M. Parouty

On discounting of health gains from human papillomavirus vaccination: Effects of different approaches

OBJECTIVES Discounting has long been a matter of controversy in the field of health economic evaluations. How to weigh future health effects has resulted in ongoing discussions. These discussions are imminently relevant for health care interventions with current costs but future benefits. Different approaches to discount health effects have been proposed. In this study, we estimated the impact of different approaches for discounting health benefits of human papillomavirus (HPV) vaccination. METHODS An HPV model was used to estimate the impact of different discounting approaches on the present value of health effects. For the constant discount approaches, we varied the discount rate for health effects ranging from 0% to 4%. Next, the impact of relevant alternative discounting approaches was estimated, including hyperbolic, proportional, stepwise, and time-shifted discounting. RESULTS The present value of health effects gained through HPV vaccination varied strongly when varying discount rates and approaches. The application of the current Dutch guidelines resulted in a present value of health effects that was eight or two times higher than that produced when using the proportional discounting approach or when using the internationally more common 4% discount rate for health effects, respectively. Obviously, such differences translate into large variations in corresponding incremental cost-effectiveness ratios. CONCLUSION The exact discount rate and approach chosen in an economic evaluation importantly impact the projected value of health benefits of HPV vaccination. Investigating alternative discounting approaches in health-economic analysis is important, especially for vaccination programs yielding health effects far into the future. Our study underlines the relevance of ongoing discussions on how and at what rates to discount.

Accumulating evidence for the case of differential discounting

. It is the specific approach taken and the exact rates utilized that differ among countries. In particular, regarding the differing approaches, much debate has been spurred concerning whether to adopt equal or differential discounting. Equal discounting is mostly used in practice and guidelines sometimes refer to pragmatic motivations, including consistency argu-ments or the ease to use one and the same rate for money and health. Differential discounting involves the application of a generally lower discount rate for health outcomes – for example, life years – moti -vated by ethical arguments on valuing life years for future generations or the potential increase in the monetary value of health-over-time related to differing growth rates in the economy and life expectancy

Differential Time Preferences for Money and Quality of Life

BackgroundThis study provides an empirical investigation into differential time preferences between money and quality of life. Thus far, time preference investigations in health have mostly involved life-years gained and lives saved. However, the quality-adjusted life-year, which is recommended by several bodies, is a multiplicative measure of life duration and quality of life. To our knowledge, our study is the first to follow this approach specifically for quality of life.MethodsA questionnaire was developed to elicit time preferences for quality of life and for money, and it was distributed to a representative sample of the Dutch population. We also investigated the impact of population characteristics, such as current health state, optimistic/pessimistic future views or gender, on time preferences.ResultsWe found that discount rates for both money and quality of life decrease with increasing time of delay, with rates of the former being consistently at least two times higher than those of the latter. Similar trends in time preferences were observed across the subgroups, with the exception of the relatively high education subgroup. ConclusionIn agreement with the results of other studies, our empirically derived discount rates are higher than the rates featured in national guidelines for health care economic assessment. Our empirical study adds to the evidence for differential discounting, both with regards to money and health, as well as in time.

Practical implications of differential discounting of costs and health effects in cost-effectiveness analysis.

[1] O’Mahony JF, de Kok IM, van Rosmalen J, Habbema JD, Brouwer W, van Ballegooijen M. Practical implications of differential discounting in cost-effectiveness analyses with varying numbers of cohorts. Value Health 2011;14:438–42. [2] Brouwer WB, Niessen LW, Postma MJ, Rutten FF. Need for differential discounting of costs and health effects in cost effectiveness analyses. BMJ 2005;331:446–8. [3] Gravelle H, Brouwer W, Niessen L, Postma M, Rutten F. Discounting in economic evaluations: stepping forward towards optimal decision rules. Health Econ 2007;16:307–17. [4] Claxton K, Sculpher M, Culyer A, et al. Discounting and costeffectiveness in NICE—stepping back to sort out a confusion. Health Econ 2006;15:1–4. [5] Claxton K, Paulden M, Gravelle H, et al. Discounting and decision making in the economic evaluation of health-care technologies. Health Econ 2011;20:2–15. [6] Dutch Health Council. Vaccination against Cervical Cancer. The Hague: Health Council; 2008. Available at: http://www. gezondheidsraad.nl/en/publications/vaccination-against-cervicalcancer-0 [Accessed September 2010]. [7] Beutels P, Scuffham PA, MacIntyre CR. Funding of drugs: do vaccines warrant a different approach? Lancet Infect Dis 2008;8:727–33. [8] Postma MJ. Cost-effectiveness analysis of human pappilomavirus (HPV) vaccination in the Netherlands: recent publication reinforces favorable cost-effectiveness despite misleading conclusion. Vaccine 2010;28:873–4. [9] Rozenbaum MH, Boersma C. Cost-effectiveness analysis of human papillomavirus vaccination in the Netherlands. J Natl Cancer Inst 2010;102:358–9. [10] Jit M, Brisson M. Modelling the epidemiology of infectious diseases for decision analysis: a primer. Pharmacoeconomics 2011;29:371–86.

Reviewing and piloting methods for decreasing discount rates; someone, somewhere in time

There has been substantial debate on the need for decreasing discounting for monetary and health gains in economic evaluations. Next to the discussion on differential discounting, a way to identify the need for such discounting strategies is through eliciting the time preferences for monetary and health outcomes. In this article, the authors investigate the perceived time preference for money and health gains through a pilot survey on Dutch university students using methods on functional forms previously suggested. Formal objectives of the study were to review such existing methods and to pilot them on a convenience sample using a questionnaire designed for this specific purpose. Indeed, a negative relation between the time of delay and the variance of the discounting rate for all models was observed. This study was intended as a pilot for a large-scale population-based investigation using the findings from this pilot on wording of the questionnaire, interpretation, scope and analytic framework.

PMC9 A NEO-RICARDIAN APPROACH TOWARD DISCOUNTING

demographic size of ACs) were calculated for selected tariffs. RESULTS: We observed lack of consistency in structure and contents of tariff lists and in tariff levels, as exemplifi ed by: different categorization of services; incomplete listing of services; different terminologies; different levels of detail for common services (e.g. MRI: 2–127 options by body area and/or complexity); wide ranges of tariffs for most items (e.g. specialist visit: c56–c191, general ward per diem: c82–c569, simple MRI: c120–c634). Wide variations were also observed for other diagnostic investigations, (non-)surgical procedures, laboratory tests and DRGs. CONCLUSIONS: Wide ranges in tariffs for health resources commonly used in economic evaluations were identifi ed across ACs, with a difference between minimum and maximum values of at least factor 2. There exists no evidence on how tariffs are calculated and if they refl ect real cost. Available AC tariffs should be used with caution and a simple or weighted average across AC tariff lists may be used as proxies for nation-wide costs. Elaboration of a nation-wide list would avoid possible bias from analysts in the selection of cost values to obtain given results.