Torrance George W
McMaster University, Hamilton, Ontario, Canada.
Pharmacoeconomics. 2006;24(11):1069-78. doi: 10.2165/00019053-200624110-00004.
The present article provides a brief historical background on the development of utility measurement and cost-utility analysis in healthcare. It then outlines a number of research ideas in this field that the author never got to. The first idea is extremely fundamental. Why is health economics the only application of economics that does not use the discipline of economics? And, more importantly, what discipline should it use? Research ideas are discussed to investigate precisely the underlying theory and axiom systems of both Paretian welfare economics and the decision-theoretical utility approach. Can the two approaches be integrated or modified in some appropriate way so that they better reflect the needs of the health field? The investigation is described both for the individual and societal levels. Constructing a 'Robinson Crusoe' society of only a few individuals with different health needs, preferences and willingness to pay is suggested as a method for gaining insight into the problem. The second idea concerns the interval property of utilities and, therefore, QALYs. It specifically concerns the important requirement that changes of equal magnitude anywhere on the utility scale, or alternatively on the QALY scale, should be equally desirable. Unfortunately, one of the original restrictions on utility theory states that such comparisons are not permitted by the theory. It is shown, in an important new finding, that while this restriction applies in a world of certainty, it does not in a world of uncertainty, such as healthcare. Further research is suggested to investigate this property under both certainty and uncertainty. Other research ideas that are described include: the development of a precise axiomatic basis for the time trade-off method; the investigation of chaining as a method of preference measurement with the standard gamble or time trade-off; the development and training of a representative panel of the general public to improve the completeness, coherence and consistency of measured preferences; and the investigation, using a model of a very small society, of the conflict between the patient perspective and the societal perspective regarding preferences. Finally, it is suggested that an important area of research, which the author never got to, would be to work closely with specific decision makers on specific decision problems, to help them formulate the problem, provide useful analyses, and to publish these as case studies to give the field a better understanding of the problems and the needs of decision makers.
本文提供了医疗保健领域效用测量和成本效用分析发展的简要历史背景。然后概述了该领域一些作者从未着手研究的想法。第一个想法极为基础。为什么卫生经济学是经济学唯一不运用经济学学科的应用领域？更重要的是，它应该运用什么学科？讨论了一些研究想法，以精确探究帕累托福利经济学和决策理论效用方法的基础理论和公理体系。这两种方法能否以某种适当方式整合或修改，从而更好地反映卫生领域的需求？针对个人和社会层面都描述了相关研究。建议构建一个仅由少数具有不同健康需求、偏好和支付意愿的个体组成的“鲁滨逊·克鲁索”社会，作为深入了解该问题的一种方法。第二个想法涉及效用以及因此的质量调整生命年（QALY）的区间性质。它特别关注效用尺度或QALY尺度上任何位置等幅度变化应同样可取这一重要要求。不幸的是，效用理论最初的限制之一表明该理论不允许进行此类比较。一项重要的新发现表明，虽然此限制在确定性世界中适用，但在诸如医疗保健这样的不确定性世界中并非如此。建议进一步研究在确定性和不确定性条件下的这一性质。所描述的其他研究想法包括：为时间权衡法建立精确的公理基础；研究将链式法作为与标准博弈或时间权衡法一起进行偏好测量的方法；开发和培训具有代表性的公众小组，以提高所测偏好的完整性、连贯性和一致性；以及使用一个非常小的社会模型，研究患者视角和社会视角在偏好方面的冲突。最后，建议一个作者从未着手研究的重要研究领域是与特定决策问题的特定决策者密切合作，帮助他们明确问题、提供有用分析，并将这些作为案例研究发表，以使该领域更好地理解问题和决策者的需求。
