Cost-benefit analysis (CBA) provides a clear decision rule: undertake an intervention if the monetary value of its benefits exceed its costs. However, due to a reluctance to characterize health benefits in monetary terms, users of cost-utility and cost-effectiveness analyses must rely on arbitrary standards (e.g., < $50,000 per QALY) to deem a program "cost-effective." Moreover, there is no consensus regarding the appropriate dollar value per QALY gained upon which to base resource allocation decisions. To address this, the authors determined the value of a QALY as implied by the value-of-life literature and compared this value with arbitrary thresholds for cost-effectiveness that have come into common use. A literature search identified 42 estimates of the value of life that were appropriate for inclusion. These estimates were classified by method: human capital (HK), contingent valuation (CV), revealed preference/job risk (RP-JR) and revealed preference/non-occupational safety (RP-S), and by U.S. or non-U.S. origin. After converting these value-of-life estimates to 1997 U.S. dollars, the life expectancy of the study population, age-specific QALY weights, and a 3% real discount rate were used to calculate the implied value of a QALY. An ordinary least-squares regression of the value of a QALY on study type and national origin explained 28.4% of the variance across studies. Most of the explained variance was attributable to study type; national origin did not significantly affect the values. Median values by study type were $24,777 (HK estimates), $93,402 (RP-S estimates), $161,305 (CV estimates), and $428,286 (RP-JR estimates). With the exception of HK, these far exceed the "rules of thumb" that are frequently used to determine whether an intervention produces an acceptable increase in health benefits in exchange for incremental expenditures.

Background Enrollment in therapeutic cancer trials remains low, and is especially challenging for patients with low health literacy. The authors tested an interactive technology designed for patients with diverse health literacy skills with the aim of improving patient receptiveness, willingness, knowledge, self‐efficacy, and positive attitudes regarding clinical trials. Methods Patients presenting for their first oncology appointment were eligible. Patients viewed an interactive teaching video concerning clinical trials that was adapted from the National Institutes of Health. Validated surveys assessing receptiveness, willingness, knowledge, self‐efficacy, and positive attitudes regarding clinical trials were administered before and after the test. Results A total of 120 patients with cancer were enrolled. Approximately 80% were non‐Hispanic white, 33% were female, 69% had >high school education, and 8% reported an income <$20,000. Approximately 33% scored within the low health literacy range. Changes between pretest and posttest demonstrated increases in knowledge (P < .001), self‐efficacy (P < .001), and positive beliefs (P = .004); a slight decrease in willingness (P = .009); and no difference in patient receptivity (P = .31). Higher health literacy was associated with improved willingness (P = .049) and non‐Hispanic white race was associated with improved receptivity (P = .034). Conclusions Interactive technology that was designed for patients with diverse health literacy skills demonstrated the ability to improve knowledge, self‐efficacy, and positive beliefs regarding cancer clinical trials. Contrary to the hypothesis of the current study, patients with lower health literacy did not appear to derive a greater advantage from this technology. There was no improvement noted with regard to patient willingness or receptivity, and clinical trial enrollment remained at historical institutional levels. Talking touchscreen technology has a potential role as an important element in informed decision making for patients, but likely needs to be coupled with more robust and multitargeted interventions.

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