Erik Nord: Abstracts

Unclear meaning of utilities 

In everyday language, people never refer to the goodness or badness of health states in terms of numbers. Hence, the meaning – and validity – of such numbers is not obvious. We asked the constructors of MAU instruments to explain the meaning of the numbers by specifying the kind of decision-oriented proposi-tions that they believe can be made on the basis of the numbers that their instruments yield. The results show that constructors of different instruments place quite different meanings on the numbers they offer. From a user’s perspective this is highly problematic. Conceptual clarification is needed.

Futile utilities? (Use in decision making.)

There is evidence that formal economic evaluation studies have and will continue to have a limited role in resource allocation decisions. On the other hand, present evidence does not suggest that studies using utilities are less attractive to users than studies using other techniques.

Even if cost-utility studies have some impact, they are not always valid. Utilities on offer today are often misconceived, without users being sufficiently aware of this problem, see next two abstracts.

Transforming utilities from MAU-instruments.

Health state values from multi-attribute utility instruments such as the EQ-5D and the HUI need to be transformed before they can be used to estimate the societal value of different health interventions. With-out transformation the values lead to a very strong overestimation of the value of interventions for moderate conditions relative to interventions for severe or fatal conditions. A rough transformation function is offered for a number of MAU instruments. For a different solution, see paper on cost-value analysis.

Cost-value analysis: incorporating concerns for fairness in economic evaluation.

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A number of empirical studies show strong concerns for fairness and equity in health care in most countries. Current economic evaluation models like the conventional QALY-model (cost-utility analysis) fail to capture these concerns. Ways to incorporate these concerns are outlined. The relevance of formal models for decision making is discussed.

DALYs and disability weights

1. I believe DALYs de facto will tend to be used as measures of societal value, i.e. of worthiness of receiving resources. For this reason I think disability weights should incorpo-rate societal concerns for fairness. I indicate possible ways of doing this.

2. If value is measured in terms of DALYs gained, the value of life extension in chronically ill or disabled people is smaller than the value of life extension in otherwise healthy people. This is in most people’s eyes unethical and offen-sive. A proposed solution is to count each lost or gained life year as 1 irrespective of disability as long as life is preferred to being dead by the person concerned.

World Health Report 2000

The paper briefly explains all the methods behind the indices in the Report. The WHO has gone too far in compressing the results of poten-tially useful primary measurements in summary indices with unclear meaning, dubious validity and little practical relevance. The WHO has also gone too far in applying the same measuring rods to countries with different histories and values and different stages of development, and in encouraging international comparisons that are of little practical relevance. The WHO needs to add an indicator of equality in access to its present indicator of fairness in financing. Weights proposed by the WHO should not be regarded as objective.