1. COCOM Kwaliteit van leven in maat en getal Jan van Busschbach

2. 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. 3 New cancer therapy SymptomsDrug XDrug Y Survival days 300 400 Days sick of chemotherapy 10 150 Days sick of disease 100 30 TWiST 190 220

4. 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. 5 Fit new therapy in fixed budget  50 patients each year (per hospital)  Drug x: 50 x euro 1.750 = euro 87.500  Drug y: 50 x euro 2.000 = euro 100.000  Drug budget for x or y = euro 50.000  Number of patient Drug x: euro 50.000 / 1.750 = 28.5 patients Drug y: euro 50.000 / 2.000 = 25.0 patients  Survival in days Drug x: 28.5 patients x 300 days = 8.550 days Drug y: 25.0 patients x 400 days = 10.000 days  Survival in TWiST Drug x: 28.5 patients x 190 TWiST = 5.415 days Drug y: 25.0 patients x 220 TWiST = 5.500 days

6. 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? 6 0.0 Quality of life 1.0

7. 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. 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. 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) = 0.80 9

10. 10 Only applies to skin disease No values available

11. 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. 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) 12 0.00 1.00 X Life years 40 80 0.5 x 80 = 40 QALYs

13. Area under the curve 13

14. 14 10 leading causes of death 2030 % of life years lost

15. 15 10 leading causes QALY loss 2030 % of life DALYs lost

16. 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. 17 DALY = life time - QALY DALY QALY

18. 18  A new wheelchair for elderly (iBOT)  Special post natal care Which health care program is the most cost-effective?

19. 19 www.ibotnow.com 19 SegwayDean Kamen

20. 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?

21. 21 6000 Citations in 2009 21

22. 22 QALY league table

23. 23 1.0 0.0 ABC Utility of Health Egalitarian Concerns: Burden of disease

24. 24 Burden as criteria Pronk & Bonsel, Eur J Health Econom 2004, 5: 274-277

25. 25 80 0 ABC Levensjaen Costs/QALY as indicator of solidarity 25 60 40 20 € 50.000 € 30.000 € 40.000

26. 26 Costs/QALY versus Burden of disease 26 € 80.000 € 60.000 € 40.000 € 20.000 € 0 Burden of disease X X X X X

27. 27 Dutch Council for Public Health and Health Care (RvZ, 2006) 27

28. 28 Burden of disease: QALY lost = DALY (Disability adjusted life year) DALY QALY

29. 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. 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. 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. 32 Conclusion  Cost effectiveness in terms of quality of life can be measured  Burden of disease is also a criterion