Intended for healthcare professionals

Analysis And Comment Health policy

Adjusting for treatment refusal in rationing decisions

BMJ 2006; 332 doi: (Published 02 March 2006) Cite this as: BMJ 2006;332:542
  1. Richard Lilford, professor of clinical epidemiology (,
  2. Alan Girling, senior research fellow1,
  3. Andrew Stevens, professor of public health1,
  4. Abdullah Almasri, visiting statistician2,
  5. Mohammed A Mohammed, senior research fellow1,
  6. Braunholtz David, senior statistician3
  1. 1 Department of Public Health and Epidemiology, University of Birmingham, Birmingham B15 2TT
  2. 2 Department of Primary Care and General Practice, University of Birmingham
  3. 3 Bill and Melinda Gates Foundation, University of Aberdeen, Aberdeen
  1. Correspondence to: R Lilford
  • Accepted 1 December 2005

Assessments of cost effectiveness are increasingly used to get the most value from limited health resources. Could adjusting for people who wouldn't want the treatment improve the process?

Many treatments improve outcomes with few material side effects. They may be expensive, but if they are made available to patients almost all would accept. However, some treatments have more serious side effects, such that a substantial minority of patients would decline. Rationing bodies such as the National Institute for Health and Clinical Excellence treat both scenarios in the same way, calculating an average quality adjusted life year (QALY) for all candidates for the new treatment. Yet people who decline do so because they have different preferences and hence different expectations about the prospect of gain from the treatment. By declining the treatment, they cannot benefit from it. In these situations we argue that considering the QALYs of only patients likely to accept the treatment will lead to a less biased assessment of cost effectiveness.

Split choice decisions

QALYs are the main measure of health gain used in cost utility assessments to determine whether a treatment or intervention should be funded. Although other social dimensions (such as the pursuit of equity) may be included in the appraisal, our discussion assumes that the health gain is an important factor. Our argument applies to any health technology that a patient may decline or accept and hence is not relevant to public health measures, such as fluoridation of the water or public advertising, that are delivered to all individuals in a population, whether they want them or not.

A group of patients with similar clinical characteristics (which we refer to as a clinical group) carry the same probability in terms of outcome of treatment. However, they may differ in their capacity to gain personal utility.1 This is …

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