Introduction

Explicit rationing—decisions not to fund certain treatments—has become a fact of life in many healthcare systems.1^–4 Health economic assessments often underpin rationing decisions, although it remains unclear whether society's values are well reflected by the utilitarian approach of maximising the units of health attainable from available resources.5 6 Health economic assessments are used to determine the additional cost per unit of health gain for different treatment options. Cost effectiveness analysis is the most common method of assessment7 8 and, for life shortening conditions, primarily focuses on the additional cost per life year gained. We propose that prognosis without treatment is an important contextual modifier of life years gained in evaluating treatments for life shortening conditions. We present initial data supporting this hypothesis and describe resource allocation strategies that use this information.

Limitations of life years gained

Life years gained represent the extra life expectancy resulting from a treatment. By definition, the comparison is with the life expectancy associated with an established standard of care for the condition. Depending on the condition, the established standard of care may be interventional or supportive.

Using life years gained in health economic assessments has several problems. The first is that they are inapplicable to treatments that do not prolong life. Most of the other problems relate to the fact that a year of life in a particular clinical setting may not have the same value as a year of life in a different clinical setting.

QALYs and contextual modifiers

Initial attempts at improving the fairness of life years gained resulted in the development of quality adjusted life years (QALYs). In a QALY, each unit of time in a health state is weighted by both …