Chim Lesley, Salkeld Glenn, Kelly Patrick, Lipworth Wendy, Hughes Dyfrig A, Stockler Martin R
Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.
Alexion Pharmaceuticals, Sydney, NSW, Australia.
PLoS One. 2017 Mar 1;12(3):e0172971. doi: 10.1371/journal.pone.0172971. eCollection 2017.
Around the world government agencies responsible for the selection and reimbursement of prescribed medicines and other health technologies are considering how best to bring community preferences into their decision making. In particular, community views about the distribution or equity of funding across the population. These official committees and agencies often have access to the best available and latest evidence on clinical effectiveness, safety and cost from large clinical trials and population-based studies. All too often they do not have access to high quality evidence about community views. We therefore, conducted a large and representative population-based survey in Australia to determine what community members think about the factors that do and should influence government spending on prescribed medicines.
A choice-based survey was designed to elicit the importance of individual criteria when considering the equity of government spending on prescribed medicines. A representative sample of 3080 adult Australians completed the survey by allocating a hypothetical budget to different combinations of money spent on two patient populations. Societal preferences were inferred from absolute majority responses i.e. populations with more than 50% of respondents' allocation for a particular allocation criterion.
This study shows that, all else being equal, severity of disease, diseases for which there is no alternative treatment available on the government formulary, diseases that affect patients who are not financially well off, and life-style unrelated diseases are supported by the public as resource allocation criteria. Where 'all else is not equal', participants allocated more resources to the patient population that gained considerable improvement in health and fewer resources to those that gained little improvement in health. This result held under all scenarios except for 'end-of-life treatments'. Responses to cost (and corresponding number of patients treated) trade-off scenarios indicated a significant reduction in the proportion of respondents choosing to divide resources equally and a shift in preference towards devoting resources to the population that were more costly to treat for all criteria with the exception of severity of disease.
The general public have clear views on what's fair in terms of government spending on prescribed medicines. In addition to supporting the application of the 'rule of rescue', important considerations for government spending included the severity of disease being treated, diseases for which there is no alternative treatment available on the government formulary, diseases that affect patients who are not financially well off and life-style unrelated diseases. This study shows that the general public are willing to share their views on what constitutes an equitable allocation of the government's drug budget. The challenge remains to how best to consider those views alongside clinical and economic considerations.
在全球范围内，负责选定和报销处方药及其他医疗技术的政府机构正在思考如何在决策过程中充分纳入社区偏好。特别是社区对于资金在人群中的分配或公平性的看法。这些官方委员会和机构通常能够获取来自大型临床试验和基于人群研究的关于临床疗效、安全性和成本的最佳可得及最新证据。但他们往往无法获取关于社区观点的高质量证据。因此，我们在澳大利亚开展了一项大规模且具有代表性的基于人群的调查，以确定社区成员对于那些确实以及应该影响政府在处方药上支出的因素的看法。
设计了一项基于选择的调查，以引出在考虑政府在处方药上支出的公平性时各个标准的重要性。3080名成年澳大利亚人的代表性样本通过将一份假设预算分配给在两类患者群体上支出的不同组合来完成该调查。社会偏好是从绝对多数回应中推断出来的，即对于特定分配标准，获得超过50%受访者分配的人群。
本研究表明，在其他条件相同的情况下，疾病的严重程度、政府药品目录上没有替代治疗方法的疾病、影响经济状况不佳患者的疾病以及与生活方式无关的疾病，作为资源分配标准得到公众支持。在“其他条件不同”的情况下，参与者将更多资源分配给健康状况有显著改善的患者群体，而将较少资源分配给健康状况改善不大的患者群体。除了“临终治疗”外，这一结果在所有情况下均成立。对成本（以及相应的接受治疗患者数量）权衡情景的回应表明，选择平均分配资源的受访者比例显著下降，并且偏好转向将资源投入到治疗成本更高的人群，对于除疾病严重程度之外的所有标准都是如此。
公众对于政府在处方药支出方面的公平性有明确看法。除了支持“救援原则”的应用外，政府支出的重要考虑因素还包括所治疗疾病的严重程度、政府药品目录上没有替代治疗方法的疾病、影响经济状况不佳患者的疾病以及与生活方式无关的疾病。本研究表明，公众愿意就政府药品预算的公平分配构成发表意见。如何在临床和经济考量之外最好地考虑这些意见仍是一项挑战。
