Advancing health equity for all - Insights from ISPOR Europe 2024

As we approach the festive season, associated with community and generosity, it is worth reflecting on how these values can inspire us to ensure equitable access to medicines.

Health equity – the absence of unfair and avoidable differences in health among population groups – is deeply connected to the structural and social determinants of health. These factors influence the health experiences and outcomes of individuals, and include elements such as housing, education, and employment. Health equity was one of the main topics of this year’s ISPOR Europe, the leading global conference for Health Economics and Outcomes Research, which took place in Barcelona in November. In this blog, we explore some of the key takeaways and ideas for solutions to improve health equity presented during the conference.

Is there an equity gap in the way we evaluate and value health technologies?

The rise in health disparities has placed health equity high on the agenda of healthcare systems. Despite this, a critical challenge remains: the absence of clear guidelines on generating equity-related data for health technology assessment (HTA) agencies, the organisations that evaluate the clinical and economic value of new medicines and healthcare interventions. A recent review highlights that most HTA agencies do not have consistent and clearly defined measures of health equity impact. There is also a lack of methods to incorporate equity-oriented metrics into evaluations, which can create challenges for manufacturers during submission processes.

During ISPOR Europe 2024, we presented a study that explored how equity is currently approached by several HTA bodies across the globe, including the National Institute for Health and Care Excellence (NICE). This revealed that while 62% of NICE appraisals identified an equity issue, only 14% of the analysed appraisals considered these issues during the decision-making process. Socioeconomic status, ethnicity or race, and geographic factors were the most frequently identified equity domains. Only six technologies were recognised by two or more HTA bodies as presenting equity concerns and there were disparities in the identification of equity issues across agencies. These findings reflect a fragmented approach and highlight the need for a more comprehensive and structured approach to equity in HTA.

The key role of DCEAs

Another relevant finding from our work was that quantitative methods are not being widely employed. This means HTA agencies may be overlooking or inadequately assessing the potential for new technologies to reduce inequities. An example of a quantitative tool that can be leveraged to assess the impact of new medicines on health equity is Distributional Cost-Effectiveness Analysis (DCEA). DCEAs evaluate the cost-effectiveness of health interventions within different demographic groups and any ensuing trade-offs between maximizing equity and overall population health. We presented the results of a systematic review at the conference mapping the growing application of DCEAs across diverse disease areas and equity domains. While DCEAs are increasingly undertaken in both low- and high-income countries, the review highlighted significant challenges, including under-reporting and variability of baseline health data, a lack of clinical trial data by domain of equity of interest, and insufficient health-related quality of life information, particularly in low- and middle-income settings. These data limitations create barriers to accurately evaluating health interventions for socially vulnerable and deprived populations.

To address these challenges, another of our posters introduced a stepwise approach to assessing the feasibility of conducting DCEA. This structured framework guides researchers in determining suitable methodologies (e.g., aggregate versus full DCEA) and evaluating data availability, while allowing for flexibility based on resource constraints. By formalising this feasibility assessment, the process enables researchers to make informed decisions about using DCEA effectively, even in resource-limited scenarios.

Practical example: Pfizer’s work on breast cancer inequalities

During the conference, we collaborated with Pfizer on two podium presentations exploring how joint expertise and innovation can advance health equity:

• The first podium session was presented by Emma Clifton-Brown, Head of Health & Value (HTA & Market Access), Pfizer UK. Emma’s presentation was a cautionary tale of the application of DCEA in breast cancer, highlighting the challenges and considerations for researchers embarking on a DCEA in a new therapy area. Importantly, we highlighted how the optimal approach to DCEA varies by disease, equity subgroup and market, with a call to action for better data to enable analysis by all relevant domains of equity, and for an equity framework to guide decision making in this area.

• The second presentation was delivered by Rachel Russell, Director Market Access Policy & Methods, Pfizer UK. This work focused on modelling the potential impact of addressing inequalities in the breast cancer care pathway in the UK. Our research identified important differences in stage at diagnosis, with black women and women in more deprived communities experiencing higher incidence of late-stage cancer diagnosis with associated poorer prognosis. We estimated that levelling up inequalities could result in black women and women in the most deprived communities gaining an additional 6 months and 3 months of life, respectively.

Collectively, these findings demonstrate how the commitment of pharmaceutical manufacturers to equity, paired with robust analytical insights, can inform better healthcare decisions.

Overcoming barriers to health equity in decision-making

We were delighted to attend several sessions at ISPOR Europe 2024 focused on the current landscape of health equity:

• The ISPOR Health Equity Research Special Interest Group held an open meeting providing insights into their work. These included scope and review initiatives, qualitative surveys, and stakeholder engagement efforts to understand and address equity considerations.
• Another session entitled “Exploring the Broader Impact of Health Technologies on Health Inequalities: Perspectives, Measures, Tradeoffs, Barriers, and Solutions” used case studies to explore the influence of health interventions on inequities and how this impact may extend beyond health. For instance, Klaas Kiesewetter, HTA Associate at MED-EL, a medical devices developer, highlighted how the application of a systematic review and DCEA contributed to identify the main determinants of hearing health and the barriers to equitable access to advanced hearing loss treatment in Chile.

Across these sessions, key themes were raised that should be addressed to incorporate health equity:

• Fostering collaborative, multi-stakeholder approaches: Progress will depend on effective partnerships between healthcare providers, policymakers, industry, patients, and health data experts.
• Addressing data gaps: Accessible and reliable data are fundamental to characterise health inequities. Limitations such as lack of data or inconsistent measures across geographies may hinder accurate evaluations.
• Developing robust frameworks for equity assessments: Standardised frameworks to interpret and apply the results of analyses like DCEAs are required. For instance, there is consensus that interventions should prioritise those with highest unmet needs. However, questions remain about how to proceed when equity analyses reveal that an intervention benefits some groups while potentially disadvantaging others.
• Enhancing transparency in decision-making: Building trust among stakeholders requires greater clarity in how decisions are made and communicated. This is particularly critical for patients, who may not understand why certain medicines are approved or reimbursed while others are not.
• Conducting retrospective evaluations: Evaluating whether interventions have delivered on their equity objectives may provide valuable feedback for refining future approaches and policies.

Despite the challenges, ISPOR Europe 2024 served as powerful reminder of the importance of advancing health equity and that we now have the tools at our fingertips to make real tractable progress.