Biomedical subjects

Trude Arnesen

Publications and source records attributed to Trude Arnesen.

4 recordsLinked to original sources

PubMed2005

Are QALYs based on time trade-off comparable?--A systematic review of TTO methodologies.

A wide range of methods is used to elicit quality-of-life weights of different health states to generate 'Quality-adjusted life years' (QALYs). The comparability between different types of health outcomes at a numerical level is the main advantage of using a 'common currency for health' such as the QALY. It has been warned that results of different methods and perspectives should not be directly compared in QALY league tables. But do we know that QALYs are comparable if they are based on the same method and perspective?The Time trade-off (TTO) consists in a hypothetical trade-off between living shorter and living healthier. We performed a literature review of the TTO methodology used to elicit quality-of-life weights for own, current health. Fifty-six journal articles, with quality-of-life weights assigned to 102 diagnostic groups were included. We found extensive differences in how the TTO question was asked. The time frame varied from 1 month to 30 years, and was not reported for one-fourth of the weights. The samples in which the quality-of-life weights were elicited were generally small with a median size of 53 respondents. Comprehensive inclusion criteria were given for half the diagnostic groups. Co-morbidity was described in less than one-tenth of the groups of respondents. For two-thirds of the quality-of-life weights, there was no discussion of the influence of other factors, such as age, sex, employment and children. The different methodological approaches did not influence the TTO weights in a predictable or clear pattern. Whether or not it is possible to standardise the TTO method and the sampling procedure, and whether or not the TTO will then give valid quality-of-life weights, remains an open question.This review of the TTO elicited on own behalf, shows that limiting cost-utility analysis to include only quality life weights from one method and one perspective is not enough to ensure that QALYs are comparable.

Attitude to Health↗

PubMed2004

Is cost-effectiveness analysis preferred to severity of disease as the main guiding principle in priority setting in resource poor settings? The case of Uganda.

INTRODUCTION: Several studies carried out to establish the relative preference of cost-effectiveness of interventions and severity of disease as criteria for priority setting in health have shown a strong preference for severity of disease. These preferences may differ in contexts of resource scarcity, as in developing countries, yet information is limited on such preferences in this context. OBJECTIVE: This study was carried out to identify the key players in priority setting in health and explore their relative preference regarding cost-effectiveness of interventions and severity of disease as criteria for setting priorities in Uganda. DESIGN: 610 self-administered questionnaires were sent to respondents at national, district, health sub-district and facility levels. Respondents included mainly health workers. We used three different simulations, assuming same patient characteristics and same treatment outcome but with varying either severity of disease or cost-effectiveness of treatment, to explore respondents' preferences regarding cost-effectiveness and severity. RESULTS: Actual main actors were identified to be health workers, development partners or donors and politicians. This was different from what respondents perceived as ideal. Above 90% of the respondents recognised the importance of both severity of disease and cost-effectiveness of intervention. In the three scenarios where they were made to choose between the two, a majority of the survey respondents assigned highest weight to treating the most severely ill patient with a less cost-effective intervention compared to the one with a more cost-effective intervention for a less severely ill patient. However, international development partners in in-depth interviews preferred the consideration of cost-effectiveness of intervention. CONCLUSIONS: In a survey among health workers and other actors in priority setting in Uganda, we found that donors are considered to have more say than the survey respondents found ideal. Survey respondents considered both severity of disease and cost-effectiveness important criteria for setting priorities, with severity of disease as the leading principle. This pattern of preferences is similar to findings in context with relatively more resources. In-depth interviews with international development partners, showed that this group put relatively more emphasis on cost-effectiveness of interventions compared to severity of disease. These discrepancies in attitudes between national health workers and representatives from the donors require more investigation. The different attitudes should be openly debated to ensure legitimate decisions.

Journal Article↗

PubMed2004

Can the value choices in DALYs influence global priority-setting?

The "disability adjusted life years" (DALYs) are increasingly used as a tool for decision-making and for describing the distribution of the Global Burden of Disease. The "DALY" combines information about mortality and morbidity, with several value choices such as disability weighting, age-weighting and discounting. These value choices imply that life years are assigned different value, depending on the age and the health state they are in. How robust is the distribution of DALYs to changes in these value choices, and are the choices transparent at the point of use? We calculated the burden attributed to "developmental disability due to malnutrition" and "major depression" with alternative value choices in a simple sensitivity analysis. In particular, we explored the relation between disability weight, health state description and incidence rate. The formulae and information needed was found in the World Health Organisation (WHO) publications using DALYs, and in a survey among international health workers. We found that alternative age-weights, disability weights and discount rate led to an inversion in the ranking of the burden of the two conditions. The DALY loss attributed to "developmental disability due to malnutrition" increased from 14 to 90%, while that of "major depression" sunk from 86 to 10%. The value choices currently used, tend at underestimating the disease burden attributed to young populations and to communicable diseases and this goes against the renewed efforts of the WHO of targeting diseases that are typical of poor populations. While the value choices may be changed, lack of transparency is a more profound problem. At the point of use, the number of DALYs attributed to a condition cannot be fully disaggregated. Hence, one cannot know which part of a DALY loss reflects the age group affected, the prevalence, the mortality rates, the disability weight assigned to it, or to how the condition has been defined. A more transparent and useful approach, we believe, would be to present the years lost due to a disease, and the years lived with a disease separately, without disability weights, age-weights and discounting. This would keep the best of the DALY approach and come closer to the aim of disentangling science from advocacy.

Decision Making, Organizational↗

PubMed2004

Roughly right or precisely wrong? Systematic review of quality-of-life weights elicited with the time trade-off method.

OBJECTIVE: Cost-utility analysis is gaining importance as a tool for setting priorities in health care. The approach requires quality-of-life weights on a scale from 0.00 (corresponding to death) to 1.00 (corresponding to perfect health). Different methods and perspectives of the evaluators tend to give different results. Time trade-off (TTO) is the most commonly used method to elicit quality-of-life weights for quality-adjusted life-years (QALYs). How reliable are the results of this method, when limited to one specific perspective, as input for cost-utility analysis? METHOD: Systematic literature review of empirical studies in which the TTO is elicited by the respondent on their own behalf. RESULTS: In 56 papers, quality-of-life weights for 102 diagnostic groups were given. Ranking of the diagnostic groups according to their quality-of-life weights had no apparent relation to severity. One specific diagnostic group was assigned quality-of-life weights ranging from 0.39 to 0.84. Altogether, 57% of respondents did not trade any life-time at all in exchange for health improvements. The distributions studied were skewed towards 1.00 and were bimodal without a central tendency. The correlation between the TTO and related methods was generally weak. Possible explanations for the poor empirical properties of the TTO are inappropriate use of the method, lack of representative samples, or that the TTO does not measure what it claims to measure. CONCLUSION: In the light of these findings, the TTO elicited from the patient perspective, as currently practised, should not be used as an input for QALYs or for comparisons of diagnostic groups.

Attitude to Health↗