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Dyslexia and Cost Effectiveness

Prof. dr. Jan van Busschbach

De Viersprong

Erasmus MC

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Health Economics

Comparing different allocations Should we spent our money on

• Wheel chairs

• Screening for cancer

• Dyslexia treatment

Comparing costs

Comparing outcome

Outcomes must be comparable Make a generic outcome measure

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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”

• Number of correct spelled words

Generic outcome are compatible Allow for comparisons between fields

• Life years

• Quality of life

Most generic outcome Quality adjusted life year (QALY)

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Quality Adjusted Life Years (QALY)

Multiply life years with quality index Quality of life index

1.0 = normal health

0.0 = death (extremely bad health)

Example Losing sense of sight

Quality of life index is 0.5

Life = 80 years

0.5 x 80 = 40 QALYs

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QALY

Quality Adjusted Life Years Area under the curve

0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1

0 10 20 30 40 50 60 70 80

Life years

Ad

jus

me

nt

fac

tor

QA

LY

Co-morbidity

With psychotherapy

No psychotherapy

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A new wheelchair for elderly (iBOT) Special post natal care

Which health care program is the most cost-effective?

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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?

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4500 Citations in PubMed

1980[pdat] AND (QALY or QALYs)

0

100

200

300

400

500

600

700

1980 1985 1990 1995 2000 2005 2010

Pub

licat

ions

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QALY league table

Intervention $ / QALYGM-CSF in elderly with leukemia 235,958

EPO in dialysis patients 139,623

Lung transplantation 100,957

End stage renal disease management 53,513

Heart transplantation 46,775

Didronel in osteoporosis 32,047

PTA with Stent 17,889

Breast cancer screening 5,147

Viagra 5,097

Treatment of congenital anorectal malformations 2,778

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Dyslexia and QALYs

Request from CvZ Cost effectiveness protocol dyslexia treatment

According to best standards

• Pharmacoeconomics guidelines

5 weeks…. Leona Hakkaart

Costs

Elly Stolk Outcome (Quality of Life)

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Model based on Patty Gerretsen

70 %

30 %

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Parameters

70% effectiveness N = 233, 1 year and 10 year

Gerretsen et al., 2006

Costs Protocol: € 4.445

CAU: € 2.080

• N = 121 pre-treatment

• Intake Regionaal Instituut voor Dyslexie

200.000 children 6% gets diagnostics

1,8% treatment

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Effect on costs in 4 years

70 %

30 %

€ 4.445

€ 4.445

€ 2.080

But what about the effects on outcome?

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Outcome

Disease specific Better reading skills

Better writing skills

Higher education

But what about generic effects? Quality of life

QALYs

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Value health states dyslexia

No dyslexia, Mild, Severe

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Uni-dimensional value

Like the IQ-test measures intelligence Ratio or interval scale

Difference 0.00 and 0.80 must be 8 time higher than 0.10

Three popular methods have these pretensions Visual analog scale

Time trade-off

Standard gamble

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Visual Analogue Scale

VAS Also called “category scaling”

From psychological research

“How is your quality of life?” “X” marks the spot

Rescale to [0..1]

Dead

Normal health

X

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Time Trade-Off

TTO Wheelchair

With a life expectancy: 50 years

How many years would you trade-off for a cure? Max. trade-off is 10 years

QALY(wheel) = QALY(healthy) Y * V(wheel) = Y * V(healthy)

50 V(wheel) = 40 * 1

V(wheel) = .8

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Of the shelf instrument: EQ-5D

Patient sample “Woortblind”

N = 265 Out of 820

Response rate 32.3%

EQ-5D Patients 0.87

(sd 0.16)

Norm 0.88 (sd 0.16)

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…..

Not sensitive in Dyslexia

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Paired comparisons

Severe dyslexia ADHA

Severe dyslexia Crohn

Severe dyslexia Mild Asthma

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Quality of life weights

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Costs per QALY

Elementary school € 33.513 Basis school

Grammar school € 16.332 Middelbare school

Secondary education € 11.558 Vervolgonderwijs

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QALY league table

Intervention $ / QALYGM-CSF in elderly with leukemia 235,958

EPO in dialysis patients 139,623

Lung transplantation 100,957

End stage renal disease management 53,513

Heart transplantation 46,775

Didronel in osteoporosis 32,047

PTA with Stent 17,889

Breast cancer screening 5,147

Viagra 5,097

Treatment of congenital anorectal malformations 2,778

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Limitations

Conservative estimates No involved cost of repeaters

Only costs of CUA in first year

No good estimates of additional income

Limited effect estimates No RCT

No formal estimates of uncertainty

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ISPOR 2007

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Conclusion

Cost per QALY is feasible in dyslexia Cost per QALY of treatment is reasonable Cost effectiveness successfully uses as

argument in reimbursement There is a need for better…

Estimates of effects

Estimates quality of life

Models