Norwegian Institute of Public Health
Parlty annotated bibliography of work published in English
Nord E. Efficiency
and priority setting. Some problems in cost-effectiveness analysis of health care.
Thesis defended at the Department of Political Science,
Nord E. Cost-value analysis in health care: Making
sense out of QALYs.
Text book in which I summarise my previous work, offer an updated review of empirical studies of preferences for resource allocation in health care and suggest an alternative to the conventional QALY model, in which population preferences are measured by means of the person trade-off technique.
1. Nord E, Vale PH. Policies to reduce the consumption of fat in milk. Health Promotion 1989;4:277-280.
replacement of full-cream milk by low-fat milk in
2. Nord E, Dahl E.
Socioeconomic status and the use of public hospitals in
Data on morbidity and admission ratios do not support a hypothesis that social discrimination violating the need principle occurs to any important extent in Norwegian hospital practice.
3. Nord E. Expenditures on health care in the last year of life. Int J Health Planning and Management 1989;4:319-322.
18-26 % of
public expenditure on health care in
4. Nord E. The significance of contextual factors in valuing health states. Health Policy 1989;13:189-198.
Several contextual factors may affect the social value assigned to a health improvement in a particular patient- year. The factors are set together in a model that may serve as a framework within which simple QALY calculations may be considered.
5. Nord E. A comment on the meaning of numerical valuations of health states. Soc Sci Med 1990;30:943-944.
While numbers for quality of life may appear meaningless, numerical expressions of strength of preference for different outcomes are not.
6. Nord E. Reducing sick leave costs by shortening waiting periods for elective surgery. Med Decis Making 1990;10:95-101.
Empirical studies suggest that reductions in sick leave costs may exceed the marginal costs of reducing waiting times.
7. Nord E. The validity of a visual analogue scale in
determining social utility weights for health states. Int J Health Planning and Management 1991;6:234-42.
2. Intervals between states on the EuroQol VAS must be weighted more the closer they are to the bottom of the scale.
8. Nord E. EuroQol:
Health-related quality of life measurement. Valuations of health states by the
general public in
1. An experiment with an alternative lay out of the EuroQol instrument added little to its feasibility.
Valuations in a random sample of Norwegian subjects were quite similar to
valuations made by subjects in
9. Nord E. Methods for quality adjustment of life years. Soc Sci & Med 1992;34:559-69.
3. Quality weights for life years are empirically more meaningful, in the sense that they are more amenable to empirical testing, if they are interpreted simply as preference weights rather than measures of amounts of well life in the utilitarian tradition.
10. Nord E. The use
of EuroQol values in QALY calculations. In: Bjørk S (red.). EuroQol Conference
Proceedings. IHE working paper 1992:2.
Using Norwegian preference data, a transformation function for EuroQol values is suggested for use in calculation of QALYs in health program evaluation.
11. Iversen T, Nord E. Priorities among waiting list patients. In Zweifel P, Frech III HE (eds). Health Economics Worldswide, 203-216. Kluwer Academic Publishers, 1992.
Consultants' stated criteria for prioritising were compared with actual criteria as revealed by data on waiting times for patients with different attributes. There was good correspondence for the variable "strong pain", a weaker correspondence for "on sick leave" and otherwise no statistically significant correspondence.
12. Nord E. An alternative to QALYs: The Saved Young Life Equivalent (SAVE). Br Med J 1992;305:875-877.
Society's appreciation of one particular health care outcome - saving a young life - is suggested as a unit of value. Other health care outcomes may be valued directly in terms of SAVEs by means of a simple equivalence of numbers technique.
13. Nord E. The relevance of health state after treatment in prioritising between patients. J Med Ethics 1993;19:37-42.
In QALY-thinking, an activity that takes N people from a bad state to the state of health for X years should have priority over an activity that takes N other people from the same bad state to a state of moderate illness for the same number of years (given equal costs). However, an empirical study indicates that Norwegians tend to emphasize equality in value of life and in entitlement to treatment rather than level of health after treatment.
14. Nord E. Towards quality assurance in QALY-calculations. Int J Techn Assess Health Care 1993;9:37-45.
1. The utility weights that were used in 15 published scientific articles mostly had a weak theoretical and empirical basis.
2. Readers were generally not provided with information that would allow independent calculations based on different choices of utility weights.
15. Nord E.
Unjustified use of the Quality of Well-Being Scale in
The QWB does not have the cardinal properties that are required in calculations of social benefit. A set of health state values based on upper end compression would have produced a priority list more in accordance with public preferences than the one based on the QWB issued by the Oregon Health Services Commission in May 1990.
16. Nord E, Richardson J, Macarounas-Kirchmann K. Social evaluation of health care versus personal evaluation of health states: Evidence on the validity of four health state scaling instruments using Norwegian and Australian surveys. Int J Techn Assess Health Care 1993;9:463-478.
Public preferences as measured in terms of person trade-offs suggest that the McMaster Health Classification System and the EuroQol Instrument assign excessively low values to health states. The Quality of Well-Being Scale appears to compress states towards the middle of the 0-1 scale. The Rosser/Kind index fits reasonably well with directly measured person trade-off data.
17. Nord E. The trade-off between severity of illness and treatment effect in cost-value analysis of health care. Health Policy 1993;24:227-238.
Cfr. paper no 12 above. Social appreciation of health care programs is a function of the severity of the patients' initial state as well as of treatment effect. Prioritising on the basis of cost per QALY misses the former point. A pilot study suggests that the trade-off between severity and effect - both measured on the same 7-point scale - can be modeled mathematically with reasonable accuracy. The social value of any outcome in terms of SAVEs may then be expressed as a function of severity and effect. Cost per SAVE may be useful as a guiding criterion in prioritising.
18. Wannag A, Nord E. Work content of Norwegian occupational physicians. Scand J Work Environ Health 1993;19:394-398.
The work of 50 randomly selected occupational physicians on 249 work days was recorded in detail and assigned to nine different categories. 22 % of the recorded time was spent on non work related illnesses.
19. Nord E. The QALY - a measure of social value rather than individual utility. Health Economics 1994;3:89-93.
The QALY interpreted as a measure of amounts of well life does not carry sufficient empirical meaning. As a measure of individuals' personal appreciation of outcomes in their own lives the QALY does not work in comparisons of life saving interventions with interventions that improve health or increase life expectancy. QALYs need to be interpreted as a measure of social value, and this requires use of the person trade-off technique for eliciting social preferences.
20. Nord E. The role of cost-effectiveness analysis in resource allocation in health care. In: Productividad, cobertura y calidad. Ministry of Health, Santiago de Chile, 1994.
There may be much productivity to be gained from applying better benefit measures in describing hospital outcomes and from applying cost-effectiveness analysis to decision making at the budget level. Such steps towards monitoring and increasing productivity ought not to be too hard for doctors to accept. On the other hand, health authorities may have to accept that CEA should continue to play a limited role in doctors' prioritising between individual patients.
21. Nord E. Outcome
measures for resource allocation decisions in health care. In Albrecht G,
Fitzpatrick R (eds). Advances in medical sociology, vol 5.
The article is based on no 19 and no 17.
22. Nord E. The person trade-off approach to valuing health care programs. Medical Decision Making 1995,15, 201-208.
The Person trade-off approach (PTO) establishes the number of patients treated in one program that people consider equal in social value to a given number of patients in another program. The approach is theoretically the most valid one for valuing different health care programs. The PTO needs to be applied in fairly large groups to keep random measurement error at an acceptable level. Possible framing effects include the effects of argument presentation, the choice of start points in numerical exercises and the choice of decision context.
23. Nord E. The use of cost-value analysis to judge patients' right to treatment. The International Journal of Medicine and Law 1995, 14,553-558.
See 17. The question is raised whether a value table for health outcomes may be helpful in judging patients' lawful right to treatment.
24. Nord E, Richardson J, Street A, Kuhse H, Singer P. Maximizing health benefits versus egalitarianism: An Australian survey of health issues. Social Science & Medicine 1995,41,1429-1437.
Economists have often treated the objective of health services as being the maximisation of the QALYs gained, irrespective of how the gains are distributed. In a cross section of Australians such a policy received very little support when the consequence is a loss of equity and access to services for the elderly and for people with a limited potential for improving their health.
25. Nord E, Richardson J, Street A, Kuhse H, Singer P. Who cares about cost? Does economic analysis impose or reflect social values? Health Policy 1995,34,79-94.
In a cross section of Australians, respondents generally felt that it is unfair to discriminate against patients who happen to have a high cost illness and that costs should therefore not be a major factor in prioritising. The majority maintained this view even when confronted with its implications in terms of the total number of people who could be treated and their own chance of receiving treatment if they fall ill.
26. Nord E, Richardson J, Street A, Kuhse H, Singer P. The significance of age and duration of effect in social evaluation of health care. Health Care Analysis 1996,4,103-111.
A study using the person trade-off technique in a cross section of Australians shows support for the assumptions in the QALY approach that duration of benefits, and hence also age, should count in prioritising at the budget level in health care.
27. Nord E. Health status index models for use in resource allocation decisions: A critical review in the light of observed preferences for social choice. The International Journal of Technology Assessment in Health Care, 1996,12,3.
Multiattribute health status index models are markeded as aids in calculating QALYs in health program evaluation. The models can be tested by comparing their implications with direct observations of how societies think resources should be distributed across patient groups. The paper reviews empirical evidence of this kind from various countries and summarises the evidence in three rules of thumb for selecting values for health states. Eight different models (QWB, HUI 1&2, EuroQol, IHQL simple & complex, 15-D, Rosser/Kind-index) are judged relative to these rules of thumb. Seven of the models underestimate the strength of social preferences for treating the severely ill before the less severely ill.
28. Eriksen BO, Almdahl SM, Hensrud A, Jæger S, Kristiansen IS, Murer FA, Nord E et al. Assessing health benefit from hospitalization: Agreement between expert panels. Int J of Techn Assess in Health Care 1996,12,126-135.
Agreement between two expert panels in assessing gain in life expectancy and quality of life gain from unselected stays in a department of internal medicine was investigated. Weighted kappas of 0.45-0.63 were found.
29. Brook R, with the EuroQol Group. EuroQol: The current state of play. Health Policy 1996, 37, 53-72.
A review of methodological issues addressed in the development of the EuroQol Instrument.
30. Magnus P, Stigum H, Nord E et al. Quality adjusted life years in planning preventive measures. Journal of the Norwegian Medical Association 1996,116,1229-1232. (Abstract in English).
Cost-per-QALY was calculated for testing blood donors for HTLV I/II.
31. Nord E. A table of values for cost-effectiveness analysis in health care. Journal of the Norwegian Medical Association 1996, 116, 3246-3249. (Abstract in English).
Further development of paper 17 above.
32. Nord E, Badia X,
Rue M, Sintonen H. Hypothetical valuations of health states versus patients'
self ratings. In Badia et al (eds).
EuroQol Plenary Meeting,
The values that patients assign to their own health state tend to be higher than the values that healthy people assign to those same states on a hypothetical basis.
The concern for equity comes out more strongly when preferences for resource allocation are elicited from subjects who respond out of self-interest from behind a veil of ignorance.
34. Nord E. Comment: Aggregating health state valuations. Journal of Health Services Research and Policy 1997, 2, 166-167.
A medians based EuroQol tariff performs better than a means based one in predicting societal person trade-off preferences because of its greater degree of upper end compression of health state values.
35. Nord E, Wisløff F, Hjorth M, Westin J. Cost-utility analysis of melphalan plus prednisone with or without interferon alpha 2B in newly diagnosed multiple myeloma. Pharmacoeconomics 1997,12, 89-103.
Adding interferon alpha 2B can at most be justifiable in terms of cost-effectiveness in subgroups with high treatment response.
36. Nord E. A review of synthetic health indicators.
Background paper prepared for the OECD Directorate for
Education, Employment, Labour and Social Affairs.
Mimeo, 43 pages. June 1997.
Gives a detailed description of existing multi-attribute utility instruments and assesses their reliability and validity.
37. Eriksen BO, Kristiansen IS, Nord E et al. Does admission
to a medical department improve patient life expectancy.
Journal of Clinical Epidemiology 1997, 50, 987-995.
The majority of admitted patients did not gain life expectancy, but a minority had substantial gains.
38. Hofoss D, Nord E. Norwegian doctors – affluent and
reputed, but not particularly contented. J Norw Med Ass
1997,117, 3476-81. (Abstract in English.)
Norwegian doctors enjoy a high standard of living but score lower than a population reference group on quality of life indicators. Stress at work is a likely explanation.
39. Neymark N, Kiebert W, .. Nord E, et al. Methodological
and statistical issues of quality of life and economic
evaluation in cancer clinical trials: Report of a workshop.
European Journal of Cancer 1998,34,1317-1333.
Gives a general discussion of a number of issues.
40. Eriksen BO, Kristiansen IS, Nord E et al. Does admission
to a department of medicine improve patients’ quality of life?
Journal of Internal Medicine 1998,244,397-404.
A department of medicine was effective in improving the QoL in 81 % of the admitted patients.
Nord E, Pinto JL,
Incorporating societal concerns for fairness in numerical
Valuations of health programs. Health Economics 1999,8,25-39.
Shows how the conventional QALY model can be modified so as to include equity weights that account for societal concerns for giving priority to the severely ill over the less severely ill and not discriminating too strongly between patients with different potentials for health.
42. Nord E, Wolfson M. Multi-attribute health state valuations: Ambiguities in meaning. Quality of life Newsletter 21/1999.
instruments place quite different meanings on the numbers
they offer, and evidence of the meanings that are claimed is poor. The situation is confusing to potential users.
Menzel P, Gold M, Nord E et al. Toward a broader view of values in
cost-effectiveness analysis of health.
A wider ethical discussion of the issues addressed in no 39 and some related issues.
44. Nord E. Towards cost-value analysis in health care? Health Care Analysis, 1999, 7, 167-175.
Summarises 41 and 43 and presents a table of person
trade-off based values for health states that could replace conventional utilities in cost-effectiveness analysis.
45. Kristiansen IS, Kvien TK, Nord E. Cost-effectiveness of replacing diclofenac with a fixed combination of misoprostol and diclofenac in patients with rheumatoid arthritis. Arthritis & Rheumatism 1999,42.
Replacing diclofenac with a fixed diclofenac/misoprostol
combination is cost-effective when restricted to RA
patients at increased risk of serious gastro-intestinal
46. Nord E. Adjusting health state utilities for use in economic evaluation. Quality of life Newsletter 23/1999.
Offers a diagram for transforming utilities from multi-
attribute utility instruments into numbers that
encapsulate concerns for fairness and therefore can be
used to estimate the societal value of health programs.
47. Arnesen T, Nord E. The value of DALY life: problems with ethics and validity of disability adjusted life years. Br Med
Journal 1999, 319, 1423-1425.
The version of the person trade-off technique used in the Global Burden of Disease Report in 1996 was found to be
unethical and incomprehensible and was rejected by a
team of European researchers. An alternative version was
48. Nord E. My goodness – and yours. A history, and some possible futures, of DALY meanings and valuation procedures.
Paper for WHO’s Global Conference on Summary Measures of Population Health, Marrakech December 1999. Mimeo, 9 pages. In press (2002) in Proceedings from the conference.
Discusses ways of establishing disability weights
depending on whether DALYs are supposed to measure health
in a narrow sense or also capture concerns for severity.
49. Wisløff F, Gulbrandsen N, Nord E. Therpeutic options in treatment of multiple myeloma. Pharmacoeconomics 1999,4, 329-341.
50. Nord E. Summary of survey about health
There is high interest, moderate knowledge and little use
of other techniques than monetary cost-benefit analysis.
51. Eriksen BO, Førde OH, Kristiansen IS, Nord E et al. Cost savings and health losses from reducing inappropriate admissions to a department of internal medicine. Int J Techn Assessment in Health Care 2000,18, 1143-1153.
Savings obtained by excluding admissions predicted to be
inappropriate were small relative to the health losses
(due to lack of specificity in ex ante judgments).
52. Stigum H, Magnus P, Samdal HH, Nord E.
Human T-cell lymphotropic virus testing of blood donors in
53. Ubel P, Nord E et al. Improving value measurement in cost-effectiveness-analysis. Medical Care 2000,38,892-901.
54. Nord E, Arnesen T, Menzel P, Pinto JL. Towards a more restricted use of the term ’quality of life’. Quality of Life Newsletter 2001/26.
55. Nord E. Health state values for multiattribute utility instruments need correction. Ann Med 2001,33,371-374.
56. Nord E. The desirability of a condition versus the well being and worth of a person. Health Economics 2001,10,579-581.
57. Nord E. Severity of illness versus expected benefit in societal evaluation of health care interventions. Expert Rev Pharmacoeconomics Outcomes Res 2001,1,85-92.
58. Gulbrandsen N, Wisløff F, Nord E et al. Cost-utility analysis of high dose melphalan with autologous blood stem cell support. Eur J Haematol 2001,66,328-336.
59. Nord E. Measures of goal attainment and
performance in the World Health Report
Health Policy 2002,59,183-191.
60. Nord E. Comments to ’A note on cost-value analysis’. Health Economics 2003,12,251-253.
61. Nord E. Fairness in evaluating health
systems. In Proceedings from WHO 1999 Conference in
63. Schwarzinger M, Lanoë J-L, Nord E, Durand-Zaleski I. Lack of multiplicative transitivity in person trade-off responses. Health Economics, 2004,13,171-181.
64. Nord E, Menzel P, Richardson J. The value of life: Individual preferences and social choice. A comment to Magnus Johannesson. Health Economics,2003,12,873-877.
65. Nord E. The usefulness of formal outcome evaluations in health policy making: Looking for the baby in the bathwater.
In: ter Meulen R et al (eds). Evidence-based practice in medicine and health care. Springer Verlag 2005.
66 Pinto JL, Nord E. Incorporating concerns for fairness in economic evaluation of health programs. Humanitas 2003 (text in Spanish).
69 Nord E. Some ethical corrections to valuing health
programs in terms of quality adjusted life years (QALYs). Virtual
70 Nord E. Values for health in QALYs and DALYs:
Desirability versus well-being and worth. In Wasserman D et al (eds). Quality
of life and human difference.
71 Nord E. Coping with depression. J Norw Med Association 2005. (Helseøkonomisk vurdering av kurs i mestring av depresjon). Text in Norwegian.
72 Nord E, Menzel P, Richardson J. Multi-method approach to valuing health states: Problems with meaning. Health Economics 2006,15,215-218.
73 Nord E. Severity of illness and priority setting: Lack of discussion of surprising finding. Journal of Health Economics 2006,25,170-172.
74 Nord E. Utilitarian Decision Analysis of Informed Consent. Am J Bioethics 2006,6, May/June.