The UK National Institute for Health and Clinical Excellence (NICE) and other agencies for assessing health technology around the world are facing up to the challenges of rationing in a systematic and transparent way. But consideration of two factors could improve their decision-making.
First, the quality-of-life evaluation mentioned in your News Feature (Nature 461, 336–339; 2009) needs more thought. NICE would achieve more if it valued health interventions according to the real suffering of patients, rather than on the basis of the hypothetical preferences of the public. There is evidence showing that the public are often prepared to sacrifice more life years than patients might be.
Also, public and patient preferences can misrepresent the impact of a particular state of health on our experiences (P. Dolan and D. Kahneman Econ. J. 118, 215–234; 2008). For example, we may imagine physical pain to be more severe than depression, but depression can make us feel worse and so we evaluate our lives less favourably.
Second, NICE should not raise the cost per quality-adjusted life year (QALY) threshold for some conditions, such as the end of life, until there is good evidence for doing so. The threshold varies across different conditions. From an implicit default position where all QALYs are treated equally, NICE can now give greater weight to QALYs at the later stages of a terminal disease. NICE justifies this position as being in accordance with the views of the general public — yet the evidence in this regard is actually quite weak.
There is some support from NICE's Citizens' Council for spending more on end-of-life care, but this preference has not been elicited in the context of what people would give up for it. In a choice between prioritizing end of life and reducing inequalities in lifetime health, it is likely that the general public would choose the latter (see http://go.nature.com/QgnrFX).
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Integrating evidence on patient preferences in healthcare policy decisions: protocol of the patient-VIP study
Implementation Science (2013)