational research, Nov 29, 2021
This study illustrates a framework for resource allocation in dental health services and will aid... more This study illustrates a framework for resource allocation in dental health services and will aid decision makers in implementing their own resource allocation systems.
Frameworks for Priority Setting in Health and Social Care
Health and social care organizations work within the context of limited resources. Different tech... more Health and social care organizations work within the context of limited resources. Different techniques to aid resource allocation and decision-making exist and are important as scarcity of resources in health and social care is inescapable. Healthcare systems, regardless of how they are organized, must decide what services to provide given the resources available. This is particularly clear in systems funded by taxation, which have limited budgets and other limited resources (staff, skills, facilities, etc.) and in which the claims on these resources outstrip supply. Healthcare spending in many countries is not expected to increase over the short or medium term. Therefore, frameworks to set priorities are increasingly required. Four disciplines provide perspectives on priority setting: economics, decision analysis, ethics, and law. Although there is overlap amongst these perspectives, they are underpinned by different principles and processes for priority setting. As the values and viewpoints of those involved in priority setting in health and social care will differ, it is important to consider how these could be included to inform a priority setting process. It is proposed that these perspectives and the consideration of values and viewpoints could be brought together in a combined priority setting framework for use within local health and social care organizations.
Assessment (HTA) programme, part of the National Institute for Health Research (NIHR), was set up... more Assessment (HTA) programme, part of the National Institute for Health Research (NIHR), was set up in 1993. It produces high-quality research information on the effectiveness, costs and broader impact of health technologies for those who use, manage and provide care in the NHS. 'Health technologies' are broadly defined as all interventions used to promote health, prevent and treat disease, and improve rehabilitation and long-term care. The research findings from the HTA programme directly influence decision-making bodies such as the National Institute for Health and Clinical Excellence (NICE) and the National Screening Committee (NSC). HTA findings also help to improve the quality of clinical practice in the NHS indirectly in that they form a key component of the 'National Knowledge Service'. The HTA programme is needs led in that it fills gaps in the evidence needed by the NHS. There are three routes to the start of projects. First is the commissioned route. Suggestions for research are actively sought from people working in the NHS, from the public and consumer groups and from professional bodies such as royal colleges and NHS trusts. These suggestions are carefully prioritised by panels of independent experts (including NHS service users). The HTA programme then commissions the research by competitive tender. Second, the HTA programme provides grants for clinical trials for researchers who identify research questions. These are assessed for importance to patients and the NHS, and scientific rigour. Third, through its Technology Assessment Report (TAR) call-off contract, the HTA programme commissions bespoke reports, principally for NICE, but also for other policy-makers. TARs bring together evidence on the value of specific technologies. Some HTA research projects, including TARs, may take only months, others need several years. They can cost from as little as £40,000 to over £1 million, and may involve synthesising existing evidence, undertaking a trial, or other research collecting new data to answer a research problem. The final reports from HTA projects are peer reviewed by a number of independent expert referees before publication in the widely read journal series Health Technology Assessment. Criteria for inclusion in the HTA journal series Reports are published in the HTA journal series if (1) they have resulted from work for the HTA programme, and (2) they are of a sufficiently high scientific quality as assessed by the referees and editors. Reviews in Health Technology Assessment are termed 'systematic' when the account of the search, appraisal and synthesis methods (to minimise biases and random errors) would, in theory, permit the replication of the review by others.
One response to the major societal challenge of financial exclusion in the United Kingdom (UK) is... more One response to the major societal challenge of financial exclusion in the United Kingdom (UK) is microcredit lending for enterprise. Typically delivered via Community Development Finance Institutions (CDFIs) in the UK, these lending institutions can be conceptualised as 'alternative' economic spaces. Yet the nature of their alterity is unclear as categorisations of alternative-oppositional or alternative-substitute institutions are possible and could also be influenced by complexities in the UK relating to the welfare system and sustainability. Alterity is rarely static, being influenced by policies and regulation, and the nature of institutions' alterity could have consequences for wellbeing, as different values and ideals underpin different conceptions of alterity which affect how these institutions operate. In this paper, the complexities of microcredit for enterprise lending within the UK are explored through in-depth interviews with UK 'supply-side' stakeholders. Conceptions of alterity are then used as an analytic lens to examine these results. Results suggest that these lenders remain in opposition to the mainstream as the needs of low-income individuals are embedded within their operating model. Microcredit lending is conceptualised in terms of responsible lenders offering fair credit to financially-excluded individuals using relationship banking practices. Such a conceptualisation provides a touchstone against which to assess shifts in lenders' alterity and a platform from which to introduce legislative and regulatory changes to protect these 'alternative-oppositional' economic spaces. This paper begins to outline these responses that could help to ensure and grow a more community-engaged and varied local financial infrastructure within the UK.
Views, obstacles, and uncertainties around the inclusion of children and young people's time in economic evaluations: Findings from an international survey of health economists
IntroductionThis research investigates how community-led organisations’ (CLOs’) use of assets-bas... more IntroductionThis research investigates how community-led organisations’ (CLOs’) use of assets-based approaches improves health and well-being, and how that might be different in different contexts. Assets-based approaches involve ‘doing with’ rather than ‘doing to’ and bring people in communities together to achieve positive change using their own knowledge, skills and experience. Some studies have shown that such approaches can have a positive effect on health and well-being. However, research is limited, and we know little about which approaches lead to which outcomes and how different contexts might affect success.Methods and analysisUsing a realist approach, we will work with 15 CLOs based in disadvantaged communities in England, Scotland and Northern Ireland. A realist synthesis of review papers, and a policy analysis in different contexts, precedes qualitative interviews and workshops with stakeholders, to find out how CLOs’ programmes work and identify existing data. We will ...
IntroductionTo ensure that the evidence generated by health technology assessment (HTA) is transl... more IntroductionTo ensure that the evidence generated by health technology assessment (HTA) is translated to policy, it is important to generate a threshold value against which the outcomes of HTA studies can be compared. In this context, the present study delineates the methods that will be deployed to estimate such a value for India.Methods and analysisThe proposed study will deploy a multistage sampling approach considering economic and health status for selection of states, followed by selection of districts based on Multidimensional Poverty Index (MPI) and identification of primary sampling units (PSUs) using the 30-cluster approach. Further, households within PSU will be identified using systematic random sampling and block randomisation based on gender will be done to select respondent from the household. A total of 5410 respondents will be interviewed for the study. The interview schedule will comprise of three sections including background questionnaire to elicit socioeconomic ...
Background and Objectives Valuing children's health states for use in economic evaluations is glo... more Background and Objectives Valuing children's health states for use in economic evaluations is globally relevant and is of particular relevance in jurisdictions where a cost-utility analysis is the preferred form of analysis for decision making. Despite this, the challenges with valuing child health mean that there are many remaining questions for debate about the approach to elicitation of values. The aim of this paper was to identify and describe the methods used to value children's health states and the specific issues that arise in the use of these methods. Methods We conducted a systematic search of electronic databases to identify studies published in English since 1990 that used preference elicitation methods to value child and adolescent (under 18 years of age) health states. Eligibility criteria comprised valuation studies concerning both child-specific patient-reported outcome measures and child health states defined in other ways, and methodological studies of valuation approaches that may or may not have yielded a value set algorithm. Results A total of 77 eligible studies were identified from which data on country setting, aims, condition (general population or clinically specific), sample size, age of respondents, the perspective that participants were asked to adopt, source of values (respondents who completed the preference elicitation tasks) and methods questions asked were extracted. Extracted data were classified and evaluated using narrative synthesis methods. The studies were classified into three groups: (1) studies comparing elicitation methods (n = 30); (2) studies comparing perspectives (n = 23); and (3) studies where no comparisons were presented (n = 26); selected studies could fall into more than one group. Overall, the studies varied considerably both in methods used and in reporting. The preference elicitation tasks included time trade-off, standard gamble, visual analogue scaling, rating/ranking, discrete choice experiments, bestworst scaling and willingness to pay elicited through a contingent valuation. Perspectives included adults' considering the health states from their own perspective, adults taking the perspective of a child (own, other, hypothetical) and a child/adolescent taking their own or the perspective of another child. There was some evidence that children gave lower values for comparable health states than did adults that adopted their own perspective or adult/parents that adopted the perspective of children. Conclusions Differences in reporting limited the conclusions that can be formed about which methods are most suitable for eliciting preferences for children's health and the influence of differing perspectives and values. Difficulties encountered in drawing conclusions from the data (such as lack of consensus and poor reporting making it difficult for users to choose and interpret available values) suggest that reporting guidelines are required to improve the consistency and quality of reporting of studies that value children's health using preference-based techniques.
Page 12 of 106 "all that happens is that people feel less and less empowered, because they feel t... more Page 12 of 106 "all that happens is that people feel less and less empowered, because they feel the government controls more and more of their lives, less and less is within their control, they take less and less responsibility [reference to top-down social policies]" (PS02) "if from when you are little you are told by your environment that you cannot, that you are limited because you don't deserve it, limited by your background, because you don't have money, and you believe that in your mind, that is going to limit you and make you think that you are useless. Create confident kids, deserving and able of everything, we are limitless" (CP13)
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