Quality of life (Utility) Measurements In Relation to Health Economics

1. Quality of life (Utility) Measurements In Relation to Health Economics • Prof. Dr. Jan J.V. Busschbach • Erasmus MC • Section Medical Psychology and Psychotherapy • Department of Psychiatry • NIHES Course • Quality of Life Measurement (HS11)

2. Slides: www.busschbach.com

3. Health Economics • Comparing different allocations • Should we spent our money on • Wheel chairs • Screening for cancer • Comparing costs • Comparing outcome • Outcomes must be comparable • Make a generic outcome measure 3

4. 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” • “Hart failure” versus “second psychosis” • Generic outcome are compatible • Allow for comparisons between fields • Life years • Quality of life • Most generic outcome • Quality adjusted life year (QALY) 4

5. Quality Adjusted Life Years: QALYs 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 5

6. Area under the curve

7. Which health care program is the most cost-effective? A new wheelchair for elderly (iBOT) Special post natal care 7

8. www.ibotnow.com Dean Kamen Segway Jimi Heselden † 26 September 2010 8

9. 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 9

10. QALY league tables Link to example sheet

11. Sackett et al.; Clinical Epidemiology

12. Introducing “Utilities”

13. 10.000 QALY publications

14. Threshold NICE • “As a guideline rule…, • …NICE accepts as cost effective those interventions with an incremental cost-effectiveness ratio of less than £20,000 per QALY … • …and that there should be increasingly strong reasons for accepting as cost effective interventions with an incremental cost-effectiveness ratio of over a threshold of £30,000 per QALY.” • Incorporating Health Economics in Guidelines and Assessing Resource Impact. The guideline Manual. NICE April 2008, Chapter 8, page 54

15. Modelling NICE decisions • At average levels for all covariates, a decision would have a 50% chance of rejection if its ICER were £45,118/QALY • Dakin, Devlin, Rice, Parkin, O’Neill, Feng (2013) The influence of cost effectveness and other factors on NICE decisions. (forthcoming)

16. Two points of critique • QALYs are measured in a invalid way • Life years is not the problem, thus… • It must be the validity of quality of life assessment… • One should not use cost effectiveness • Often referred to as ‘ethics’ 16

17. Eric Nord: Egalitarian concerns 1.0 Utility of Health B 0.0 B C A 17

18. Burden as criteria Pronk & Bonsel, Eur J Health Econom 2004, 5: 274-277 18

19. Costs/QALY as indicator of solidarity € 40.000 80 € 30.000 60 € 50.000 Utility 40 20 0 A B C 19

20. Works with life years as well… it is not just QoL! € 40.000 80 € 30.000 60 € 50.000 Live years 40 20 0 A B C 20

21. Costs/QALY versus Burden of disease € 80.000 € 60.000 € 40.000 € 20.000 € 0 X X X X X Burden of disease 21

22. Dutch Council for Public Health and Health Care (RvZ, 2006) 22

23. Burden / Costs effectiveness NICE; Higer values end of life medication The decisions to allow NHS use of trastuzumab (Herceptin) and imatinib (Glivec) pushed NICE’s cost effectiveness threshold above its notional £30 000 (€34 000; $46 000) per QALY. These decisions took place against a background of legal action by patients, attendant publicity, and political discomfort. James Raftery, BMJ CvZ: Pakketbeheer in de Praktijk 2 Bij de bepaling van de kosteneffectiviteit van een interventie hanteert het CVZ een bandbreedte van 10.000 euro per QALY bij lage ziektelast tot 80.000 euro per QALY bij hoge ziektelast. J. Zwaap, CvZ

24. DALYs: Chris Murray • WHO avoid QALY • Havard • School of Public Health • Worked outside • Health economics • Med Decision Making • DALY • Person Trade-Off • Reinvented

25. Burden of disease: QALY lost = DALY (Disability adjusted life year) DALY QALY

26. Burden of disease expressed as “QALY lost” = DALY • Disability adjusted life years • The inverse of QALY • Used by the WHO • Expresses burden of disease • Measure of priority • More burden, more investment • QALY lost (DALY) = Measure of solidarity 26

27. QALY: both for effectiveness and solidarity • Evaluations assess cost-effectiveness in term of cost/QALY • But many decisions can not be explained by cost/QALY • Explanation in terms of fairness • People disagree with distributional implications of QALY maximisation • Fairness is burden of disease • Burden of disease is QALY lost (DALY) 27

28. QALY debate

29. QALY debate • Fairness is the issue in the QALY debate • QALY measurement is the straw man • Complex metric discussion • But same discussion applies with life years gained • Obviously QALYs must measured validly • That debate = rest of the course 29

30. 100 persons additionally 1 healthy year ?? persons 1 year free from disease Q Person Trade-Off • Values between patients • Not ‘within’ a patient like SG, TTO and VAS • Better equipped for QALY? • V(Q) = 1 - (A / B) • For instance: • V(Q) = 1 - (100/300) • V(Q) = 1 - 0.33 • V(Q) = 0.67

31. PTO gives extreme low values

32. PTO and it’s psychometrics • Paul Kind: • If we look at TTO and PTO... • we see that one of them is wrong • If we look at PTO alone... • We still see that one of them is wrong... PTO is not a quick fix

33. Alternative applications • Link to out of pocket payments • Greater out of pocket payments for conditions with lower proportional shortfall • E.g. France and Belgium • For example: • No reimbursement for the mildest conditions, such as common cold, acute tonsillitis, acute bronchitis, onychomycosis, tinea pedis • Partial reimbursement for conditions mild to moderate conditions: Haemorrhoids, candidiasis, gastritis, osteoporosis, erectile dysfunction, acne conglobata • Etc.

34. Direct utility assessment • SG, TTO, PTO, VAS

35. Indirect utility assessment • HUI, EQ-5D, AQoL, 15D, Rosser index MOBILITY • I have no problems in walking about • I have some problems in walking about • I am confined to bed SELF-CARE • I have no problems with self-care • I have some problems washing or dressing myself • I am unable to wash or dress myself USUAL ACTIVITIES (e.g. work, study, housework family or leisure activities) • I have no problems with performing my usual activities • I have some problems with performing my usual activities • I am unable to perform my usual activities PAIN/DISCOMFORT • I have no pain or discomfort • I have moderate pain or discomfort • I have extreme pain or discomfort ANXIETY/DEPRESSION • I am not anxious or depressed • I am moderately anxious or depressed • I am extremely anxious or depressed