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1
The Future of Quality of Life Assessment
in Cost-Effectiveness Research
Prof. Jan J. v. Busschbach, Ph.D.Erasmus MC
Medical Psychology and PsychotherapyViersprong Institute for studies on Personality Disorders
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)…
But QALY rules…
1980[pdat] AND (QALY or QALYs)
0100200300400500600700800900
1000
1975 1980 1985 1990 1995 2000 2005 2010 2015
Pu
bli
cati
on
s
From 1980 till 2010: 7049 publications in PubMed
7
Raad voor de Volksgezondheid en Zorg
Weight QALYs by severity of illness QALYs determine “severity”
8
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
Efficiency frontier
Germany IQWiG Still discussion
whether it is possible ‘in theory’ to make such value judgments, let alone in practice
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 dominates Discrete choice coming up SG slips aside VAS not in favor in health economics WTP 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 But QALY is ok for big issues in care No care = dead
QALY might not be sensitive Care might be involve other aspects than health For instance: does not measure autonomy
Same issues as in cure? Disease specific instrument Involve need and innovation
17
Discrete choice in care
New instrument for care ICECAP ASCOTT Several other initiatives
What is the relation with QALY? Why go for another scale?
18
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