Understanding Societal Preferences for Priority by Disease Severity in England and Wales

A number of health technology assessment bodies, including the National Institute for Health and Care Excellence (NICE), have introduced "severity modifiers" that assign greater value to health gains to patients with greater health shortfalls. Such modifiers are consistent with qualitative societal values, but their alignment with quantitative strength of preference among the public is not clear. We sought to understand quantitative preferences over severity in England and Wales, relative to NICE's severity modifier.

We elicited person trade-off weights, severity cutoffs, and attitudinal questions to understand the range of public concern for severity and the additional weight (if any) given to health gains for patients with greater health shortfalls. The questionnaire was developed via qualitative interviews and administered to a representative sample of the public in England and Wales. Severity was defined in terms of proportional and absolute health shortfall.

Based on 990 complete-case responses, we find that the median value of health gains to patients in more-severe health states increases over the lower range of health shortfall and plateaus beyond 65% proportional health shortfall. The person trade-off value function and stated severity cutoffs suggest public concern for severity extends beyond NICE's current range. Our absolute health shortfall results are not directly comparable to NICE's discounted cutoffs.

Societal concern for severity appears to begin at substantially lower shortfalls, and the relative value of health gains is greater at almost every level of severity, than NICE's current modifier. Further research will be required to confirm this interpretation, especially in understanding preferences for older or younger reference ages and incorporating NICE's discounting of shortfall.