Viewpoints among experts and the public in the Netherlands on including a lifestyle criterion in the healthcare priority setting.

CONTEXT: It remains unclear whether there would be societal support for a lifestyle criterion for the healthcare priority setting. This study examines the viewpoints of experts in healthcare and the public regarding support for a lifestyle-related decision criterion, relative to support for the currently applied criteria, in the healthcare priority setting in the Netherlands. METHODS: We conducted a Q methodology study in samples of experts in healthcare (n = 37) and the public (n = 44). Participants (total sample N = 81) ranked 34 statements that reflected currently applied decision criteria as well as a lifestyle criterion for setting priorities in healthcare. The ranking data were subjected to principal component analysis, followed by oblimin rotation, to identify clusters of participants with similar viewpoints. FINDINGS: We identified four viewpoints. Participants with Viewpoint 1 believe that treatments that have been proven to be effective should be reimbursed. Those with Viewpoint 2 believe that life is precious and every effort should be made to save a life, even when treatment still results in a very poor state of health. Those with Viewpoint 3 accept government intervention in unhealthy lifestyles and believe that individual responsibility should be taken into account in reimbursement decisions. Participants with Viewpoint 4 attribute importance to the cost-effectiveness of treatments; however, when priorities have to be set, treatment effects are considered most important. All viewpoints were supported by a mix of public and experts, but Viewpoint 1 was mostly supported by experts and the other viewpoints were mostly supported by members of the public. CONCLUSIONS: This study identified four distinct viewpoints on the healthcare priority setting in the Netherlands, each supported by a mix of experts and members of the public. There seems to be some, but limited, support for a lifestyle criterion-in particular, among members of the public. Experts seem to favour the decision criteria that are currently applied. The diversity in views deserves attention when policymakers want to adhere to societal preferences and increase policy acceptance.

Think of the Children: A Discussion of the Rationale for and Implications of the Perspective Used for EQ-5D-Y Health State Valuation.

OBJECTIVES: The recently published EQ-5D-Y valuation protocol prescribes the general public values EQ-5D-Y health states for a 10-year-old child. This child perspective differs from the individual perspective applied for valuation of adult EQ-5D instruments. This article discusses the rationale for and implications of applying a child perspective for EQ-5D-Y health state valuation. METHODS: This article was informed by an exploration of the normative and empirical literature on health state valuation. We identified and summarized key discussion points in a narrative review. RESULTS: Although valuing EQ-5D-Y health states from an individual perspective is feasible, it may be problematic for several reasons. The use of a child perspective implies that-rather than valuing one's own health-someone else's health is valued. This may require the projection of one's own beliefs, expectations, and preferences on others, which could change the decision processes underlying the elicited preferences. Furthermore, because preferences are obtained for a 10-year-old child, it is unclear if this given age as well as other (missing) information on the described child beneficiary (should) affect valuation of EQ-5D-Y health states. CONCLUSIONS: The change from an individual to a child perspective in the valuation of EQ-5D-Y will likely lead to differences in utilities. This has implications for the estimation of incremental health-related quality-of-life gains in economic evaluations of health technologies for children and adolescents and therefore might affect reimbursement decisions. Further research is necessary for gaining insight into the extent to which this impact is normatively and empirically justified.

Unit Costs of Delinquent Acts for Use in Economic Evaluations.

BACKGROUND: Youth mental health interventions aimed at reducing substance use and delinquency in adolescents compete with other types of interventions for reimbursement from public funding. Within the youth mental health domain, delinquent acts impose high costs on society. These costs should be included in economic evaluations conducted from a societal perspective. Although the relevance of these costs is recognized, they are often left out because the unit costs of delinquent acts are unknown. AIMS OF THE STUDY: This study aims to provide a method for estimating the unit costs per perpetrator of 14 delinquent acts common in the Netherlands and included in self reported delinquency questionnaires: robbery/theft with violence, simple theft/pickpocketing, receiving stolen goods, destruction/vandalism of private or public property, disorderly conduct/discrimination, arson, cybercrime, simple and aggravated assault, threat, forced sexual contact, unauthorised driving, driving under the influence, dealing in soft drugs, and dealing in hard drugs. METHODS: Information on government expenditures and the incidence of crimes, number of perpetrators, and the percentage of solved and reported crimes was obtained from the national database on crime and justice of the Research and Documentation Centre of the Ministry of Justice and Security, Statistics Netherlands, and the Council for the Judiciary in the Netherlands. We applied a top-down micro costing approach to calculate the point estimate of the unit costs for each of the delinquent acts and, subsequently, estimated the mean (SD) unit costs for each of the delinquent acts by taking random draws from a triangular distribution while taking into account a 10% uncertainty associated with the associated point estimate. RESULTS: The mean (SD) unit costs per delinquent act per perpetrator ranged between EUR495 (EUR1.30) for "Driving under the influence" and EUR33,813 (EUR78.30) for a "Cybercrime". These unit costs may be considered as outliers as most unit costs ranged between EUR 2,600 and EUR 13,500 per delinquent act per perpetrator. DISCUSSION: This study is the first to estimate the unit costs per delinquent act per perpetrator in the Netherlands. The results of this study enable the inclusion of government expenditures associated with crime and justice in economic evaluations conducted from a societal perspective. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Youth mental health interventions aimed at reducing substance use and delinquency in adolescents are increasingly subjected to economic evaluations. These evaluations are used to inform decisions concerning the allocation of scarce healthcare resources and should cover all the costs and benefits for society, including those associated with delinquent acts. IMPLICATIONS FOR HEALTH POLICIES: The results of this study facilitate economic evaluations of youth mental health interventions aimed at reducing substance use and delinquency in adolescents, conducted from a societal perspective. IMPLICATIONS FOR FURTHER RESEARCH: Based on health-economic evaluations conducted in the field of youth mental health and the results of the current study, we recommend including the estimated unit costs in guidelines for health-economic evaluations conducted from a societal perspective. Future research could aim at examining whether these unit costs require regular updating. The methodology applied in this study allows for this.

Comparing heuristic valuation processes between health state valuation from child and adult perspectives.

OBJECTIVES: Health state valuation assumes that respondents trade off between all aspects of choice tasks and maximize their utility. Yet, respondents may use heuristic valuation processes, i.e., strategies to simplify or avoid the trade-offs that are core to health state valuation. The objective of this study is to explore if heuristic valuation processes are more prevalent for valuation from a 10-year-old child's perspective compared to the use of an adult perspective. METHODS: We reused existing data in which EQ-5D health states were valued from adult and child perspectives with composite time trade-off (cTTO) and discrete choice experiment (DCE) tasks. Our analyses focused on comparing completion time and responding patterns across both perspectives. We also explored how reflective of a set of heuristic strategies respondents' choices were in both perspectives. RESULTS: We found no evidence for systematic differences in completion time across perspectives. Generally, we find different responding patterns in child perspectives, e.g., more speeding, dominance violations, and clustering of utilities at 1.0, 0.8, and 0. Very few heuristic strategies provide a coherent explanation for the observed DCE responses. CONCLUSION: Our results provide some, albeit indirect, evidence for differences in heuristic valuation processes between perspectives, although not across all data sources. Potential effects of heuristic valuation processes, such as transfer of responsibility, may be identified through studying responding patterns in cTTO and DCE responses.

Severity-Adjusted Probability of Being Cost Effective.

BACKGROUND: In the context of priority setting, a differential cost-effectiveness threshold can be used to reflect a higher societal willingness to pay for quality-adjusted life-year gains in the worse off. However, uncertainty in the estimate of severity can lead to problems when evaluating the outcomes of cost-effectiveness analyses. OBJECTIVES: This study standardizes the assessment of severity, integrates its uncertainty with the uncertainty in cost-effectiveness results and provides decision makers with a new estimate: the severity-adjusted probability of being cost effective. METHODS: Severity is expressed in proportional and absolute shortfall and estimated using life tables and country-specific EQ-5D values. We use the three severity-based cost-effectiveness thresholds (€20.000, €50.000 and €80.000, per QALY) adopted in The Netherlands. We exemplify procedures of integrating uncertainty with a stylized example of a hypothetical oncology treatment. RESULTS: Applying our methods, taking into account the uncertainty in the cost-effectiveness results and in the estimation of severity identifies the likelihood of an intervention being cost effective when there is uncertainty about the appropriate severity-based cost-effectiveness threshold. CONCLUSIONS: Higher willingness-to-pay thresholds for severe diseases are implemented in countries to reflect societal concerns for an equitable distribution of resources. However, the estimates of severity are uncertain, patient populations are heterogeneous, and this can be accounted for with the severity-adjusted probability of being cost effective proposed in this study. The application to the Netherlands suggests that not adopting the new method could result in incorrect decisions in the reimbursement of new health technologies.