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Monday, Sept. 17 Measuring effectiveness and other CEA considerations

Monday, Sept. 17 Measuring effectiveness and other CEA considerations. by  Donald S. Shepard, Ph.D. Schneider Institute for Health Policy Heller School, MS 035 Brandeis University Waltham, MA 02454-9110 USA Tel: 781-736-3975 • Fax: 781-736-3965 Web: http://www.sihp.brandeis.edu/shepard

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Monday, Sept. 17 Measuring effectiveness and other CEA considerations

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  1. Monday, Sept. 17Measuring effectiveness and other CEA considerations by  Donald S. Shepard, Ph.D. Schneider Institute for Health Policy Heller School, MS 035 Brandeis University Waltham, MA 02454-9110 USA Tel: 781-736-3975 • Fax: 781-736-3965 Web: http://www.sihp.brandeis.edu/shepard E-mail: Shepard@Brandeis.edu 1

  2. Practical information • Teaching assistant: Jsuaya@Brandeis.edu • Administrative assistant: Linda Purrini, Next to library in Heller 781-736-3930 Purrini@Brandeis.edu • Cost of packet: $6.00 2

  3. Measuring Effectiveness and Outcomes, QALYs and DALYs  Donald S. Shepard, Ph.D. Schneider Institute for Health Policy Heller School, MS 035 Brandeis University Waltham, MA 02454-9110 USA Tel: 781-736-3975 • Fax: 781-736-3965 Web: http://www.sihp.brandeis.edu/shepard E-mail: Shepard@Brandeis.edu 3

  4. Outline • Types of indexes • Measuring national disease burden • Health status questionnaires 4

  5. Needs for combining length and quality of life • Assessing the disease burden of a country or a region, to see which health problems are greatest, and how one country or region compares with another. • Evaluating a program that may impact both mortality and morbidity. 5

  6. Indexes for combining length and quality of life • Quality Adjusted Life Years, QALYs (Zeckhauser and Shepard, 1976) • Potential Days of Life Lost, PDLLs (Ghana health assessment team, 1980) • Disability Adjusted Life Years, DALYs (World Development Report, 1993) 6

  7. Types of scales for assessing quality of life • Value scale: a measure of preferences on a scale with arbitrary endpoints (example, SF36, scale of 0 to 100). • Utility scale: a measure of preferences on a scale with endpoints of 0 and 1 and spacing consistent with probability theory. 7

  8. Burden of disease 8

  9. Ways of assessing utilities • Probability approach – breakeven probability • Time tradeoff - breakeven time 9

  10. General health question In general, would you say your health is poor, fair, good, very good, or excellent? 1 poor 2  fair 3  good 4  very good 5  excellent 10

  11. Limitation of physical activities Here are a list of activities that you might do during a typical day. How much does your health limit you right now in moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf? 1 A lot 2 A little 3 Not at all 11

  12. Limitation of social activities During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities like visiting with friends or relatives?   1 All of the time 2 Most of the time 3 A good bit of the time 4 Some of the time 5 A little of the time 6 None of the time 12

  13. Time tradeoff • Time tradeoff - find the breakeven time • Suppose we were to live 10 years with an impaired state, I • Instead, we could live Y years with perfect health. • Suppose the the value y would make us just indifferent. • Then the utility of I is y / 10. • E.g., if y is 7, then the utility is 7/10 = 0.70 13

  14. Von Neumann – Morgenstern Utility 1 • Suppose we have a “good” outcome which has a utility of 1 (e.g. living year in perfect health) • Bad outcome has a utility of 0 (e.g. dying at the start of the year) • Intermediate outcome (I) has utility of x (e.g. living with a health limitation), x = u(I) 14

  15. Von Neumann – Morgenstern Utility 2 • Suppose I is indifferent between probability p of good outcome, and 1-p of bad outcome • The utility is von Neumann-Morgernstern if x equals p. 15

  16. Illustration: gastroenteritis in Ghana,c. 1980 16

  17. Remaining life expectancy by age, Ghana (1968) 17

  18. Disease burden for gastroenteritis (1): Mortality loss burden per death 18

  19. Disease burden for gastroenteritis (2): Mortality loss burden per case 19

  20. Disease burden for gastroenteritis (3): Morbidity loss burden per case 20

  21. Disease burden for gastroenteritis (4): Total burden per case (days) 21

  22. Disease burden for gastroenteritis (5): Total annual burden per 1000 persons 22

  23. Extensions:Discounting of health impacts • Impacts in future years should be discounted, just as money is discounted • Discounting arises due to “time preference”: • We are anxious to get good things soon. • If we have to wait, them “good” is less highly valued now. 23

  24. Discount factors 24

  25. Graph of discount factors (at 3%) 25

  26. Table of DALYs 26

  27. DALYs from a life of specified number of years 27

  28. Disease burden exercise • Illustrate the calculation of PDLLs from exercise on web site • http://www.sihp.brandeis.edu/shepard 28

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