methods for incorporating health equity impacts in economic evaluation with applications to low and...
TRANSCRIPT
Andrew Mirelman
Co-Authors: Richard Cookson, Miqdad Asaria, Susan Griffin, Marc Suhrcke
Methods for Incorporating Health
Equity Impacts in Economic
Evaluation with Applications to Low
and Middle Income Countries
1
Objectives
1. To describe different approaches for including equity in economic evaluation.
2. To show the requirements for each approach and what information each provides.
3. To improve understanding of how CHE’s work on distributional cost-effectiveness analysis (DCEA) may be moved forward and potentially applied in low and middle income countries.
Reviews of Equity in Economic Evaluation1. Sassi et al. Equity and the Economic Evaluation of
Healthcare. Health Technology Assessment; 2001.
2. Weatherly et al. Methods for assessing the cost-effectiveness of public health interventions: Key challenges and recommendations. Health Policy; 2009.*
3. Johri et al. Can Cost-Effectiveness Analysis Integrate Concerns for Equity? Systematic Review. Int. Journal of Technology Assessment in Health Care; 2012.
*also see: Cookson et al. Health Economics, Policy Law; 2009.
Sassi et al. 2001
• Identifies 2 methods for incorporating equityi. Equity weighting – requires defining of a social
welfare function (SWF) and normative decisions inherent to the analysis.
ii. Tabulation – sub-group analysis, a descriptive and positive approach to incorporating equity.
Source: Sassi et al. 2001
Sassi et al. 2001 – Some Conclusions• Proposes a two-stage solution for moving forward:
i. Tabulation approach in the short term with adequate sub-group sensitivity analyses.
ii. Conceptual and methodological work should be explored in the medium-long term that could offer a solution that uses equity-weighting.
Weatherly et al. 2009
• Defines four approaches to incorporating equity in economic evaluation:
i. Review equity information
ii. Health inequality impact assessment (HIIA)
iii. Opportunity cost analysis
iv. Equity weighting of health outcomes
Weatherly et al. 2009
• Defines four approaches to incorporating equity in economic evaluation:
i. Review equity information
ii. Health inequality impact assessment (HIIA)
iii. Opportunity cost analysis
iv. Equity weighting of health outcomes
…makes distinction that #4 explicitly values the equity-efficiency trade-off.
Weatherly et al. 2009 – Some Conclusions• Invokes Sassi et al. and concludes that positive and
normative approaches is in a similar vein to Culyer’s deliberative versus algorithmic differentiation.
• Also concludes that equity weighting research should proceed in order to better understand health equity impacts.
Johri et al. 2012
• Focuses on three approaches to incorporating equity:
i. Weighting
ii. Opportunity costs
iii. Multi-criteria decision analysis (MCDA)
Johri et al. 2012
• Additionally provides a useful framework for what normative criteria are useful
i. Disease-related
ii. Social groups
iii. Financial and social effects
• These provide a mapping for discussing equity criteria and were also adopted as appropriate equity criteria for the GPS-Health checklist (Norheim et al. 2014).
Johri et al. 2012 – Some Conclusions• They conclude that these methods (weighting,
opportunity costs and MCDA) should be employed.
“To foster the best overall decision under specific circumstances, we recommend that HTA bodies use techniques for explicit consideration of equity such as those reviewed in this study as part of a deliberative process that emphasizes procedural fairness through accountability, transparency, consistency, and the proper use of scientific evidence.”
Four Approaches for Equity
• From these three reviews, we distilled four types of analysis for incorporating equity in economic evaluation:
1. Equity Evidence Review
2. Equity Constraint Analysis
3. Equity Distribution Analysis
4. Equity Trade-off Analysis
Four Approaches for Equity
1. Equity Evidence Review• What are the equity issues; what is already known about
them; what do stakeholders think?
2. Equity Constraint Analysis• How much benefit is foregone if a more cost-effective
option is ruled out on equity grounds?
3. Equity Distribution Analysis• How much do different groups gain and lose?
4. Equity Trade-Off Analysis• For values of the equity-efficiency trade-off, which
intervention is selected based on improving outcomes and reducing inequality?
Types of equity analysis and benefits considered
Approach Health Benefits Health + Financial Benefits
1. Equity Evidence Review
A B
2. Equity Constraint Analysis
C D
3. Equity Distribution Analysis
E F
4. Equity Trade-Off Analysis
G H
Four Approaches for Equity – Pros and Cons
1. Equity Evidence Review1. Pro – Requires no new analysis.2. Con – Requires that evidence exists.
2. Equity Constraint Analysis1. Pro – Flexible to many types of equity or non-equity constraints.2. Con – Don’t know the distribution of equity impact and does not
value the equity-efficiency trade-off.
3. Equity Distribution Analysis1. Pro – Gives you group specific information about who gains and who
loses.2. Con – Data on sub-groups may not exist.
4. Equity Trade-Off Analysis1. Pro – Can be incorporated into consistent equity framework.2. Con – Calculations can be complex and can be demanding on the
data to have all parameters in terms of common metric (e.g. QALY).
Examples of Equity Approaches
1. Equity Evidence Review• Miljeteig I, Johansson KA, Sayeed SA, Norheim OF. End-of-life decisions as
bedside rationing. An ethical analysis of life support restrictions in an Indian neonatal unit. Journal of Medical Ethics 2010;36; 473-478.
2. Equity Constraint Analysis• Cleary, Susan, Gavin Mooney, and Di McIntyre. "Equity and efficiency in
HIV‐treatment in South Africa: the contribution of mathematical programming to priority setting." Health Economics 19.10 (2010): 1166-1180.
3. Equity Distribution Analysis• Verguet, Stéphane, et al. "The consequences of tobacco tax on household health
and finances in rich and poor smokers in China: an extended cost-effectiveness analysis." The Lancet Global Health 3.4 (2015): e206-e216.
4. Equity Trade-Off Analysis • Asaria, M, Griffin, S, Cookson, R, Whyte, S, Tappenden, P. (2015). Distributional
cost-effectiveness analysis of health care programmes – a methodological case study of the UK Bowel Cancer Screening Programme. Health Economics. 24(6): 742–754 http://onlinelibrary.wiley.com/doi/10.1002/hec.3058/abstract
When are we interested in equity impacts?
• Adding equity to economic evaluation imposes a cost.
• Clear win-win situations may not require it.• Situations where it could be warranted include:
1. Making decisions when there are trade-offs in health and equity. • When it’s not cost-effective, should we accept it?
2. For population-wide, preventive interventions, there are benefits that aren’t accounted for in cost-effectiveness analysis and re-design may lead to more equal distribution.
Net Equity Impact (NEI)
+
-
-
Equity-Efficiency Impact Plane
Net Health Impact (NHI)
I. Win-WinBeneficial Health ImpactBeneficial Equity Impact
III. Lose-LoseHarmful Health Impact Harmful Equity Impact
IV. Lose-WinHarmful Health Impact Beneficial Equity Impact
II. Win-LoseBeneficial Health Impact Harmful Equity Impact
+
Health(H)
Cost (C)
CA
A
Standard Economic Evaluation with Threshold Value of Health, k
k
Is A Cost-Effective?
Health(H)
Cost (C)
HDAHGA
CA
A
Net Health Benefit (NHB)= Health Gained (HG)
Minus Health Displaced (HD)
Standard Economic Evaluation with Threshold Value of Health, k
NHB
k
NHB
Health (H)
Cost (C)
HDBHGB
CB
B
Net Health Loss (NHL)HG – HD < 0
Is B cost-effective?
k
NHL
NHL
B
Net Health Impact (NHI) = Health Benefit - Health Opportunity Cost
-
A
0
+
Standard Economic Evaluation
Intervention Bis NOT cost-effective
(-ve net health impact) compared with do nothing (0)
Intervention Ais cost-effective
(+ve net health impact) compared with do nothing (0)
Note: positive and negative NHI are switched
Net Health Impact (NHI)
Net Equity Impact (NEI)
-ve
-ve
+ve
Estimating Equity Impacts
A
B
HARMFULequity impact
BENEFICIAL equity impact
Net Health Impact (NHI)
Net Equity Impact (NEI)
-ve
-ve
+ve
Estimating Equity Impacts
A
B
HARMFULequity impact
BENEFICIAL equity impact
Net Health Impact (NHI)
1. Is this beneficial equity impact of B worth the net health loss?
2. Is this harmful equity impact of A justified by the net health gain?
NEI
NHI
-ve
-ve
+ve
Method 1: Equity Evidence Review
A
B
Example of equity review – Miljeteig2010• Explores cost-effectiveness
and equity evidence side by side.
• Use a systematic case review methodology.
• Diagram equity weights when discussing the evidence for valuing lives.
• Also a careful discussion of the context of resource scarcity.
Source: Miljeteig et al. J Med Ethics 2010; 36:473-478.
Net Equity Impact (NEI)
Net Health Impact (NHI)
-ve
-ve
+ve
Method 2: Equity Constraint Analysis
A
B
Net health loss if equity constrains us to implement B and not to implement A
Example of equity constraint analysis –Cleary 2010
• Describe three treatment scenarios across a range of budgets:
1. equal treatment2. decent minimum3. health maximization
Source: Cleary et al. Health Econ. 2010; 19:1166-1180.
Net Equity Impact (NEI)
Net Health Impact (NHI)
-ve
-ve
+ve
Method 3: Equity Distribution Analysis
A
B
Quantifies the distribution of health impacts, and so reduces uncertainty
NEI
NHI
-ve
-ve
+ve
Method 3: Equity Distribution Analysis
A
B
Quantifies the distribution of health impacts, and so reduces uncertainty
Example of equity distribution analysis – Verguet 2015
• Packaged as a form of analysis called Extended Cost-Effectiveness Analysis (ECEA) and used widely in the latest round of the Disease Control Priorities Project.
• Adds financial risk protection as a benefit.
• Typically broken down by wealth quintile.
Source: Verguet et al. 2015
NEI
-ve
-ve
+ve
A
B
NHI
Method 4: Equity Trade-Off Analysis
Adds comparable summary estimates of net equity impact, and so reduces uncertainty further
Enables analysis of trade-offs between health and equity impact
Example of equity trade-off analysis
• Distributional cost-effectiveness analysis (DCEA) done at CHE.
• Assesses baseline levels of health and can incorporate group-specific opportunity costs.
• Transforms QALYs into equally distributed equivalent (EDE) QALYs, which are weighted according to an Atkinson Index given a level of inequality aversion.
Key Additional Data Requirements
1. Total health levels without intervention.
2. Incidence or eligibility for intervention.
3. Treatment effect in terms of health gains and resources used.
4. Health opportunity costs.
5. #1-4 in terms of equity relevant characteristics (e.g. income, ethnicity).
6. Quantified trade-off in equity and efficiency from SWF. Examples from DCEA so far use Atkinson (relative) and Kolm (absolute) indices.
Source: Asaria et al. 2015
Examples of approaches of equity analysis and benefits considered
Approach Health Benefits Health + Financial Benefits
1. Equity Evidence Review
A B
2. Equity Constraint Analysis
C: Opportunity Cost of Equity (with MP)
D
3. Equity Distribution Analysis
E: Sub-groups analysis
F: ECEA
4. Equity Trade-Off Analysis
G: DCEA H: DCBA*
Conclusions
• We describe four approaches to incorporating equity into economic evaluation.
• Previous reviews have found that equity is lacking in economic evaluation and proposed different methodological approaches.
• ECEA, being used more in global health, provides a dashboard of health equity and financial equity impact.
• The DCEA approach provides a framework for multiple inequality measures, incorporating baseline health and looking at group-specific opportunity costs.
• DCEA also requires quantifying the health-equity trade-off -- such as an inequality aversion parameter.
Thank You