I left Dublin this year, at the close of ISPOR's 16th Annual European Congress, thinking in terms of what is important when making a decision. The parameters need to be simple, intuitive and transparent in any evaluation model. This sounds straightforward, but which parameters should be measured, and how is a fair decision made?
We all make trade-offs in our evaluation of any decision, whether this is related to healthcare or any other aspect of life. As consumers, we subconsciously assess affordability versus value. For instance, in my day-dream of what I would buy if I won the lottery, high on the list is a full-length, white, pure cashmere coat. This is obviously totally impractical, as such a coat would need cleaning after each wear and carries a prohibitively expensive purchase price. In my dreams, though, I can evaluate the purchase over a number of years on a per-wear basis, which then may offer greater value for money than buying a mid-priced coat every year for the next 10 years. The problem is my bank balance is not in a state today to make that investment. My coat is not affordable today.
I see parallels to this in the debate around cost-effectiveness models and the measurement of value for a patient. Should interventions take into account the wider societal benefits of a patient on a particular drug? The broader impact of the 'cost of treatment' could be proven to be effective, by virtue of that patient having a healthier and hence more productive life. However, at a practical level, is the approach affordable? Can the treatment be purchased today? Fundamentally, is there enough money in today's budget to pay for it?
A cost-effectiveness approach takes into account the uni-variate measure of the impact of that intervention on the patient for the duration of her life in terms of healthcare. But, this does not include the multi-dimensional nature of her life, i.e., the impact in terms of her time at work, or having children, or being a grandparent - broader, society-based measures. It is very complex to draw up which criteria feed into this multi-dimensional consideration. There is no broad consensus on which criteria to use, nor are all criteria easily quantifiable. Finally, not everything is equal, so how do we decide which of these measures are more or less important than others? These questions can generate a lot of academic debate, but pity the policy-maker who has to draw up the methodology to make these decisions and stand by them morally, while the tabloid press has a field-day. You can see the headlines now: 'Cancer drugs denied to elderly patients'.
Multi-criteria decision analysis (MCDA) may be in the early stages of development, but just because it is difficult to define should not mean that we stick with a one-size-fits-all approach to cost-effectiveness. Being slightly right about how to evaluate the impact of an intervention is better than being slightly wrong, and the reality of a fairer and more realistic way forward for evaluation is much closer than my dreams of white cashmere coats.