We aimed to develop and demonstrate a method for examining public preferences for priority setting in healthcare, using EQ-5D-5L health states valued at an individual level. We examine the Norwegian population’s preferences for prioritizing the “worse off” in terms of health at a cost to health maximization. This intuition is a part of healthcare priority setting frameworks in several countries. Preference studies help explore the legitimacy of such policies, but most studies do not use individual-level health state values, which may distort their conclusions.
Task-based face-to-face interviews were conducted in the Norwegian general population. First, respondents valued a set of EQ-5D-5L health states using time trade-off. Second, discrete choice tasks were administered, describing health state improvements that contrasted utility maximization and benefit to the worse off, according to each respondent’s valuation. Analysis used mixed-effects models with choice and respondent properties.
We conducted 606 interviews, of which 468 respondents were included in the priority setting exercise. Respondents’ choices were influenced by the size of the health improvement, but not by an option being worse in terms of a lower pretreatment health state value. Choice behavior was influenced by respondents’ gender, religion, and age. On average, the choices indicate a preference for prioritizing the better off.
Our two-stage design using individual health state values is feasible, although there are trade-offs and room for development with such a design. We found no support for a preference for prioritizing the worse off when using individual-level health state valuations.
What is it about? Many countries use healthcare policies that favor treating people in the worst health, even when this leads to less health overall. This approach is common in Norway, the United Kingdom, and several other countries. However, previous research studying public support for this approach had a critical flaw: they assumed everyone values health states the same way, when people differ in how they value health states. This study examined whether past research might have given misleading results by ignoring these individual differences. The researchers created a method where each person first rated different health states, and these personal ratings were then used to test their choices about who should receive treatment. When using this approach, the preference for helping the worst off was weaker than previously believed.
How was the research conducted? The central methodological approach was to measure each person's health values before asking them to make treatment decisions. The researchers conducted face-to-face interviews with participants in 2 stages. First, each participant rated health states using a standardized method (time trade-off). Then, participants completed 4 choice tasks where they decided between treating one of two patient groups: one starting in worse health but gaining less improvement, versus one starting in better health but gaining greater improvement. The study included 606 Norwegian adults recruited through social media and community groups. Using individual health values ensures that the treatment comparisons shown to each person reflect what that person actually considers important, rather than assuming everyone thinks alike.
What were the results? Participants showed little tendency to treat the patient group with the worst health. Their choices were influenced by how much health improvement each treatment offered, but the starting health state of the patient groups made no difference. Most surprisingly, participants slightly favored treating the better off group, even when health improvements were equal.
Why are the results important? These findings question the research used to justify policies in Norway, the United Kingdom, and other countries. Healthcare decision-makers may need to reconsider whether giving extra priority to the severely ill at the cost of total health gains truly reflects public values. The study also demonstrates that measuring individual health values works in practice, enabling future research to better capture public preferences. Over time, the improved research methods and these findings could improve how societies make healthcare decisions.
What are the strengths and weaknesses of this study? The study's main strength is that it accounts for how different people value health states, making it more accurate than previous research. However, the study had to exclude 22% of participants because their health state valuations could not be used in the subsequent analysis, and the sample had more young, female, and highly educated people than the general Norwegian population. Future research should explore whether these findings hold in other contexts, for example whether including life years gained would change preferences, or whether similar patterns appear in different populations and healthcare settings.
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