Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Valuing Health at the End of Life

2,213 views

Published on

Presentation by Koonal Shah at Erasmus University, Rotterdam, June 2015

Valuing Health at the End of Life

  1. 1. Koonal Shah Presentation at Erasmus University Rotterdam ● June 2015 Valuing health at the end of life
  2. 2. Valuing health at the end of life 22/09/15 2 • This research is a collaboration between Koonal Shah (Office of Health Economics; University of Sheffield) and Professors Aki Tsuchiya and Allan Wailoo (both University of Sheffield) • The literature review reported here is in-progress and its results should be treated as preliminary • The views, and any errors or omissions, expressed are of the presenting author only Study status and acknowledgements
  3. 3. Valuing health at the end of life 22/09/15 3 Criteria that need to be satisfied for NICE’s supplementary end of life policy to apply are currently as follows: NICE end of life criteria C2 The treatment is indicated for patients with a short life expectancy, normally less than 24 months There is sufficient evidence to indicate that the treatment offers an extension to life, normally of at least an additional three months, compared to current NHS treatment The treatment is licensed or otherwise indicated, for small patient populations C3 C1
  4. 4. Valuing health at the end of life 22/09/15 4 • Placing additional weight on survival benefits in patients with short remaining life expectancy could be considered a valid representation of society's preferences • But the NICE consultation revealed concerns that there is little scientific evidence to support this premise • Two (unpublished) reviews of the stated preference / empirical ethics literature undertaken in 2011 did not identify many relevant studies NICE end of life criteria (2)
  5. 5. Valuing health at the end of life 22/09/15 5 • To review the published literature that is relevant to the following research question: Do members of the general public wish to place greater weight on a unit of health gain for end of life patients than on that for other types of patients? • To identify the extent to which public preferences on this topic have been studied in the peer-reviewed literature • To provide an in-depth account of the methods used to elicit preferences and the findings of the studies, with the intention of informing policy decisions and future research in this area Objectives
  6. 6. Valuing health at the end of life 22/09/15 6 • Primary source of data: electronic search of the Social Sciences Citation Index (SSCI) within Web of Science • Follow-up of reference lists of articles identified using the final SSCI search • Articles already known to me that met the criteria for inclusion Data sources
  7. 7. Valuing health at the end of life 22/09/15 7 • Search terms developed using an iterative process • Base search terms: end of life AND preferences – 1,076 results • Added two alternative terms related to end of life: severity and terminal – 2,387 results • Designation of three studies already known to me as ‘key papers’ – examined abstracts of the key papers to identify further search terms (see next slide) Search terms
  8. 8. Valuing health at the end of life 22/09/15 8 Search terms (2)
  9. 9. Valuing health at the end of life 22/09/15 9 • Search terms developed using an iterative process • Added health, respondents (+ subjects, participants, sample), life expectancy • Conducted informal assessments of whether the additional records identified by adding individual search terms contained at least some potentially relevant records (this justifying their inclusion) • Checked whether any key records were missed after adding certain terms – this ruled out patient, treatment, evidence, public and population • Also checked random sample of additional records identified by adding synonyms for preferences (attitudes, choices, utilities, values) Search terms (3)
  10. 10. Valuing health at the end of life 22/09/15 10 ("end of life" OR severity OR terminal OR “life expectancy”) AND preferences AND health AND (respondents OR subjects OR participants OR sampl*) • Yielded 598 unique results Final strategy
  11. 11. Valuing health at the end of life 22/09/15 11 To be included, articles had to meet all of the following sequential criteria: 1. Publication: Article must be published in English in a peer-reviewed source. 2. Empirical data: Article must review, present or analyse empirical data. 3. Priority-setting context: Article must relate to a health care priority- setting or resource allocation context. 4. Stated preference data: Article must report preferences that were elicited in a hypothetical, stated context using a choice-based approach involving trade-offs. 5. End of life: Article must address the topic of giving priority to end of life patients (i.e. patients with short life expectancy) or to treatments for such patients. 6. Original research: Article must present original research and must not be solely a review of the literature. Selection of studies for inclusion
  12. 12. Valuing health at the end of life 22/09/15 12 To be included, articles had to meet all of the following sequential criteria: 1. Publication: Article must be published in English in a peer-reviewed source. 2. Empirical data: Article must review, present or analyse empirical data. 3. Priority-setting context: Article must relate to a health care priority- setting or resource allocation context. 4. Stated preference data: Article must report preferences that were elicited in a hypothetical, stated context using a choice-based approach involving trade-offs. 5. End of life: Article must address the topic of giving priority to end of life patients (i.e. patients with short life expectancy) or to treatments for such patients. 6. Original research: Article must present original research and must not be solely a review of the literature. Selection of studies for inclusion
  13. 13. Valuing health at the end of life 22/09/15 13 • Author(s) • Year of publication • Country of origin of data • Sample size • Type of sample • Sample recruitment process • Exclusion criteria • Mode of administration • Objective(s) • Pilot reporting • Preference elicitation technique • Perspective • End of life definition • Life expectancy without treatment attribute levels • Life expectancy gain from treatment attribute levels • Was disease labelled/named? • Did the study examine whether quality of life improving or life extending treatments are preferred? Data extraction fields
  14. 14. Valuing health at the end of life 22/09/15 14 • What were respondents choosing between (or choosing to do)? • Were indifference options offered? • Were visual aids used? • Was strength of preference examined at the individual level? • Number of tasks completed by each respondent • Time taken to complete survey reported? • Summary of finding: end of life vs. non-end of life • Summary of finding: quality of life improvement vs. life extension • Other results of potential interest • Other factors examined • Impact of background characteristics • Were qualitative data or explanatory factors sought? • Was any reference made to age- related or time-related preferences? Data extraction fields (2)
  15. 15. Valuing health at the end of life 22/09/15 15 Search results
  16. 16. Valuing health at the end of life 22/09/15 16 Summary of included studies (n=17) Authors (date) Country Sample size (type) Method Mode Summary of primary study objective(s) Abel Olsen (2013) NOR 503 (public) Choice Internet survey To test for support for end of life prioritisation and the fair innings approach Baker et al. (2010) UK 587 (public) DCE CAPI To test for support for multiple prioritisation criteria Dolan and Cookson (2000) UK 60 (public) Choice Focus groups Qualitative examination of support for multiple prioritisation criteria Dolan and Shaw (2004) UK 23 (public) Choice Focus group To test for support for multiple prioritisation criteria Dolan and Tsuchiya (2005) UK 100 (public) Choice; ranking Self-completion survey To compare support for prioritisation according to age vs. prioritisation according to severity/life expectancy Kvamme et al. (2010) NOR 2,143 (public) WTP Internet survey To test for non-linear utility of short life extensions from an individual perspective Lim et al. (2012) KOR 800 (public) DCE Internet survey To test for support for multiple prioritisation criteria Linley and Hughes (2013) UK 4,118 (public) Budget allocation Internet survey To test for support for multiple prioritisation criteria Pennington et al. (2015) Multiple 17,657 (public) WTP Internet survey To compare WTP for different types of QALY gain Pinto-Prades et al. (2014) SPA 813 (public) WTP; PTO CAPI To test for support for end of life prioritisation and to compare support for life extensions vs. quality of life improvements Richardson et al. (2012) AUS 544 (public) Other Internet survey and self-completion survey To test a technique for measuring support for health-maximisation and health sharing Rowen et al. (2015) UK 3,669 (public) DCE Internet survey To test for support for multiple prioritisation criteria Shah et al. (2014) UK 50 (public) Choice Person interview To test for support for end of life prioritisation Shah et al. (2015) UK 3,969 (public) DCE Internet survey To test for support for end of life prioritisation Skedgel et al. (2015) CAN 656 (public, decision- makers) DCE Internet survey To test for support for multiple prioritisation criteria Stahl et al. (2008) USA 623 (public) Choice Internet survey To test for support for multiple prioritisation criteria Stolk et al. (2005) NLD 65 (students, researchers, health policy makers) Choice Personal interview To test for support for multiple approaches to priority-setting
  17. 17. Valuing health at the end of life 22/09/15 17 Summary of findings Freq. % Overall finding: end of life premium - Evidence consistent with an end of life premium - Evidence not consistent with an end of life premium - Mixed or inconclusive evidence 7 7 3 41.2% 41.2% 17.6% Overall finding: QOL-improving vs. life-extending end of life treatments - QOL improvement preferred - Life extension preferred - Not examined / reported 2 1 14 11.8% 5.9% 82.4%
  18. 18. Valuing health at the end of life 22/09/15 18 Distribution of selected variables, by overall study finding * Study combining PTO and WTP methods counted as two studies since separate results are reported for both. Study combining ranking exercise and other choice exercise counted as one study since this is considered to be a single hybrid method. Variable Evidence consistent with an end of life premium Evidence not consistent with an end of life premium Country - UK - Europe (non-UK) - Rest of the world 2 3 2 4 2 1 Method* - DCE - Other choice exercise - Willingness to pay - Other 2 2 3 1 2 3 0 2 Mode of administration - Internet survey - Other 5 2 4 3 Indifference option(s) offered? - Yes - No or not reported 5 2 1 6 Visual aids used? - Yes - No or not reported 5 2 2 5
  19. 19. Valuing health at the end of life 22/09/15 19 Discussion point: choice of method • Most studies asked respondents to adopt a social decision maker perspective and to answer questions typically of concern to a health care decision maker • Respondents are expected to answer the questions based on what they consider to be appropriate and acceptable for society – would not necessarily expect to benefit personally from their choices • The three WTP studies asked respondents to adopt an individual or ‘own health’ perspective • Consistent with the welfarist view that confines the evaluative space to individual utility only • But are WTP valuations made by individuals facing the prospect of imminent death a useful way of guiding decisions about how to spend a common pool of funding?
  20. 20. Valuing health at the end of life 22/09/15 20 Discussion points: indifference options and visual aids • Studies offering opportunity to express indifference between alternatives were more likely to report evidence consistent with an end of life premium than those that did not • Way in which indifference options are framed may affect respondents’ willingness to choose those options • e.g. 50:50 split of resources vs. ‘I have no preference’ • When no indifference option is available, a respondent who is indifferent may pursue a strategy other than making choices at random • Trend towards DCEs administered via internet surveys suggests that indifference options may become less frequent • Studies that used visual aids were more likely to report evidence consistent with an end of life premium that those that did not • Could graphical representations unintentionally lead to different respondents interpreting the information in different ways?
  21. 21. Valuing health at the end of life 22/09/15 21
  22. 22. Valuing health at the end of life 22/09/15 22 Discussion points: age and time- related preferences • Majority of studies included patient age in the study design • In some cases age was one of several prioritisation criteria being examined; in other cases researchers sought to examine whether respondents’ end of life-related preferences were influenced by the ages of the patients • Some evidence that respondents become less concerned about the number of life years remaining when the patients in question are relatively old • UK policy context: age cannot be used as a priority-setting criterion • Few studies mentioned time-related preferences; even fewer attempted to control for them • Could an observed preference for treating patients with short life expectancy be driven by a preference for benefits occurring sooner rather than later? • Could an observed preference for treating patients with short life expectancy be driven by concern about how long those patients have to ‘prepare for death’?
  23. 23. Valuing health at the end of life 22/09/15 23 Both patients are same age today (Time=0) Age denotes time in full quality of life denotes life extension (at full quality of life) achievable from treatment Time (years) 0 1 2 3 4 5 6 7 8 9 10 11 Patient A Patient B Source: Shah et al. (2014)
  24. 24. Valuing health at the end of life 22/09/15 24 Patient B is 9 years older than patient A today Age (2) Time (years) 0 1 2 3 4 5 6 7 8 9 10 11 Patient A Patient B Source: Shah et al. (2014)
  25. 25. Valuing health at the end of life 22/09/15 25 Both patients are same age today Time Time (years) -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 A B Source: Shah et al. (2014)
  26. 26. Valuing health at the end of life 22/09/15 26 Limitations of the review • Searched only one database – covers all major health economics and health policy journals but may not cover specialist scientific journals • Included only articles that have been published in English, and the review was (to a large extent) motivated by the policy context in the UK • Search terms considered are likely to reflect the language used by health economics researchers in the UK – may not be well suited for identifying, say, articles authored by ethicists or researchers based in LMICs • No formal assessment of study quality – used publication in a peer- reviewed source as a proxy for quality • Assignment of study findings into categories (consistent; not consistent; inconclusive) involved a degree of subjective judgement • No clear definition of what counts as “consistent with an end of life premium” • Unanimous preferences are rarely observed in stated preference studies • Not always possible to use authors’ own conclusions as a guide
  27. 27. Valuing health at the end of life 22/09/15 27 Conclusions • Primary finding of the review is that the existing evidence is mixed • Reviews of severity-related preferences more generally have been able to make more decisive conclusions – i.e. an overall preference for giving priority to treating those who are terminally ill • Suggests that people are more concerned about treating patients with poor quality of life than treating patients with short life expectancy – but this supposition is not supported by individual studies that examined both simultaneously • Gaps in the literature / recommendations for further research • Given the known issues associated with framing effects, researchers could use multiple methods or designs to test the robustness of their results • It would be informative to seek to understand the extent to which respondents agree with researchers’ interpretations of their choices • Preferences regarding ‘preparedness’ have received limited attention in the literature to date – further investigation would be welcomed
  28. 28. Valuing health at the end of life 22/09/15 28 To enquire about additional information and analyses, please contact Koonal Shah at kshah@ohe.org To keep up with the latest news and research, subscribe to our blog, OHE News. Follow us on Twitter @OHENews, LinkedIn and SlideShare. Office of Health Economics (OHE) Southside, 7th Floor 105 Victoria Street London SW1E 6QT United Kingdom +44 20 7747 8850 www.ohe.org OHE’s publications may be downloaded free of charge for registered users of its website. ©2013 OHE Thank you for listening

×