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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. Outcomes in health economics. Specific outcome are incompatible

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health economics
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
outcomes in health economics
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”
  • Generic outcome are compatible
    • Allow for comparisons between fields
      • Life years
      • Quality of life
  • Most generic outcome
    • Quality adjusted life year (QALY)
quality adjusted life years qaly
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
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
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

top 6 journals cost utility analysis
Top 6 journals Cost Utility Analysis

www.tufts-nemc.org/cearegistry

most debate about the qol estimates
Most debate about the QoL estimates
  • Unidimensional QoL
    • In QALY we need a unidimensional assessment of Quality of life
  • Rules out multidimensional questionnaires
    • SF-36, NHP, WHOQOL
utility assessment
Utility assessment
  • Unidimensional QoL
  • Often called ‘utility’
who to ask
Who to ask?

The patient, of course!

the clinical perspective
The clinical perspective
  • Quality of life is subjective…..
    • “Given its inherently subjective nature, consensus was quickly reached that quality of life ratings should, whenever possible, be elicited directly from patients themselves. “
      • (Niel Aaronson, in B. Spilker: Quality of life and Pharmacoeconomics in Clinical Trails, 1996, page 180)
  • …therefore ask the patient!
patient values count
Patient values count….
  • […] the best way to do this, the technology, is a patient-based assessment. They report, they evaluate, they tell you in a highly standardized way, and that information is used with the clinical data and the economic data to get the best value for the health care dollar.”
  • John Ware
a problem in the patient perspective

Healthy

Death

A problem in the patient perspective….
  • Stensman
    • Scan J Rehab Med 1985;17:87-99.
  • Scores on a visual analogue scale
    • 36 subjects in a wheelchair
    • 36 normal matched controls
  • Mean score
    • Wheelchair: 8.0
    • Health controls: 8.3
the economic perspective
The economic perspective
  • In a normal market: the consumer values count
  • The patient seems to be the consumer
    • Thus the values of the patients….
  • If indeed health care is a normal market…
  • But is it….?
health care is not a normal market
Health care is not a normal market
  • Supply induced demands
  • Government control
    • Financial support (egalitarian structure)
  • Patient  Consumer
    • The patient does not pay
  • Consumer = General public
    • Potential patients are paying
  • Health care is an insurance market
    • A compulsory insurance market
health care is an insurance market
Health care is an insurance market
  • Values of benefit in health care have to be judged from a insurance perspective
  • Who values should be used the insurance perspective?
who determines the payments of unemployment insurance
Who determines the payments of unemployment insurance?
  • Civil servant
    • Knowledge: professional
    • But suspected for strategical answers
      • more money, less problems
      • identify with unemployed persons
  • The unemployed persons themselves
    • Knowledge: specific
    • But suspected for strategical answers
  • General public (politicians)
    • Knowledge: experience
    • Payers
who s values of quality of life should count in the health insurance
Who’s values (of quality of life) should count in the health insurance?
  • Doctors
    • Knowledge: professional
    • But suspected for strategical answers
      • See only selection of patient
      • Identification with own patient
  • Patients
    • Knowledge: disease specific
    • But suspected for strategical answers
    • But coping
  • General public
    • Knowledge: experience
    • Payers
    • Like costs: the societal perspective
validated questionnaires
Validated questionnaires

MOBILITY

  • I have no problems in walking about
  • I have some problems in walking about
  • I am confined to bed

SELF-CARE

  • I have no problems with self-care
  • I have some problems washing or dressing myself
  • I am unable to wash or dress myself

USUAL ACTIVITIES (e.g. work, study, housework family or leisure activities)

  • I have no problems with performing my usual activities
  • I have some problems with performing my usual activities
  • I am unable to perform my usual activities

PAIN/DISCOMFORT

  • I have no pain or discomfort
  • I have moderate pain or discomfort
  • I have extreme pain or discomfort

ANXIETY/DEPRESSION

  • I am not anxious or depressed
  • I am moderately anxious or depressed
  • I am extremely anxious or depressed
validated questionnaires1
Describe health states

Have values from the general public

Rosser Matrix

QWB

15D

HUI Mark 2

HUI Mark 3

EuroQol EQ-5D

Validated Questionnaires
eq 5d hui and sf 36

EQ-5D, HUI and SF-36

Of the shelf instruments….

the rosser kind index1
The Rosser & Kind index
  • One of the oldest valuation
  • 1978: Magnitude estimation
    • Magnitude estimation  PTO
    • N = 70: Doctors, nurses, patients and general public
  • 1982: Transformation to “utilities”
  • 1985: High impact article
    • Williams A. For Debate... Economics of Coronary Artery Bypass Grafting. British Medical Journal 291: 326-28, 1985.
    • Survey at the celebration of 25 years of health economics: chosen most influential article on health economics
more health states
More health states
  • Criticism on the Rosser & Kind index
    • Sensitivity (only 30 health states)
    • The unclear meaning of “distress”
    • The compression of states in the high values
    • The involvement of medical personnel
  • New initiatives
    • Higher sensitivity (more then 30 states)
    • More and better defined dimensions
    • Other valuation techniques
      • Standard Gamble, Time Trade-Off
    • Values of the general public
no longer value all states
No longer value all states
  • Impossible to value all health states
    • If one uses more than 30 health states
  • Estimated the value of the other health states with statistical techniques
    • Statistically inferred strategies
      • Regression techniques
      • EuroQol, Quality of Well-Being Scale (QWB)
    • Explicitly decomposed methods
      • Multi Attribute Utility Theory (MAUT)
      • Health Utility Index (HUI)
statistically inferred strategies
Statistically inferred strategies
  • Value a sample of states empirically
  • Extrapolation
    • Statistical methods, like linear regression
    • 11111 = 1.00
    • 11113 = .70
    • 11112 = ?
explicitly decomposed methods
Explicitly Decomposed Methods
  • Value dimensions separately
    • Between the dimensions
    • What is the relative value of:
      • Mobility…... 20%
      • Mood…….. 15%
      • Self care.… 24%.
  • Value the levels
    • Within the dimensions
    • What is the relative value of
      • Some problems with walking…… 80%
      • Much problems with walking…... 50%
      • Unable to walk…………………….10%
explicitly decomposed methods1
Explicitly Decomposed Methods
  • Combine values of dimensions and levels with specific assumptions
    • Multi Attribute Utility Theory (MAUT)
      • Mutual utility independence
      • Structural independence
explicitly decomposed methods2
Explicitly Decomposed Methods
  • Health Utilities Index (Mark 2 & 3)
    • Torrance at McMaster
    • 8 dimensions
    • Mark 2: 24.000 health states
    • Mark 3: 972.000 health states
  • The 15-D
    • Sintonen H.
    • 15 dimensions
    • 3,052,000,000 health states (3 billion)
more health states higher sensitivity 1
More health states, higher sensitivity ? (1)
  • EuroQol criticised for low sensitivity
    • Low number of dimensions
      • Development of EQ-5D plus cognitive dimension
    • Low number of levels (3)
      • Gab between best and in-between level
more health states higher sensitivity 2
More health states, higher sensitivity ? (2)
  • Little published evidence
    • Sensitivity EQ-5D < SF-36
      • Compared as profile, not as utility measure
    • Sensitivity EQ-5D  HUI
  • Sensitivity  the number of health states
    • How well maps the classification system the illness?
    • How valid is the modelling?
    • How valid is the valuation?
more health states more assumptions
More health states, more assumptions
  • General public values at the most 50 states
  • The ratios empirical (50) versus extrapolated
    • Rosser & Kind 1:1
    • EuroQol 1:5
    • QWB 1:44
    • SF-36 1:180
    • HUI (Mark III) 1:19,400
    • 15D 1:610,000,000
  • What is the critical ratio for a valid validation?
sf 36 as utility instrument
SF-36 as utility instrument
  • Transformed into SF6D
  • SG
  • N = 610
  • Inconsistencies in model
    • 18.000 health states
    • regression technique stressed to the edge
  • Floor effect in SF6D
conflicting evidence sensitivity sf 36
Conflicting evidence sensitivity SF-36

Liver transplantation, Longworth et al., 2001

conclusions
Conclusions

More states  better sensitivity

The three leading questionnaires

have different strong and weak points

value a health state
Value a health state
  • Wheelchair
    • Some problems in walking about
    • Some problems washing or dressing
    • Some problems with performing usual activities
    • Some pain or discomfort
    • No psychosocial problems
uni dimensional value
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
visual analogue scale

Normal health

X

Dead

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]
  • Different anchor point possible:
    • Normal health (1.0) versus dead (0.0)
    • Best imaginable health versusworse imaginable health
time trade off
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
standard gamble
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
health economics prefer tto sg
Health economics prefer TTO/SG
  • Visual analogue scale
    • Easy
    • No trade-off: no relation to QALY
      • No interval proportions
  • Standard Gamble / Time trade-Off
    • Less easy
    • Trade-off: clear relation to QALY
      • Interval proportions
  • Little difference between SG and TTO
little difference between cost life year and cost qaly
Little difference between Cost/Life Year and Cost/QALY

Richard Chapman et al, 2004, Health Economics

difference in qalys makes little difference in outcome
Difference in QALYs makes little difference in outcome
  • Richard Chapman et al, 2004
    • “In a sizable fraction of cost-utility analyses, quality adjusting did not substantially alter the estimated cost-effectiveness of an intervention, suggesting that sensitivity analyses using ad hoc adjustments or 'off-the-shelf' utility weights may be sufficient for many analyses.”
    • “The collection of preference weight data should […] should only be under-taken if the value of this information is likely to be greater than the cost of obtaining it.”
qalys make a difference when
QALYs make a difference when:
  • Chronic disease
  • Palliative
  • Long term negative consequences
conclusions1
Conclusions
  • SG/TTO are preferred in Health economics
    • Reproducible results
  • Problems in QALYs are overestimated
    • Difference in QALYs makes little difference in outcome
      • Compared to cost per life year
      • With exception of chronic illness