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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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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

Symptoms Drug X Drug 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

slide10

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

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
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
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

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
ad