1. 1 Dyslexia and Cost Effectiveness Prof. dr. Jan van Busschbach De Viersprong Erasmus MC

2. 2 Health Economics  Comparing different allocations  Should we spent our money on Wheel chairs Screening for cancer Dyslexia treatment  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” Number of correct spelled words  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 (QALY)  Multiply life years with quality index  Quality of life index  1.0 = normal health  0.0 = death (extremely bad health)  Example  Losing sense of sight  Quality of life index is 0.5  Life = 80 years  0.5 x 80 = 40 QALYs

5. 5 QALY  Quality Adjusted Life Years  Area under the curve

6. 6  A new wheelchair for elderly (iBOT)  Special post natal care Which health care program is the most cost-effective?

7. 7  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?

8. 8 4500 Citations in PubMed

9. 9 QALY league table

10. 10 Dyslexia and QALYs  Request from CvZ  Cost effectiveness protocol dyslexia treatment  According to best standards Pharmacoeconomics guidelines  5 weeks….  Leona Hakkaart  Costs  Elly Stolk  Outcome (Quality of Life)

11. 11 Model based on Patty Gerretsen 70 % 30 %

12. 12 Parameters  70% effectiveness  N = 233, 1 year and 10 year  Gerretsen et al., 2006  Costs  Protocol: € 4.445  CAU: € 2.080 N = 121 pre-treatment Intake Regionaal Instituut voor Dyslexie  200.000 children  6% gets diagnostics  1,8% treatment

13. 13 Effect on costs in 4 years 70 % 30 % € 4.445 € 2.080 But what about the effects on outcome?

14. 14 Outcome  Disease specific  Better reading skills  Better writing skills  Higher education  But what about generic effects?  Quality of life  QALYs

15. 15 Value health states dyslexia  No dyslexia, Mild, Severe

16. 16 Uni-dimensional value  Like the IQ-test measures intelligence  Ratio or interval scale  Difference 0.00 and 0.80 must be 8 time higher than 0.10  Three popular methods have these pretensions  Visual analog scale  Time trade-off  Standard gamble

17. 17 Visual Analogue Scale  VAS  Also called “category scaling”  From psychological research  “How is your quality of life?”  “X” marks the spot  Rescale to [0..1] Dead Normal health X

18. 18 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

19. 19 Of the shelf instrument: EQ-5D  Patient sample  “Woortblind”  N = 265  Out of 820  Response rate 32.3%  EQ-5D  Patients 0.87 (sd 0.16)  Norm 0.88 (sd 0.16)  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….. Not sensitive in Dyslexia

20. 20 Paired comparisons Severe dyslexiaADHASevere dyslexiaCrohnSevere dyslexiaMild Asthma

21. 21 Quality of life weights

22. 22 Costs per QALY  Elementary school € 33.513  Basis school  Grammar school € 16.332  Middelbare school  Secondary education € 11.558  Vervolgonderwijs

23. 23 QALY league table

24. 24 Limitations  Conservative estimates  No involved cost of repeaters  Only costs of CUA in first year  No good estimates of additional income  Limited effect estimates  No RCT  No formal estimates of uncertainty

25. 25 ISPOR 2007

26. 26 Conclusion  Cost per QALY is feasible in dyslexia  Cost per QALY of treatment is reasonable  Cost effectiveness successfully uses as argument in reimbursement  There is a need for better…  Estimates of effects  Estimates quality of life  Models