Table 1

Value elements that relate to the evaluation of health outcomes

Value elementRationaleImplicationsIssues
Alternatives or variation to existing HRQoL dimensions and measuresSome outcomes, such as sensory impairment and mental health may not be adequately captured by generic measures, such as the EQ-5D.16 17 Requires modification of the metric used to generate utilities in QALY calculations.No such validated metric is currently available.
Value of hopeProvision of hope for previously untreatable condition has added value.6 Relates to the potential risk-seeking preferences of those with severe disease.7 Benefits for previously untreatable conditions are preferred to greater total benefits from treating other conditions.Risks double counting.
Difficult to quantify.
May not be appropriate from a societal perspective.
Insurance valueAdded value assigned to new options that ‘insure’ against ill health.6 Relates to risk-avoidance regarding rare but high impact health events.Additional value assigned to high impact treatments compared with multiple smaller incremental benefits.Risks double counting.
Difficult to quantify.
May not be appropriate from a societal perspective.
Value of cureReturn to full health (cure) may be perceived as having added value.6 Smaller chance of (or fewer people) achieving large gains in length/quality of life preferred to larger chance (or greater numbers) gaining smaller benefits.Risks double counting.
May conflict with ‘burden-of-disease’ and ‘real option value’.
May not be appropriate from a societal perspective.
End-of-life treatmentsAdditional weight may be given to benefits of life-extending treatments given to people with short life expectancy.11 Similar to burden of disease (see below) but has been more narrowly applied in relation to life expectancy rather than HRQoL.Incorporated into NICE methodology, although there is little evidence to suggest that it reflects societal preferences.
Burden of diseaseSome evidence for higher value placed on gains in health for those with the greatest burden of disease.18 Equivalent gains in health are considered more valuable for those with poorer initial health. That is, utility change from 0.1 to 0.2 given more weight than 0.8–0.9Was considered in NICE consultation on value-based assessment to replace end-of-life guidance, using a ‘proportional shortfall’ model and rejected.14
Cancer labelConditions and treatments related to a cancer diagnosis may be given special status.34 Equivalent benefit for people with cancer diagnosis is given preference over similar benefit in other conditions.The Cancer Drugs Fund in the UK was founded on the assumption that cancer should be given special treatment This does not appear to have rational basis or align with public preferences.60
Real option valueLife extending treatments provide the potential to benefit from future medical developments.6 Gains that come from increased survival from a non-curative treatment for a chronic condition are preferred to similar benefits from cure or improved HRQoL.Difficulty in defining the conditions and treatments to which this is relevant and conflicts with valuing cure.
Discount rateLower discount rates have been suggested for treatments with extended benefits.61 There is considerable debate about appropriate discount rates.62 63 Lower rates for extended benefits advantages technologies with high early costs offset by late benefits and would also advantage screening and preventative measures.Discount rates may be considered to be a technical economic issue or relate to societal time preferences. Either way there seems little rationale for varying the discount rates for different technologies.
  • HRQoL, health-related quality of life; NICE, National Institute for Health and Care Excellence; QALY, quality-adjusted life-years.