Health Economics

  • Unfair discrimination against old people. A charge against the use of life-years as an outcome measure in cost-effectiveness analysis (CEA) and related studies, or life-years weighted for quality (as in the quality-adjusted life-year, QALY), is that they discriminate against the use of technologies that are used mainly by the elderly, or indeed any whose life expectancy is shorter than others. The arithmetic is plain: they have fewer years over which to enjoy the better health that is expected to result from the technology in question, so those that are to be used mainly by those with shorter life expectancies will tend to be less preferred if this criterion is used alone and without sensitivity to the potential for what may be deemed to be unfair. In cost-effectiveness analysis, benefit is not, however, the sole criterion on which decisions are (or ought to be) based. So whether a shorter expectation of life prejudices them will also depend partly on the opportunity cost, which, other things being equal, will also be less on account of being incurred over a shorter time period, and on the view taken of the role of CEA in public decision-making - for example, whether QALYs, or other time-related outcome measures, and associated cost information, and the values embedded in them, are regarded as the only relevant data. Most decision-making rubrics emphasize these algorithms as aids to decisions not determinants of them. Other data are also taken into consideration if CEA is used as a part of a deliberative process. Spirited defenders include Claxton and Culyer (2006, 2007, 2008).