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Justice and Economic Evaluation
Prof. Dr. Jan Busschbachj.vanbusschbach@erasmusmc.nl
+31 10 7043807
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Equity concerns
In cost per QALY… Patients with low cost, high gains win…
But the general public wants that … Patients with the highest need win … Irrespectively the capacity to benefit….
A higher burden relates to more health care
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Erik Nord on the fairness in distributing health care resourcesISPOR Berlin 2012
Only Equity?
All resources to the highest burden? What about the others? What about waste resources?
Doesn’t effectiveness count?
“It should be a combination” Erik Nord: Obviously,….. of course!
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What does ‘need’ mean?
Need can mean: The availability of a (cost-)effective treatment “Burden” Low life expectancy Low quality of life
WHO The Burden of Disease Project Which people have the highest ‘need for health care’
• Low life expectancy• Low quality of life
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WHO: Burden of disease
DALY “Need” for health care Disability adjusted life year = QALY lost
Need defined by Fixed lifespan Max QoL Lost in lifespan and QoL
“Fair innings”
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DALY
QALY
1.0
0.0A B C
Kw
alit
eit
van
lev
enFalsification QALY
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Efficiency
EquityLif
e ye
ars
A B C
Falsification of life years
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80
0
Lif
e ye
ars 60
40
20
8
80
0A B C
Lif
e Y
ears
& Q
oL
Threshold costs/QALY:indicator of solidarity
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60
40
20
€ 50.000
€ 30.000
€ 40.000
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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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Does this make Erik a happy man?
Rule of rescue
What if cancer occurs at 80 years of age? “Fair innings” foregone?
No treatment?
Age discrimination? QALY was already suspected
Rule of rescue Severity of illness More severe….
• …. More priority
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DALY
QALY
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Fair Innings vs Rule of Rescue
Fair innings What have you already got? How good has it been? Loss in QALYs
Rule of Rescue Severity of illness How bad is it now? Expected QALYs
• Life expectancy….
But what if the severity of illness is a result of old age?
Discriminate the old?
Compares loss in QALY with expected QALY Combines fair innings with rule of rescue The more you loss of what you had expected… André Ament
Proportional short fall
Prop. Short Fall = 25% Prop. Short Fall = 50% Prop. Short Fall = 60%
QALY lostQALY gain
Life expectancy
QoL
Prop. Short Fall = 50%
Now
Now Life expectancy
the old and disabled
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Implementation
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Strengths and limitation
Combines two definitions of equity Fair innings Rule of rescue
Little data necessary Might overcompensate
The old The severe ill
Seen as complex… Might not capture everything…
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