Discounting in economic evaluation of healthcare interventions: what about the risk term?

Results from economic evaluations of long-term outcomes are strongly dependent on the chosen discount rate. A recent review of national guidelines for evaluation of healthcare interventions finds that "the level of currently used discount rates seems relatively high in many countries". However, this conclusion comes from a comparison to rates derived or observed for investments in safe assets, while rate of return requirements are typically considerably higher when investment involves risk. This paper reviews recent literature on how to account for project-specific risk in determination of the social rate of discount and discusses implications for economic evaluation of healthcare interventions. It concludes that the available empirical evidence strongly suggests that the demand for and consumer value of health and healthcare is co-variant with income, which therefore implies that there is a non-diversifiable risk component of health-related investment.

Economic Return on Investment of Parent Training Programmes for the Prevention of Child Externalising Behaviour Problems.

Economic models to inform decision-making are gaining popularity, especially for preventive interventions. However, there are few estimates of the long-term returns to parenting interventions used to prevent mental health problems in children. Using data from a randomised controlled trial evaluating five indicated parenting interventions for parents of children aged 5-12, we modeled the economic returns resulting from reduced costs in the health care and education sector, and increased long-term productivity in a Swedish setting. Analyses done on the original trial population, and on various sized local community populations indicated positive benefit-cost ratios. Even smaller local authorities would financially break-even, thus interventions were of good value-for-money. Benefit-cost analyses of such interventions may improve the basis for resource allocation within local decision-making.

Dread and Risk Elimination Premium for the Value of a Statistical Life.

The value of a statistical life (VSL) is a widely used measure for the value of mortality risk reduction. As VSL should reflect preferences and attitudes to risk, there are reasons to believe that it varies depending on the type of risk involved. It has been argued that cancer should be considered a "dread disease," which supports the use of a "cancer premium." The objective of this study is to investigate the existence of a cancer premium (for pancreatic cancer and multiple myeloma) in relation to road traffic accidents, sudden cardiac arrest, and amyotrophic lateral sclerosis (ALS). Data were collected from 500 individuals in the Swedish general population of 50-74-year olds using a web-based questionnaire. Preferences were elicited using the contingent valuation method, and a split-sample design was applied to test scale sensitivity. VSL differs significantly between contexts, being highest for ALS and lowest for road traffic accidents. A premium (92-113%) for cancer was found in relation to road traffic accidents. The premium was higher for cancer with a shorter time from diagnosis to death. A premium was also found for sudden cardiac arrest (73%) and ALS (118%) in relation to road traffic accidents. Eliminating risk was associated with a premium of around 20%. This study provides additional evidence that there exist a dread premium and risk elimination premium. These factors should be considered when searching for an appropriate value for economic evaluation and health technology assessment.

The value of a statistical life in Sweden: a review of the empirical literature.

Recent focus on cost-benefit/socio-economic assessment of government "life-saving" programmes within public health, pharmaceutics, transport, and civil contingencies has spurred a wave of empirical research on the value of a statistical life (VSL) in Sweden. This paper provides an overview of the received evidence from a range of studies in one country and over a relatively short time period. A literature search was conducted in Econlit, Pubmed, Google Scholar and in bibliographies of published papers. Twelve studies on VSL with a total of 48 VSL estimates, published with data from Sweden from 1996 onwards, were identified. Among all estimates VSL varies from 9 to 1121 million SEK (€0.9-121 million). Based on a set of additional quality inclusion criteria, as used also in a recent global review of VSL studies, the sample is restricted to 9 studies with a total of 29 VSL estimates with VSL varying from 9 to 98 million SEK (€0.9-10.6 million). The raw mean among these estimates is 34.6 million SEK (€3.7 million) and the median is 23 million SEK (€2.5 million). Currently, official authorities in Sweden recommend a VSL of 22 million Swedish kronor (€2.4 million). We also point out important concerns regarding validity of these estimates: primarily the problem that VSL is significantly related to the size of the mortality risk reduction showing significant scale insensitivity, in contrast to theoretical assumptions but in line with previous empirical findings.