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Is the societal approach wide enough to include relatives?: incorporating relatives' costs and effects 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.
Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
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. Vol. 8, no 1, 25-35 p.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-53069DOI: 10.2165/11313910-000000000-00000PubMedID: 20038191OAI: oai:DiVA.org:liu-53069DiVA: diva2:286662
Note

The previous status of this article was Manuscript.

Available from: 2010-01-15 Created: 2010-01-15 Last updated: 2017-12-12Bibliographically approved
In thesis
1. How to include relatives and productivity loss in a cost‐effectiveness analysis
Open this publication in new window or tab >>How to include relatives and productivity loss in a cost‐effectiveness analysis
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:nbn:se:liu:diva-16999 (URN)978-91-7393-693-4 (ISBN)
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

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Davidson, ThomasLevin, Lars-Ake

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