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1 The QALYs debate Prof. dr. Jan J.V. Busschbach, Ph.D. Erasmus MC Institute for Medical Psychology and Psychotherapy
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2 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 2
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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) 3
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4 Example Blindness Time trade-off value is 0.5 Life span = 80 years 0.5 x 80 = 40 QALYs Quality Adjusted Life Years (QALY) 4 0.00 1.00 X Life years 40 80 0.5 x 80 = 40 QALYs
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5 Time Trade-Off TTO Wheelchair With a life expectancy: 50 years How many years would you trade-off for a cure? Max. trade-off is 10 years QALY(wheel) = QALY(healthy) Y * V(wheel) = Y * V(healthy) 50 V(wheel) = 40 * 1 V(wheel) =.8
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6 Standard Gamble SG Wheelchair Life expectancy is not important here How much are risk on death are you prepared to take for a cure? Max. risk is 20% wheels = (100%-20%) life on feet V(Wheels) = 80% or.8
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1970
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8 Area under the curve
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9 Which health care program is the most cost-effective? A new wheelchair for elderly (iBOT) Special post natal care 9
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10 www.ibotnow.com 10 SegwayDean Kamen
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11 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: $ 4,000 per life year QALY = Y x V(Q) = 10 x 0.1 = 1 QALY Costs are 10 x $4,000 = $30,000 Cost/QALY = 40,000/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 11
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12 QALY league table 12
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Milton Weinstein In the face of uncertainty … and fear will The decision will be made, if not actively then by default 13
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14 7000 Citations in PubMed
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QALY = Utility: Welfare theory QALY can be see as the ‘value of health’ The value of a good or service: “utility” Also called “nut” (Dutch) Welfare theory: maximize utility Maximize QALY Do we want to maximize QALY? Doubtful… 15
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16 CB 0.0 1.0 Utility of Health Is the utility scale valid? AB
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17 We do not maximize QALY But nevertheless we want to maximize utility By (economic) definition.. That means: QALYs measured utility in an invalid way Life years is not the problem, thus… It must be the validity of quality of life assessment… Critique 17
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…it must be that QALYs are invalid We don’t like the results…
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In the past, much criticism Cohen CB. Quality of life and the analogy with the Nazis. Journal of Medicine and Philosophy 8: 113-35, 1983.
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Criticism remains 20 ….the strictly fascist essence of those QALYs (so-called Quality-Adjusted Life Years)…
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21 Burden as criteria 21 Pronk & Bonsel, Eur J Health Econom 2004, 5: 274-277
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22 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
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23 TTO does not correlate with PTO
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24 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
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25 CB Life Years Falsification even with life years AB
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26 CB 0.0 1.0 Utility of Health Utility? AB
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27 Utility Utility Total benefit Including distribution Also called “Nut” (Dutch) Quality of life might be part of total benefit QALYs do not include distribution But it is said that ‘Standard Gamble’ measures utilities! Van N-M utilities by definition utility But in SG only “health for your self” Does not include distribution
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28 ABC Costs/QALY as indicator of solidarity 28 € 50.000 € 30.000 € 40.000 QALY
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29 Costs/QALY versus Burden of disease 29 € 80.000 € 60.000 € 40.000 € 20.000 € 0 Burden of disease X X X X X
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30 Dutch Council for Public Health and Health Care (RvZ, 2006) 30
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If a medical treatment costs >€80,000 to give one patient one extra life year of good quality, it should not be reimbursed in the basic health care insurance Council advises the Minister of Health to use this limit in order to keep the budget of health care under control; They realize the topic is controversial.
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32 Chris Murray WHO avoid QALY Havard School of Public Health Worked outside Health economics Med Decision Making DALY Person Trade-Off Reinvented
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33 Burden of disease: QALY lost = DALY (Disability adjusted life year) DALY QALY
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34 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 34
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35 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) 35
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36 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 36
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37 Reimbursement arguments Burden of disease Effects Cost effectiveness
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38 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.
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39 Take home message Quality of life assessment and health assessment is crucial Not only to estimate health gains (efficiency) But also to estimate need (equity) It is not the measurement of quality of life but the efficiency/equity trade-off which heats up the debate
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