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Education And Debate

Prognosis without treatment as a modifier in health economic assessments

BMJ 2005; 330 doi: (Published 09 June 2005) Cite this as: BMJ 2005;330:1382
  1. Ross Camidge, clinical lecturer in cancer therapeutics (,
  2. Andrew Walker, senior lecturer in health economics2,
  3. James J Oliver, clinical lecturer in clinical pharmacology and therapeutics1,
  4. Fiona Nussey, clinical lecturer in medical oncology3,
  5. Simon Maxwell, senior lecturer in clinical pharmacology and therapeutics1,
  6. Duncan Jodrell, reader in oncology3,
  7. David J Webb, professor of clinical pharmacology and therapeutics1
  1. 1Clinical Pharmacology Unit, Western General Hospital, Edinburgh EH4 2XU,
  2. 2Robertson Centre for Biostatistics, University of Glasgow, Glasgow G12 8QQ,
  3. 3Edinburgh Cancer Centre, Western General Hospital
  1. Correspondence to: R Camidge
  • Accepted 1 April 2005

How long someone has to live intuitively seems important in rationing decisions. Incorporating it into economic assessments, as described here, could make decisions fairer


Explicit rationing—decisions not to fund certain treatments—has become a fact of life in many healthcare systems.14 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 …

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