POINT OF VIEW

appropriate training and support for the triage nurse and other carers and access to medical backup are all required. Sick-care services must have direct access to medical consultation, including telephone contact with paediatric and public health advisers. l 6 Advisers who have a predominantly clinical focus in their usual work, such as general practitioners and paedia- tricians, may need reorientation to public health aspects of communicable diseases.

Illness in child care has an impact on both the infectious diseases burden carried by the community and on parental employment. Approaches to reduce the impact of children’s illness on parental absentee- ism from work include a combination of structural change in the workplace and options for sick child care. All industrial awards and agreements should provide a minimum amount of unpaid parental leave to care for sick children. This minimum amount may be gleaned from the increasingly voluminous over- seas literature on days of illness experienced by chil- dren in child care, or may await the results of prospective Australian studies. Moreover, some industries, workplaces and occupations are amenable to flexible work practices which allow parents to either work from home whilst caring for sick children or make up the lost time once the children have returned to usual care. As many occupations are not suited to flexible working hours, facilities for the care of mildly sick children must also be available in the community. Whilst workplace reform will require advocacy from many sectors of society, the public health community has a clear and immediate role in guiding the development and operation of programs for care of mildly sick children.

Mark J. Ferson Public Health Unit

Eastern Sydney Area Health Smice

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Bagnall AR. Lobour force status and other churactleristics of famil- ies, Awtralia, July 1980. Cat. no. 6224.0. Canberra: Aus- tralian Bureau of Statistics, 1981. McLennan W. Labour forcestutusandothercharacte7isticc offam- ilies, Australia, June 1990. Cat. no. 6224.0. Canberra: Aus- tralian Bureau of Statistics, 1990. Castles I . Child care arrangements, Australia, June 1987. Cat. no. 4402.0. Canberra: Australian Bureau of Statistics, 1989. Wald ER, Dashefsky B, Kyers C, Cuerra N, Taylor F. Fre- quency and seventy of infections in day care./ Pedidr 1988; 112: 540-6. Ponka A, Nurmi T, Salminen E, Nykiri E. Infections and other illnesses of children in day-care centers in Helsinki. 1: Incidences and effects of home and day-care centre variables. Infection 1991; 19: 230-6. Rasmussen F, Sundelin C. Use of medical care and antibiotics among preschool children in different day care settings. Actu Paediatr Scad 1990; 79: 838-46. VandenHeuvel A. When roles overlap: workers with family resparibilities. (AIFS monograph no. 14). Melbourne: Aus- tralian Institute of Family Studies, 1993: 36-8. Ferson MJ, Fisher K, French C. Impact on work absenteeism of infectious illness among preschool children: results of a workplace-based survey. Fourth Australian Family Research Conference, February 1993. Ferson MJ. Health and economic cost of chickenpox in child care. Med J A w t 1992; 156: 364. MoNabane N, McCroskey J. Child care for sick children. In: Burud SL, Aschbacher PR, McCroskey J, editors. Employer- supporied child care. Boston: Auburn House Publishing Com- pany, 1984; 203-12. Jordan AE. The unresolved child care dilemma: care for the acutely ill child. RN Infect Dis 1986; 8: 626-30.

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Landis SE, Chang A. Child care options for sick children. Pediatrics 1991; 88: 705-18. Chang A, Zeledon-Friendly A, Britt A, Ewing B. Management of illness and temporary disability in children enrolled in day- care centres. Am/ Dis Chi1 1988; 142: 6651-5. Macdonald KL, White KA, Heiser J, Gabriel L, Osterholm MT. Evaluation of a sick child day care program: lack of detected increased risk of subsequent infections. Pediatr Infect Dis 1990; 9: 15-20. Desguin BW, Murray DL. Triage decisions in child care for sick children. Am J Dis Child 1990; 144: 190-6. Grayson R. The senior pediatrician and day care. Pedatrics 1993; 91: 146-7.

QALYs for resource allocation: a-reply to Burrows and Brown Democracy is the w m t pssiblL* system, except for all the allerndives

Winston Churchill

In the last edition of the Journal, there were two articles on cost-utility analysis and the use of quality- adjusted life years (QALYs) on which cost-utility analysis is based.’V2 The first of these we wrote. The second article by Burrows and Brown was, in effect, an extended critique of our article which we had made available to them. They had not given us similar access to their article. Consequently, the following note represents our reply.

Kenneth Arrow won the Nobel prize for, among other things, showing that there is no ‘perfect’ voting system: all have flaws. Despite this imperfection, we do not reject democracy, because the alternatives appear even more ‘imperfect’. Instead we accept the inevitable presence of some flaws, but try to minimise their number and impact. Thus, we argue about pro- portional versus ‘first past the post’ voting, not about whether we should vote at all.

In a similar vein, Burrows and Brown have asked: ‘Are QALYs flawed?’. They, we and Arrow would answer ‘yes’. However, this is fundamentally the wrong question. Instead we should ask: ‘Are other methods better than QALYs?’. Are other methods as open to scrutiny? Do other methods consider both the quality and quantity of life gained by an inter- vention (and the inevitable trade-offs between these), and are other methods as fair? These questions are difficult to answer, and are the questions which should have been, but were not, addressed by Bur- rows and Brown. Instead they point out the (inevi- table) flaws and argue that further efforts to improve the methods of cost-utility analysis are misplaced. Let us look in detail then at their arguments.

The case against QALYs Burrows and Brown appear to defend the following propositions: 1. The differences in quality of life between differ-

ent health outcomes is likely to be so large that assessment ‘does not require anything like the measurement precision of a single index’ (as in the case of transplant verses renal patients). Alternatively, differences are likely to be so small that measurement error will swamp conclusions (as Burrows and Brown argue would occur in our hypothetical example).

2. Validated, disease-specific, quality-of-life instru- ments are probably superior to QALYs.

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POINT OF VIEW

3. Quality of life is a construct; its validation requires the steps outlined in the psychometric theory of validation.

4. Scenarios used for holistic judgments are not adequately validated.

5. There is a large number of recognised but unresolved problems associated with QALYs.

6. The QALYs procedure is ethically unacceptable.

Misrepresentation of issues In our view, the paper does not represent a balanced assessment of these issues. It is polemical. To achieve the objective of discrediting QALYs the authors mis- represent several issues. Examples are as follows:

‘The grand value judgment is that health care is an investment rather than a consumption good . . . completely analogous to future cash flows in a text- book . . . capital analysis. The decision maker is entreated to act . . . akin to a profit maximising entrepreneur.. .’ (p. 283). It is hard to avoid the conclusion that the authors are relying here entirely upon the common misunderstanding of economic jargon to promote their argument. Stripped of their emotive connotations the ‘grand value judgment’ of QALY analysis is that the pur- pose of health care is to make people healthy; it is not an end in itself. Burrows and Brown appear to disagree with this but they do not explain why. QALY analysis involves ‘the acceptance of the utilitarianism-based ethic of ‘neutral’ QALYs’ (p. 283). This is untrue. We note that QALYs are based upon the egalitarian principle that the ‘dif- ference in utility between being dead and being healthy is set equal across people’ (p. 274). Econ- omics, as the authors must know, explicitly includes the possibility of trade-offs between efficiency and equity or social justice. We note in our article the likelihood of such a trade-off. The relationship between health output and the ‘social welfare func- tion’ is also the subject of a recent a r t i ~ l e . ~ Evans is quoted favourably as ‘pointing out’ that QALYs ‘mean treating women rather than men, white patients rather than black, and upper social classes rather than the lower’ (p. 283). If this out- come occurred as an unintentional and unaccept- able result of QALY maximisation, it could be the subject of explicit policy as presently occurs with affirmative action programs. However, it is not clear that Evans’ assertions are true. Women have a longer life expectancy but men experience serious, life-threatening illness earlier. It is not, therefore, clear which group has the greater potential QALY gain at the time of illness. Similarly, black and lower social classes have a shorter life expectancy but more ill-health and greater opportunities to gain from QALY maximisation. We see no evidence for, and therefore no reason to accept, Evans’ assertions. QALYs are portrayed as a decision making process that involves ‘only economics’ which excludes ethi- cal and social values (p. 285). This is untrue. The QALY procedure involves epidemiologists and clinicians for assessing medical impact; the public or patients to assess the value of the impact and (ideally) social values to judge distributional results. QALY analysts document and make explicit these assessments and values.

‘The discounting of QALYs is always assumed to follow the same compound interest relationship as that for a financial in~estment’~ (p. 284). This is not true in practice, where the estimated time preference is usually used, and it is not uniquely required by the theory underlying QALYs (see E ~ a n s ) . ~ ‘Few other than the investigators will know much about the content of its health state . . . scenarios’ (p. 284). This seems to be a critique of publishing habits. We agree that authors should be required to append their scenarios to published works. The holistic, scenario-based, approach to QALYs ‘is grounded directly in axiomatic utility theory’. This is untrue. Axiomatic utility theory is the rationale for using a particular scaling instrument -the standard gamble. That is, if the von Neumann Morgenstern axioms are assumed to be true then there is a direct link between the answers given to a standard gamble question and the strength of a person’s preferences (utility). The standard gamble can be used either to scale (cali- brate) holistic scenarios or to scale the ‘over-the- counter questionnaires’ (pp. 279-SO), that is, a multi-attribute matrix description of quality of life. Two of the best known multi-attribute instruments, the McMaster and the Rosser-Kind health status indices, have recently been revised using the stan- dard gamble. There is, however, considerable debate about the use of the standard gamble, and many prefer scaling techniques which do not rely upon these axioms.6

In defence of QALYs The last of Burrows and Brown’s criticisms, that QALYs are ethically unacceptable, may be disposed of quickly. As noted in the last section, the assertions that QALYs purport to be value-free or that cost- utility analysis ignores nonutilitarian values, is false. Burrows and Brown almost acknowledge this (p. 284) but argue that QALYs are insufficiently precise to serve as a basis for the calculations required to incor- porate other values. This is a repetition of their tech- nical criticism and not an independent ethical argument.

The claim that quality-of-life gains are either too large or too small to warrant QALY analysis is a judg- ment with which, as a general proposition, we dis- agree. More importantly, as stated, the argument appears to embody a misunderstanding of the most fundamental property of the QALY-and a misun- derstanding perpetuated throughout the paper. The quality-of-life difference between recipients of dialy- sis and kidney transplants may be obvious. But the trade-off between this quality-of-life difference and life per se is not obvious. Knowledge of this trade-off is necessary if the decision about these options is to be compared with other options available in the health sector. The fundamental and unique charac- teristic of a QALY is that it represents an exchange rate between the quantity and quality of lif. and it there- fore allows comparison of competing options. For this reason, the use of most disease-specific quality- of-life instruments is not an acceptable substitute for QALYs because most have not been constructed to act as an exchange rate.

AUSTRALIAN JOURNAL OF PUBLIC HEALTH 1993 vot. 17 NO. 4 395

POINT OF VIEW

Burrows and Brown argue that holistic scenarios have not been validated adequately and they are probably inferior to the multi-attribute matrix descriptions which may be subject to validation. Vali- dation is context-specific. A scale which is appropri- ate for measuring the quality of life associated with particular coronary-related health states may be inappropriate for urology-related health states. Scenarios are used precisely because they can be tail- ored to the requirements of unusual health states and can, potentially, incorporate issues of risk and prog- nosis that generic instruments cannot, or have not to date, incorporated. Their validity relies upon the val- idity of the qualitative methods used in their con- struction. This involves another disciplinary tradition from the psychometric tradition that Burrows and Brown appear to hold as the gold standard. It is worth noting that the quality of the description embodied in scenarios will almost certainly be the equal of, or superior to, (unvalidated) health state descriptions given to policy makers under the present decision-making regime.

PONCEing and the logic of QALY evaluation This final issue illustrates our most fundamental dis- agreement with the authors. Their rejoinder consists almost exclusively of disembodied criticism of QALYs without serious consideration of the available alternatives and whether they suffer from the same defects. We quote Dowie at length on this issue as his recent critique of QALY critics could have been writ- ten in anticipation of our reply.6

I rejected PONCE-Partial or Non-Comparative Evaluation. I reject it when the PONCEing is intra-mode, as when a particu- lar method of dealing with (e.g.) time discounting is criticised and rejected on the grounds of its internal flaws, without show- ing how some recommended (or any) alternative method is better-r even how it acknowledges the problem. And I reject it especially when the PONCEing is inter-mode. The endemic form of inter-mode PONCEing involves criticising any or all [system-aided judgment] approaches without exposing [peer- aided intuitive judgment] alternative/s to the same criticisms-or even accepting that the latter have somehow to address the problem that the [system-aided] method is actually tackling (albeit in a flawed, even highly flawed, way) (p. 8) . . . Why put the onus on QALY procedures to be ‘ideal’ and why confine the argument to ‘correctly applied’ Cost Utility Analysis? Such bias is a clear example of inter-mode PONCEing. (p. 11) Throughout their paper, Burrows and Brown rely

upon the type of argument described by Dowie. Some examples illustrates this:

We . . . invite readers to look at the costs included in the many cost-per-QALY analyses in the literature. There they will find great variation in the cost categories and definitions used, the extent of costs sought and methods of valuation (p. 279).

Are non-QALY policy techniques exempt from this type of problem? Inconsistencies can and should be systematically eliminated from all comparative data, QALY or other.

If we assume, for the candidate interventions in Table 1, a rela- tively small potential error of 10 per cent in the cost figures and a 0.02 range about the quality adjustments, . . . the effects on the marginal cost per QALY are large (p. 279).

Can this problem be overcome by providing decision makers with undigested data? Or are correct decisions more likely to be achieved through careful calculation and sensitivity analysis.

Even more worrying is the scant attention given to the manner in which health state scenarios should be developed. In many cases their derivation appears to be essentially ad hoc, they have seldom been subjected to validation tests in their own right (p. 280).

Do decision makers currently receive better (more

Noone who has served on policy committees should doubt this’ [the compulsion to follow numerical values].

Do committees presently engage in neutral decision making unflawed by group dynamics, indi- vidual idiosyncrasies, etc?

systematic and validated) information?

Current status of cost-utility analysis We are unaware of any approach currently available which provides a method for systematically incorpor- ating the patient’s and/or the public’s preferences into the trade-offbetween the f l e f e rme for quantity ver- sus quality of lijk At the very least, the QALY method is based upon democratic procedures (that is, public- or patient-stated preferences) even if this does not, at present, provia% a fully validated measure or utility. Many of Burrows and Brown’s criticisms of the QALY procedures are correct. They indicate areas where further work is required. This is especially true with respect to the process of validation. Quoting Dowie again from a related context:

Such research would be extremely demanding but those under- taking it should not be overly concerned by the criticism of PONCErs, particularly of the inter-mode variety, who will revel in pointingout that the attributes are not independent, or that their dependence has not been adequately modelled, or that people cannot respond to questions of such Ptolemaic com- plexity, o r . . . -but who will not be at all forthcoming about how the . . . alternative they implicitly recommend actually deals with such problems-except by ignoring them (p. 32).

Jeffrey Richardson NHMRC National Centre for Health

Program Evaluation, M m h University, Melbourne

Steven Schwartz Department of Psychology, University of Queensland,

Brisbane Paul P. Glasziou

Department of Social and Preventive Medicine, University of @ensland, Brisbane

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Schwartz S, Richardson J, Glasziou P. Quality-adjusted life years: origins, measurements, applications, objections. A w t J Public Health 1993; 17: 272-8. QALYs for resource allocation: probably not and certainly not now. A w t J Public Health 1993; 17: 278-86. Dowie J. ‘fimss utility ’can s m ‘ m l y damage your health service valuation but the generic m e a r e of the bnujit should include ‘ser- v i u &oms’. Presented to the Health Economist Study Group, University of Strathclyde, Glasgow, July 2,1993, Fac- ulty of Social Sciences, Open University, Milton Keynes, UK. Wagstaff A. QALYs and the equity efficiency trade-off. J Health Econ 1991; 10: 21-42. Evans DB. The discount rate for use in public sector projects. In: Scotton RB, Goss JR, editors. Economic evaluation of health mites. Health Economics series no. 1. Canberra: Australian Institute of Health, 1988. Richardson J. Cost utility analysis: What should be measured?. Soc Sci Med 1994. In press.

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