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1
Quality of life (Utility) Measurements In Relation to Health Economics
Prof. Dr. Jan J.V. Busschbach Erasmus MC
Section Medical Psychology and Psychotherapy
• Department of Psychiatry
NIHES Course Quality of Life Measurement (HS11)
Slides: www.busschbach.com
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Health Economics
Comparing different allocations Should we spent our money on
• Wheel chairs
• Screening for cancer
Comparing costs
Comparing outcome
Outcomes must be comparable Make a generic outcome measure
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Outcomes in health economics
Specific outcome are incompatible Allow only for comparisons within the specific field
• Clinical successes: successful operation, total cure
• Clinical failures: “events”“Hart failure” versus “second psychosis”
Generic outcome are compatible Allow for comparisons between fields
• Life years
• Quality of life
Most generic outcome Quality adjusted life year (QALY)
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Example Blindness
Time trade-off value is 0.5
Life span = 80 years
0.5 x 80 = 40 QALYs
Quality Adjusted Life Years: QALYs
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0.00
1.00
X
Life years40 80
0.5 x 80 = 40 QALYs
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Area under the curve
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Which health care program is the most cost-effective?
A new wheelchair for elderly (iBOT) Special post natal care
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www.ibotnow.com
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Segway Dean Kamen
Jimi Heselden † 26 September 2010
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Which health care program is the most cost-effective?
A new wheelchair for elderly (iBOT) Increases quality of life = 0.1
10 years benefit
Extra costs: $ 3,000 per life year
QALY = Y x V(Q) = 10 x 0.1 = 1 QALY
Costs are 10 x $ 3,000 = $30,000
Cost/QALY = 30,000/QALY
Special post natal care Quality of life = 0.8
35 year
Costs are $ 250,000
QALY = 35 x 0.8 = 28 QALY
Cost/QALY = 8,929/QALY
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QALY league tables
Intervention $ / QALYGM-CSF in elderly with leukemia 235,958
EPO in dialysis patients 139,623
Lung transplantation 100,957
End stage renal disease management 53,513
Heart transplantation 46,775
Didronel in osteoporosis 32,047
PTA with Stent 17,889
Breast cancer screening 5,147
Viagra 5,097
Treatment of congenital anorectal malformations 2,778
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Link to example sheet
Sackett et al.; Clinical Epidemiology
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Introducing “Utilities”
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10.000 QALY publications
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200
400
600
800
1000
1200
1970 1980 1990 2000 2010 2020
Pu
bli
cati
ons
1980[pdat] AND (QALY or QALYs)
Threshold NICE
“As a guideline rule…, …NICE accepts as cost effective those interventions with an
incremental cost-effectiveness ratio of less than £20,000 per QALY …
…and that there should be increasingly strong reasons for accepting as cost effective interventions with an incremental cost-effectiveness ratio of over a threshold of £30,000 per QALY.”
• Incorporating Health Economics in Guidelines and Assessing Resource Impact. The guideline Manual. NICE April 2008, Chapter 8, page 54
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Modelling NICE decisions
At average levels for all covariates, a decision would have a 50% chance of rejection if its ICER were £45,118/QALY Dakin, Devlin, Rice, Parkin, O’Neill, Feng (2013) The
influence of cost effectveness and other factors on NICE decisions. (forthcoming)
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QALYs are measured in a invalid way Life years is not the problem, thus…
It must be the validity of quality of life assessment…
One should not use cost effectiveness Often referred to as ‘ethics’
Two points of critique
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1717
CB0.0
1.0
Uti
lity
of
Hea
lth
Eric Nord: Egalitarian concerns
A B
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Burden as criteria
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0
5
10
15
20
25
30
Accepted Rejected
High burden Low burden
Pronk & Bonsel, Eur J Health Econom 2004, 5: 274-277
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80
0A B C
Uti
lity
Costs/QALY as indicator of solidarity
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60
40
20
€ 50.000
€ 30.000
€ 40.000
20
80
0A B C
Liv
e ye
ars
Works with life years as well… it is not just QoL!
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60
40
20
€ 50.000
€ 30.000
€ 40.000
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Costs/QALY versus Burden of disease
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€ 80.000
€ 60.000
€ 40.000
€ 20.000
€ 0
Burden of disease
X
XX
XX
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Dutch Council for Public Health and Health Care (RvZ, 2006)
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Burden / Costs effectiveness
NICE; Higer values end of life medication• The decisions to allow NHS use of trastuzumab
(Herceptin) and imatinib (Glivec) pushed NICE’s cost effectiveness threshold above its notional £30 000 (€34 000; $46 000) per QALY. These decisions took place against a background of legal action by patients, attendant publicity, and political discomfort.
James Raftery, BMJ
CvZ: Pakketbeheer in de Praktijk 2 • Bij de bepaling van de kosteneffectiviteit van een
interventie hanteert het CVZ een bandbreedte van 10.000 euro per QALY bij lage ziektelast tot 80.000 euro per QALY bij hoge ziektelast.
J. Zwaap, CvZ
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DALYs: Chris Murray
WHO avoid QALY Havard
School of Public Health
Worked outside Health economics
Med Decision Making
DALY Person Trade-Off
Reinvented
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Burden of disease: QALY lost = DALY (Disability adjusted life year)
DALY
QALY
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Burden of disease expressed as “QALY lost” = DALY
Disability adjusted life years The inverse of QALY
Used by the WHO
Expresses burden of disease Measure of priority
More burden, more investment
QALY lost (DALY) = Measure of solidarity
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QALY: both for effectiveness and solidarity
Evaluations assess cost-effectiveness in term of cost/QALY
But many decisions can not be explained by cost/QALY
Explanation in terms of fairness People disagree with distributional implications of QALY
maximisation
Fairness is burden of disease Burden of disease is QALY lost (DALY)
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QALY debate
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QALY debate
Fairness is the issue in the QALY debate QALY measurement is the straw man
Complex metric discussion
But same discussion applies with life years gained
Obviously QALYs must measured validly
• That debate = rest of the course
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Person Trade-Off
Values between patients Not ‘within’ a patient like SG, TTO and VAS
Better equipped for QALY?
V(Q) = 1 - (A / B) For instance:
V(Q) = 1 - (100/300)
V(Q) = 1 - 0.33
V(Q) = 0.67
?? persons 1 year free from disease Q
100 persons additionally 1 healthy year
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PTO gives extreme low values
0.0
0.2
0.4
0.6
0.8
1.0
Uti
liti
es
TTO
PTO
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PTO and it’s psychometrics Paul Kind: If we look at TTO and PTO...
we see that one of them is wrong
If we look at PTO alone... We still see that one of them is wrong...
0.0
0.2
0.4
0.6
0.8
1.0
Utilitie
s
TTO
PTO
0.0
0.2
0.4
0.6
0.8
1.0
Utilitie
s
PTO
PTO is not a quick fix
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Alternative applications
Link to out of pocket payments Greater out of pocket payments for conditions with lower
proportional shortfall
E.g. France and Belgium
For example: No reimbursement for the mildest conditions, such as
common cold, acute tonsillitis, acute bronchitis, onychomycosis, tinea pedis
Partial reimbursement for conditions mild to moderate conditions: Haemorrhoids, candidiasis, gastritis, osteoporosis, erectile dysfunction, acne conglobata
Etc.
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Direct utility assessment
SG, TTO, PTO, VAS
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Indirect utility assessment
HUI, EQ-5D, AQoL, 15D, Rosser index
MOBILITY I have no problems in walking about I have some problems in walking about I am confined to bed
SELF-CARE I have no problems with self-care I have some problems washing or dressing myself I am unable to wash or dress myself
USUAL ACTIVITIES (e.g. work, study, housework family or leisure activities)
I have no problems with performing my usual activities I have some problems with performing my usual activities I am unable to perform my usual activities
PAIN/DISCOMFORT I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort
ANXIETY/DEPRESSION I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed