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How to include relatives and productivity loss in a cost‐effectiveness analysis
Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Health economic evaluations are today commonly used in the decision‐making process in health care. Within the field of cost‐effectiveness analysis (CEA), there are several methodological and empirical issues that cause debate about what is included in the analysis. This thesis covers two such issues; costs and effects for relatives, and the valuation of individuals’ productivity loss due to morbidity. The objective of the thesis is to provide further knowledge about what should be included in CEAs which take a societal approach. The papers that the thesis is based on, four in total, examine the theoretical aspects of the studied issues and test these aspects empirically. Three different data materials were used. The CEA and the estimation of costs and effects are central in all the papers. The outcome measure used is quality‐adjusted life years (QALYs).

The relatives of an individual with a disease or disability often provide informal care, and there may also be concomitant effect on their own well‐being. Nevertheless, the costs and effects for the relatives are generally excluded from CEAs, and there are few guidelines for how to include relatives’ effects. This thesis suggests the use of a new measure, R‐QALYs, which can be used both to visualise relatives’ effects and to include them in the analysis. We found that while the EQ‐5D instrument can be used to capture some of the relatives’ effects, it most likely misses a number of important attributes, for example altruistic preferences. Methods of eliciting R‐QALY weights include direct valuation methods and indirect methods, using existing relativerelated instruments. However, none of these methods are without difficulties, and there is a need for more studies on estimating valid relatives’ effects. Another possible approach with high potential is to use monetary measurements for both the costs and effects relevant to relatives.

The results also show that income affects the QALY weights if the individuals include the utility generated by consumption within their QALY weights. The empirical tests showed that a majority of individuals do not consider their own income when they value health states. An explicit instruction to take income into account seemed to affect the valuation of those health states that were assumed to have consequences on the ability to perform daily activities. These findings give support for including the productivity costs caused by morbidity in the analysis; as these costs are not, or are only to a minor extent, implicitly incorporated in individuals’ QALY weights. The loss of leisure time, however, is captured in the QALY weight, and care must be taken to avoid double counting this loss in the analysis.

The results of CEAs will only be partial if relatives’ costs and effects and the costs of individuals’ productivity loss are excluded for health interventions where they are assumed to be of significant importance.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2009. , 73 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1101
National Category
Economics and Business
Identifiers
URN: urn:nbn:se:liu:diva-16999ISBN: 978-91-7393-693-4 (print)OAI: oai:DiVA.org:liu-16999DiVA: diva2:200966
Public defence
2009-03-13, Aulan, Hälsan Hus, Campus US, Linköpings Universitet, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2009-03-02 Created: 2009-03-02 Last updated: 2017-04-15Bibliographically approved
List of papers
1. Is the societal approach wide enough to include relatives?: incorporating relatives' costs and effects in a cost-effectiveness analysis.
Open this publication in new window or tab >>Is the societal approach wide enough to include relatives?: incorporating relatives' costs and effects in a cost-effectiveness analysis.
2010 (English)In: Applied Health Economics and Health Policy, ISSN 1175-5652, E-ISSN 1179-1896, Vol. 8, no 1, 25-35 p.Article in journal (Refereed) Published
Abstract [en]

It is important for economic evaluations in healthcare to cover all relevant information. However, many existing evaluations fall short of this goal, as they fail to include all the costs and effects for the relatives of a disabled or sick individual. The objective of this study was to analyse how relatives' costs and effects could be measured, valued and incorporated into a cost-effectiveness analysis. In this article, we discuss the theories underlying cost-effectiveness analyses in the healthcare arena; the general conclusion is that it is hard to find theoretical arguments for excluding relatives' costs and effects if a societal perspective is used. We argue that the cost of informal care should be calculated according to the opportunity cost method. To capture relatives' effects, we construct a new term, the R-QALY weight, which is defined as the effect on relatives' QALY weight of being related to a disabled or sick individual. We examine methods for measuring, valuing and incorporating the R-QALY weights. One suggested method is to estimate R-QALYs and incorporate them together with the patient's QALY in the analysis. However, there is no well established method as yet that can create R-QALY weights. One difficulty with measuring R-QALY weights using existing instruments is that these instruments are rarely focused on relative-related aspects. Even if generic quality-of-life instruments do cover some aspects relevant to relatives and caregivers, they may miss important aspects and potential altruistic preferences. A further development and validation of the existing caregiving instruments used for eliciting utility weights would therefore be beneficial for this area, as would further studies on the use of time trade-off or Standard Gamble methods for valuing R-QALY weights. Another potential method is to use the contingent valuation method to find a monetary value for all the relatives' costs and effects. Because cost-effectiveness analyses are used for decision making, and this is often achieved by comparing different cost-effectiveness ratios, we argue that it is important to find ways of incorporating all relatives' costs and effects into the analysis. This may not be necessary for every analysis of every intervention, but for treatments where relatives' costs and effects are substantial there may be some associated influence on the cost-effectiveness ratio.

Place, publisher, year, edition, pages
Springer, 2010
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-53069 (URN)10.2165/11313910-000000000-00000 (DOI)20038191 (PubMedID)
Note

The previous status of this article was Manuscript.

Available from: 2010-01-15 Created: 2010-01-15 Last updated: 2017-12-12Bibliographically approved
2. In pursuit of QALY weights for relatives: Empirical estimates in relatives caring for older people
Open this publication in new window or tab >>In pursuit of QALY weights for relatives: Empirical estimates in relatives caring for older people
2008 (English)In: European Journal of Health Economics, ISSN 1618-7598, E-ISSN 1618-7601, Vol. 9, no 3, 285-292 p.Article in journal (Refereed) Published
Abstract [en]

This study estimates quality-adjusted life-year (QALY) weights for relatives caring for an older person. The data used are from the Swedish part of the EUROFAMCARE study. A new measure is introduced called the R-QALY weight, defined as the effect on a relative’s QALY weight due to being a relative of a disabled or sick individual. R-QALY weights were created by comparing relatives’ QALY weights with population-based QALY weights. They were also created by comparing with QALY weights reassessed for a hypothetical situation in which the older person needed no care. The results indicate that R-QALY weights are small when compared with population-based weights, but large when compared with QALY weights reassessed for the hypothetical situation. Moreover, R-QALY weights were affected by relatives’ age, sex, and subjective perception of positive and negative aspects of the caregiving situation. These aspects should therefore be taken into account in health economics evaluations using a societal approach.

Place, publisher, year, edition, pages
SpringerLink, 2008
Keyword
Economics, Relatives, Caregivers, QALY weight
National Category
Economics and Business
Identifiers
urn:nbn:se:liu:diva-16948 (URN)10.1007/s10198-007-0076-z (DOI)
Available from: 2009-03-02 Created: 2009-02-26 Last updated: 2017-12-13Bibliographically approved
3. Direct valuation of health state among patients with chest pain: Does income level matter
Open this publication in new window or tab >>Direct valuation of health state among patients with chest pain: Does income level matter
(English)Manuscript (preprint) (Other (popular science, discussion, etc.))
Abstract [en]

There is still uncertainty over where to include the production loss caused by morbidity in cost-effectiveness analyses. This loss could be included as a cost; but if individuals take their own income into consideration when valuing health states, this would lead to double counting. The purpose of this study was to find out whether individuals’ incomes can explain their valuations of their own current health states.

The sample consisted of 156 patients (312 observations) admitted to hospital with chest pain (the FRISC II trial). These patients valued their own current health states by using the time trade-off method (TTO) and a visual analogue scale (VAS). They also answered the EQ-5D instrument and stated their monthly income. Income level was additionally controlled via their taxed income at the tax agency, together with their income generated from capital. Generalised estimation equations were used to test whether the EQ- 5D dimensions and monthly gross income could explain the variation in the valuations of the health states.

The results indicate that neither self-stated nor taxed income could explain the variation in the valuations made by TTO. However, self-stated income (but not taxed income) was a significant variable in explaining variation in the VAS valuations.

These findings support the inclusion of the production loss caused by morbidity in the analysis, as these costs are not, or at least not to any great extent, implicitly incorporated in the individuals’ QALY weights when TTO is used to value the health states. Using a VAS, some income effects may be included.

Keyword
Outcome research, QALY, income, cost-effectiveness analysis
National Category
Economics and Business
Identifiers
urn:nbn:se:liu:diva-16952 (URN)
Note

This paper will not be published.

Available from: 2009-02-26 Created: 2009-02-26 Last updated: 2017-01-11Bibliographically approved
4. Do individuals consider expected income when valuing health states?
Open this publication in new window or tab >>Do individuals consider expected income when valuing health states?
2008 (English)In: International Journal of Technology Assessment in Health Care, ISSN 0266-4623, E-ISSN 1471-6348, Vol. 24, no 4, 488-494 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: The purpose of this study was to empirically explore whether individuals take their expected income into consideration when directly valuing predefined health states. This was intended to help determine how to handle productivity costs due to morbidity in a cost-effectiveness analysis.

Methods: Two hundred students each valued four hypothetical health states by using time trade-off (TTO) and a visual analogue scale (VAS). The students were randomly assigned to two groups. One group was simply asked, without mentioning income, to value the different health states (the non-income group). The other group was explicitly asked to consider their expected income in relation to the health states in their valuations (the income group).

Results: For health states that are usually assumed to have a large effect on income, the valuations made by the income group seemed to be lower than the valuations made by the non-income group. Among the students in the non-income group, 96 percent stated that they had not thought about their expected income when they valued the health states. In the income group, 40 percent believed that their expected income had affected their valuations of the health states.

Conclusion: The results show that, as long as income is not mentioned, most individuals do not seem to consider their expected income when they value health states. This indicates that productivity costs due to morbidity are not captured within individuals’ health state valuations. These findings, therefore, suggest that productivity costs due to morbidity should be included as a cost in cost-effectiveness analyses.

Keyword
Cost-effectiveness analysis, Valuation, Health state utility, Expected income
National Category
Economics and Business
Identifiers
urn:nbn:se:liu:diva-16949 (URN)10.1017/S0266462308080641 (DOI)
Available from: 2009-03-02 Created: 2009-02-26 Last updated: 2017-12-13Bibliographically approved

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