QALY: veel bekritiseerd, maar nooit meer dan het alternatief”

1. QALY: veel bekritiseerd, maar nooit meer dan het alternatief” Symposium “De validiteit van de QALY” 14 maart 2008 NVTAG, RIVM, Bilthoven Jan van Busschbach 1

2. QALY seem to survived criticism for years now…. QALY is difficult to appreciated…. but in 2007: 4150 Citations in PubMed Could it be that there is a flaw in the criticism?

3. Three problems with the criticism ….. • Argument often represent aversion limited budget • Proposed alternatives turn out the be the same • Even equity concerns are in need of QALY

4. First critique 1983 Cohen C.B. Quality of life and the analogy with the Nazis. Journal of Medicine and Philosophy 8: 113‑35 1989 Rawles Castigating QALYs [Debate]. Journal of Medical Ethics 15:143-7 4

5. First outcome discussion • Rawles J., Rawles K. • The QALY argument: a physician's and a philosopher's view. • Journal of Medical Ethics 16: 93-4, 1990 “… In spite of the rhetoric there is a broad measure of agreement about the deficiencies of QALYs as a means of distributing scarce resources….” “…The main area of conflict is that John Rawles favours campaigning for more resources while Gavin Mooney, constrained by his remit as a health economist, favours acceptance of the present level of funding and better methods of distributing resources.” (blz. 93)

6. Positions • Pro • Budget is limited • QALY might be a solution • Although not perfect…. • Contra • Budget is not yet limited • QALY is not perfect • QALY is a problem

7. Positions still apply… • 2007: Kees van Bezooijen • Patient representative • In discussion during introduction cost effectiveness parameter in reimbursement expensive hospital medications “…Wij hebben duidelijk aangegeven dat een discussie over "wat maatschappelijk nog aanvaardbaar is" [kosten per QALY] alleen gevoerd mag worden als geldverslindende "frivoliteiten" door de maatschappij […] zijn uitgebannen. Bijvoorbeeld "joint strike fighters“…

8. A limited budget is reality • There is no prominent school of though that advocates that the budget is unlimited • A limited budget is the norm • Unlimited is not a realistic position

9. Three problems with the criticism ….. • Argument often represent aversion limited budget • Proposed alternatives turn out the be the same • Even equity concerns are in need of QALY

10. Neil Aaronson, 1996 • QALY is a the wrong answer for a very complex process…. • We are in need of a robust, simple and new method…. • TWiST

11. Time Without Symptoms of disease and subjective Toxic effects of treatment • TWiST • Developed by Richard Gelber (statistician) • In search for a typical “cancer” problem • Often prolonged life but also a reductions in quality of life • At the beginning (side effects) • At the end • Only count the days without symptoms of disease and subjective toxic effects of the treatment

12. TWiST in cancer therapy

13. 0.0 Quality of life 1.0 TWiST: ignores differences in quality of life • TWiST • Healthy = 1 • Sick (dead) = 0 • There is more to life than sick/health • Make intermediate values of quality of life • Q-TWiST • Quality of life adjusted TWiST • But then: 365 x Q-TWiST = 1 x QALY • Thus alternative is just the same

14. Burden of Disease Project • WHO Global Burden of Disease (GBD) • Impact of diseases world wide • Estimates of epidemiology per disease • Mortality • Quality of life losses • In need of one measure of health • But WHO disliked QALY… 14

15. Chris Murray • Havard • School of Public Health • Worked outside • Health economics • Med Decision Making • DALY • Disability Adjusted Life Years • Lost life years • Lost Quality of life 15

16. DALY / QALY DALY QALY 16

17. Q-TWiST and DALY • Both are presented as alternatives for QALY • But are in fact the same… • See also • Healthy Year Equivalent (HYE) • Saved Young Life Equivalent (SAVE)

18. Three problems with the criticism ….. • Argument often represent aversion limited budget • Proposed alternatives turn out the be the same • Even equity concerns are in need of QALY

19. Efficiency / equity debate • Cost per QALY represents efficiency • But is our health care system based on efficiency? • In health care, next to efficiency… • Compassion • Solidarity • Commiseration

20. 1.0 Utility of Health 0.0 B C Nord: “Egalitarian and efficiency concerns both exist …” A B

21. 1.0 Utility of Health 0.0 B C Nord: “Egalitarian and efficiency concerns both exist …” A B

22. 1.0 Utility of Health 0.0 B C Nord: “Egalitarian and efficiency concerns both exist …” A B

23. Several definition of equity • Severity of illness • How bad is it now? • Fair innings • How good has it been? • In all cases…. QALY is used to express equity • “QALY equity” to correct “QALY efficiency”

24. Dutch Council for Public Health and Health Care (De Raad voor de Volksgezondheid en Zorg, 2006)

25. Three problems with the criticism ….. • Argument often represent aversion limited budget • Proposed alternatives turn out the be the same • Even equity concerns are in need of QALY

26. First QALY • 1968 Klarman, Fransis & Rosenthal • Cost effectiveness analysis applied to the treatment of chronic renal disease • Medical Care 6: 48‑54, 1968. • 1970 Fanshel & Bush • A health-status index and its application to health services outcomes. • Operations Research 18: 1021‑66, 1970 • 1976 Torrance • Social Preferences for Health Status: an empirical evaluation of three measurement techniques. • Socio-Economic Planning Science 10: 129‑36, 1976. 26