QALY: veel bekritiseerd, maar nooit meer dan het alternatief” Symposium “De validiteit van de QALY” 14 maart 2008 NVTAG, RIVM, Bilthoven Jan van Busschbach 1

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?

Three problems with the criticism ….. Argument often represent aversion limited budget Proposed alternatives turn out the be the same Even equity concerns are in need of QALY

First critique 1983 Cohen C.B. 1989 Rawles 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 4

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)

Positions Pro Contra 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

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“…

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

Three problems with the criticism ….. Argument often represent aversion limited budget Proposed alternatives turn out the be the same Even equity concerns are in need of QALY

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

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

TWiST in cancer therapy

TWiST: ignores differences in quality of life 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 1.0 But TWiST ignores differences in quality of life: therefore Q-TWiST, which uses in-between levels of QoL. But then: How to scale quality of life?

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… 14

Chris Murray Havard Worked outside DALY School of Public Health Health economics Med Decision Making DALY Disability Adjusted Life Years Lost life years Lost Quality of life 15

DALY / QALY DALY QALY 16

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)

Three problems with the criticism ….. Argument often represent aversion limited budget Proposed alternatives turn out the be the same Even equity concerns are in need of QALY

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

Nord: “Egalitarian and efficiency concerns both exist …” 0.0 1.0 Utility of Health A B

Nord: “Egalitarian and efficiency concerns both exist …” 0.0 1.0 Utility of Health A B

Nord: “Egalitarian and efficiency concerns both exist …” 0.0 1.0 Utility of Health A B

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”

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

Three problems with the criticism ….. Argument often represent aversion limited budget Proposed alternatives turn out the be the same Even equity concerns are in need of QALY

First QALY 1968 Klarman, Fransis & Rosenthal 1970 Fanshel & Bush 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. 26