Health outcomes in economic evaluation: who should value health?

Abstract

The valuation of health states is an integral part of economic evaluation studies. The source of these valuations (general public vs. patients) is surrounded by controversy. Health state values generated by the general public are often different compared with those of patients. General public values may not account for adaptation of the patients; patients' values potentially incorporate self-interest. Decisions on the appropriate source of health values ultimately depend on the specific decision-making context and objectives of the evaluation. Differences in valuations and implications for decision-making should be explicitly addressed. Further research should systematically identify circumstances in which public and patients' valuations diverge. There appears ground for development of methods that allow the simultaneous incorporation of patients and public preferences. Existing literature which discusses the issues around the health state valuation is summarized.

A comparison of injured patient and general population valuations of EQ-5D health states for New Zealand

“…people with direct personal experience of illness or injury – assign different health state valuations than the general population [7,8]. A literature review by De Wit et al [9] and a meta-analysis by Peeters et al [10] concluded that patients’ valuations of their own (actual) health states tend to be higher than hypothetical valuations of descriptions of the same states by the general population.…”

Valuation of quality of life in rheumatoid arthritis

“…Conversely, the health economists' perspective uses a societal perspective in which members of the general public generate utilities in the context of decisions about the alternative allocation of resources. Arguments include the fact that it is not patients who bear the costs associated with health-care decisions but rather the general public (86), and that members of the general public are therefore the best judges of health states because they can at least partially act under 'a veil of ignorance', i.e. they are ignorant of their own future health states and needs, and they are blind to their own self-interest (85,87).…”

“…they are ignorant of their own future health states and needs, and they are blind to their own self-interest (85,87). Nevertheless, there are also strong arguments in favour of using a patient perspective in the context of resource allocation, because patients have full knowledge of, and experience with, their health condition (86)(87)(88) and are directly affected by interventions (89). In addition, even when providing members of the general public with as much information as possible, these descriptions of health states remain incomplete (87,90), leaving the general public with a 'lack of scope' (91).…”

“…One explanation for this is the fact that people tend to focus more on the negative aspects associated with the disease, e.g. impairments in activities, while ignoring the positive aspects such as unaffected or even enhanced activities; a phenomenon which is defined as focusing illusion (86,90,92,93). In addition, people fail to take account of the fact that they will adapt to health changes (86,90,92,93), which can be mediated by a phenomenon called response shift.…”

“…impairments in activities, while ignoring the positive aspects such as unaffected or even enhanced activities; a phenomenon which is defined as focusing illusion (86,90,92,93). In addition, people fail to take account of the fact that they will adapt to health changes (86,90,92,93), which can be mediated by a phenomenon called response shift. Response shift refers to the fact that people redefine their internal standards of what comprises health, change their values and priorities, and/or may redefine the concept of QoL, as a result of a diminishing health state (94).…”