Health State Utility Values: The Implications of Patient versus Community Ratings in Assessing the Value of Care

Background Health-state utility values (HSUVs) are key inputs into cost-utility analyses. There is debate over whether they are best derived from the community or patients, with concerns raised that community-derived preferences may devalue benefits to ill, elderly, or disabled individuals. This tutorial compares the effects of using patient-derived HSUVs versus community-derived HSUVs on incremental cost-effectiveness ratios (ICERs) and shows their implications for policy. Design We review published studies that compared HSUVs derived from patients and the community. We then present equations for the gains in quality-adjusted life-years (QALYs) that would be estimated for an intervention using patient versus community HSUVs and discuss the implications of those QALY gains. We present a numerical example as another way of showing how ICERs change when using patient versus community HSUVs. Results Patient HSUVs are generally higher than community HSUVs for severe health states. When an intervention reduces mortality , patient ratings yield more favorable ICERs than do community ratings. However, when the intervention reduces morbidity , patient ratings yield less favorable ICERs. For interventions that reduce both morbidity and mortality, the effect on ICERs of patient versus community HSUVs depends on the relative contribution of each to the resulting QALYs. Conclusions The use of patient HSUVs does not consistently favor treatments directed at those patients. Rather, the effect depends on whether the intervention reduces mortality, morbidity, or both. Since most interventions do both, using patient HSUVs has mixed implications for promoting investments for people with illness and disabilities. A nuanced discussion of these issues is necessary to ensure that policy matches the intent of the decision makers. Highlights The debate about whether health state utility values (HSUVs) are best derived from patients or the community rests in part on the presumption that using community values devalues interventions for disabled persons or those with chronic diseases. However, we show why the effect of using patient HSUVs depends on whether the intervention in question primarily reduces mortality or morbidity or has substantial effects on both. If the intervention reduces mortality, using patient HSUVs will make the intervention appear more cost-effective than using community HSUVs, but if it reduces morbidity, using patient HSUVs will make the intervention appear less cost-effective. If the intervention reduces both morbidity and mortality, a common situation, the effect of patient versus community HSUVs depends on the relative magnitudes of the gains in quality and length of life.