Transcript Quality of life Assessment

Reconciliation of Economic
Arguments and Clinical Practice
• Monday November 4, 2002
• ISPOR, Rotterdam
• Jan Busschbach PhD,
– Department of Medical Psychology and
Psychotherapy, Erasmus MC
– Psychotherapeutic Centrum ‘De Viersprong’
– [email protected]
• Elly Stolk, Marten Poley, Werner
Brouwer
– institute for Medical Technology Assessment
(iMTA), Erasmus University
1
Medical Technology Assessment
• A combination of arguments
–
–
–
–
Health economic
Juridical
Social
Ethical
• What are these other arguments?
– Are they important?
– How can we use them?
2
Ad hoc arguments
• If economics evaluation fails
– Reimbursement of lung transplantation
– No reimbursement of Viagra
• First, debate about the validity of the health
economics
– lung transplantation: not all cost of screening / waiting list should be included
– Viagra: preferences for sex (erectile functioning) can not be measured
• Secondly, ad hoc arguments are used
– lung transplantation: it is unethical to let someone die
– Viagra: erectile dysfunction in old men is not a disease
3
Ad hoc argument repressed
equity concerns
• Severity of illness
– Looking forwards
» Prospective health
– lung transplantation: it is unethical to let someone die
» Rule of rescue
» Necessity of care
» Eric Nord
• Faire innings
– Looking backwards
» Total health
– Viagra: when you get older, erectile dysfunction is not longer considered a
disease
» Alan Williams
4
Person trade-off
• Incorporates equity concerns in QALY
– Nord / Richardson / Murray
100 persons
additionally 1 healthy year
?? persons 1 year
free from disease Q
5
PTO elicits extreme values
1,0
TTO
Utilities
0,8
PTO
0,6
0,4
0,2
0,0
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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
TTO
PTO
PTO
Utilities
0,8
0,6
PTO is not a quick fix
0,4
0,2
0,0
Qu
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7
Incorporated equity in model
• Weight QALY by equity
– Wagstaff 1991
– Equity-efficiency trade-off
• Dunning’s Funnel
– 1990
– Government declaration 2002
– Necessary care
» Need
» Equity elements
– Efficacy
– Cost effectiveness
– Own account and responsibility
8
Funnel suggest no interaction
• The criteria are called sieve
– Dutch: “zeven”
– An intervention passes the sieve or it stays on top
– “Only after the health care intervention has
passed the sieve, the next criterion is applied.”
» Stronks, 1995
• The suggestion is wrong
– Dunning 2002
– The funnel is an interactive model
» Necessary care (equity) interacts with (cost)
effectiveness
9
Several definition of equity
• Severity of illness
But what if the severity of illness is
a result of old age?
– How bad is it now?
• Fair innings
– How good has it been?
Discriminate the old?
• Necessary care
– Is this a normal life?
How do we define “a normal life”
10
Proportional short fall
• Compares loss in QALY with expected QALY
– The higher the proportion
– The higher the need for equity compensation
QoL 
QALY gain
Now
Prop. Short Fall = 50%
QALY lost
t
50%
25%
Prop. Short Fall = 60%
11
Intermediate position
• Severity of illness
– Looking forwards
– Prospective health
• Fair innings
Proportional
short fall
B
– Looking backwards
– Total health
• Proportional
short fall
B
– Intermediate
Now
Prospective health patient A
Birth
Total health patient A
t
12
What can we do with it?
• Better understand health policy
– Why are some cost effective treatments not reimbursed
– Why are some not cost effective treatment reimbursed
• Cost effectiveness interact with equity
– Is there indeed a shifting threshold?
– Tested in policy practice
13
A shifting threshold
Cost per QALY
80000
20,000 per QALY
Increase threashold
60000
40000
20000
0
0
0,8
0,6
0,4
0,2
0
Severity of disease: proposional short fall
14
Practice
Proportional short fall
Onychomycosis
Osteoporosis
Symptomatic BPH
Hypertension
High Cholesterol
Arteriosclerosis
COPD
Pneumococcal pneumonia
Pulmonary hypertension
Non-Hodgkin Lymphoma
0.02
0.08
0.09
0.26
0.28
0.55
0.61
0.82
0.96
0.97
15
CE-ratio by equity
16
Efficiency / Equity trade-off
• The more severe the health state
– The more we are willing to contribute
– The more money we are willing the spend
– We accept a high cost per QALY
• Ad the price of a lower average level of health in
the population
– We reduce variance at the price of lower average health in the population
17
Implication
• Ethics can be measured
• Makes health care policy more understandable
– Reimbursement of lung transplantation
» Bad cost effectiveness, high burden
– No reimbursement of Viagra
» Good cost effectiveness, low burden
• Explains the existence of burden of disease
studies
18