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QALY: veel bekritiseerd, maar nooit meer dan het alternatief”

Symposium “De validiteit van de QALY”

14 maart 2008

NVTAG, RIVM, Bilthoven

Jan van Busschbach

QALY seem to survived criticism for years now….

QALY is difficult to appreciated…. but in 2007: 4150 Citations in PubMed Could it be that there is a flaw in the criticism?

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1980[pdat] AND (QALY or QALYs)

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1980 1985 1990 1995 2000 2005 2010

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Three problems with the criticism …..

1. Argument often represent aversion limited budget

2. Proposed alternatives turn out the be the same

3. Even equity concerns are in need of QALY

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First critique

1983 Cohen C.B. Quality of life and the analogy with the Nazis.

Journal of Medicine and Philosophy 8: 113‑35

1989 Rawles Castigating QALYs [Debate].

Journal of Medical Ethics 15:143-7

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First outcome discussion

Rawles J., Rawles K. The QALY argument: a physician's and a philosopher's view.

Journal of Medical Ethics 16: 93-4, 1990

“… In spite of the rhetoric there is a broad measure of agreement about the deficiencies of QALYs as a means of distributing scarce resources….”

“…The main area of conflict is that John Rawles favours campaigning for more resources while Gavin Mooney, constrained by his remit as a health economist, favours acceptance of the present level of funding and better methods of distributing resources.” (blz. 93)

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Positions

Pro Budget is limited

QALY might be a solution

• Although not perfect….

Contra Budget is not yet limited

QALY is not perfect

• QALY is a problem

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Positions still apply…

2007: Kees van Bezooijen Patient representative

In discussion during introduction cost effectiveness parameter in reimbursement expensive hospital medications

“…Wij hebben duidelijk aangegeven dat een discussie over "wat maatschappelijk nog aanvaardbaar is" [kosten per QALY] alleen gevoerd mag worden als geldverslindende "frivoliteiten" door de maatschappij […] zijn uitgebannen. Bijvoorbeeld "joint strike fighters“…

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A limited budget is reality

There is no prominent school of though that advocates that the budget is unlimited

A limited budget is the norm Unlimited is not a realistic position

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Three problems with the criticism …..

1. Argument often represent aversion limited budget

2. Proposed alternatives turn out the be the same

3. Even equity concerns are in need of QALY

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Neil Aaronson, 1996

QALY is a the wrong answer for a very complex process….

We are in need of a robust, simple and new method….

TWiST

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Time Without Symptoms of disease and subjective Toxic effects of treatment

TWiST Developed by Richard Gelber (statistician)

In search for a typical “cancer” problem Often prolonged life but also a reductions in quality of

life

• At the beginning (side effects)

• At the end

Only count the days without symptoms of disease and subjective toxic effects of the treatment

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TWiST in cancer therapy

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1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

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Placebo

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TWiST: ignores differences in quality of life

TWiST Healthy = 1

Sick (dead) = 0

There is more to life than sick/health Make intermediate values of quality of life

Q-TWiST

• Quality of life adjusted TWiST

But then: 365 x Q-TWiST = 1 x QALY Thus alternative is just the same 0.0

Quality

of life

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Burden of Disease Project

WHO Global Burden of Disease (GBD) Impact of diseases world wide Estimates of epidemiology per disease

Mortality

Quality of life losses

In need of one measure of health But WHO disliked QALY…

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Chris Murray

Havard School of Public Health

Worked outside Health economics

Med Decision Making

DALY Disability Adjusted Life Years

Lost life years

Lost Quality of life

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DALY / QALY

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QALY

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Q-TWiST and DALY

Both are presented as alternatives for QALY But are in fact the same… See also

Healthy Year Equivalent (HYE)

Saved Young Life Equivalent (SAVE)

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Three problems with the criticism …..

1. Argument often represent aversion limited budget

2. Proposed alternatives turn out the be the same

3. Even equity concerns are in need of QALY

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Efficiency / equity debate

Cost per QALY represents efficiency But is our health care system based on

efficiency? In health care, next to efficiency…

Compassion

Solidarity

Commiseration

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CB0.0

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A B

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CB0.0

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Nord: “Egalitarian and efficiency concerns both exist …”

A B

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CB0.0

1.0

Uti

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Nord: “Egalitarian and efficiency concerns both exist …”

A B

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Several definition of equity

Severity of illness How bad is it now?

Fair innings How good has it been?

In all cases…. QALY is used to express equity “QALY equity” to correct “QALY efficiency”

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Dutch Council for Public Health and Health Care (De Raad voor de Volksgezondheid en Zorg, 2006)

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Three problems with the criticism …..

1. Argument often represent aversion limited budget

2. Proposed alternatives turn out the be the same

3. Even equity concerns are in need of QALY

1980[pdat] AND (QALY or QALYs)

0

100

200

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600

1980 1985 1990 1995 2000 2005 2010

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First QALY

1968 Klarman, Fransis & Rosenthal Cost effectiveness analysis applied to the treatment of chronic renal

disease

Medical Care 6: 48‑54, 1968.

1970 Fanshel & Bush A health-status index and its application to health services

outcomes.

Operations Research 18: 1021‑66, 1970

1976 Torrance Social Preferences for Health Status: an empirical evaluation of

three measurement techniques.

• Socio-Economic Planning Science 10: 129‑36, 1976.

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