Do they just know more, or do they also have different preferences? An exploratory analysis of the effects of self-reporting serious health problems on health state valuation.

BACKGROUND: Health state valuation is often conducted by people valuing either only their own health state (experience-based valuation) or several stylised states (hypothetical valuation). The approach used can affect the elicited values, but it is not clear whether this is caused by different understandings of the states (an "information mechanism") and/or by different opinions of the states (a "preference mechanism"). Justifying privileging the valuations of those with the relevant health state experience solely because they are better informed is insufficient when their opinions differ. This study proposes a new framework to examine the effect of having health problems on health state valuation by distinguishing "within-dimensional" effects (which can be due to better information or due to differences in opinion) and "cross-dimensional" effects (which must be due to differences in opinion). METHODS: Secondary data from the UK that valued EQ-5D-5L using Discrete Choice Experiments with duration (DCETTO) are remodelled controlling for whether a respondent self-reports serious (viz., severe or extreme) problems in "pain or discomfort" (PD) or "anxiety or depression" (AD). The main analysis uses respondents who have serious PD or serious AD alongside matched respondents who do not, and assumes constant proportional time trade-off. RESULTS: Self-reporting serious PD or serious AD problems has no within-dimensional effect on health state preferences. However, self-reporting serious AD problems has negative cross-dimensional effects on the utility of having any problem in PD, which suggests that the preference mechanism is present. A similar pattern holds when all available (unmatched) data are used and when constant proportional time trade-off is relaxed. CONCLUSIONS: Findings consistent with the preference mechanism indicate that those with serious health problems may have different opinions on the value of health states compared to the rest of the population, which has normative implications for the debate on which values to use.

Evaluating delay of gamma oscillations in patients with schizophrenia using evoked response audiometry system.

Impaired gamma oscillations found in a 40-Hz auditory steady-state response (ASSR) in patients with schizophrenia are the robust findings that can be used for future biomarker-based therapeutics. To apply these significant observations into the clinical practice, a clinical system for evoked response audiometry (ERA) may be available. In this study, the delayed 40-Hz ASSR, which was reported as a potent biomarker for schizophrenia, was examined using the ERA system in patients with schizophrenia and its clinical relevance was investigated. The phase of ASSR was significantly delayed in patients with schizophrenia compared with the healthy subjects. The delayed phase was associated with severity of the disease symptoms in the patients. A phase delay with aging was found in healthy subjects, but not in patients with schizophrenia. These findings show availability of the ERA system to identify the delayed 40-Hz ASSR and its clinical implication in patients with schizophrenia. Further applications of the ERA system in clinical psychiatry are warranted in developing biological assessments of schizophrenia with 40-Hz ASSR.

Should We Consider Including a Value for "Hope" as an Additional Benefit Within Health Technology Assessment?

Health technology assessment (HTA) typically uses average health-related quality of life gain as its main measure of benefit used in economic evaluation. Nevertheless, there have been calls to consider novel aspects of benefit including the "value of hope," defined as a patients' potential preferences for a wider distribution of treatment benefit with a positive skew, in the hope that they will be one of the lucky ones. The value of hope may also derive from feeling hopeful as a positive mental state, which may be missing from current measures of health-related quality of life. The value attributed to feeling hopeful could be related to, or additional to, the value derived from possible risk-seeking preferences. Here, we reflect upon the strength of the case for the inclusion of the "value of hope" taking a critical look at the commonly referenced evidence for including the "value of hope" as risk-seeking preferences. We also draw attention to other conceptions of hope-as an emotion, a cognitive process, or a combination of both-and reflect upon the potential of including these broader notions of hope into HTA. The case for the inclusion of the "value of hope" based on risk-seeking preferences is weak. We suggest research questions that could give further evidence on whether hope is an important missing value from HTA.

The EQ-HWB: Overview of the Development of a Measure of Health and Wellbeing and Key Results.

OBJECTIVES: Existing measures for estimating quality-adjusted life-years are mostly limited to health-related quality of life. This article presents an overview of the development the EQ-HWB (EQ Health and Wellbeing), which is a measure that encompasses health and wellbeing. METHODS: Stages: (1) Establishing domains through reviews of the qualitative literature informed by a conceptual framework. (2) Generation and selection of items to cover the domains. (3) Face validation of these items through qualitative interviews with 168 patients, social care users, general population, and carers across 6 countries (Argentina, Australia, China, Germany, United Kingdom, United States). (4) Extensive psychometric testing of candidate items (using classical, factor analysis, and item response theory methods) on > 4000 respondents in the 6 countries. Stakeholders were consulted throughout. RESULTS: A total of 32 subdomains grouped into 7 high-level domains were identified from the qualitative literature and 97 items generated to cover them. Face validation eliminated 36 items, modified 14, and added 3. Psychometric testing of 64 items found little difference in missing data or problems with response distribution, the conceptual model was confirmed except in China, and most items performed well in the item response theory in all countries. Evidence was presented to stakeholders in 2 rounds of consultation to inform the final selection of items for the EQ-HWB (25-item) and the short version of EQ-HWB (9-items). CONCLUSIONS: EQ-HWB measures have been developed internationally for evaluating interventions in health, public health, and social care including the impact on patients, social care users, and carers.

The QALY at 50: One story many voices.

Research on quality adjusted life year (QALY) has been underway for just over 50 years, which seems like a suitable milestone to review its history. The purpose of this study is to provide a historical overview of why the QALY was developed, the key theoretical work undertaken by Torrance, Bush and Fanshel and how two seminal papers shaped its subsequent development. Moving the QALY forward - there are several historical and reflective exercises. The historical interplay between politics, policy and the challenges facing the National Health Service (NHS) in formulating the QALY concept in the UK has been explored in some depth already, whilst the conceptualization and development of the methodological framework is relatively underexplored. We address this gap by viewing the QALY through the lens of the methodological debates, reflecting upon two key papers underpinning the QALY methodology and how these methods have been developed over time. In part the changes in technology e.g. Google Scholar, and the availability of tools to search for early uses of the QALY allow us to better understand the historical context in which the theoretical development of the QALY has taken place. Here we celebrate two seminal papers that shaped early QALY development. The first section provides a history of these papers, summaries their contributions and explores the uptake of these papers over time. The second section reviews the methodological debates that have surrounded the QALY over the last 50 years and looks at how the QALY has moved to address these challenges. The third section presents the voices of diverse commentators representing the field of health economics who have contributed to the subsequent development of the QALY in both theoretical and empirical capacities and captures their thoughts about future research and policy use of QALYS.

Application of evoked response audiometry for specifying aberrant gamma oscillations in schizophrenia.

Gamma oscillations probed using auditory steady-state response (ASSR) are promising clinical biomarkers that may give rise to novel therapeutic interventions for schizophrenia. Optimizing clinical settings for these biomarker-driven interventions will require a quick and easy assessment system for gamma oscillations in psychiatry. ASSR has been used in clinical otolaryngology for evoked response audiometry (ERA) in order to judge hearing loss by focusing on the phase-locked response detectability via an automated analysis system. Herein, a standard ERA system with 40- and 46-Hz ASSRs was applied to evaluate the brain pathophysiology of patients with schizophrenia. Both ASSRs in the ERA system showed excellent detectability regarding the phase-locked response in healthy subjects and sharply captured the deficits of the phase-locked response caused by aberrant gamma oscillations in individuals with schizophrenia. These findings demonstrate the capability of the ERA system to specify patients who have aberrant gamma oscillations. The ERA system may have a potential to serve as a real-world clinical medium for upcoming biomarker-driven therapeutics in psychiatry.

Behavioral Theories That Have Influenced the Way Health State Preferences Are Elicited and Interpreted: A Bibliometric Mapping Analysis of the Time Trade-Off Method With VOSviewer Visualization.

Aim: The aim of this paper is to develop an understanding of how behavioral theories have influenced the way preferences for health-related quality of life are elicited and interpreted. We focus on the Time Trade-off (TTO) method given it represents the quality-adjusted life-year (QALY) concept-that survival in less-than-full health can be deemed equivalent to a shorter survival in full health. To our knowledge this is the first review using a combination of systematic scoping review, bibliometrics and VOSviewer visualization to map the development of ideas in health economics. Methods: A priori, we selected three behavioral theories to explore within our review, referred to here as Expected Utility Theory, Non-Expected Utility Theory and Probabilistic Choice Theory. A fourth topic, Order Effects, is defined broadly to encompass behavioral theories around timing/sequence of events. For the main search, Scopus was used to identify literature that had (a) elicited TTO values and/or (b) contributed to the way TTO values were elicited and interpreted, from inception to July 2021. Papers that focused on the latter category were given the label "behavioral" and underwent additional analyses. A two stage-screening was applied to assess eligibility. Co-citation, co-authorship and co-occurrence of keywords was used to chart the development of TTO over time. Results: A total of 1,727 records were retrieved from Scopus and were supplemented by an additional 188 papers. There were 856 applied and 280 behavioral papers included in the final corpus, with the behavioral set split equally into four sets of 70 papers to chart the development of keywords over time: (1) 1972-1999; (2) 2000-2010, (3) 2010-2015 and (4) 2015-2021. Discussion: The keyword analysis suggested that whilst some ideas transition quickly from economic theory to the TTO literature, such as the impact of Order Effects, others take longer to be assimilated, for example Non-Expected Utility models or failure of constant discounting. It is therefore important that researchers within health economics work more closely with those in mainstream economics and keep abreast of the wider economics and behavioral sciences to expedite the uptake of new and relevant ideas.

Equity in healthcare access and service coverage for older people: a scoping review of the conceptual literature.

There is currently no global review of the conceptual literature on the equity of healthcare coverage (including access) for older people. It is important to understand the factors affecting access to health and social care for this group, so that policy and service actions can be taken to reduce potential inequities. A scoping review of published and grey literature was conducted with the aim of summarising how health and social care service access and coverage for older people has been conceptualised. PubMed, MEDLINE, PsycINFO, CINAHL, Web of Science, SciELO, LILACS, BIREME and Global Index Medicus were searched. Selection of sources and data charting were conducted independently by two reviewers. The database searches retrieved 10 517 citations; 32 relevant articles were identified for inclusion from a global evidence base. Data were summarised and a meta-framework and model produced listing concepts specific to equitable health and social care service coverage relating to older people. The meta-framework identified the following relevant factors: acceptability, affordability, appropriateness, availability and resources, awareness, capacity for decision-making, need, personal social and cultural circumstances, physical accessibility. This scoping review is relevant to the development and specification of policy for older people. It conceptualises those factors, such as acceptability and affordability, that affect an older person's ability and capacity to access integrated, person-centred health and social care services in a meaningful way. These factors should be taken into account when seeking to determine whether equity in service use or access is being achieved for older people.

Perceptions of Wind Turbine Noise and Self-Reported Health in Suburban Residential Areas.

Wind turbines play an important role in the worldwide mission of producing renewable energy. The development toward integrating large-scale wind turbines in the urban environment has raised concerns over the noise impacts on urban residents. While most of the existing studies on wind turbine noise (WTN) have focused on rural settings, this paper investigates the relationship between WTN, noise perception and self-reported health of people, and controlling for background characteristics of the residents in urbanized areas. Questionnaire surveys were carried out around three suburban wind farms in the UK with 359 respondents. A-weighted sound pressure levels of WTN were predicted using noise mapping, for the most exposed façade of each dwelling of the respondent. The dose-response relationship was found between WTN and annoyance, moderated by age and degree of education. WTN was associated with some aspects of self-reported health, including raised health concerns, having headaches, nausea, and ear discomfort, but was not related to sleep disturbance directly. Noise sensitivity, attitudes to wind energy, and visibility of the wind turbines were found to significantly influence self-reported health. By employing a second variant of the questionnaire with the research aim masked, this study also addressed the focusing effects induced by the questionnaire design. The significant differences in the reported adverse health between questionnaire variants implied focusing bias among the sample who knew the research purpose. This elicited a methodological finding that should be noted in future research.

Valuing child and adolescent health: a qualitative study on different perspectives and priorities taken by the adult general public.

BACKGROUND: Quantitative health preference research has shown that different "perspectives", defined here as who is imagined to be experiencing particular health states, impact stated preferences. This qualitative project aimed to elucidate this phenomenon, within the context of adults' valuation of child and adolescent health states. METHODS: Six focus groups with 30 members of the UK adult public were conducted between December 2019 and February 2020 and analysed using framework analysis. Each focus group had two stages. First, participants individually completed time trade-off tasks and a pairwise task (mirroring a discrete choice experiment without duration) for two EQ-5D-Y health states, assuming a series of perspectives: (a) themselves at current age; (b) another adult; (c) 10-year old child; (d) themselves as a 10-year old child. Second, a semi-structured discussion explored their responses. RESULTS: Participants' views were often heterogeneous, with some common themes. Qualitatively, participants expressed a different willingness to trade-off life years for a 10-year old child versus themselves or another adult, and this differed by the health profile and child imagined. The same health states were often viewed as having a different impact on utility for a 10-year old child than adults. Imagining a 10-year old child is difficult and there is variation in who is imagined. Participants found answering based on their own-adult perspective most acceptable. There were no strong preferences for prioritising child health over working-age adults' health. CONCLUSIONS: If an adult sample is used to value child- and adolescent-specific health states it is important to consider the perspective employed. Members of the adult public provide different responses when different perspectives are used due to differences in the perceived impact of the same health states. If adults are asked to imagine a child, we recommend that sampling is representative for parental status, since this can affect preferences.

What is the best approach to adopt for identifying the domains for a new measure of health, social care and carer-related quality of life to measure quality-adjusted life years? Application to the development of the EQ-HWB?

Economic evaluation combines costs and benefits to support decision-making when assessing new interventions using preference-based measures to measure and value benefits in health or health-related quality of life. These health-focused instruments have limited ability to capture wider impacts on informal carers or outcomes in other sectors such as social care. Sector-specific instruments can be used but this is problematic when the impact of an intervention straddles different sectors.An alternative approach is to develop a generic preference-based measure that is sufficiently broad to capture important cross-sector outcomes. We consider the options for the selection of domains for a cross-sector generic measure including how to identify domains, who should provide information on the domains and how this should be framed. Beyond domain identification, considerations of criteria and stakeholder needs are also identified.This paper sets out the case for an approach that relies on the voice of patients, social care users and informal carers as the main source of domains and describes how the approach was operationalised in the 'Extending the QALY' project which developed the new measure, the EQ-HWB (EQ health and wellbeing instrument). We conclude by discussing the strengths and limitations of this approach. The new measure should be sufficiently generic to be used to consistently evaluate health and social care interventions, yet also sensitive enough to pick up important changes in quality of life in patients, social care users and carers.

Does the UK-public's aversion to inequalities in health differ by group-labelling and health-gain type? A choice-experiment.

Public health policy has two primary aims: promoting population health and reducing health inequalities. When these aims conflict, policy-makers must determine the relative importance to place on each in decision-making. We conducted a computer-based, face-to-face, choice-experiment to explore how the UK-public think government should act in these situations; and to explore how "inequality-aversion" may differ depending on the groups between which a health inequality exists and type of health an intervention provides. We tested three hypotheses: (1) the UK-public are more averse to inequalities in health between socioeconomic groups than they are to inequalities in health between neutrally labelled groups; (2) this difference is, at least in part, driven by the role non-health information plays in determining aversion to inequalities in health between socioeconomic groups; and (3) the UK-public are more willing to prioritise groups with lower lifetime health over groups with higher lifetime health if an intervention improves life-expectancy than if it improves quality-of-life. Eighty people participated in Sheffield and Hull in May/June 2019. Each participant completed three Person-Trade-Off exercises between interventions that would improve population health and reduce health inequalities, or improve population health by a larger amount but increase health inequalities. Participants were randomised to exercises involving scenarios with socioeconomic groups or neutrally-labelled groups, and each answered questions about three health-benefit types: increased life-expectancy; pain-relief; and mobility-improvement. Following the exercises, participants provided rationales for their selections. Respondents were (1) more averse to inequalities in health between socioeconomic groups than neutrally labelled groups. Participant rationales suggest (2) this divergence is partly motivated by factors other than health: for example, financial inequality between socioeconomic groups. The sample was also (3) more willing to prioritise neutrally labelled groups with lower lifetime health if an intervention improves life-expectancy rather than if it improves quality-of-life.

Understanding the composite dimensions of the EQ-5D: An experimental approach.

The EQ-5D(-5L) includes two composite dimensions: "Pain or Discomfort" (P/D) and "Anxiety or Depression" (A/D), which involves an inherent ambiguity. Little is known about how these composite dimensions are interpreted across contexts where (i) individuals self-report their own health; and (ii) individuals value stylised health states. We detail the nature of the ambiguity and present experimental evidence from two large online surveys (n = 1007 and n = 1415). In one survey, individuals reported both their current health and their health at the time they felt the worst because of their health. In the other, they valued stylised EQ-5D states using Discrete Choice Experiments with duration as an attribute. In both surveys, participants were randomised into treatments in which the presentation of one of the composite dimensions was altered, or a control. Our results suggest (1) In self-report, use of the composite dimensions differs across the dimensions, with P/D used mainly to report Pain, but A/D used mainly to mean the more severe component of Anxiety and Depression. (2) In valuation, Pain was perceived to be worse than Discomfort at the same level, and Depression was perceived to be worse than Anxiety at the same level. (3) In valuation, the composite dimension P/D was interpreted to mean Pain, whilst the composite dimension A/D was interpreted to lie between Anxiety and Depression. We conclude that care must be taken when interpreting responses to existing health (or wellbeing) descriptive systems that rely on composite dimensions, and that caution should be applied when designing new ones.

Implausible States: Prevalence of EQ-5D-5L States in the General Population and Its Effect on Health State Valuation.

The EQ-5D is made up of health state dimensions and levels, in which some combinations seem less "plausible" than others. If "implausible" states are used in health state valuation exercises, then respondents may have difficulty imagining them, causing measurement error. There is currently no standard solution: some valuation studies exclude such states, whereas others leave them in. This study aims to address 2 gaps in the literature: 1) to propose an evidence-based set of the least prevalent two-way combinations of EQ-5D-5L dimension levels and 2) to quantify the impact of removing perceived implausible states from valuation designs. For the first aim, we use data from 2 waves of the English General Practitioner Patient Survey (n = 1,639,453). For the second aim, we remodel a secondary data set of a Discrete Choice Experiment (DCE) with duration that valued EQ-5D-5L and compare across models that drop observations involving different health states: 1) implausible states as defined in the literature, 2) the least prevalent states identified in stage 1, and 3) randomly select states, alongside 4) a model that does not drop any observations. The results indicate that two-way combinations previously thought to be implausible actually exist among the general population; there are other combinations that are rarer, and removing implausible states from an experimental design of a DCE with duration leads to value sets with potentially different characteristics depending on the criterion of implausible states. We advise against the routine removal of implausible states from health state valuation studies.

A decrease in spontaneous activity in medial prefrontal cortex is associated with sustained hallucinations in chronic schizophrenia: An NIRS study.

In functional imaging, accumulating evidence suggests that spontaneous activity decreases during the resting state in the core brain regions of the default-mode network [e.g. medial prefrontal cortex (mPFC)] in schizophrenia. However, the significance of this decreased activity has not been clarified in relation to its clinical symptoms. In this study, near-infrared spectroscopy (NIRS), which is a simple imaging modality suitable for resting state paradigm, was used to evaluate the intensity of the spontaneous activity during the resting state in chronic schizophrenia. Consistent with previous findings of fMRI studies, spontaneous activity decreased in the mPFC of patients with schizophrenia. In addition, the decreased spontaneous activity was associated with severe hallucinations in this region where reality monitoring is fundamentally engaged. These results may encourage additional application of NIRS with the resting state paradigm into daily clinical settings for addressing the broad phenotypes and unstable course of schizophrenia.

Comparing aversions to outcome inequality and social risk in health and income: An empirical analysis using hypothetical scenarios with losses.

Evaluation of future social welfare may not only depend on the aggregate of individual prospects, but also on how the prospects are distributed across individuals. The latter in turn would depend on how people perceive inequality and risk at the collective level (or "social risk"). This paper examines distributional preferences regarding inequality in outcomes and social risk for health and income in the context of losses. Specifically, four kinds of aversions are compared, (a) outcome-inequality aversion in health, (b) outcome-inequality aversion in income, (c) social-risk aversion in health, (d) and social-risk aversion in income. Face-to-face interviews of a representative general public sample in Spain are undertaken using hypothetical scenarios involving losses in health or income across otherwise equal groups. Aversion parameters are compared assuming social welfare functions with constant relative or constant absolute aversion. We find that in both domains, outcome-inequality aversion and social-risk aversion are not the same; and that neither aversion is the same across the two domains. Outcome-inequality aversion in income is the strongest, followed by social-risk aversion in income and social-risk aversion in health, and outcome-inequality aversion in health coming last, where most of these are statistically significantly different from each other.

How averse are the UK general public to inequalities in health between socioeconomic groups? A systematic review.

There is growing interest in the use of "distributionally-sensitive" forms of economic evaluation that capture both the impact of an intervention upon average population health and the distribution of that health amongst the population. This review aims to inform the conduct of distributionally sensitive evaluations in the UK by answering three questions: (1) How averse are the UK public towards inequalities in lifetime health between socioeconomic groups? (2) Does this aversion differ depending upon the type of health under consideration? (3) Are the UK public as averse to inequalities in health between socioeconomic groups as they are to inequalities in health between neutrally framed groups? EMBASE, MEDLINE, EconLit, and SSCI were searched for stated preference studies relevant to these questions in October 2017. Of the 2155 potentially relevant papers identified, 15 met the predefined hierarchical eligibility criteria. Seven elicited aversion to inequalities in health between socioeconomic groups, and eight elicited aversion between neutrally labelled groups. We find general, although not universal, evidence for aversion to inequalities in lifetime health between socioeconomic groups, albeit with significant variation in the strength of that preference across studies. Second, limited evidence regarding the impact of the type of health upon aversion. Third, some evidence that the UK public are more averse to inequalities in lifetime health when those inequalities are presented in the context of socioeconomic inequality than when presented in isolation.

The SIPHER Consortium: Introducing the new UK hub for systems science in public health and health economic research.

The conditions in which we are born, grow, live, work and age are key drivers of health and inequalities in life chances. To maximise health and wellbeing across the whole population, we need well-coordinated action across government sectors, in areas including economic, education, welfare, labour market and housing policy. Current research struggles to offer effective decision support on the cross-sector strategic alignment of policies, and to generate evidence that gives budget holders the confidence to change the way major investment decisions are made. This open letter introduces a new research initiative in this space. The SIPHER ( Systems Science in Public Health and Health Economics Research) Consortium brings together a multi-disciplinary group of scientists from across six universities, three government partners at local, regional and national level, and ten practice partner organisations. The Consortium's vision is a shift from health policy to healthy public policy, where the wellbeing impacts of policies are a core consideration across government sectors. Researchers and policy makers will jointly tackle fundamental questions about: a) the complex causal relationships between upstream policies and wellbeing, economic and equality outcomes; b) the multi-sectoral appraisal of costs and benefits of alternative investment options; c) public values and preferences for different outcomes, and how necessary trade-offs can be negotiated; and d) creating the conditions for intelligence-led adaptive policy design that maximises progress against economic, social and health goals. Whilst our methods will be adaptable across policy topics and jurisdictions, we will initially focus on four policy areas: Inclusive Economic Growth, Adverse Childhood Experiences, Mental Wellbeing and Housing.

Manipulating the 5 Dimensions of the EuroQol Instrument: The Effects on Self-Reporting Actual Health and Valuing Hypothetical Health States.

Background. The EQ-5D instrument has 5 dimensions. This article reports on the effects of manipulating a) the order in which the 5 dimensions are presented (appearing first v. last), b) splitting of the composite dimensions ("pain or discomfort" and "anxiety or depression"), and c) removing or "bolting off" 1 of the 5 EQ-5D dimensions at a time. The effects were examined in 2 contexts: 1) self-reporting health and 2) health state valuations. Methods. Three different types of discrete choice experiments (DCE) including a duration attribute were designed. An online survey with 12 subtypes, each with 10 DCE tasks, was designed and completed by 2494 members of the UK general public. Results. Of the 3 manipulations in the self-reporting context, only b) splitting anxiety or depression had a significant effect. In the health state valuation context, b) splitting level 5 pain or discomfort (relative to pain) and splitting level 5 anxiety or depression (relative to anxiety) had significant effects as did c) bolting off dimensions. Conclusions. We find that the values given to certain health dimensions are sensitive to the way in which it is described and the other health dimensions presented. Of particular interest is the effect of splitting composite dimensions: a given EQ-5D(-5L) profile may mean different things depending on whether the profile is used to self-report one's health or to value hypothetical states, so that the health state values of EQ-5D(-5L) in population tariffs may not correspond to the states that patients self-report themselves in.

Striving for a Societal Perspective: A Framework for Economic Evaluations When Costs and Effects Fall on Multiple Sectors and Decision Makers.

In most societies, resources are distributed by individuals acting in markets and by governments through some form of collective decision-making process. Economic evaluation offers a set of tools to inform collective decisions by examining the resource requirements and outcomes of alternative policies. The 'societal perspective' has been advocated, but less consideration has been given to what this should include and its practical implementation. This paper presents a framework for economic evaluation of policies with costs and outcomes falling on different sectors (e.g. health, criminal justice, education) and involving different decision makers. It extends the 'impact inventory' developed by the Second Panel on Cost-Effectiveness in Health and Medicine by considering all affected individuals and reflecting how outcomes attributed to an intervention can be compared with outcomes forgone as a result of resources not being available for other purposes. The framework sets out the series of assessments to be made, distinguishing points at which value judgements feed into the evaluation, and the implications of alternative judgements. These assessments reflect the institutional arrangements of public bodies, for example, their funding, the outcomes they consider important and their relative valuations of these outcomes. By avoiding the use of an abstract 'societal perspective', the contribution of the framework is to inform multiple decision makers with different objectives and provide practical guidance on overall societal impact.