Kwaliteit van leven in maat en getal
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Kwaliteit van leven in maat en getal. Jan van Busschbach. Quality of life and Cost-Effectiveness An Interactive Introduction. Prof. Jan J. v. Busschbach, Ph.D. Erasmus MC Medical Psychology and Psychotherapy Viersprong Institute for studies on Personality Disorders. New cancer therapy.

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Kwaliteit van leven in maat en getal

Kwaliteit van leven in maat en getal

Jan van Busschbach


Quality of life and cost effectiveness an interactive introduction

Quality of life and Cost-Effectiveness An Interactive Introduction

Prof. Jan J. v. Busschbach, Ph.D.

Erasmus MC

Medical Psychology and Psychotherapy

Viersprong Institute for studies on Personality Disorders


New cancer therapy

New cancer therapy

SymptomsDrug XDrug Y

Survival days 300 400

Days sick of chemotherapy 10 150

Days sick of disease 100 30

TWiST 190 220


T ime wi thout s ymptoms of disease and subjective t oxic effects of treatment twist

Time Without Symptoms of disease and subjective Toxic effects of treatment: TWiST

  • Richard Gelber

    • statistician

  • Count …

    • Days not sick from treatment

    • Days not sick from disease

4


Fit new therapy in fixed budget

Fit new therapy in fixed budget

  • 50 patients each year (per hospital)

    • Drug x: 50 x euro 1.750 = euro 87.500

    • Drug y: 50 x euro 2.000 = euro 100.000

  • Drug budget for x or y = euro 50.000

    • Number of patient

      • Drug x: euro 50.000 / 1.750 = 28.5 patients

      • Drug y: euro 50.000 / 2.000 = 25.0 patients

    • Survival in days

      • Drug x: 28.5 patients x 300 days = 8.550 days

      • Drug y: 25.0 patients x 400 days = 10.000 days

    • Survival in TWiST

      • Drug x: 28.5 patients x 190 TWiST = 5.415 days

      • Drug y: 25.0 patients x 220 TWiST = 5.500 days


Twist ignores differences in quality of life

TWiST: ignores differences in quality of life

0.0 Quality of life 1.0

  • TWiST

    • Healthy = 1

    • Sick (dead) = 0

  • Q-TWiST

    • Quality of life adjusted TWiST

  • Make intermediate values

    • 1.0; 0.75; 0.50; 0.25; 0.00

  • How to scale quality of life?

  • 6


    Visual analogue scale

    Visual Analogue Scale

    Normal health

    X

    Dead

    ?=

    • Does the scale fit Q-TWIST?

      • Is 2 days 0.5 = 1 day 1.0?

    7


    Q twist qaly

    Q-TWiST = QALY

    • Several initiatives early seventies

      • Epidemiologist and health economists

    • Part of QALY concept

      • Quality Adjusted Life Years

      • QALY = Q-TWiST

    8


    Time trade off

    Time Trade-Off

    • Wheelchair

      • With a life expectancy: 50 years

    • How many years would you trade-off for a cure?

      • Max. trade-off: 10 years

    • QALY(wheel) = QALY(healthy)

      • Y * V(wheel) = Y * V(healthy)

      • 50 V(wheel) = 40 * 1.00

    • V(wheel) = 0.80

    9


    Kwaliteit van leven in maat en getal

    No values available

    Only applies to skin disease


    Euroqol eq 5d

    EuroQol EQ-5D

    • 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…..


    Quality adjusted life years qaly

    Quality Adjusted Life Years (QALY)

    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

    12


    Area under the curve

    Area under the curve

    13


    10 leading causes of death 2030

    10 leading causes of death 2030

    % of life years lost


    10 leading causes qaly loss 2030

    10 leading causes QALY loss 2030

    % of life DALYs lost


    Chris murray

    Chris Murray

    • WHO avoided QALY

      • (read: disliked QALYs)

      • (read disliked health economics)

    • But WHO in need of a measure of health…

    • Asked Havard…

      • Anything but QALY

    • Chris Murray

      • School of Public Health

    • Worked outside

      • Health economics

      • Med Decision Making

    • DALY


    Daly life time qaly

    DALY = life time - QALY

    DALY

    QALY

    17

    17


    Which health care program is the most cost effective

    Which health care program is the most cost-effective?

    • A new wheelchair for elderly (iBOT)

    • Special post natal care


    Www ibotnow com

    www.ibotnow.com

    Segway

    Dean Kamen

    19


    Which health care program is the most cost effective1

    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


    6000 citations in 2009

    6000 Citations in 2009

    21


    Qaly league table

    QALY league table


    Egalitarian concerns burden of disease

    Egalitarian Concerns:Burden of disease

    1.0

    Utility of Health

    0.0

    A

    B

    C


    Burden as criteria

    Burden as criteria

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


    Costs qaly as indicator of solidarity

    Costs/QALY as indicator of solidarity

    € 40.000

    80

    € 30.000

    60

    € 50.000

    Levensjaen

    40

    20

    0

    A

    B

    C

    25


    Costs qaly versus burden of disease

    Costs/QALY versus Burden of disease

    € 80.000

    € 60.000

    € 40.000

    € 20.000

    € 0

    X

    X

    X

    X

    X

    Burden of disease

    26


    Dutch council for public health and health care rvz 2006

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

    27


    Burden of disease qaly lost daly disability adjusted life year

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

    DALY

    QALY


    Qaly both for effectiveness and solidarity

    QALY: both for effectiveness and solidarity

    • Evaluations assess cost-effectiveness in term of cost/QALY

    • Fairness is burden of disease

      • Burden of disease is QALY lost (DALY)

    29


    Qaly debate

    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

        • That debate = rest of the course

    30


    Drawback

    Drawback

    • The more differentiation of the threshold…

      • The lower the population health

    • If we spend all our money in curing the worst of patients…

      • All others die sooner…

    • Equity-efficiency trade-off

      • Wagstaff 1991


    Conclusion

    Conclusion

    • Cost effectiveness in terms of quality of life can be measured

    • Burden of disease is also a criterion


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