Quality of life (Utility) Measurements In Relation to Health Economics Prof. Dr. Jan J.V. Busschbach Erasmus MC Section Medical Psychology and Psychotherapy Department of Psychiatry NIHES Course Quality of Life Measurement (HS11)

Slides: www.busschbach.com

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 3 3

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) 4 4

Quality Adjusted Life Years: QALYs Example Blindness Time trade-off value is 0.5 Life span = 80 years 0.5 x 80 = 40 QALYs 0.00 1.00 X 0.5 x 80 = 40 QALYs Life years 40 80 5 5

Area under the curve Stel een persoon ontwikkelt een persoonlijkheidsstoornis. Bij zijn geboorte is ons voorbeeld nog naïef en gelukkig: een kwaliteit van leven vlak bij het optimum van 1. Maar dan wordt hij ouder, en in de pubertijd ontwikkelt zich een persoonlijkheidsstoornis en verliest hij kwaliteit van leven. Dit afglijden van de kwaliteit van leven bereikt een voorlopig dieptepunt rond zijn vijftigste. Na z’n 70e wordt het nog erger, want dan ontwikkeld hij ook allerhande lichamelijke klachten en op z’n 80e sterft hij. Stel dat zo iemand een bewezen effectieve psychotherapie had gekregen rond zijn 25e levensjaar (KLIK). Als de therapie inderdaad werkzaam zou zijn, dan verbetert de kwaliteit van leven. Het blauwe gestreepte oppervlakte vertegenwoordigt dan de winst in termen van QALYs door de therapie. (KLIK) Het grijze valk wat overblijft vertegenwoordigd de restziekten. Ik nam een patiënt met persoonlijkheidsstoornissen als voorbeeld, maar ik had hetzelfde grafiek kunnen tekenen voor een patiënt met diabetes. Bijvoorbeeld, de patiënt komt er op 25 jarige leeftijd achter dat hij diabeet is, en begint dan met insuline-injecties die de hem er weer redelijk bovenop helpen. Als je twee heel verschillende ziektes in dezelfde grafiek kunnen weergeven (bijvoorbeeld persoonlijkheidsstoornissen en diabetes), dan kunnen we de ernst van die ziekten ook gemakkelijk met elkaar vergelijken. 6

Which health care program is the most cost-effective? A new wheelchair for elderly (iBOT) Special post natal care 7 7

www.ibotnow.com Dean Kamen Segway Jimi Heselden † 26 September 2010 8

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: $ 3,000 per life year QALY = Y x V(Q) = 10 x 0.1 = 1 QALY Costs are 10 x $ 3,000 = $30,000 Cost/QALY = 30,000/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 9 9

QALY league tables Link to example sheet 10

Sackett et al.; Clinical Epidemiology

Introducing “Utilities”

10.000 QALY publications

Threshold NICE “As a guideline rule…, …NICE accepts as cost effective those interventions with an incremental cost-effectiveness ratio of less than £20,000 per QALY … …and that there should be increasingly strong reasons for accepting as cost effective interventions with an incremental cost-effectiveness ratio of over a threshold of £30,000 per QALY.” Incorporating Health Economics in Guidelines and Assessing Resource Impact. The guideline Manual. NICE April 2008, Chapter 8, page 54

Modelling NICE decisions At average levels for all covariates, a decision would have a 50% chance of rejection if its ICER were £45,118/QALY Dakin, Devlin, Rice, Parkin, O’Neill, Feng (2013) The influence of cost effectveness and other factors on NICE decisions. (forthcoming) We then used the regression equation to predict probability of rejection at different ICER values Keeping all other variables at mean values Plot rejection probability against ICER This Basic model implies that a decision would have a 50% chance of rejection if its ICER were £45,118/QALY

Two points of critique QALYs are measured in a 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’ 16 16

Eric Nord: Egalitarian concerns B 0.0 1.0 Utility of Health A B 17 17

Burden as criteria Pronk & Bonsel, Eur J Health Econom 2004, 5: 274-277 18 18

Costs/QALY as indicator of solidarity € 40.000 80 € 30.000 60 € 50.000 Utility 40 20 A B C 19

Works with life years as well… it is not just QoL! € 40.000 80 € 30.000 60 € 50.000 Live years 40 20 A B C 20

Costs/QALY versus Burden of disease X € 80.000 € 60.000 € 40.000 € 20.000 € 0 Samen met onder andere Prof Frans Rutten, Elly Stolk en Prof Werner Brouwer hebben we toen de volgende grafiek gemaakt. Op de verticale as (KLIK) staat de kostprijs per QALY (KLIK) die we overhebben voor verschillende interventies. Op de horizontale as (KLIK) staan ziektelast (KLIK), op een manier uitgedrukt ongeveer net zo als dat de World Health Organisation dat doet (KLIK). Beide getallen hebben we voor verschillende interventies uitgereken (KLIK) en we vonden de volgende punten (KLK). Burden of disease 21

Dutch Council for Public Health and Health Care (RvZ, 2006) 22 22

Burden / Costs effectiveness NICE; Higer values end of life medication The decisions to allow NHS use of trastuzumab (Herceptin) and imatinib (Glivec) pushed NICE’s cost effectiveness threshold above its notional £30 000 (€34 000; $46 000) per QALY. These decisions took place against a background of legal action by patients, attendant publicity, and political discomfort. James Raftery, BMJ CvZ: Pakketbeheer in de Praktijk 2 Bij de bepaling van de kosteneffectiviteit van een interventie hanteert het CVZ een bandbreedte van 10.000 euro per QALY bij lage ziektelast tot 80.000 euro per QALY bij hoge ziektelast. J. Zwaap, CvZ

DALYs: Chris Murray WHO avoid QALY Havard Worked outside DALY School of Public Health Worked outside Health economics Med Decision Making DALY Person Trade-Off Reinvented

Burden of disease: QALY lost = DALY (Disability adjusted life year) 25

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 26

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) 27 27

QALY debate

QALY debate Fairness is the issue in the QALY debate QALY measurement is the straw man Complex metric discussion But same discussion applies with life years gained Obviously QALYs must measured validly That debate = rest of the course 29

100 persons additionally 1 healthy year Person Trade-Off Values between patients Not ‘within’ a patient like SG, TTO and VAS Better equipped for QALY? V(Q) = 1 - (A / B) For instance: V(Q) = 1 - (100/300) V(Q) = 1 - 0.33 V(Q) = 0.67 ?? persons 1 year free from disease Q 100 persons additionally 1 healthy year

PTO gives extreme low values

PTO and it’s psychometrics Paul Kind: If we look at TTO and PTO... we see that one of them is wrong If we look at PTO alone... We still see that one of them is wrong... PTO is not a quick fix

Alternative applications Link to out of pocket payments Greater out of pocket payments for conditions with lower proportional shortfall E.g. France and Belgium For example: No reimbursement for the mildest conditions, such as common cold, acute tonsillitis, acute bronchitis, onychomycosis, tinea pedis Partial reimbursement for conditions mild to moderate conditions: Haemorrhoids, candidiasis, gastritis, osteoporosis, erectile dysfunction, acne conglobata Etc.

Direct utility assessment SG, TTO, PTO, VAS

Indirect utility assessment HUI, EQ-5D, AQoL, 15D, Rosser index 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