Editorial by Paula DeCola – Global Patient Affairs/Lead Healthy Ageing Center of Excellence at Pfizer

The term value-centred healthcare is increasingly replacing the concept of patient-centred healthcare.  On the surface, this doesn’t seem to be problematic, given that patients intuitively seek value, but it is dependent on the inclusion of patient perspectives.   However, the components of value have yet to be standardised. Aspects such as quality and cost are part of a number of value equations, although the prioritization or weighting of these elements can be a sticking point amongst stakeholders.    

PARADIGM is charged with developing patient engagement processes and tools related to medicines R &D to ensure structured, effective, meaningful, ethical, innovative and sustainable collaborations.  As part of this endeavour, metrics are required to assess the success of both the new processes and the outputs from these processes. In turn, the ultimate output of the R& D process, namely new medicines, also needs to have a defined value metric.  

The classical approach to assessing medicines value is a cost-effectiveness ratio, determining the cost per quality-adjusted life-years gained.1 This analysis provides the ability to look across therapies. However, this formula does not consider value drivers that are defined by patients, or those that may have broader societal implications.

Patients take into account aspects of value that allow for healthier lives, this includes the alleviation of symptoms, their ability to retain functionality to its fullest and other aspects of well-being.  Patient relevant outcomes and their core priorities may be quite different than those anticipated by regulators, biopharmaceutical companies, or payers.

For example, patients’ willingness to accept risk varies in association with the seriousness of their illness.  Therefore, considerations which relate to somewhat intangible criteria, such as hope, can be of great worth to some patients.  Hope can take different forms, including the hope that life can be extended long enough for a new more effective treatment to be developed.   

This type of criteria could have been applied in the area of HIV/AIDS, where the use of a single antiviral agent allowed a vast number of people to stay alive long enough to benefit from antiretroviral combination treatment. In this case, the overall benefit went beyond the individual and was experienced by society as a whole.

Societal value can take different forms; this includes caregiver respite. In the case of terminal breast cancer, 70% of care providers have been shown to have decreased work levels and 30% reported depression.2 (Gunfield 2004 CMAJ)  

The value of a treatment that reduces caregiver burden has an effect beyond the patient, and this consideration is not routinely factored into health technology assessments.  In the event that provision of care is factored into these calculations, it is generally associated with formal or paid care, rather than that of the “informal” caregiver.

Another potentially related facet of societal value is connected to the wellbeing of others associated with a person dealing with an illness; since these individuals wellbeing can be negatively affected.  One way this is demonstrated is by the higher rates of hospitalisation3 and mortality4 of the spouse of a person who has died. Some therapies have been shown to be cost-effective when these types of considerations are incorporated into the assessment.5

Progress has been made, newer value models have expanded beyond the cost per quality-adjusted life-years gained.  Yet, none of the current value frameworks considers patients’ perspective in their short- or long-term evaluations.6 This is counter-intuitive since the patient perspective should be a natural component of any value rubric related to medicines.

A holistic perspective of value requires the incorporation of societal and patient perspectives.  The focus should not be on the cost of a single healthcare intervention; rather the arbitrator of value should be the overall cost of health.

References

  1.   Weinstein MC, Stason WB. Foundations of cost-effectiveness analysis for health and medical practices. N Engl J Med 1997;296:716–21.
  2.   Grunfeld E, Coyle D, Whelan T, et al. Family caregiver burden: results of a longitudinal study of breast cancer patients and their principal caregivers. CMAJ. 2004;170(12):1795–801.
  3.   Christakis NA, Allison PD. Mortality after the hospitalization of a spouse. N Engl J Med. 2006;354(7):719–30.
  4.   Elwert F, Christakis NA. The effect of widowhood on mortality by the causes of death of both spouses. Am J Public Health. 2008;98(11):2092–8.
  5.   Basu A, Meltzer D. Implications of spillover effects within the family for medical cost-effectiveness analysis. J Health Econ. 2005;24(4):751–73.

6.   Milken Institute Avalere. Integrating the patient perspective into the development of value frameworks. March 2016. www.fastercures.org/assets/Uploads/value-coverage-framework-March-2016.pdf

Read another piece by Paula DeCola Value Creation: Making Room for Innovation