Transcript Intro QALY & need assessment

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)
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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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Quality Adjusted Life Years: QALYs
 Example
 Blindness
 Time trade-off value is 0.5
 Life span = 80 years
 0.5 x 80 = 40 QALYs
1.00
X
0.5 x 80 = 40 QALYs
0.00
40
80
Life years
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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
Dean Kamen
Segway
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
$ / 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
Link to example sheet
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Sackett et al.; Clinical Epidemiology
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Introducing “Utilities”
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10.000 QALY publications
1980[pdat] AND (QALY or QALYs)
1200
Publications
1000
800
600
400
200
0
1970
1980
1990
2000
2010
2020
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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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Two points of critique
 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’
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Eric Nord: Egalitarian concerns
1.0
A
B
C
0.0
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Burden as criteria
30
25
20
15
10
5
0
Accepted
High burden
Rejected
Low burden
Pronk & Bonsel, Eur J Health Econom 2004, 5: 274-277
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Costs/QALY as indicator of solidarity
€ 40.000
80
€ 30.000
60
€ 50.000
40
20
0
A
B
C
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Works with life years as well…
it is not just QoL!
€ 40.000
80
€ 30.000
60
€ 50.000
40
20
0
A
B
C
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Costs/QALY versus Burden of disease
X
€ 80.000
X
€ 60.000
X
€ 40.000
X
€ 20.000
€
X
0
Burden of disease
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Dutch Council for Public Health and
Health Care (RvZ, 2006)
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Burden / Costs effectiveness
 NICE;

• 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:

Higer values end of life medication
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

Worked outside

DALY
Person Trade-Off


 School of Public Health
 Health economics
 Med Decision Making
 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
100 persons
additionally 1 healthy year
?? persons 1 year
free from disease Q
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PTO gives extreme low values
1.0
TTO
Utilities
0.8
PTO
0.6
0.4
0.2
0.0
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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...
1.0
0.8
TTO
PTO
PTO
0.6
Utilities
PTO is not a quick fix
0.4
0.2
0.0
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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
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