eAppendix 1. Vignette Wordings
eAppendix 2. Item Wordings of Variables
eTable. Demographic Profile of Weighted Sample, n=1007 respondents
Botta MD, Blendon RJ, Benson JM. Cost-Effectiveness Decision Making and US Public Opinion. JAMA Intern Med. 2014;174(1):141-143. doi:10.1001/jamainternmed.2013.11332
As nations seek to stem the tide of rising health care spending, many have turned to cost-effectiveness research (CER) as a way to reduce spending on low-value interventions. Agencies in the United Kingdom, Italy, Germany, and Australia judge the clinical benefits and costs of new treatments relative to the current standards of care and set explicit thresholds to justify paying for new treatments. In the United States, however, CER is the subject of ongoing political controversy, but little is known about Americans’ attitudes toward government use of CER in decision making. In this article, we present findings from a recently conducted nationwide public survey about CER. We report public opinion on government use of CER and on specific decisions driven by CER using vignettes derived from real-world international decisions.
The data are derived from a survey by the Harvard School of Public Health. Institutional review board approval was waived. Field work was conducted using SSRS (Social Science Research Solutions; Media, Pennsylvania) via telephone (land line and cell) with a nationally representative sample of 1017 adults 18 years or older. To correct for nonresponse bias, responses were weighted according to US Census data to reflect the demographic makeup of the adult population. The margin of error is ±3.9 percentage points at the 95% confidence level.
The primary outcome measures for this study are support for a government CER agency and support for each of 4 CER-driven decision vignettes (see eAppendix 1 in the Supplement). Vignettes were written on the basis of decisions made by the Health Technology Assessment (HTA) bodies in 3 nations: the United Kingdom, Germany, and Italy. Vignettes were designed to present a fair depiction of how the debate over each decision was framed in each nation at the time to give as accurate a depiction as possible of how the debate might be framed in the United States for similar decisions. The intervention in question/disease/country for the 4 decisions were as follows: (1) Avastin/bowel cancer/United Kingdom, access to the drug limited to a subpopulation; (2) Avastin and/or Lucentis/wet age-related macular degeneration (wet AMD)/Italy, reimbursement provided only for an off-label treatment; (3) β-interferon/multiple sclerosis/United Kingdom, drug not provided because life extension judged too short; and (4) positron emission tomography (PET) scans/head and neck tumors/Germany, imaging method allowed only for a subset of cancers.1- 6
Most of the overall study population opposed a government CER agency. About 56% of respondents would oppose such an agency (Table). Democrats and Independents were about evenly split on the issue, while a significantly smaller percentage of Republicans would support such an agency (26.9%). Younger respondents, aged 18 to 29 years, were significantly more likely to support an agency (64.7%) than respondents 65 years or older (31.2%).
None of the vignettes had majority support, with vignettes 1 and 2 holding significantly less support than a government CER agency. Unlike opinion over a government role for CER in coverage decisions, partisan affiliations do not appear to drive public opinion on specific vignette decisions.
In the modern American political system, for a policy option to successfully navigate the path from a bill to a law often requires widespread public appeal, or at least little public opposition. This study should offer a warning to the research community that, despite the cost-saving potential of CER, it is likely to engender widespread opposition when put into practice in the United States—particularly if decisions are widely known by the public. Growing health care spending will require smarter choices on the part of health care payers and consumers. This research suggests that the public often will not support the federal government making those decisions for them.
Corresponding Author: Michael D. Botta, PhD, PhD Program in Health Policy, Harvard School of Medicine, 14 Story St, Fourth Floor, Cambridge, MA 02139 (firstname.lastname@example.org).
Published Online: October 7, 2013. doi:10.1001/jamainternmed.2013.11332.
Author Contributions: Dr Botta had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition of data: Botta, Benson.
Analysis and interpretation of data: All authors.
Drafting of the manuscript: Botta.
Critical revision of the manuscript for important intellectual content: Botta, Blendon, Benson.
Statistical analysis: Botta.
Obtained funding: Botta, Blendon.
Administrative, technical, or material support: Benson.
Conflict of Interest Disclosures: None reported.
Funding/Support: The survey was supported by a grant to the Alliance for Aging Research from Bayer AG.
Role of the Sponsor: Bayer AG had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.