跟讀練習: Olivia - 通過影片學習英語口語

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learning from our international experiences, looking at preliminary evidence from Thailand,

and considering what these ideas may mean for the future of Thai HTA.

Today, we are very fortunate to have three outstanding speakers with us.

The first speaker is Professor Olivia Wu, William R.

Lindsay Chair of Health Economics at the University of Glasgow,

and also our adjunct professor at the Faculty of Pharmacy, Mahidon University.

Professor Wu brings extensive international experience in HTA,

including 10 years as a member of a NICE Technology Appraisal Committee.

Currently, she is the director of two NIHR research programs,

Better Met Thoughts, Better Research and Program Grants for Applied Research.

She will share her insights on 9th severity modifier from principle to policy.

And our second speaker is our faculty member,

Associate Professor Muntalat Thawan -Jaran -Sap.

From the Faculty of Pharmacy,

my name is Dr. Hwagin.

Mahidong University, she's preliminary results sharing some initial findings on how severity -based weighting might affect HTA decision in the Thai context.

And our last speaker on the third speaker is Professor Darius Lakdawala.

He is a professor of pharmaceutical economics

and public policy from the University of Southern California and holds the Queen Thai Chair in pharmaceutical development and regulatory innovation.

He is one of the key developers of the GRACE model, or we call Generalized Risk Adjusted Cost -Effectiveness.

He will introduce a broader perspective on how we might better

capture the value health gains across patients with different health conditions and levels of risk.

After the presentation, Associate Professor Montalak will lead our panel discussion and Q &A.

I hope today's webinar will give us a new perspective and stimulate a thoughtful discussion.

We are not necessarily looking for a final answer today, but rather to better understand the evidence

and ask for important questions what should Thailand consider before giving greater recognition to the security and equity in HTA.

So without further delay, let me invite our first speaker, Professor Olivia Wu, to begin her presentation.

Professor Olivia, the floor is yours.

Thank you.

thank you dr yusa um

so um i'm going to set the scene for for everybody now um

so this phrase um dr yusa has already mentioned

it a quality is a quality is a quality this is a phrase

that does a great deal of work for hta the assumption as dr yusa has explained is

that a unit of health gain has the same social value to whoever receives it and whenever their starting point is.

So the cost per quality threshold, the willingness to pay threshold that some countries use,

it is only coherent as a decision rule because of this assumption.

And the justification for this is opportunity cost.

When the health system funds a new technology, it displaces health elsewhere.

So equal weighting is how we avoid making arbitrary trade -offs between one group of patients and another.

But equal weighting is a value judgment.

And for more than 15 years, NICE has been under pressure to move away from this.

I'm going to talk about how it has done so.

And first, through the end of life criteria

and then through the severity modifier introduced in 2022 and what we know about it and how the modifier has been behaving.

So end of life criteria, the most important thing to remember is it came out of a political moment.

The end of life criteria wasn't created because of scientific underpinning.

It was because of politics.

In 2008, NICE was undergoing appraisal for several drugs for advanced renal cancer.

cancer.

And NICE was under intense criticism from the Government Review.

And in 2009, NICE introduced supplementary advice to its committee on appraising life -extending end -of -life treatments.

Now, I remember this really well, because 2009 was the year I joined NICE.

And that was when we're trying to grapple with

and understand how to apply this end -of -life criteria in our decision making as a committee.

There are two key features to this.

First, the criteria were drafted with advanced cancer in mind,

because the whole reason why I started thinking about this was because of this appraisal on renal carcinoma.

And this has shaped the design of it. And second,

Now, if you remember, our threshold at that time was £20 ,000 per QALY.

So the end -of -life criteria remained NICE's only explicit modifier for 13 years until 2002,

when the NICE manual, the reference case,

was revised and it was replaced. So, So,

means less than 24 months.

The second element is that there had to be sufficient evidence that it offers an extension to life.

So people have to be living longer with the treatment, normally at least three months compared with the current treatment.

Now, the third element is an element that was added on slightly later on.

The treatment has to be licensed for a small patient population.

And normally that doesn't exceed 7 ,000 people.

Now, if these were met, the committee could take additional account of the quality gain.

And if it is satisfied that the estimates of life extension were robust

because we're looking for an additional three months and the modelling assumptions are plausible, then we could apply the end of life criteria.

But it's important to also note what is missing here.

There's no measure of quality of life.

There's no measure of how much health is lost relative to normal life.

And there's no formula that turns the criteria into a weight.

So it was all down to our judgment call.

sorry i've moved on too many slides um yes

so the obvious question for us is whether this end of

life criteria allowing a premium reflected what the public actually values because

that was the whole point of it the whole point was the without the end of life criteria before

then it's not we're not reflecting what the public truly values

and so the question for us once the end of life criteria is introduced was whether it does

that job and the honest answer is

that evidence base the evidence base was thin and the evidence

that existed was not actually very supportive of putting more emphasis more weight towards the end of life

so this is one of the big studies

that was done at the time stated preference work using discrete choice experiment

that showed there was very little evidence

that people actually place extra value on the quality gain simply

because it's occurring at the end of life and later studies actually pointed to the same direction

Now what people seem to respond to is severity and prospects.

That's how much health someone stands to lose rather than closeness to death is what people value more.

The length of survival with a poor quality of life matters to people

but the end of life criteria does not really see to that.

And then there are other criticism as well.

Weighting one group's gain means displacing health from patients who don't receive extra weighting.

And if the threshold that we use is already estimated above opportunity cost,

and there's a lot of evidence that's been critical of that.

100

So if you think about the work that

101

York University did suggesting that the threshold should be lower than 20 ,000.

102

In fact, I think they placed it at 30 ,500.

103

then this additional weighting widens the gap.

104

So ultimately, this will lead to a net population health cost being lost.

105

So by 2019, the end of life criteria had a weak preference base,

106

a narrow design and also opportunity cost problem.

107

And the question for NICE was whether to abolish this or replace it with something better.

108

So 10 years on, after a lot of consultation and work,

109

NICE decided that the end -of -life criteria should be replaced. And

110

so the 2022 manual introduced a modifier based on the severity

111

of the condition defined as the future health lost by people living with it under standard care in the NHS.

112

So the nicest reasoning for this is that it aligns with the values held by the society,

113

because it extends the premium to conditions that never qualified before.

114

And the design has four broad objectives to broaden the eligibility beyond people who are close to death.

115

So the short survival cancers to replace a binary grade with weighted with graded weights.

116

So if you remember, the end of life criteria was very binary.

117

Are people going to live beyond 24 months?

118

Can we extend life for three months?

119

So it's a very yes or no question.

120

And also, the new severity modifier anchors the measure in quantities that can be calculated.

121

So it's not purely a judgment call.

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And the final element is that the severity modifier remain approximately opportunity cost neutral.

123

So the overall value given under the new rules match the old criteria.

124

So there will be no big losers or winners because of this change.

125

Now, there are other reasons for replacing the end of life criteria.

126

So first of all, the narrow scope, because the criteria focus on just purely short survival and small population.

127

So if you think about a child with severe genetic disease

128

or an adult with a long term musculoskeletal or mental health condition, they could suffer a very large loss of health,

129

but they would still fail to qualify.

130

So the narrow scope of the previous end of life criteria was a big problem.

131

Secondly, the dichotomous eligibility criteria, which I've just mentioned, the 24 months and the three month threshold were binary.

132

So it really, treatment outside these criteria got nothing, regardless of how much health the patient lost.

133

Thirdly, these criteria is based on weak societal preference, which I've just described.

134

And the policy assumed that, the new policy, the severity modifier assumed that it's reflecting public preference now.

135

And then finally, transparency.

136

The criteria depended on committee judgment.

137

So there's huge criticism on the decision being not transparent because it cannot be clearly calculated.

138

So those were the additional reasons for making these changes.

139

So how is severity measured?

140

So severity is measured as a shortfall.

141

So the idea is quite simple.

142

If you take the qualities of the people the same age

143

and sex would expect to have over the rest of their life,

144

and you also take the qualities of the patients with the condition who are expected to have under current care,

145

the difference is the health lost to the disease.

146

So NICE used two versions of this difference.

147

The absolute shortfall is the gap in QALYs

148

and the proportional shortfall is a gap as a fraction of the QALYs that the general population would expect.

149

And both are discounted at three and a half percent.

150

And the committee can apply whichever gives the higher weight.

151

So I'm going to just give you a clearer example of how this is done.

152

Now, to calculate this, we need three inputs to drive the equation.

153

First is the expected qualies in the general population built from life tables, age and sex specific to EQ5D utility norms.

154

So if the dark blue bars represent the qualies of a healthy person.

155

So in this example, we assume that this is 12 qualies.

156

Now, the second calculation is the expected QALYs with current care, which in practice comes from the comparator arm of the economic model.

157

So it's basically the light blue bar here, the QALYs for the people with a certain condition.

158

So here in my example is one.

159

And the third element is discounting.

160

So three and a half percent discount is applied to these estimates.

161

And so in an absolute shortfall,

162

the difference between the qualities for a healthy person and the quality for a person with a condition is the shortfall.

163

So here is 12 minus 1 and it gives us 11.

164

Now, NICE has given very clear calculation for calculating shortfalls.

165

And the decision support unit has published a technical support document together with a calculator now

166

but the difficulty is

167

that on the patient side of the equation it is actually a modeled output

168

so it inherits all the uncertainties and all the limitations from the actual model

169

so the survive extrapolation the utility values the baseline age

170

and sex mix and the definition of the population

171

that all comes from the model so if there are

172

if you're if the model is inaccurate it will then feed into this calculation as well.

173

So for proportional shortfall, it's a slightly different calculation.

174

So in the same example where a healthy person's QALY is 12,

175

and then the QALY for a person with a certain condition is 1, Your loss quali is 11.

176

And for proportional shortfall, the calculation is essentially the loss quali divided by the quali of a healthy person.

177

So here we get 0 .92.

178

So this is how we calculate a proportional shortfall.

179

So in terms of decisions, there are two things to think about.

180

So first, the weight is applied to the incremental qualis, not the actual threshold.

181

So the effect on the decision is equivalent to raising the threshold.

182

So the previous 20 to 30 ,000 pounds range,

183

a weight of 1 .2 corresponds to the effective threshold of 24 to 36 ,000.

184

And the 1 .7 weight corresponds to 34 ,000 to 51 ,000.

185

So since April 2026, the standard range has now been raised.

186

So this will be raised accordingly as well.

187

But in terms of the decision,

188

the committee is allowed to pick whichever one gives us the greater benefit between the proportional and the absolute shortfall.

189

So what has happened since 2022 since this was introduced?

190

Now, this is based on work that NICE has done to review how the severity modifier has been implemented.

191

This is a decision support units analysis by Alan Waylu and his colleagues.

192

The starting point, their starting point was a surprise that NICE has already noticed.

193

In the first year of implementation,

194

fewer topics met the one -time anticipation through consultation ahead of applying the disease modifier.

195

And so they then had a closer look at how the severity relates to the end of life

196

and age in using 555 appraisal decisions between 2009 -2024,

197

there were three key findings from this comparison work.

198

So firstly, they found that severity weights do not map precisely onto the end -of -life criteria,

199

which is what you would expect because the severity weight is supposed to be broader than the end -of -life,

200

so it shouldn't be mapping exactly if it's doing its job, so that's fine.

201

Secondly, 91 % of the decisions that had met end -of -life criteria would have met a severity weight above one.

202

So the majority of previously eligible technologies should still be eligible, which again is good.

203

Third, the authors concluded that a change from end -of -life to severity weights has been approximately cost neutral as intended.

204

So, in 2024, they concluded that the modifier is working as intended and no change is needed.

205

And NICE had also reported that positive recommendations of cancer treatments were somewhat higher under this criteria,

206

which is 75%.

207

So, NICE is satisfied that this policy is doing what it's intended to do.

208

So what does the industry partners think?

209

So this is a report from the Association of British Pharmaceutical Industry.

210

And so when they looked at what's been applied,

211

so this it's from 2022 when it was first introduced all the way to the most recent 2025 to 2026 and

212

they they what they argued is they do not disagree

213

that the severity modifier it's an improvement in terms of conceptual improvement from the end of life criteria

214

but they they have issues with the calibration.

215

So they found that 72 % of eligible topics received no severity weighting, and 59 % of those were in oncology.

216

NICE's own analysis suggests about 8 % of these topics would receive a 1 .7 modifier, and about 30 % should receive a 1 .2 modifier.

217

And so the ABPI interprets this as evidence that the modifier has been applied more conservatively than the opportunity cost neutral requires.

218

So they are calling for more work to be done on this.

219

And NICE is planning to do more work on whether this is reflecting societal preference.

220

And in the meantime, the ABPI has argued that they should have a downward adjustment to this shortfall cutoff.

221

So there are still a lot of recognition that there are limitations to this approach.

222

Now, of course, there are also methodological challenges.

223

So first of all, discounting, the shortfall calculation used discounted qualities.

224

And there's always an argument that discounting penalizes chronic diseases because morbidity and mortality accumulate over a long period of time.

225

So this is an argument that is not unique to this policy.

226

The cutoff, so the proportional shortfall threshold,

227

the top weight of 0 .95 is much higher than what other countries use.

228

So for example, in the Netherlands, their proportional shortfall is 0 .7.

229

The other methodological challenge is related to the borderline estimates.

230

So if you remember, we talked about a lot of the estimates from the patient's aspect, especially is fed from the modelling.

231

So small changes in assumptions can actually mean a difference in whether you qualify

232

or not for the effect for the severity modifier.

233

So it's quite challenging.

234

The choice of baseline and comparative is also relevant.

235

So before 2022, NICE could not calculate shortfall in about a third of the cases, often because there were no committee preferred scenarios.

236

And so baseline age or comparative qualities could not be identified.

237

So it's quite difficult to make to draw those comparisons.

238

And then finally, in terms of reporting,

239

there's inconsistent reporting of shortfall calculations limited by transparency and comparability across appraisals.

240

So it's not always clear how these calculations were made.

241

So I'm just going to finish by saying that the severity modifier,

242

I think, is a more coherent instrument than the end of life criteria.

243

It is a step forward.

244

It's broader, it's graded, and it's more transparent in principle

245

but it also but it remains a calibrated compromise

246

if you like rather than a genuine preference based weight um

247

so the the next stage of the debate probably will be

248

whether nice choose um a more preference aligned um approach um rather than continue what um making adjustment to this

249

or whether there will be further changes ahead.

250

But ultimately, I always would like to remind everyone that...

251

The severity modifier is a replacement for the end -of -life criteria.

252

And the end -of -life criteria exists because fundamentally of politics,

253

not really because there was a strong scientific basis to drive this.

254

Thank you.

255

Thank you.

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本課的詞彙與口語要點

影片中反覆出現的詞有：criteria, severity, modifier, shortfall, weight。這段影片共有 255 個句子、3078 個單詞可供跟讀。講話部分時長為 25:42。說話人語速平穩，每分鐘約 120 個詞，很適合跟讀。只有 81% 的單詞屬於英語最常用的 3,000 詞，詞彙難度較高。

影片中的重點詞彙

影片中 15 個值得學習的單詞，附發音和釋義：

單詞	發音	釋義
severity 名詞	/səˈvɛɹ.ə.ti/	嚴厲
threshold 名詞	/ˈθɹɛʃ(h)oʊld/	門檻 /門檻, 門限 /門限
calculation 名詞	/ˌkælkjuˈleɪʃn̩/	計算 /計算
preference 名詞	/ˈpɹɛf(ə)ɹ(ə)ns/	優選 /優選, 選擇 /選擇
discount 名詞	/ˈdɪskaʊnt/	折扣
calculate 動詞	/ˈkælkjʊleɪt/	計算 /計算, 算
element 名詞	/ˈɛləmənt/	要素
reflect 動詞	/ɹɪˈflɛkt/	反映, 反射
estimate 名詞	/ˈɛs.tɪ.mət/	估計 /估計
judgment 名詞	/ˈd͡ʒʌd͡ʒ.mənt/	判斷 /判斷
assumption 名詞	/əˈsʌm(p).ʃ(ə)n/	假設 /假設
topic 名詞	/ˈtɑpɪk/	主題 /主題, 話題 /話題
narrow 形容詞	/ˈnæɹəʊ/	窄
survival 名詞	/sɚˈvaɪ.vəl/	生存
faculty 名詞	/ˈfæk.əl.ti/	系

影片中的語法

說話人最常用的結構，並附上影片中的原話：

結構	影片中的用法
現在完成時 have/has + 過去分詞 — 過去發生但與現在仍有關聯的事	has already mentioned · has explained · has been
被動語態 be + 過去分詞 — 強調發生了什麼，而不是誰做的	wasn't created · were drafted · was revised

需要注意的發音

說話人用了 15 次縮略和弱讀形式，例如 I'm, I've, we're。請按聽到的簡短形式來說。

“th” 音: threshold /ˈθɹɛʃ(h)oʊld/, thin /ˈθɪn/, thoughtful /ˈθɔːtfəl/, methodological /ˌmɛθ.ə.dəˈlɑ.d͡ʒɪ.kəl/
“sh” 和 “zh” 音: threshold /ˈθɹɛʃ(h)oʊld/, calculation /ˌkælkjuˈleɪʃn̩/, assumption /əˈsʌm(p).ʃ(ə)n/, recognition /ˌɹɛkəɡˈnɪʃ(ə)n/, extension /ɪkˈstɛnʃən/
長單詞——注意重音位置: severity /səˈvɛɹ.ə.ti/, eligible /ˈɛl.ɪ.d͡ʒɪ.bəl/, pharmaceutical /ˌfɑː.məˈs(j)uː.tɪ.kl̩/, recognition /ˌɹɛkəɡˈnɪʃ(ə)n/, economics /ˌiːkəˈnɒmɪks/

中文母語者容易讀錯的音：

/v/ — 不要讀成 /w/，上齒輕觸下唇: severity /səˈvɛɹ.ə.ti/, survival /sɚˈvaɪ.vəl/, comparative /kəmˈpæɹətɪv/, whichever /wɪt͡ʃˈɛvɚ/, relative /ˈɹɛl.ə.tɪv/
詞尾子音 — 要讀清楚，後面不要加母音: threshold /ˈθɹɛʃ(h)oʊld/, preference /ˈpɹɛf(ə)ɹ(ə)ns/, discount /ˈdɪskaʊnt/, calculate /ˈkælkjʊleɪt/, element /ˈɛləmənt/
/r/ 和 /l/ 的區別: threshold /ˈθɹɛʃ(h)oʊld/, reflect /ɹɪˈflɛkt/, neutral /ˈnuː.tɹəl/, principle /ˈpɹɪn.sɪ.pəl/, preliminary /pɹɪˈlɪmɪnɛɹi/

如何用這段影片練習

先完整聽一遍影片，不要開口，記下不認識的單詞。
用正常速度逐句跟讀，每句重複到你的節奏與說話人一致為止。
錄下自己的聲音並與原聲對比，特別注意 severity, threshold, calculation 這類單詞。

什麼是跟讀法？

跟讀法 (Shadowing) 是一種有科學依據的語言學習技巧，最初開發用於專業口譯員的培訓，並由多語言者Alexander Arguelles博士普及。這個方法簡單而強大：您在聽英語母語原聲的同時立即大聲重複——就像是一個延遲1-2秒緊跟說話者的影子。與被動聽力或語法練習不同，跟讀法強迫您的大腦和口腔肌肉同時處理並模模擬實的講話模式。研究表明它能顯著提高發音準確性，語調，節奏，連讀，聽力理解和口語流利度——使其成為雅思口語備考和真實英語交流最有效的方法之一。

影子跟讀法: 閱讀完整分步指南 →

跟讀練習: Olivia - 通過影片學習英語口語

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本課的詞彙與口語要點

影片中的重點詞彙

影片中的語法

需要注意的發音

如何用這段影片練習

什麼是跟讀法？