1. 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

2. 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?

3. 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

4. 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

5. 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)

6. 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

7. 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“…

8. 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

9. 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

10. 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

11. 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

12. TWiST in cancer therapy

13. 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
Quality of life
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?

14. 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

15. 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

16. DALY / QALY
DALY
QALY 16

17. 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)

18. 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

19. 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

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

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

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

23. 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”

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

25. 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

26. 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