Transcript Intro QALY & need assessment

Interactive session
design cost effectiveness
• Jan J. v. Busschbach, Ph.D.
• Erasmus MC
– Institute for Medical Psychology and Psychotherapy
PO Box 1738
3000 DR Rotterdam
+31 10 4087807
[email protected]
• Psychotherapeutic centre 'De Viersprong’
– PO Box 7
4660 AA Halsteren
+ 31 164 632200
[email protected]
• Presentations can be found at
– http://www.xs4all.nl/~jannetvb/busschbach/
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Questions to be solved;
• Who is the audience?
– Who’s perspective?
•
•
•
•
Should we evaluated at all?
What are the costs?
What are the effects?
How do effects relate to the costs in practice?
– Model
• Who to interpret the cost effectiveness ratio?
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The societal perspective
• Standard in health economics
• Determine cost (and effects) from the societal
viewpoint
– Resource used by all parties concerned
– The cost for society as a whole
• No matter who paying
• Other perspectives are possible
– Insurance, government, hospital, patient, industry, doctor
When to evaluated?
Effects
Costs
Worse
Better
Higher
Reject
Evaluate
Lower
Evaluate
Accept
Tariffs
• Cutback operation, correction of anus
anterior
– Small operation
– Halve hour
– Tariff: 1571
Euro
• Posterior Saggital Anorectoplasty (PSARP)
– Large operation
– 3 to 5 hours
– Tariff: 374
Euro
Cost price investigations
• Measure only volumes of major costs drivers
• Estimated “real market prices”
– One should include all resources used
» The societal perspective
– Shadow pricing
• Tariffs are only used in health economics
– If they are a reasonable accurate indication of the resources
used
– If they are a small proportion of the total costs
– If they volumes do not contribute to the incremental costs
» (the difference between to alternative programs)
We are in need of uni-dimensional
effects
• For instance:
–
$ 10,000 .1 hip transplantation
–
$ 15,000 ,1 wheelchair
• Costs can be compared
– Are uni-dimensionaal
• Effects are less easy to compare
– Effects are multi-dimensional
• How to make the effects also uni-dimensional?
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How to make the effects unidimensional?
• Three methods
– Cost Benefit Analysis
» Express effects in money
– Cost Effectiveness Analysis
» Focus on one effect
– Cost per QALY Analysis (Utility)
» QALY
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QALY league table
Intervention
$ / QALY
GM-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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Visual Analogue Scale
• VAS
Normal
health
– Also called category scaling
• From psychological research
• “How is your quality of life today ?”
• “X” marks the spot
X
– Response in centimeters
– Rescale to [0..1]
• Different anchor point possible:
– Normal health (1.0) versus dead (0.0)
– Best imaginable health versus
worse imaginable health
Dead
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Time Trade-Off
• TTO
• Wheelchair
– With a life expectancy: 50 years
• How many years would you trade-off for a
cure?
– Max. trade-off is 10 years
• QALY(wheel) = QALY(healthy)
– Y * V(wheel) = Y * V(healthy)
– 50 V(wheel) = 40 * 1
• V(wheel) = .8
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The EuroQol EQ-5D
•
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
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Validated Questionnaires
• Describe health states
• Have values from the general public
–
–
–
–
–
–
Rosser
QWB
15D
HUI Mark 2
HUI Mark 3
EuroQol EQ-5D
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Patient Perspective
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The Societal Perspective
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How to get these
societal values?
• Patient fills in
questionnaire
• Choose the value
function from the
literature
• Calculate societal value
COMPUTE MVH_A1 = 1.
VARIABLE LABELS MVH_A1 'York A1 tariff'.
DO IF (NVALID(mo, sc, ua, pd, ad) < 5 ).
RECODE
MVH_A1 (1 = SYSMIS).
END IF.
IF (MAX(mo, sc, ua, pd, ad) > 1) MVH_A1 = MVH_A1 -.081.
IF (mo = 2) MVH_A1 = MVH_A1 - .069.
IF (mo = 3) MVH_A1 = MVH_A1 - .314.
IF (sc = 2) MVH_A1 = MVH_A1 - .104.
IF (sc = 3) MVH_A1 = MVH_A1 - .214.
IF (ua = 2) MVH_A1 = MVH_A1 - .036.
IF (ua = 3) MVH_A1 = MVH_A1 - .094.
IF (pd = 2) MVH_A1 = MVH_A1 - .123.
IF (pd = 3) MVH_A1 = MVH_A1 - .386.
IF (ad = 2) MVH_A1 = MVH_A1 - .071.
IF (ad = 3) MVH_A1 = MVH_A1 - .236.
IF (MAX(mo, sc, ua, pd, ad) > 2) MVH_A1 = MVH_A1 - .269.
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An example of a value function
* SPSS syntax Dolan 1997, Medical Care, 1997;35:1095-108.
* mo = mobility, sc= self care, ua = usual activities, pd = pain & discomfort , ad = anxiety and depression.
COMPUTE MVH_A1 = 1.
VARIABLE LABELS MVH_A1 'York A1 tariff'.
DO IF (NVALID(mo, sc, ua, pd, ad) < 5 ).
RECODE
MVH_A1 (1 = SYSMIS).
END IF.
IF (MAX(mo, sc, ua, pd, ad) > 1) MVH_A1 = MVH_A1 -.081.
IF (mo = 2) MVH_A1 = MVH_A1 - .069.
IF (mo = 3) MVH_A1 = MVH_A1 - .314.
IF (sc = 2) MVH_A1 = MVH_A1 - .104.
IF (sc = 3) MVH_A1 = MVH_A1 - .214.
IF (ua = 2) MVH_A1 = MVH_A1 - .036.
IF (ua = 3) MVH_A1 = MVH_A1 - .094.
IF (pd = 2) MVH_A1 = MVH_A1 - .123.
IF (pd = 3) MVH_A1 = MVH_A1 - .386.
IF (ad = 2) MVH_A1 = MVH_A1 - .071.
IF (ad = 3) MVH_A1 = MVH_A1 - .236.
IF (MAX(mo, sc, ua, pd, ad) > 2) MVH_A1 = MVH_A1 - .269.
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Some values
• Broken arm
• 12211
–
–
–
–
–
no problems in walking about
some problems washing or dressing
some problems with performing usual activities
no pain or discomfort
not anxious or depressed
• Societal value = 0.779
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Some values
• Broken hip
• 22222
–
–
–
–
–
some problems in walking about
some problems washing or dressing
some problems with performing usual activities
moderate pain or discomfort
moderately anxious or depressed
• Societal value = 0.516
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Outcome Research
• Clinical research
– Does it work?
– Efficacy
– Perfect patient
» No co morbidity
• Outcome research
– Does it work in practice
– Effectiveness
– Every day patient
» Normal co morbidity
• Randomized Clinical
Trial
• Trials in a
naturalistic setting
– Controlled conditions
– Real life conditions
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Trial versus Clinical Practise
•
•
•
•
•
•
Subject homogeneity
Double blind
Placebo comparison
Forced compliance
Fixed procedures
High motivation
•
•
•
•
•
•
Representativeness
Open treatment
Usual care
Real compliance
Flexible procedure
Daily motivation
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Trial versus Clinical Practise
• Validity
– High internal
– Low external
• Increase validity by
– Search for large deviations
of practice
– Model outcomes to practice
• Modelling
– Use trial effect
– Add external elements
• Validity
– Log internal
– High external
• Increase validity by
– Search for causal relations
– Model outcomes to new
situation
• Modelling
– Use natural history
– Add effect
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Modelling depression
Depressive patient
Cure
Sex
Age
Number of relapses
suicide
Duration of illness
Natural death
Still depressive
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Books
• Oostenbrink, J. B., M. A. Koopmanschap, et
al.
– "Handleiding voor Kostenonderzoek. Methoden en
Richtlijnprijzen voor Economische Evaluaties in de
Gezondheidszorg.” 2000, College voor Zorgverzekeringen
• Rutten-van Mölken MPMH, Busschbach JJV,
Rutten FFH.
– Van Kosten tot Effecten: Een Handleiding voor
Evaluatiesstudies in de Gezondheidszorg. Elsevier
Gezondheidszorg, Maassen, ISBN: 90 352 2281 4. Zomer
2000
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