QALY maximisation and people's preferences: a methodological review of the literature

In cost-utility analysis, the numbers of quality-adjusted life years (QALYs) gained are aggregated according to the sum-ranking (or QALY maximisation) rule. This requires that the social value from health improvements is a simple product of gains in quality of life, length of life and the number of persons treated. The results from a systematic review of the literature suggest that QALY maximisation is descriptively flawed. Rather than being linear in quality and length of life, it would seem that social value diminishes in marginal increments of both. And rather than being neutral to the characteristics of people other than their propensity to generate QALYs, the social value of a health improvement seems to be higher if the person has worse lifetime health prospects and higher if that person has dependents. In addition, there is a desire to reduce inequalities in health. However, there are some uncertainties surrounding the results, particularly in relation to what might be affecting the responses, and there is the need for more studies of the general public that attempt to highlight the relative importance of various key factors.