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Kwaliteit van leven in maat en getal

Kwaliteit van leven in maat en getal. Jan van Busschbach. 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. New cancer therapy.

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Kwaliteit van leven in maat en getal

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  1. 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 Symptoms Drug X Drug Y Survival days 300 400 Days sick of chemotherapy 10 150 Days sick of disease 100 30 TWiST 190 220

  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 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. TWiST: ignores differences in quality of life 0.0 Quality of life 1.0 • 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

  7. Visual Analogue Scale Normal health X Dead ?= • Does the scale fit Q-TWIST? • Is 2 days 0.5 = 1 day 1.0? 7

  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) = 0.80 9

  10. No values available Only applies to skin disease

  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. Quality Adjusted Life Years (QALY) 1.00 X 0.00 0.5 x 80 = 40 QALYs 80 40 Life years • Example • Blindness • Time trade-off value is 0.5 • Life span = 80 years • 0.5 x 80 = 40 QALYs 12

  13. 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 17 17

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

  19. www.ibotnow.com Segway Dean Kamen 19

  20. 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: $ 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

  21. 6000 Citations in 2009 21

  22. QALY league table

  23. Egalitarian Concerns:Burden of disease 1.0 Utility of Health 0.0 A B C

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

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

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

  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

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