Is the societal approach wide enough to include relatives? Incorporating relatives' costs and effects in a cost-effectiveness analysis.

It is important for economic evaluations in healthcare to cover all relevant information. However, many existing evaluations fall short of this goal, as they fail to include all the costs and effects for the relatives of a disabled or sick individual. The objective of this study was to analyse how relatives' costs and effects could be measured, valued and incorporated into a cost-effectiveness analysis. In this article, we discuss the theories underlying cost-effectiveness analyses in the healthcare arena; the general conclusion is that it is hard to find theoretical arguments for excluding relatives' costs and effects if a societal perspective is used. We argue that the cost of informal care should be calculated according to the opportunity cost method. To capture relatives' effects, we construct a new term, the R-QALY weight, which is defined as the effect on relatives' QALY weight of being related to a disabled or sick individual. We examine methods for measuring, valuing and incorporating the R-QALY weights. One suggested method is to estimate R-QALYs and incorporate them together with the patient's QALY in the analysis. However, there is no well established method as yet that can create R-QALY weights. One difficulty with measuring R-QALY weights using existing instruments is that these instruments are rarely focused on relative-related aspects. Even if generic quality-of-life instruments do cover some aspects relevant to relatives and caregivers, they may miss important aspects and potential altruistic preferences. A further development and validation of the existing caregiving instruments used for eliciting utility weights would therefore be beneficial for this area, as would further studies on the use of time trade-off or Standard Gamble methods for valuing R-QALY weights. Another potential method is to use the contingent valuation method to find a monetary value for all the relatives' costs and effects. Because cost-effectiveness analyses are used for decision making, and this is often achieved by comparing different cost-effectiveness ratios, we argue that it is important to find ways of incorporating all relatives' costs and effects into the analysis. This may not be necessary for every analysis of every intervention, but for treatments where relatives' costs and effects are substantial there may be some associated influence on the cost-effectiveness ratio.