Economic evaluations comparing the costs and benefits of different health care interventions have become an important tool for policy decision-makers regarding the allocation of health care resources. This study underlines the limitations of economic evaluations. While they can be very informative in choosing between programs with similar target populations and outcomes, larger policy decisions regarding the allocation of resources must take into account the extra dimensions of equity, social justice, and public preferences.

Background: Economic evaluations comparing the costs and benefits of different health care interventions have become an important tool for resource allocations by policy decision-makers. In Ontario, economic evaluations are particularly popular for use in setting the content and pricing of products on the Ontario Drug Benefit formulary. The methodology for performing these evaluations is strictly age-neutral. "Age neutral" means that gains in health status and life expectancy are considered of equal value regardless of the age (or any other characteristics) of the individuals to whom these gains accrue. Many have argued that this age-neutrality poorly reflects actual public preferences for the allocation of health care resources. Previous research has shown that the public generally prefers to allocate health care to younger patients. This finding has caused some to argue that economic evaluations should be adjusted to reflect these preferences. However, the great majority of previous studies have generally focused only on life-saving interventions. This study set out to investigate whether public perceptions of the importance of age in resource allocation decisions differ among intervention types, and how these perceptions may influence the interpretation of economic evaluations.

Methods: A short questionnaire was administered to a sample of willing participants recruited from a cafeteria of a university medical centre. The 147 respondents were placed in the role of a health system planner and presented with a choice between funding one or two programs. In each case, the two programs were identical in all respects except for patient age, where patients were either 35 years old in one program or 65 in the other. Two such scenarios were posed: a liver transplant (life-saving treatment) and a palliative care program. Respondents were also asked to directly indicate the importance of age as a factor in allocating scarce resources for six different health care interventions.

Findings: Respondents showed a clear preference for treating 35-year-olds (57%) over 65-year-olds (4%) for the liver transplant program, while there was no significant age preference for a program of palliative care. The preference for the younger patients in the first scenario increased with the age of the respondent. Among the six health care interventions, respondents indicated that age was most important as a consideration in allocating infertility treatment and least important for depression treatment. In all cases, there was a wide distribution of responses with substantial numbers responding that age was either not at all important or very important. The most common reasons cited for favouring younger patients in life-saving scenarios were increased productivity and the right of younger patients to enjoy the full life span already realized by older patients. The most common reasons for remaining age-neutral in resource allocation were equity (no age discrimination) and objective need.

Conclusions: Survey responses clearly indicate that public preferences for the age-related allocation of health care resources vary with the nature of the intervention(s) under consideration; thus illustrating the high degree of polarization among the public on these considerations. The suggestion that economic evaluations be age-weighted to reflect public preferences should therefore be handled with caution. Certainly, a range of intervention types should be considered, and the lack of public consensus on the matter is such that simply applying average preferences would misrepresent the true nature of public values. This study underlines the limitations of economic evaluations. While they can be very informative in choosing between programs with similar target populations and outcomes, larger policy decisions regarding the allocation of resources must take into account the extra dimensions of equity, social justice, and public preferences.

Reference: Johri M, Damschroder LJ, Zikmund-Fisher BJ, Ubel PA. The Importance of Age in Allocating Health Care Resources: Does Intervention Type Matter? Health Economics 2005, 14, 669-678.

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