Transcript Intro QALY & need assessment
VAS, SG, TTO and PTO Measuring quality of life An Interactive Introduction
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Quality of life
“…. Health is physical, mental and social well being and not merely the absence of disease or infirmity...”
World Health Organization, 1947
Extending health to well-being: Quality of life
What is the definition of quality of life?
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Many definitions
Quality of life is the degree of need and satisfaction within the physical, psychological, social, activity, material and structural area (Hörnquist, 1982).
Quality of life is the subjective evaluation of good and satisfactory character of life as a whole (De Haes, 1988).
Health related quality of life is the subjective experiences or preferences expressed by an individual, or members of a particular group of persons, in relation to specified aspects of health status that are meaningful, in definable ways, for that individual or group (Till, 1992).
Quality of life is a state of well-being which is a composite of two components: 1) the ability to
perform
everyday activities which reflects physical psychological, and social well-being and 2) patient related symptoms (Gotay et al., 1992).
satisfaction
with levels of functioning and the control of disease and/or treatment An individual’s perception of their position in life in the context of the culture and values systems in which they live and in relation to their goals, expectations, standards and concerns (WHO Quality of life Groups, 1993).
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No clear definition
Researchers are free to choose
The notion of measuring the quality of life could include the measurement of practically anything of interest to anybody. And, no doubt, everybody could find arguments supporting the selection of whichever set of indicators to be his choice…
Andrews & Withey, 1976, page 6 4
No clear definition because…
Different origins of research
Clinical decision making • Does the patient benefit from the treatment?
Epidemiology (public health) • what is the morbidity of the population?
Health economics • Is it worth the money?
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Common items in definitions:
It is not the doctor who reports
Quality of life is subjective….
“Given its inherently subjective nature, consensus was quickly reached that quality of life ratings should, whenever possible, be elicited directly from patients themselves. “ (Aaronson, in B Spilker (Ed): Quality of life and Pharmacoeconomics in Clinical Trails, 1996, page 180) Reports between proxies and patients vary.
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Common items in definitions:
Health related
Multidimensional
Physical, psychological, social
Questionnaires
Standardize questions and response • Reproducible results: sciences • Quantify subjectivity
Operational defined
Like IQ and temperature.
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How to measure quality of life form a clinical point of view?
Choose items
Are you able to walk one kilometer ?
Do you feel depressed ?
Choose response mode
Binary Multiple (Likert) Continuous ( Visual Analogue Scale ) yes / no yes / at bid / hardly / no Always ————
X
—— Never
Combine items to dimensions of quality of life
Sum up the items belonging to one dimension Rescale sum on a scale from 0 to 100 8
Patient Items to value
Health state
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Uni-dimensional value
QALYs need a uni-dimensional value
Like the IQ-test measures intelligence
QALYs need a ratio or interval scale
Difference 0.00 and 0.80 must be 8 time higher than 0.10
Five popular methods have these pretensions
Visual analog scale Time trade-off Standard gamble Person Trade-off Discrete Choice 10
Visual Analogue Scale
From psychological research
Also called “category scaling” Rescale from 0.00 to 1.00
Main critique
No guarantee ratio scale Lower value then face value 11
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) = .80
Main critique
Discounting effect More complicated than VAS 12
Standard Gamble (SG)
Wheelchair
Life expectancy is not important here
How much are risk on death are you prepared to take for a cure?
Max. risk is 20% wheels = (100%-20%) life on feet V(Wheels) = 80% or .80
Main critique
More complicated than VAS and TTO Risk aversion 13
Health economists prefer TTO/SG
Visual analogue scale
No trade-off: no relation to QALY No interval proportions
Standard Gamble / Time Trade-Off
Trade-off: clear relation to QALY Interval proportions 14
Values differ, but differences are often constant
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
12 11 1 11 21 1 21 11 1 11 12 1 11 11 2 11 12 2 32 21 1 21 23 2 33 32 1 22 32 3
EQ-5D health states
N = 103 students SG TTO VAS 22 23 3 33 33 3 15
Person Trade-Off
Values between patients
Not ‘within’ a patient like VAS
V(Q) = A / B
For instance:
V(Q) = 100/300 V(Q) = 0.33
100 persons additionally 1 healthy year ?? persons 1 year free from disease Q 16
Person Trade-Off (PT0)
Values between patients
Not ‘within’ a patient like SG, TTO and VAS
For instance:
300 V(Q) = 100 V(Full Health) 300 V(Q) = 100 * 1.00
V(Q) = 0.33
100 persons additionally 1 healthy year ?? persons 1 year free from disease Q 17
Incorporation of solidarity
Values between patients
Not ‘within’ a patient like SG, TTO and VAS Suggested for health priority setting
Burden of Disease project
WHO Chris Murray, Eric Nord 18
PTO gives low values
0,4 0,2 0,0 1,0 0,8 0,6 TTO PTO Qu adri ple Se gia ve r de Stro pre ssi ke on (mo Se ve dera re st able te imp Se ve re a an airme gina nt) Diffi sth ma cu lt to Chro co nic ntro l dia Dise low er b bete ase s fre ack Visi e bre pain on d ast iso rde ca r (mi nce r ld to mo dera te) 19
Questionable 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...
TTO PTO PTO
PTO is not a quick fix
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First markers WHO look better
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Smoothing by consensus
King CH (2008) Asymmetries of Poverty: Why Global Burden of Disease Valuations Underestimate the Burden of Neglected Tropical Diseases. PLoS Negl Trop Dis 2(3): e209.
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Replication PTO
Stouthard et al. Eur J Public Health 2000; 10: 24-30 23
PTO uses calibrated VAS
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Vos T, et al., 1999
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Essink-Bot et al., Cross-national comparability of burden of disease estimates: the European Disability Weights Project.
Bull World Health Organ. 2002;80(8):644-52.
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Validity of PTO
Health economists have a complex relation with PTO
Unclear incorporation of equity (solidarity) Bad psychometric proportions Unclear use of consensus by expert panels
Not preferred
But often used, as values for many health state are available 27
Discrete Choice Experiments (DCE)
State 1
Moderate problems in walking about Some problems washing or dressing Some problems with performing usual activities Some pain or discomfort No psychosocial problems
State 1
Some problems in walking about Moderate problems washing or dressing Some problems with performing usual activities Some pain or discomfort No psychosocial problems 28
Preference relate to distance
A B 20% state A; 80% state B A B 30% state A; 70% state B 45% state A; 55% state B A B B A 80% state A; 20% state B
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DQI meet de kwaliteit van leven van personen met dementie op basis van vragen over 6 domeinen
Geheugen Oriëntatie Zelfzorg Lichamelijke gezondheid 1 2 3 1 2 3 1 2 3 1 2 3 Geen problemen Enige problemen Ernstige problemen Geen problemen Enige problemen Ernstige problemen Geen problemen Enige problemen Ernstige problemen Geen problemen Enige problemen Ernstige problemen Sociaal functioneren 1 2 3 Geen problemen Enige problemen Ernstige problemen Stemming 1 2 3 Geen problemen Enige problemen Ernstige problemen Bijvoorbeeld, een scorecombinatie van 121122 betekent de volgende gezondheidstoestand: Geen geheugenproblemen Enige oriëntatieproblemen Geen problemen met de zelfzorg Geen problemen met de lichamelijke gezondheid Enige problemen met sociaal functioneren Enige stemmingsproblemen Bron: Scholzel et. Al. Health and Quality of Life Outcomes 2012 Rosan Oostveen
Elke gezondheidtoestand zegt iets over de kwaliteit van leven Best = 0
0,0 -0,5 -1,0 -1,5 -2,0 -2,5 -3,0 • • Uit positie op meetlat is voor iedere gezondheidsdomein aan ieder antwoord een wegingsfactor toegekend aan de score Hoe groter de invloed van een score op een domein op de kwaliteit van leven, hoe hoger de wegingsfactor -3,5 -4,0
Slechtst = -3,98 Domeinen DQI
Lichamelijke gezondheid Geheugen Zelfzorg Stemming Sociaal functioneren Orientatie
Totaalscore
Ernstige problemen (3)
-0,82 -0,80 -0,71 -0,59 -0,57 -0,49
-3,98
Enige problemen (2)
-0,18 -0,23 -0,21 -0,11 -0,17 -0,08
-0,98
• De totaalscore op kwaliteit van leven van een dementerende is een optelling van de wegingsfactoren per vraag. De antwoorden van de persoon met dementie bepalen de wegingsfactoren
Geen problemen (1)
0 0 0 0 0 0
0
Bron: Scholzel et. Al. Health and Quality of Life Outcomes 2012
Little difference between Cost/Life Year and Cost/QALY
Richard Chapman et al, 2004, Health Economics
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Difference in QALYs makes little difference in outcome
Richard Chapman et al, 2004
“In a sizable fraction of cost-utility analyses, quality adjusting did not substantially alter the estimated cost-effectiveness of an intervention, suggesting that sensitivity analyses using ad hoc adjustments or 'off-the-shelf' utility weights may be sufficient for many analyses.” “The collection of preference weight data should […] should only be under-taken if the value of this information is likely to be greater than the cost of obtaining it.” 33
QALYs make a difference when:
Chronic disease
Palliative
Long term negative consequences
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