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Quality of life (Utility) Measurements In Relation to Health Economics

Prof. Dr. Jan J.V. Busschbach Erasmus MC

Section Medical Psychology and Psychotherapy

• Department of Psychiatry

NIHES Course Quality of Life Measurement (HS11)

Slides: www.busschbach.com

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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: QALYs

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0.00

1.00

X

Life years40 80

0.5 x 80 = 40 QALYs

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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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www.ibotnow.com

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Segway Dean Kamen

Jimi Heselden † 26 September 2010

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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: $ 3,000 per life year

QALY = Y x V(Q) = 10 x 0.1 = 1 QALY

Costs are 10 x $ 3,000 = $30,000

Cost/QALY = 30,000/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 tables

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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Link to example sheet

Sackett et al.; Clinical Epidemiology

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Introducing “Utilities”

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10.000 QALY publications

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1970 1980 1990 2000 2010 2020

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1980[pdat] AND (QALY or QALYs)

Threshold NICE

“As a guideline rule…, …NICE accepts as cost effective those interventions with an

incremental cost-effectiveness ratio of less than £20,000 per QALY …

…and that there should be increasingly strong reasons for accepting as cost effective interventions with an incremental cost-effectiveness ratio of over a threshold of £30,000 per QALY.”

• Incorporating Health Economics in Guidelines and Assessing Resource Impact. The guideline Manual. NICE April 2008, Chapter 8, page 54

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Modelling NICE decisions

At average levels for all covariates, a decision would have a 50% chance of rejection if its ICER were £45,118/QALY Dakin, Devlin, Rice, Parkin, O’Neill, Feng (2013) The

influence of cost effectveness and other factors on NICE decisions. (forthcoming)

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QALYs are measured in a invalid way Life years is not the problem, thus…

It must be the validity of quality of life assessment…

One should not use cost effectiveness Often referred to as ‘ethics’

Two points of critique

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CB0.0

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Eric Nord: Egalitarian concerns

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Burden as criteria

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Accepted Rejected

High burden Low burden

Pronk & Bonsel, Eur J Health Econom 2004, 5: 274-277

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Uti

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Costs/QALY as indicator of solidarity

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€ 50.000

€ 30.000

€ 40.000

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Works with life years as well… it is not just QoL!

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€ 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

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Dutch Council for Public Health and Health Care (RvZ, 2006)

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Burden / Costs effectiveness

NICE; Higer values end of life medication• The decisions to allow NHS use of trastuzumab

(Herceptin) and imatinib (Glivec) pushed NICE’s cost effectiveness threshold above its notional £30 000 (€34 000; $46 000) per QALY. These decisions took place against a background of legal action by patients, attendant publicity, and political discomfort.

James Raftery, BMJ

CvZ: Pakketbeheer in de Praktijk 2 • Bij de bepaling van de kosteneffectiviteit van een

interventie hanteert het CVZ een bandbreedte van 10.000 euro per QALY bij lage ziektelast tot 80.000 euro per QALY bij hoge ziektelast.

J. Zwaap, CvZ

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DALYs: 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

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QALY debate

Fairness is the issue in the QALY debate QALY measurement is the straw man

Complex metric discussion

But same discussion applies with life years gained

Obviously QALYs must measured validly

• That debate = rest of the course

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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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PTO gives extreme low values

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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...

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Utilitie

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TTO

PTO

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PTO

PTO is not a quick fix

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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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Direct utility assessment

SG, TTO, PTO, VAS

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Indirect utility assessment

HUI, EQ-5D, AQoL, 15D, Rosser index

MOBILITY I have no problems in walking about I have some problems in walking about I am confined to bed

SELF-CARE I have no problems with self-care I have some problems washing or dressing myself I am unable to wash or dress myself

USUAL ACTIVITIES (e.g. work, study, housework family or leisure activities)

I have no problems with performing my usual activities I have some problems with performing my usual activities I am unable to perform my usual activities

PAIN/DISCOMFORT I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort

ANXIETY/DEPRESSION I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed