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“Introduction to Patient Preference Methods used for QALYs”
Presented by:
Jan Busschbach, PhD, Chair Section Medical Psychology and Psychotherapy, Department of Psychiatry, Erasmus MC, Rotterdam
The Netherlands
Saturday, 2 November 2013
Utility Measurements Preference-based Techniques
Prof. Dr. Jan J.V. Busschbach Erasmus MC
Department for Medical Psychology and Psychotherapy
Saturday, 2 November 2013: 14:00 - 18:00
2
Program before the break
14:00 – 14:30 Introduction + email questions (Presentation 1)
14:30 – 15:30 Indirect utility measurement Lecture: Introduction EQ-5D, HUI and SF-36 in QALYs
(Presentation 2)
Exercise: Indirect utility measurement (Exercise 1)
Lecture continued: EQ-5D, HUI and SF-36 in QALYs (Presentation 2 continued)
The difference between patient and social perspective (Presentation 3)
15:30 – 16:00 Direct utility measurement Lecture: Direct utility measurement: The validity of Standard Gamble,
Time Trade-Off and Visual Analogue Scale (Presentation 4)
16:00 – 16:15 Break
3
Program after the break
16:15 – 17:00 Direct utility measurement Exercise: Direct utility measurement (Exercise 2) Discussion: which instrument when to use?
17:00 – 17:15 Disease specific utility measurement Lecture: Disease specific instruments for QALY-
analysis + Person Trade-Off (Presentation 5)
17:15 – 17:45 Cultural differences (Presentation 7)
17:45 – 18:00 Round up
4
5
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
Identification of major problems
Issues emailed by participants What topics in quality of life research are most
relevant/interesting for you and/or your work?
6
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
7
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)
8
Example Blindness
Time trade-off value is 0.5
Life span = 80 years
0.5 x 80 = 40 QALYs
Quality Adjusted Life Years (QALY)
9
0.00
1.00
X
Life years40 80
0.5 x 80 = 40 QALYs
Area under the curve
Which health care program is the most cost-effective?
A new wheelchair for elderly (iBOT) Special post natal care
11
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 $3,000 = $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
13
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
14
QALYs are measured in an 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
15
16
CB0.0
1.0
Uti
lity
of
Hea
lth
Eric Nord: Egalitarian concerns
A B
Burden as criteria
17
0
5
10
15
20
25
30
Accepted Rejected
High burden Low burden
Pronk & Bonsel, Eur J Health Econom 2004, 5: 274-277
80
0A B C
Lev
ensj
aen
Costs/QALY as indicator of solidarity
18
60
40
20
€ 50.000
€ 30.000
€ 40.000
Costs/QALY versus Burden of disease
19
€ 80.000
€ 60.000
€ 40.000
€ 20.000
€ 0
Burden of disease
X
XX
XX
Dutch Council for Public Health and Health Care (RvZ, 2006)
20
Burden of disease: QALY lost = DALY (Disability adjusted life year)
DALY
QALY
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
22
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)
23
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 That debate = rest of the course
24
Most debate about the QoL estimates
Unidimensional QoL In QALY we need a unidimensional assessment of Quality of life
Rules out multidimensional questionnaires SF-36, NHP, WHOQOL
25
0
10
20
30
40
50
60
70
80
90
100
Physic
al fu
nctio
ning
Social
Functio
ning
Role P
hysi
cal
Role e
motio
nal
Men
tal h
ealth
Vitalit
y
Bodily p
ain
Genera
l Hea
lth
Sc
ore
s o
n S
F-3
6
General pop.
Diabetes II
Growth hormon def.
Depression
Direct utility assessment
SG, TTO, PTO, VAS
26
Indirect utility assessment
HUI, EQ-5D, AQoL, 15D, Rosser index
27
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