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The QALYs debate

Prof. dr. Jan J.V. Busschbach, Ph.D. Erasmus MC

Institute for Medical Psychology and Psychotherapy

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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

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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”“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)

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Example Blindness

Time trade-off value is 0.5

Life span = 80 years

0.5 x 80 = 40 QALYs

Quality Adjusted Life Years (QALY)

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0.00

1.00

X

Life years40 80

0.5 x 80 = 40 QALYs

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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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Standard Gamble

SG Wheelchair Life expectancy is not important here How much are risk on death are you prepared

to take for a cure? Max. risk is 20%

wheels = (100%-20%) life on feet

V(Wheels) = 80% or .8

1970

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Area under the curve

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Which health care program is the most cost-effective?

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

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www.ibotnow.com

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Segway Dean Kamen

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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: $ 4,000 per life year

QALY = Y x V(Q) = 10 x 0.1 = 1 QALY

Costs are 10 x $4,000 = $30,000

Cost/QALY = 40,000/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

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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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Milton Weinstein

In the face of uncertainty … and fear The decision willwill be made, if not actively then

by default

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7000 Citations in PubMed

1980[pdat] AND (QALY or QALYs)

0100200300400500600700800900

1000

1975 1980 1985 1990 1995 2000 2005 2010 2015

Pu

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QALY = Utility: Welfare theory

QALY can be see as the ‘value of health’ The value of a good or service: “utility”

Also called “nut” (Dutch)

Welfare theory: maximize utility Maximize QALY

Do we want to maximize QALY? Doubtful…

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Is the utility scale valid?

A B

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We do not maximize QALY But nevertheless we want to maximize utility

• By (economic) definition..

That means:

QALYs measured utility in an invalid way Life years is not the problem, thus…

It must be the validity of quality of life assessment…

Critique

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…it must be that QALYs are invalid

We don’t like the results…

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

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….the strictly fascist essence of those QALYs (so-called

Quality-Adjusted Life Years)…

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Burden as criteria

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0

5

10

15

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25

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Accepted Rejected

High burden Low burden

Pronk & Bonsel, Eur J Health Econom 2004, 5: 274-277

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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

?? persons 1 year free from disease Q

100 persons additionally 1 healthy year

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TTO does not correlate with PTO

0.0

0.2

0.4

0.6

0.8

1.0

Uti

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TTO

PTO

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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...

0,0

0,2

0,4

0,6

0,8

1,0

Utilitie

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TTO

PTO

0,0

0,2

0,4

0,6

0,8

1,0

Utilitie

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PTO

PTO is not a quick fix

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CB

Lif

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Falsification even with life years

A B

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Utility?

A B

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Utility

Utility Total benefit

Including distribution

Also called “Nut” (Dutch)

Quality of life might be part of total benefit

QALYs do not include distribution

But it is said that ‘Standard Gamble’ measures utilities! Van N-M utilities by definition utility

But in SG only “health for your self”

Does not include distribution

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A B C

Costs/QALY as indicator of solidarity

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€ 50.000

€ 30.000

€ 40.000

QA

LY

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Costs/QALY versus Burden of disease

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€ 80.000

€ 60.000

€ 40.000

€ 20.000

€ 0

Burden of disease

X

XX

XX

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

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If a medical treatment costs >€80,000 to give one patient one extra life year of good quality, it should not be reimbursed in the

basic health care insurance

Council advises the Minister of Health to use this limit in order to keep the budget of health care under control; They realize the

topic is controversial.

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Chris Murray

WHO avoid QALY Havard

School of Public Health

Worked outside Health economics

Med Decision Making

DALY Person Trade-Off

Reinvented

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

DALY

QALY

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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

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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)

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QALY debate

Fairness is the issue in the QALY debate QALY measurement is the straw man

Complex metric discussion

QALYs are needed to operationalize fairness

Most debate about quality of life assessment Again as straw man

But also within the metric debate of QALY

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Reimbursement arguments

Burden of disease

Effects

Cost effectiveness

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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.

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Take home message

Quality of life assessment and health assessment is crucial Not only to estimate health gains (efficiency)

But also to estimate need (equity) It is not the measurement of quality of life

but the efficiency/equity trade-off which heats up the debate