COCOM Kwaliteit van leven in maat en getal Jan van Busschbach
2 Quality of life and Cost-Effectiveness An Interactive Introduction Prof. Jan J. v. Busschbach, Ph.D. Erasmus MC Medical Psychology and Psychotherapy Viersprong Institute for studies on Personality Disorders
3 New cancer therapy SymptomsDrug XDrug Y Survival days Days sick of chemotherapy Days sick of disease TWiST
4 Time Without Symptoms of disease and subjective Toxic effects of treatment: TWiST Richard Gelber statistician Count … Days not sick from treatment Days not sick from disease 4
5 Fit new therapy in fixed budget 50 patients each year (per hospital) Drug x: 50 x euro = euro Drug y: 50 x euro = euro Drug budget for x or y = euro Number of patient Drug x: euro / = 28.5 patients Drug y: euro / = 25.0 patients Survival in days Drug x: 28.5 patients x 300 days = days Drug y: 25.0 patients x 400 days = days Survival in TWiST Drug x: 28.5 patients x 190 TWiST = days Drug y: 25.0 patients x 220 TWiST = days
6 TWiST: ignores differences in quality of life TWiST Healthy = 1 Sick (dead) = 0 Q-TWiST Quality of life adjusted TWiST Make intermediate values 1.0; 0.75; 0.50; 0.25; 0.00 How to scale quality of life? Quality of life 1.0
7 Visual Analogue Scale Does the scale fit Q-TWIST? Is 2 days 0.5 = 1 day 1.0? 7 Dead Normal health X ?=?=
8 Q-TWiST = QALY Several initiatives early seventies Epidemiologist and health economists Part of QALY concept Quality Adjusted Life Years QALY = Q-TWiST 8
9 Time Trade-Off Wheelchair With a life expectancy: 50 years How many years would you trade-off for a cure? Max. trade-off: 10 years QALY(wheel) = QALY(healthy) Y * V(wheel) = Y * V(healthy) 50 V(wheel) = 40 * 1.00 V(wheel) =
10 Only applies to skin disease No values available
11 EuroQol EQ-5D MOBILITY I have no problems in walking about I have some……. I am confined to bed SELF-CARE I have no problems with self-care I have some problems….. I am unable… USUAL ACTIVITIES I have no problems with performing my usual activities I have some problems… I am unable…. PAIN/DISCOMFORT I have no pain or discomfort I have moderate ….. I have extreme…….. ANXIETY/DEPRESSION I am not anxious or depressed I am moderately…….. I am extremely…..
12 Example Blindness Time trade-off value is 0.5 Life span = 80 years 0.5 x 80 = 40 QALYs Quality Adjusted Life Years (QALY) X Life years x 80 = 40 QALYs
Area under the curve 13
14 10 leading causes of death 2030 % of life years lost
15 10 leading causes QALY loss 2030 % of life DALYs lost
16 Chris Murray WHO avoided QALY (read: disliked QALYs) (read disliked health economics) But WHO in need of a measure of health… Asked Havard… Anything but QALY Chris Murray School of Public Health Worked outside Health economics Med Decision Making DALY
17 DALY = life time - QALY DALY QALY
18 A new wheelchair for elderly (iBOT) Special post natal care Which health care program is the most cost-effective?
SegwayDean Kamen
20 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 Which health care program is the most cost-effective?
Citations in
22 QALY league table
ABC Utility of Health Egalitarian Concerns: Burden of disease
24 Burden as criteria Pronk & Bonsel, Eur J Health Econom 2004, 5:
ABC Levensjaen Costs/QALY as indicator of solidarity € € €
26 Costs/QALY versus Burden of disease 26 € € € € € 0 Burden of disease X X X X X
27 Dutch Council for Public Health and Health Care (RvZ, 2006) 27
28 Burden of disease: QALY lost = DALY (Disability adjusted life year) DALY QALY
29 QALY: both for effectiveness and solidarity Evaluations assess cost-effectiveness in term of cost/QALY Fairness is burden of disease Burden of disease is QALY lost (DALY) 29
30 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 Again as straw man But also within the metric debate of QALY That debate = rest of the course 30
31 Drawback The more differentiation of the threshold… The lower the population health If we spend all our money in curing the worst of patients… All others die sooner… Equity-efficiency trade-off Wagstaff 1991
32 Conclusion Cost effectiveness in terms of quality of life can be measured Burden of disease is also a criterion