Evidence, Uncertainty and the Policy Pursuit of Fairness

The article considers the interrelationships between ideas of fairness and ideas of evidence, and how progress in the policy pursuit of fairness in health and healthcare has been plagued by problems with vocabulary, vagueness as to values, deplorable absences of relevant empirical knowledge and failure to address appropriate means of making decisions about fairness in health and healthcare. Specific proposals are suggested as possible ways forward.equity, fairness, evidence, uncertainty, healthcare policy

Rights, responsibilities and NICE: a rejoinder to Harris

Harris' reply to our defence of the National Institute for Clinical Excellence's (NICE) current cost-effectiveness procedures contains two further errors. First, he wrongly draws a conclusion from the fact that NICE does not and cannot evaluate all possible uses of healthcare resources at any one time and generally cannot know which National Health Service (NHS) activities would be displaced or which groups of patients would have to forgo health benefits: the inference is that no estimate is or can be made by NICE of the benefits to be forgone. This is a non-sequitur. Second, he asserts that it is a flaw at the heart of the use of quality-adjusted life years (QALYs) as an outcome measure that comparisons between people need to be made. Such comparisons do indeed have to be made, but this is not a consequence of the choice of any particular outcome measure, be it the QALY or anything else

Does cost-effectiveness analysis discriminate against patients with short life expectancy? Matters of logic and matters of context

The aim of this paper is to explore the claim of ageism made against the National Institute for Health & Clinical Excellence and like organisations, and to identify circumstances under which ageist discrimination might arise. We adopt a broad definition of ageism as representing any discrimination against individuals or groups of individuals solely on the basis that they have shorter life expectancy than others. A simple model of NICE?s decision making process is developed which demonstrates that NICE?s recommendations do not inherently discriminate on the basis of life expectancy per se but that scope for discrimination may arise in the case of specific technologies having identifiable characteristics. Such discrimination may favour patients with either longer or shorter life expectancy. It is shown that NICE?s policies, procedures and the context in which NICE makes its decisions not only reduce the scope for discriminatory recommendations but also – in the case of “end of life” treatments – increase the likelihood that NICE?s recommendations favour those with shorter, rather than longer, life expectancy.

Use of Evidence-Informed Deliberative Processes – Learning by Doing. Comment on “Use of Evidence-informed Deliberative Processes by Health Technology Assessment Agencies Around the Globe”

It was determined that the process of technology appraisal was to be open, multi-disciplinary, multiprofessional and multi-institutional, and it would have “lay” participation. It was heavily dependent upon people’s willingness to serve pro bono. It was plain from the outset that very large numbers of people would be involved and the Institute itself would be largely a virtual organization. Few LMICs might be able to afford anything as comprehensive in scale and scope as NICE’s forms of deliberation. NICE itself had to modify some processes on grounds of cost. However, some approximations might be usefully attempted and then developed as experience teaches.The article by Oortwijn, Jansen, and Baltussen (OJB) is much more important than it appears because, in the absence of any good general theory of “evidence-informed deliberative processes” (EDP) and limited evidence of how they might be shaped and work in institutionalising health technology assessment (HTA), the best approach seems to be to accumulate the experience of a variety of countries, preferably systematically, from which some general principles might subsequently be inferred. This comment reinforces their arguments and provides a further example.https://10.15171/IJHPM.2019.11

Four decades of health economics through a bibliometric lens

This paper takes a bibliometric tour of the past 40 years of health economics using bibliographic"metadata"from EconLit supplemented by citation data from Google Scholar and the authors'topical classifications. The authors report the growth of health economics (33,000 publications since 1969 -- 12,000 more than in the economics of education) and list the 300 most-cited publications broken down by topic. They report the changing topical and geographic focus of health economics (the topics'Determinants of health and ill-health'and'Health statistics and econometrics'both show an upward trend, and the field has expanded appreciably into the developing world). They also compare authors, countries, institutions, and journals in terms of the volume of publications and their influence as measured through various citation-based indices (Grossman, the US, Harvard and the JHE emerge close to or at the top on a variety of measures).Health Monitoring&Evaluation,Health Systems Development&Reform,Health Economics&Finance,Rural Development Knowledge&Information Systems,Health Law

Does Cost-Effectiveness Analysis Discriminate against Patients with Short Life Expectancy?

Does the use of quality-adjusted life-years (QALYs) in cost-effectiveness analyses (CEAs) of health care interventions necessarily discriminate against patients with short life expectancy compared with others? This paper reviews the arguments both that it does and that it does not, and demonstrates that whether the use of any time-dependent outcome measure in CEA will result in discrimination depends, in the context of any given choice between interventions, upon the choice of cost-effectiveness ‘threshold’ adopted by the decision maker, whether the incremental cost-effectiveness ratio (ICER) of the intervention for a subgroup of patients with relatively short life expectancy lies above the cost-effectiveness threshold, and whether the ICER for a subgroup of patients with longer life expectancy falls below the cost-effectiveness threshold. For discrimination to result against such patients requires that the long term ratio of costs to QALYs associated with the intervention be lower than the short term ratio of costs to QALYs. The implications for agencies which use CEA as part of their decision making are then discussed.

Economics, social policy and social administration: the interplay between topics and disciplines

The article uses a distinction between topic and discipline to argue that social administration, like economics, is characterized by both, but that social administration has the special advantage, in treating the topic of social policy, of being multi-disciplinary. An account is presented of why economics is underrepresented among the disciplines of social administration and three important contributory roles are outlined for economics to play in the development of social administration

Economics, social policy and social administration: the interplay between topics and disciplines

The article uses a distinction between topic and discipline to argue that social administration, like economics, is characterized by both, but that social administration has the special advantage, in treating the topic of social policy, of being multi-disciplinary. An account is presented of why economics is underrepresented among the disciplines of social administration and three important contributory roles are outlined for economics to play in the development of social administration

Expanding HTA – Correcting a Misattribution, Clarifying the Scope of HTA and CEA; Comment on “Ethics in HTA: Examining the ‘Need for Expansion’”

Abrishami, Oortwijn, and Hofman (AOH) attribute to me a position I do not hold and an argument I did not make. The purpose of this note is make clear what my position actually is and to clarify the main differences between health technology assessment (HTA) and cost-effectiveness analysis (CEA)