Severity-of-illness and priority-setting: a review of the literature

Presenter: Koonal Shah, Office of Health Economics (OHE)

Abstract

Background. It is widely assumed that the principle objective of healthcare is to maximise health using available resources. However, there is evidence that people are willing to sacrifice aggregate health gains in order to achieve a range of other social objectives. One such objective is to direct resources towards those who are worst-off in terms of the severity of their health state without treatment. This is known as the severity approach to healthcare resource allocation.

Aims: This paper reviews the published literature on severity-of-illness in the context of economic evaluation, with the aim of establishing whether or not available evidence on societal preferences concerning severity imply a departure from the objective of maximising aggregate health for resource allocation decisions in health care.

Data / Methods: The literature search was based on an electronic keyword search of major economics and medical databases, and a hand-search of key articles written by leading researchers in the subject area (with follow-up of the references in these articles).

Results: The empirical evidence currently available suggests that the people are, on the whole, willing to sacrifice aggregate health in order to give priority to the severely ill. However, there are a number of unresolved issues concerning the stability and applicability of the observed results. People’s severity preferences appear to depend both on the context within which the severity exists and on the way in which this context is presented to them. There is also a lack of clarity about the ways in which people trade off concerns for severity against other distributional concerns.

Conclusion: There is substantial qualitative and quantitative evidence indicative of public support for prioritisation according to severity. However, given our limited understanding of severity preferences, it seems premature to attempt to systematically incorporate severity concerns into the resource allocation process using an adjusted cost-utility algorithm. Instead, it is recommended that research results are fed into the decision-making process and that further empirical investigation is undertaken.