title: Why equal treatment is not always equitable: the impact of existing ethnic health inequalities in cost-effectiveness modeling.
abstract: BACKGROUND
  A critical first step toward incorporating equity into cost-effectiveness analyses is to appropriately model interventions by population subgroups. In this paper we use a standardized treatment intervention to examine the impact of using ethnic-specific (Māori and non-Māori) data in cost-utility analyses for three cancers.
  
  
  METHODS
  We estimate gains in health-adjusted life years (HALYs) for a simple intervention (20% reduction in excess cancer mortality) for lung, female breast, and colon cancers, using Markov modeling. Base models include ethnic-specific cancer incidence with other parameters either turned off or set to non-Māori levels for both groups. Subsequent models add ethnic-specific cancer survival, morbidity, and life expectancy. Costs include intervention and downstream health system costs.
  
  
  RESULTS
  For the three cancers, including existing inequalities in background parameters (population mortality and comorbidities) for Māori attributes less value to a year of life saved compared to non-Māori and lowers the relative health gains for Māori. In contrast, ethnic inequalities in cancer parameters have less predictable effects. Despite Māori having higher excess mortality from all three cancers, modeled health gains for Māori were less from the lung cancer intervention than for non-Māori but higher for the breast and colon interventions.
  
  
  CONCLUSIONS
  Cost-effectiveness modeling is a useful tool in the prioritization of health services. But there are important (and sometimes counterintuitive) implications of including ethnic-specific background and disease parameters. In order to avoid perpetuating existing ethnic inequalities in health, such analyses should be undertaken with care.
authors.affiliation: Department of Public Health, University of Otago Wellington, PO Box 7343 23 Mein Street, Newtown Wellington, New Zealand.
authors.forename: Melissa
authors.initials: M
authors.lastname: McLeod
authors.affiliation: Department of Public Health, University of Otago Wellington, PO Box 7343 23 Mein Street, Newtown Wellington, New Zealand.
authors.forename: Tony
authors.initials: T
authors.lastname: Blakely
authors.affiliation: Department of Public Health, University of Otago Wellington, PO Box 7343 23 Mein Street, Newtown Wellington, New Zealand.
authors.forename: Giorgi
authors.initials: G
authors.lastname: Kvizhinadze
authors.affiliation: Department of Public Health, University of Otago Wellington, PO Box 7343 23 Mein Street, Newtown Wellington, New Zealand.
authors.forename: Ricci
authors.initials: R
authors.lastname: Harris
keywords: Cost effectiveness; Equity; Ethnicity; Heterogeneity; Māori; New Zealand