Venue: The Fuqua School of Business, Duke University, 1 Towerview Drive, Durham, NC 27708-0120
Presentation
Equity and the Economic Evaluation of Prevention of Birth Defects and Disability
Background: Economic evaluations are used to prioritize interventions in health and healthcare in terms of their efficiency in achieving health improvements with scarce resources. However, efficiency assumes an objective function to be maximized. There is little agreement as to what measures of health should be optimized. Techniques to value and aggregate endpoints can lead to different rankings of the economic efficiency of health interventions, with equity implications if used for resource allocation.
Purpose: This paper focuses on the ethical implications of economic approaches to valuation of health outcomes with specific application to the economic evaluation of interventions for the prevention of fetal anomalies and health promotion among people with disabilities.
Methods: Measures of heath include natural units of deaths averted, life-years gained, preference-based measures such as quality-adjusted life-years (QALYs) and disability-adjusted life-years (DALYs), and monetary measures such as cost-of-illness (COI) and willingness-to-pay (WTP). Different methods for estimating QALYs and WTP raise important ethical questions. For QALYs, these include the type of method used to elicit preferences and whether instruments are administered to affected individuals, experts, or the general public. Techniques for estimating WTP include hedonic price analyses, contingent valuation studies, and discrete choice experiments. Ethical issues include the recruitment of people with disabilities and dependence of WTP valuations on income and wealth.
Findings: COI techniques are straightforward but devalue life stages that are not associated with paid employment. QALYs and DALYs have limitations in assessing benefits of health interventions for people with disabilities, particularly for valuations based on the judgments of medical professionals and the general public rather than people with disabilities. Furthermore, because people with disabilities have lower QALY and DALY weights, extension of life for people with disabilities yields fewer QALYs or DALYs. These measures are inconsistent with evidence that people place the same value on prevention of deaths regardless of variation in individual health states. QALY and DALY estimates are also problematic for methodological and ethical reasons in interventions aimed at pre-pregnant women, fetuses, and infants. For example, published QALY and DALY estimates of interventions to prevent birth defects have excluded fetal anomalies that result in miscarriage or pregnancy termination. Yet the prevention of a fetal anomaly through adequate folic acid intakes prior to and following conception results in a healthy live birth regardless of whether the anomaly would have resulted in a termination, stillbirth or, live birth followed by neonatal death. Inclusion of prevention of all cases of fetal neural tube defects (NTDs), including terminations, in estimates of expanded QALYs is shown to reduce incremental cost-effectiveness ratios by approximately 50% in an economic evaluation of a NTD prevention program.
Implications: Alternatives or modifications of current methods of economic valuations of health outcomes are needed to assure equity and efficiency in economic evaluation of health programs. More information is needed on public preferences regarding willingness to spend resources to improve health of people with disabilities and to improve women's health in order to reduce fetal anomalies.