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Valuing therapy

Allan Tyrer | 01.12.2008

In a keynote speech at the 2008 Oxford Dysfluency Conference, Paul Dolan argued that healthcare economists should pay more heed to the attention-grabbing nature of stammering. Allan Tyrer reports.

The value of anything, argued Paul, is ultimately determined by its impact on the quality of our experiences, as we judge them. Clinical outcomes such as 'how much is blood pressure reduced' or 'how much is stuttered speech reduced' are not ends in themselves, but have value only in so far as they are relevant to improving our thoughts and feelings. The importance of stammering is that by negatively impacting on thoughts and feelings it reduces people's quality of life, including that of parents etc.

Paul suggested that current methods used to prioritise health service spending may underestimate the impact stammering has on quality of life, compared with other health conditions. How do these methods work? NICE (the National Institute for Health and Clinical Excellence) recommends a measure called EQ-5D. This has 5 dimensions (eg 'mobility', 'anxiety and depression') with 3 levels of severity in each. Let's say that under 'mobility' you 'have some problems in walking about', and that you will continue like that for the remainder of your life, assumed to be another 10 years. If you could be returned to health but you have to trade some of those remaining 10 years of life, how many years would you be willing to trade? In surveys asking a few thousand people, 'some problems walking' comes out at 0.850 (ie you would be willing to trade 1.5 years of your remaining life to be returned to full mobility). Being 'moderately anxious or depressed' comes out at 0.848. So the conditions are broadly comparable.

Paul was largely responsible for generating these values earlier in his career but he is now highly critical of them and their usefulness in informing resource allocation decisions. For example, vitality and energy are not included in the 5 dimensions. Also, when a person is asked to imagine having a condition, he thinks about thinking about that condition. But you only think about it when your attention is drawn to it. If you ask a person how bad it would be to be blind, they will say it would be awful, as they imagine spending their remaining 10 years thinking about being blind. In fact, things impact a lot when they first happen, but not so much over time. (Your pay rise seems great at first, then your attention moves elsewhere.) We are not good at imagining the withdrawing of attention.

So, the methods currently used by most health economics will misallocate resources, argued Paul. 'Some problems walking about' may be less bad than 'being anxious' - because the former does not draw attention to itself in same way as a mental health problem. 'Being anxious' may well be worse in the experience than in the imagination, so its score (.848) could well be lower, meaning it should attract greater resources. He would argue that this is also likely to be true for stammering - it too keeps grabbing your attention, so it could well score lower. Methods of health economists are unlikely to favour stammering, but the experience of having this attention-grabbing condition might merit more concern from policy-makers.

Finally, Paul also urged therapists and researchers to measure stammering and effectiveness of therapy according to thoughts and feelings, and to seek outcome measures which correspond with longer term effect on those.

Paul Dolan is a Professor of Economics at Imperial College, London

From the Winter 2008 issue of 'Speaking Out', page 7.