Is the Value of a Life-Year Saved Context Specific?

Background: A number of recent findings imply that the value of a life saved, life-year saved or QALY saved varies depending on the characteristics of the life, life-year or QALY under consideration (Dolan et al, 2005). Despite the proliferation of such findings, budget allocations continue to be made under the assumption of 'distributive neutrality' such that - aside from adjustments for magnitude of health gains associated with duration and quality of life - the value of a life, life-year or QALY is typically assumed to be "independent of the personal characteristics of the recipient" (Nord et al, 1995). This continued focus on simple health maximisation is partly attributable to gaps in the available evidence - particularly with regards to tradeoffs between non-health arguments but also between non-health arguments such as age or severity and either cost or effectiveness. To close these data gaps, the present study estimates the marginal rate of substitution between cost, effectiveness and various non-health arguments including the life-stage of beneficiaries, the extent to which beneficiaries have contributed to their illness via voluntary adoption of risky lifestyle, the extent to which beneficiaries will contribute to the cost of the intervention, the type of intervention (lifestyle versus medical), and the aim of the intervention (cure versus prevention). Participants: 274 respondents resident in Australia from a random sample of 4,000 addressees taken from the WhitePages telephone directory. Methods: Discrete choice experiment to obtain stated-preference data over pairs of multi-attribute profiles. Odds of selecting profile B over profile A estimated via binary logistic regression for population-average, random effects and fixed effects models. Marginal rates of substitution between attributes (including cost) were then derived from estimated regression coefficients. Results: Preferences over profiles were related to small-area indicators of socio-economic status but were not related to individual characteristics of respondents (such as age, insurance status and whether the individual has any children). Respondents were more likely to select less costly, more effective interventions with a strong evidence base where the beneficiary did not contribute to their illness. Preliminary results also suggest that respondents preferred prevention over cure. Interventions for young children were most preferred, followed by interventions for young adults, then interventions for working age adults and with interventions for the elderly given the lowest priority. While these results and the implied marginal rates of substitution are consistent with expectations, results also suggest that - despite providing more output per dollar of government funding - profiles that entail out-of-pocket contributions are a lower priority. Conclusions: Marginal rates of substitution between cost, effectiveness and non-health arguments confirm that community values are inconsistent with simple health maximisation. Our experience also confirms that pragmatic constraints on the design of discrete choice experiments are likely to frustrate attempts to derive a comprehensive set of weights that captures all relevant main effects and interactions. Further debate is required to canvass the tradeoffs associated with adopting second-best options such as a partial set of value-weights or the piecemeal derivation and application of one set of weights over another