A health equity framework in health technology assessment could enable ‘health-driven prosperity’ – LCP

A collaborative health equity framework could further standardise and guide equity considerations in Health Technology Assessments (HTA), according to LCP in a new Lancet article - as NICE consults on its proposed modular update to consider quantitative evidence on health inequalities in technology appraisals.
  
In their recent consultation, NICE formally invites submission of quantitative evidence on health inequalities for the UK population in technology appraisals. According to LCP, the consultation documents reveal the balance NICE has sought to strike between appropriately considering health inequalities and the risk of increasing complexity and uncertainty in decision making, potentially extending appraisal timelines and delaying patient access. This will also be at the forefront of manufacturers’ minds as they deliberate whether to invest in generating this evidence.  

Distributional cost-effectiveness analysis (DCEA) has emerged as a method to address this challenge of quantifying the equity benefits of a drug or technology, offering a more nuanced assessment by evaluating health benefits and costs across subpopulations. NICE recently considered a DCEA for exagamglogene autotemcel (Casgevy), an innovative gene therapy treatment for sickle cell disease and transfusion-dependent thalassaemia, which disproportionately affect Black African and Caribbean populations, and Mediterranean, South Asian, and Middle Eastern populations, respectively. NICE's appraisal committee concluded that Casgevy could help mitigate inequalities. Consequently, they were willing to accept greater uncertainty in clinical effectiveness data and adjust the cost-effectiveness ratio, while being mindful of associated opportunity cost.

According to LCP, NICE’s position in its modular updates is generally a sensible and fair reflection of the current evidence base on health inequalities and DCEA. However, there are two areas that would benefit from greater clarity and development in future updates to generate more progress – discussion of other equity sub-groups (e.g. ethnicity) and considerations of form of DCEA.  

Routine use of DCEAs in HTA, in the UK and beyond, faces several challenges; health equity encompasses multiple domains that vary across diseases and countries. The inclusion, use, and value of real-world evidence (RWE) in medicines assessment have improved remarkably, largely due to initiatives such as NICE's RWE Framework. Building on this success, a collaborative health equity framework could further standardise and guide equity considerations in HTA, offering guidance on equity domains, dataset considerations, and methods to measure inequalities.

Creating a health equity framework that embeds both qualitative and quantitative equity assessments within HTA could mark a meaningful step to sector-wide consideration of health inequalities, given the Health Technology Assessment (HTA) agencies influence patient access and ultimately population health through evaluating new drugs and technologies.