1 the qalys debate prof. dr. jan j.v. busschbach, ph.d. erasmus mc institute for medical...
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The QALYs debate
Prof. dr. Jan J.V. Busschbach, Ph.D. Erasmus MC
Institute for Medical Psychology and Psychotherapy
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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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Example Blindness
Time trade-off value is 0.5
Life span = 80 years
0.5 x 80 = 40 QALYs
Quality Adjusted Life Years (QALY)
4
0.00
1.00
X
Life years40 80
0.5 x 80 = 40 QALYs
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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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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 .8
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1970
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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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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: $ 4,000 per life year
QALY = Y x V(Q) = 10 x 0.1 = 1 QALY
Costs are 10 x $4,000 = $30,000
Cost/QALY = 40,000/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 table
Intervention $ / QALYGM-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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Milton Weinstein
In the face of uncertainty … and fear The decision willwill be made, if not actively then
by default
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7000 Citations in PubMed
1980[pdat] AND (QALY or QALYs)
0100200300400500600700800900
1000
1975 1980 1985 1990 1995 2000 2005 2010 2015
Pu
blic
ati
on
s
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QALY = Utility: Welfare theory
QALY can be see as the ‘value of health’ The value of a good or service: “utility”
Also called “nut” (Dutch)
Welfare theory: maximize utility Maximize QALY
Do we want to maximize QALY? Doubtful…
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CB0.0
1.0U
tili
ty o
f H
ealt
h
Is the utility scale valid?
A B
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We do not maximize QALY But nevertheless we want to maximize utility
• By (economic) definition..
That means:
QALYs measured utility in an invalid way Life years is not the problem, thus…
It must be the validity of quality of life assessment…
Critique
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…it must be that QALYs are invalid
We don’t like the results…
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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.
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Criticism remains
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….the strictly fascist essence of those QALYs (so-called
Quality-Adjusted Life Years)…
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Burden as criteria
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0
5
10
15
20
25
30
Accepted Rejected
High burden Low burden
Pronk & Bonsel, Eur J Health Econom 2004, 5: 274-277
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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
?? persons 1 year free from disease Q
100 persons additionally 1 healthy year
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TTO does not correlate with PTO
0.0
0.2
0.4
0.6
0.8
1.0
Uti
liti
es
TTO
PTO
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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...
0,0
0,2
0,4
0,6
0,8
1,0
Utilitie
s
TTO
PTO
0,0
0,2
0,4
0,6
0,8
1,0
Utilitie
s
PTO
PTO is not a quick fix
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CB
Lif
e Y
ears
Falsification even with life years
A B
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2626
CB0.0
1.0U
tili
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Utility?
A B
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Utility
Utility Total benefit
Including distribution
Also called “Nut” (Dutch)
Quality of life might be part of total benefit
QALYs do not include distribution
But it is said that ‘Standard Gamble’ measures utilities! Van N-M utilities by definition utility
But in SG only “health for your self”
Does not include distribution
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A B C
Costs/QALY as indicator of solidarity
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€ 50.000
€ 30.000
€ 40.000
QA
LY
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Costs/QALY versus Burden of disease
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€ 80.000
€ 60.000
€ 40.000
€ 20.000
€ 0
Burden of disease
X
XX
XX
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Dutch Council for Public Health and Health Care (RvZ, 2006)
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If a medical treatment costs >€80,000 to give one patient one extra life year of good quality, it should not be reimbursed in the
basic health care insurance
Council advises the Minister of Health to use this limit in order to keep the budget of health care under control; They realize the
topic is controversial.
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Chris Murray
WHO avoid QALY Havard
School of Public Health
Worked outside Health economics
Med Decision Making
DALY Person Trade-Off
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
Fairness is the issue in the QALY debate QALY measurement is the straw man
Complex metric discussion
QALYs are needed to operationalize fairness
Most debate about quality of life assessment Again as straw man
But also within the metric debate of QALY
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Reimbursement arguments
Burden of disease
Effects
Cost effectiveness
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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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Take home message
Quality of life assessment and health assessment is crucial Not only to estimate health gains (efficiency)
But also to estimate need (equity) It is not the measurement of quality of life
but the efficiency/equity trade-off which heats up the debate