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In standard economic evaluation of competing health programmes, it is not customary to account for consumption and production in life-years gained. Whether or not these items ought to be included on the cost side has been the subject of much theoretical debate [1–12]. The purpose of this commentary is not to pick up all the loose ends of that debate but to drive home an inescapable analytical point: All else equal, a given number of qualityadjusted life-years (QALYs) from life prolongation will normally be more costly from a societal perspective than the same number of QALYs from programmes that improve quality of life. It is a matter for debate how much this fact should affect society’s priority setting between quality-improving and life-prolonging programmes. But this normative issue should not bar the inclusion of consumption and production effects in economic analyses when their purpose is to show decision makers the societal opportunity costs of different courses of action. Consider two ways of spending a million euros on healthcare in a community. In alternative A, ten people will each get an improvement in quality of life of 0.1 on the 0–1 utility scale used in QALY calculations, and each will get to enjoy this for 10 years. The gain (undiscounted) is 10 QALYs. In alternative B, one person will gain 10 years of life in perfect health. Again, the undiscounted gain is 10 QALYs. Given that the intervention costs are the same, the two options at first glance seem to be on a par economically speaking, but, in fact, they are not. In alternative B, for the benefit of 10 QALYs to be realized, the intervention itself must be followed up by provision of means to the saved person so that he/she can actually live the saved years. The costs of these means are value (consumption) sacrificed by the rest of society. In alternative A, there are no such additional costs to the rest of society, since the years lived by the ten individuals who get increased quality of life are years that would have been lived anyway. The sacrifice made by the rest of society to sustain the person whose life is prolonged may be offset by production by that person in the saved years. A ‘net sustainment cost’ may then be calculated. Sometimes this will be a negative number or, in other words, a net gain. But, in a wide range of life-prolonging programmes, saved life-years will typically have positive net sustainment costs because most saved life-years are provided to elderly people with low or no work contribution to society. Regarding the consumption component, there is already consensus among health economists that necessary medical follow-up treatment for the condition in question (so-called related medical costs) needs to be part of the cost assessment [13]. Beyond that, willingness among health economists to accept ‘medical treatments for other conditions’ (‘unrelated medical costs’) as relevant in cost assessment has been greater than acceptance of other types of private or public consumption. But our question is simply how many resources are taken from other possible uses as a consequence of patients living longer and consuming while they do so. There is then no reason to distinguish between different kinds of consumption. It follows from this reasoning that the 10 QALYs gained in alternative B are statistically more costly to society than those in alternative A. This translates into a general point: All else equal, a given number of QALYs from life & Erik Nord erik.nord@fhi.no

Including Future Consumption and Production in Economic Evaluation of Interventions that Save Life-Years: Commentary