The future of QALYs
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Transcript The future of QALYs
The Future of
Quality of Life Assessment
in Cost-Effectiveness Research
Prof. Jan J. v. Busschbach, Ph.D.
Erasmus MC
Medical Psychology and Psychotherapy
Viersprong Institute for studies on Personality Disorders
1
QoL in HTA: QALY
In the past, much criticism
Cohen CB.
Quality of life and the analogy with
the Nazis.
Journal of Medicine and Philosophy
8: 113-35, 1983.
Criticism remains
….the strictly fascist essence
of those QALYs (so-called
Quality-Adjusted Life Years)…
4
But QALY rules…
Publications
1980[pdat] AND (QALY or QALYs)
1000
900
800
700
600
500
400
300
200
100
0
1975
1980
1985
1990
1995
2000
2005
2010
From 1980 till 2010: 7049 publications in PubMed
2015
There is not yet an alternative…
Raad voor de Volksgezondheid en Zorg
Weight
QALYs by severity of illness
QALYs determine “severity”
7
Value based pricing
Health
Secretary Andrew Lansley
Measures "will help ensure better access for patients to
effective drugs and innovative treatments on the NHS"
Like
RvZ
Again adding severity
Adding Innovation
QALY still at the hart of the judgment
Severity and innovation both expressed
terms of QALYs
8
Efficiency frontier
Germany
IQWiG
Still
discussion
whether it is possible ‘in theory’ to make such value
judgments, let alone in practice
9
Which measure?
Questionnaires
EQ-5D
HUI
SF-6D
Direct
measures
TTO
Discrete choice
SG
VAS
Questionnaires
EQ-5D
Dominates health economics
Said to be insensitive
New 5 level version is on its way
SF-6D
Overtook HUI in popularity
Little support development
HUI
Little recent development
Expensive
Disease specific instruments
As
validation methodology becomes
cheaper…
Why not validate a disease specific instrument?
The
big research question
Are values valid?
Are the values the same as with HUI, SF-6D etc
Narrow
scope
Values are too high
Attention
bias
Differences are too big
Bold-on instruments
Combine
generic instruments with disease
specific dimensions
“Bold-on” the disease specific dimension
Can
solve the narrow scope
Absolute value level might be valid
Could
avoid attention bias
Does it also avoid the attention bias?
Direct measures
Used
to value health states in models
TTO
Discrete
SG
VAS
WTP
choice
dominates
coming up
slips aside
not in favor in health economics
never more than a promise
The big questions
TTO
Values below dead
Discrete
choice
Is discrete choice valid within the QALY approach?
How to anchor in death – normal health scale
• TTO?
Care
QALY
in care is disputed
QALY
might not be sensitive
Same
issues as in cure?
But QALY is ok for big issues in care
No care = dead
Care might be involve other aspects than health
For instance: does not measure autonomy
Disease specific instrument
Involve need and innovation
Discrete choice in care
New
instrument for care
ICECAP
ASCOTT
Several other initiatives
What
is the relation with QALY?
Why go for another scale?
17
Conclusion: Standardization
Questionnaires
Could merge to EQ-5D
But disease specific instruments might blur
Direct
valuation
TTO seems to prevail, but not yet one methodology
Care
Just the start of development
18
Future questionnaires
Cheap
EQ-5D
Sensitive
SF-6D
Simple to use
EQ-5D
Many translations SF-6D
Many value sets
EQ-5D
Will
EQ-5D-5L dominate?
SF-6D
HUI
SF-6D
EQ-5D
HUI
There must be room for more instruments…
HUI
EQ-5D (3L)
HUI
HUI
SF-6D