Health Equity on the Agenda

The concept of equity in health and healthcare is well-established. However, equity has always felt like a minor part of the ISPOR conversation, with past ISPOR programmes generally dominated by discussions that relate, implicitly or explicitly, to efficiency and health maximisation. ISPOR International 2022 felt different, reflecting ISPOR placing health equity at number 3 in its top 10 HEOR trends for 2022-2023 and marking a timely shift following the formation of ISPOR’s new Health Equity Research Special Interest Group (SIG).1, 2

Efforts to address health inequities via the HEOR field rely broadly on three pillars, all of which were reflected across the conference sessions:

  1. Data to capture equity-relevant variables for analysis.
  2. Methods for analysis of this data, to provide robust assessment of equity impacts.
  3. Understanding of how to use the results of such analyses to inform decision-making.

Data

The importance of inclusive clinical trials for advancing health equity was discussed, with speakers noting the FDA’s guidance on enhancing the diversity of clinical trial populations.3, 4 There are two dimensions to the importance of diversity in clinical research. Firstly, in the case of prospective clinical trials of new interventions, entry into these trials provides a route to access potentially beneficial new treatments, so the underrepresentation of certain groups in such clinical research can exacerbate health inequities. Secondly, a lack of diversity in clinical research study populations means our understanding of the health effects of new interventions may not be generalisable to underrepresented and minority populations. The second plenary session drove this point home with the example of how the lack of representation of non-European patients in datasets that have traditionally been used to inform the development of polygenic risk scores means that the resulting risk prediction models, which are applied globally, do not perform well for non-European populations.

In relation to collection of data regarding race, a key concern with feeding this data into prediction models that aim to guide assessment of health risks is that this has the potential to contribute to racial disparities in health care; some have therefore argued for race-free clinical risk assessment. However, in general, speakers at the second plenary session were of the consensus that, provided a subgroup label (e.g. race) has predictive value, then it is worth including as a covariate in predictive models. Nonetheless, there was also agreement that this should not take away from the need for us to find better predictive variables (including social determinants of health) than current racial subgroup categories – our current approaches have predictive value but effectively represent crude proxies.

Methods

Regarding methods, a workshop on the first day of the conference presented details of two metrics developed by Sutter Health: the Health Equity Index and the COVID-19 Vaccine Equity Index.5, 6 These indices provide a way to quantify disparities in specific health outcomes amongst subgroups (e.g. subgroups defined by race or socio-economic class); in doing so, they can help to guide healthcare decision-making aimed at achieving equity in health across these equity-relevant subgroups.

More relevant to attempts to formally incorporate equity concerns into cost-effectiveness driven decision-making frameworks, Dr. Lov-Koh (Honorary Research Fellow, NICE) discussed the availability of distributional cost-effectiveness analysis (DCEA). DCEA is a term for economic evaluations that provide information not only about the aggregate costs and effects of a new health intervention (as traditional cost-effectiveness analysis) but also about the distributional impacts in terms of where the benefits and costs fall.7 It was noted that the DCEA method itself is reasonably well developed and that the greatest barriers to formal consideration of equity in health technology assessment via methods such as DCEA relate to the challenges over obtaining the necessary data inputs and a need for decision-makers to understand how they would use such information in their decision-making. 

Decision-making

Many HTA bodies include some statement on equality or equity in their terms of reference and equity was noted as an additional element of value in ISPOR’s value flower, published in 2011; it is therefore clear that those involved in value assessment consider equity an important factor in decision-making. However, the second plenary session challenged the commitment currently shown to incorporating equity concerns, noting that this typically represents more of a “check” on behalf of decision-makers that they are satisfied there are no major equality implications, rather than a systematic approach to incorporating equity concerns alongside – and perhaps in competition to – those of efficiency. Charles Manski (Professor of Economics, Northwestern University), argued that we need to be actively including equity in our social welfare function if we want to start taking it seriously and it was apparent from a number of discussions at the conference that there is a way to go in this regard. For example, in discussing when we might see methods like DCEA formally implemented in HTA frameworks, Dr. Lov-Koh noted a current lack of consensus and understanding over whether – and the extent to which – populations are willing to trade-off potential health gains in order to reduce inequities in health, making it challenging to incorporate analyses of distributional effects as part of a quantitative decision rule. In alignment with this, NICE’s recent methods and process consultation noted the need for further work before a formal quantitative modifier for health inequalities could be introduced, though also indicated that NICE may prioritise the topic of health inequity for a future modular update of their methods.8 Even if getting to a formal quantitative equity “modifier” feels a way off and equity concerns therefore remain something that are considered as part of more deliberative processes, it will be interesting to see if HTA bodies begin to explore the use of methods like DCEA as a way to at least provide more systematic, transparent and quantitative analysis of equity impacts to feed into those deliberations.

References

  1. 2022-2023 Top 10 HEOR Trends. International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Available online here. Last accessed June 2022.
  2. Health Equity Research Special Interest Group. International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Available online here. Last accessed June 2022.
  3. Enhancing the Diversity of Clinical Trial Populations — Eligibility Criteria, Enrollment Practices, and Trial Designs Guidance for Industry. Food and Drug Administration. Available online here. Last accessed June 2022.
  4. Diversity Plans to Improve Enrollment of Participants from Underrepresented Racial and Ethnic Populations in Clinical Trials Guidance for Industry [Draft]. Food and Drug Administration. Available online here. Last accessed June 2022.
  5. Pressman A, Lockhart S, Petersen J, et al. Measuring Health Equity for Ambulatory Care Sensitive Conditions in a Large Integrated Health Care System: The Development of an Index. Health Equity 2019;3:92-98.
  6. Pressman AR, Lockhart SH, Shen Z, et al. Measuring and Promoting SARS-CoV-2 Vaccine Equity: Development of a COVID-19 Vaccine Equity Index. Health Equity 2021;5:476-483.
  7. Distributional Cost-Effectiveness Analysis. University of York – Centre for Health Economics. Available online here. Last accessed June 2022.
  8. Review of Methods, Processes and Topic Selection for Health Technology Evaluation Programmes: Conclusions and Final Update – Appendix: Discussion and Rationale for Conclusions – Methods. National Institute for Health and Care Excellence. Available online here. Last accessed June 2022.

If you would like any further information on the themes presented above, please do not hesitate to contact Matt Griffiths, Global Head of HTA and also an active member of the ISPOR Health Equity Research Special Interest Group. Matt Griffiths is an employee at Costello Medical. The views/opinions expressed are his own and do not necessarily reflect those of Costello Medical’s clients/affiliated partners.

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