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Explore the evolution of Quality-Adjusted Life Years (QALYs) in healthcare decision-making from 1980 to present, the controversy surrounding them, and the potential for new methodologies to enhance quality of life assessment in cost-effectiveness research. This analysis delves into the role of severity, innovation, and disease-specific instruments, providing insights into the value judgments and measures that shape healthcare policies. Discover the current landscape, future possibilities, and questions surrounding health state valuation methodologies.
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The Future of Quality of Life Assessment in Cost-Effectiveness Research Prof. Jan J. v. Busschbach, Ph.D. Erasmus MC Medical Psychology and Psychotherapy Viersprong Institute for studies on Personality Disorders
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.
Criticism remains ….the strictly fascist essence of those QALYs (so-called Quality-Adjusted Life Years)…
But QALY rules… From 1980 till 2010: 7049 publications in PubMed
Raad voor de Volksgezondheid en Zorg • Weight QALYs by severity of illness • QALYs determine “severity”
Value based pricing • Health Secretary Andrew Lansley • Measures "will help ensure better access for patients to effective drugs and innovative treatments on the NHS" • Like RvZ • Again adding severity • Adding Innovation • QALY still at the hart of the judgment • Severity and innovation both expressedterms of QALYs
Efficiency frontier • Germany • IQWiG • Still discussion • whether it is possible ‘in theory’ to make such value judgments, let alone in practice
Which measure? • Questionnaires • EQ-5D • HUI • SF-6D • Direct measures • TTO • Discrete choice • SG • VAS
Questionnaires • EQ-5D • Dominates health economics • Said to be insensitive • New 5 level version is on its way • SF-6D • Overtook HUI in popularity • Little support development • HUI • Little recent development • Expensive
Disease specific instruments • As validation methodology becomes cheaper… • Why not validate a disease specific instrument? • The big research question • Are values valid? • Are the values the same as with HUI, SF-6D etc • Narrow scope • Values are too high • Attention bias • Differences are too big
Bold-on instruments • Combine generic instruments with disease specific dimensions • “Bold-on” the disease specific dimension • Can solve the narrow scope • Absolute value level might be valid • Could avoid attention bias • Does it also avoid the attention bias?
Direct measures • Used to value health states in models • TTO dominates • Discrete choice coming up • SG slips aside • VAS not in favor in health economics • WTP never more than a promise
The big questions • TTO • Values below dead • Discrete choice • Is discrete choice valid within the QALY approach? • How to anchor in death – normal health scale • TTO?
Care • QALY in care is disputed • But QALY is ok for big issues in care • No care = dead • QALY might not be sensitive • Care might be involve other aspects than health • For instance: does not measure autonomy • Same issues as in cure? • Disease specific instrument • Involve need and innovation
Discrete choice in care • New instrument for care • ICECAP • ASCOTT • Several other initiatives • What is the relation with QALY? • Why go for another scale?
Conclusion: Standardization • Questionnaires • Could merge to EQ-5D • But disease specific instruments might blur • Direct valuation • TTO seems to prevail, but not yet one methodology • Care • Just the start of development
Future questionnaires • Cheap EQ-5D SF-6D HUI • Sensitive SF-6D HUI EQ-5D (3L) • Simple to use EQ-5D SF-6D HUI • Many translations SF-6D EQ-5D HUI • Many value sets EQ-5D HUI SF-6D • Will EQ-5D-5L dominate? • There must be room for more instruments…