Quality of life and Cost-Effectiveness An Interactive Introduction

1. 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

2. 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

3. 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 3

4. 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

5. 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? 5

6. Visual Analogue Scale Normal health X Dead ?= • Does the scale fit Q-TWIST? • Is 2 days 0.5 = 1 day 1.0? 6

7. 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 7

8. 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 8

9. QALY Count life years Value (V) quality of life (Q) V(Q) = [0..1] 1 = Healthy 0 = Dead One dimension Adjusted life years (Y) for value quality of life QALY = Y * V(Q) Y: numbers of life years Q: health state V(Q): the value of health state Q Also called “utility analysis”

10. Q-TWiST = QALY • Several initiatives early seventies • Epidemiologist and health economists • Part of QALY concept • Quality Adjusted Life Years • QALY = Q-TWiST 10

11. Area under the curve

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

13. www.ibotnow.com Dean Kamen Segway 13

14. 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?

15. QALY league table

16. 6000 Citations in 2009 16

17. Orphan drugs • Pompe disease • Classical form: € 300.000 – 900.000 per QALY • Non classical form: up to € 15.000.000 per QALY • If maximum = € 80.000 • Ration is almost 1:200 • Low cost effectiveness but… • High burden • Low prevalence • Little own influence on disease • High consensus in the field • Coalition patient, industry, doctors and media • Low perceived incertainty

18. Light version cost effectiveness Formal cost effectiveness is expensive Is there a light version?

19. What do we have? Costs Patient count Costs per Patient DBC / DOT Cost per DBC TWiST Costs per Time without psychosis Costs per Time in normal health Cost per Recovered patient Routine Outcome Monitoring (ROM) Could be of help here

20. Routine Outcome Monitoring • ROM has the potential of • Cost per ‘outcome’ ratio • Difficulties getting data at end of treatment

21. Cost effectiveness Cost benefit Benefit in monetary terms minus cost Can seldom be done in health care What is the value of a life year Cost per QALY Cost utility analysis Makes comparisons possible between diseases Cost per effect Cost effectiveness Like: Cost per cure Stays within one disease

22. Improve cost effectiveness • Other ways to improve cost effectiveness • Insight in costs • Stop rules

23. Costs often unknown… Cost price therapy is mostly unknown in metal health No insight in costs of components therapy Typically salary + fixed overhead (for instance 37%)

24. Activity Based Costing can help

25. Insights in costs will allow for… • Informal cost effectiveness analysis • Which therapy is most cost effective? • Assumes that outcomes / patients are sufficient comparable • Effects • Cost per ‘cure’ • Cost per increase on a specific scale • Cost per DBC

26. Weighting components Which components of therapy contribute most to the cost price? Does this ranking relates to the indented effects? Benchmark

27. Stop rules We seem to know when a therapy is needed But do we know when to stop? If all the ‘potential’ of the patient is reached?

28. Within social health insurance • Reasonable stop rules might be: • When no progress is made anymore • When the patient is comparable with the general population • > 5 – 10%

29. Monitor the patient • ….frequently during therapy • Looks like Routine Outcome Measure • but with a high frequency

30. Position patients versus normal population

31. Michael Lambert N = 400 Kim de Jong et al in press Erasmus MC Monitoring reduces the number of treatments

32. …and gives better results Feed back Non feed back

33. Conclusion Holy grail Formal cost effectiveness analysis (CEA) Costs per QALY Holy grail might be too expensive Formal cost effectiveness is indeed expensive Informal CEA might already reveal much Cost per treatment Cost per successful treatment There is a need for real cost prices Especially price of components To start bench mark procedure