Severity of illness and priority setting in healthcare: A review of the literature

Background: It is widely assumed that the principal objective of healthcare is to maximise health. However, people may be willing to sacrifice aggregate health gain in order to direct resources towards those who are worst off in terms of the severity of their pre-treatment health state. Objectives: This paper reviews the literature on severity in the context of economic evaluation, with the aim of establishing the extent to which popular preferences concerning severity imply a departure from the health maximisation objective. Methods: Data were obtained using a keyword search of major databases and a hand search of articles written by leading researchers in the subject area. Results: The empirical evidence suggests that people are, on the whole, willing to sacrifice aggregate health in order to give priority to the severely ill. However, there remain unresolved issues regarding the elicitation and interpretation of severity preferences (and indeed popular preferences generally). Conclusions: The use of severity as a priority setting criterion is supported by a large number of empirical studies of popular preferences. Further work is needed, however, to accurately estimate the strength of this support. (C) 2009 Elsevier Ireland Ltd. All rights reserved.