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Background Interventions in health care often not only have an efect on patients, but also on their informal caregivers.Caregiving can have a profound impact on the health and wellbeing of carers. Ignoring these spillovers in economic evaluations risks labelling interventions mistakenly as cost-efective, at the expense of informal caregivers.Objective This paper investigates willingness-to-accept (WTA) values for an hour of informal care, corrected for positiveand negative impacts of informal care, to facilitate the inclusion of informal care hours on the cost side of economic evaluations without double-counting spillover efects.Methods A discrete choice experiment (DCE) was conducted among a representative sample of the adult population in theNetherlands (n=552) in September 2011. An experimental design minimizing the D-error was used to construct choicesets with two unlabelled alternatives with the attributes ‘hours caregiving’, ‘monetary compensation for caregiving’ andseven impacts of caregiving. To operationalize the random utility model, we used a panel mixed multinomial logit (MMNL)parameter model. For calculation of WTA, we used both population-level parameters and individual-level parameters.Results The mean WTA for an additional hour of informal care, corrected for positive and negative impacts of informal care,was €14.57. The signs of the coefcients were all in the expected directions.Conclusions This study reports a preference-based monetary value for informal care, corrected for other impacts. This valuation facilitates the inclusion of informal care hours on the cost side in economic evaluations without double-counting anyspillover efects included on the efects side.

Appropriate discounting rules in economic evaluations have received considerable attention in the literature and in national guidelines for economic evaluations. Rightfully so, as discounting can be quite influential on the outcomes of economic evaluations. The most prominent controversies regarding discounting involve the basis for and height of the discount rate, whether costs and effects should be discounted at the same rate, and whether discount rates should decline or stay constant over time. Moreover, the choice for discount rules depends on the decision context one adopts as the most relevant. In this article, we review these issues and debates, and describe and discuss the current discounting recommendations of the countries publishing their national guidelines. We finish the article by proposing a research agenda.

Many countries have national guidelines for performing economic evaluations in healthcare.1 These guidelines should ensure the comparability and quality of such evaluations, which should facilitate making well informed policy decisions regarding reimbursement of interventions. Given the developments in both the methodology and policy context of economic evaluation of healthcare interventions, these guidelines require periodical revision. Recently, the Dutch National Health Care Institute issued new guidance for economic evaluations in healthcare [1]. The new guidelines update and replace three separately published previous guidelines: those for pharmacoeconomic evaluation (latest version 2006), outcomes research (latest version 2008) as well as the Dutch costing manual (latest version 2010). In this editorial, we highlight the distinguishing features of the new Dutch guidelines. Moreover, we highlight which developments, in our opinion, are desirable in coming updates, but are still in development or controversial.

Recently, Grima and colleagues [1] made a case for excluding unrelated medical costs in life-years gained from economic evaluations of life-prolonging interventions. They provide an insightful overview of several economic evaluations in patients with chronic kidney disease (CKD) on dialysis and convincingly show that inclusion or exclusion of dialysis costs has an enormous impact on the cost effectiveness of any intervention in this patient group (and that there is considerable practice variation in this respect). This results in life-prolonging interventions such as statin treatment, which are highly cost effective in some target groups, becoming cost ineffective (if judged against conventional thresholds), in CKD patients when including the costs of dialysis in life-years gained. Grima and colleagues [1] argue that the inclusion of dialysis costs in lifeyears gained in CKD patients thus places an ‘‘unreasonable … barrier’’ to demonstrating cost effectiveness in this patient group. Hence, they advocate exclusion of these costs from economic evaluations of therapies for CKD patients on dialyses. They indicate that this solution would be methodologically correct in light of current pharmacoeconomic guidelines, which commonly advocate the exclusion of so-called unrelated medical costs [2].1 In this response, we demonstrate the rather absurd consequences of the line of reasoning by Grima et al. [1] (indeed supported by many guidelines) and how these are in sharp contrast with the underlying goals of economic evaluations. The solution for the problems signalled by Grima and colleagues should be found in changing guidelines on the point of inclusion of indirect medical costs and a sound appraisal phase in which ethical dilemmas are addressed explicitly.

Increasing life expectancy and decreasing marginal valuation of additional QALYs over time may serve as a basis for discounting future health effects from a societal perspective. Therefore, we tested the hypothesis that societal time preference for health is related to perceived future life expectancy.A sample of 223 people from the general population prioritised healthcare programmes with differential timing of health benefits and costs from a societal perspective. Furthermore, we asked respondents to estimate future life expectancy.The relationship between future life expectancy and time preference for health is ambiguous. We observed that people who expected a higher future life expectancy elicited higher discount rates for health effects than those with lower life expectancy growth expectations for all four time periods (5, 10, 20 and 40 years into the future), but the differences were never significant. On average, providing explicit information on growth in life expectancy did significantly alter discount rates in the expected direction but, on an individual level, the results were rather inconsistent. We observed a significantly stronger time preference (i.e. higher discount rates) for health effects than for costs. As commonly observed, discount rates for health and money decreased with time delay following a hyperbolic function.Our data indicate that it is troublesome to elicit societal discount rates empirically, especially rates that are in line with the theoretical arguments on societal discounting. The influence of life expectancy remains ambiguous, but there seems to be at least some positive relationship between growth in life expectancy and discount rates that deserves additional attention.

The friction-cost method has been put forward as an alternative to the human-capital method as it allows more realistic estimates of productivity costs to be calculated for use in economic evaluations. The possibility of replacement of (long-term) absentees is at the heart of the friction-cost method. It recognises that society will restore initial production levels after some period of adaptation, the length of which may depend on the availability of labour and, hence, on unemployment. The friction-cost method has received two main criticisms in the literature: (i) it has no theoretical underpinning; and (ii) it treats leisure time as having no value. We demonstrate in a simple 'theoretical' time-allocation model how time use shifts in the friction-cost method and that leisure is not treated as having no value. Rather, it is considered to be valued in terms of QALYs - as is normally the case in economic evaluation. The time-allocation model also demonstrates that when using the friction-cost or human-capital method the changes in the amount of unpaid work and leisure time need to be valued separately. Unpaid production losses from the previously unemployed may be larger than the gain in unpaid production gain of the absentee, resulting in a societal loss of unpaid work or the sacrifice of leisure in order to make up for lost unpaid work. These changes should be incorporated into economic analyses.