The Future of
Quality of Life Assessment
in Cost-Effectiveness Research
Prof. Jan J. v. Busschbach, Ph.D.
Erasmus MC
Medical Psychology and Psychotherapy
Viersprong Institute for studies on Personality Disorders
1
QoL in HTA: QALY
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
….the strictly fascist essence
of those QALYs (so-called
Quality-Adjusted Life Years)…
4
But QALY rules…
Publications
1980[pdat] AND (QALY or QALYs)
1000
900
800
700
600
500
400
300
200
100
0
1975
1980
1985
1990
1995
2000
2005
2010
From 1980 till 2010: 7049 publications in PubMed
2015
There is not yet an alternative…
Raad voor de Volksgezondheid en Zorg
 Weight
QALYs by severity of illness
 QALYs determine “severity”
7
Value based pricing
 Health
Secretary Andrew Lansley
 Measures "will help ensure better access for patients to
effective drugs and innovative treatments on the NHS"
 Like
RvZ
 Again adding severity
 Adding Innovation
 QALY still at the hart of the judgment
 Severity and innovation both expressed
terms of QALYs
8
Efficiency frontier
 Germany
 IQWiG
 Still
discussion
 whether it is possible ‘in theory’ to make such value
judgments, let alone in practice
9
Which measure?
 Questionnaires
 EQ-5D
 HUI
 SF-6D
 Direct
measures
 TTO
 Discrete choice
 SG
 VAS
Questionnaires
 EQ-5D
 Dominates health economics
 Said to be insensitive
 New 5 level version is on its way
 SF-6D
 Overtook HUI in popularity
 Little support development
 HUI
 Little recent development
 Expensive
Disease specific instruments
 As
validation methodology becomes
cheaper…
 Why not validate a disease specific instrument?
 The
big research question
 Are values valid?
 Are the values the same as with HUI, SF-6D etc
 Narrow
scope
 Values are too high
 Attention
bias
 Differences are too big
Bold-on instruments
 Combine
generic instruments with disease
specific dimensions
 “Bold-on” the disease specific dimension
 Can
solve the narrow scope
 Absolute value level might be valid
 Could
avoid attention bias
 Does it also avoid the attention bias?
Direct measures
 Used
to value health states in models
 TTO
 Discrete
 SG
 VAS
 WTP
choice
dominates
coming up
slips aside
not in favor in health economics
never more than a promise
The big questions
 TTO
 Values below dead
 Discrete
choice
 Is discrete choice valid within the QALY approach?
 How to anchor in death – normal health scale
• TTO?
Care
 QALY
in care is disputed
 QALY
might not be sensitive
 Same
issues as in cure?
 But QALY is ok for big issues in care
 No care = dead
 Care might be involve other aspects than health
 For instance: does not measure autonomy
 Disease specific instrument
 Involve need and innovation
Discrete choice in care
 New
instrument for care
 ICECAP
 ASCOTT
 Several other initiatives
 What
is the relation with QALY?
 Why go for another scale?
17
Conclusion: Standardization
 Questionnaires
 Could merge to EQ-5D
 But disease specific instruments might blur
 Direct
valuation
 TTO seems to prevail, but not yet one methodology
 Care
 Just the start of development
18
Future questionnaires
 Cheap
EQ-5D
 Sensitive
SF-6D
 Simple to use
EQ-5D
 Many translations SF-6D
 Many value sets
EQ-5D
 Will
EQ-5D-5L dominate?
SF-6D
HUI
SF-6D
EQ-5D
HUI
 There must be room for more instruments…
HUI
EQ-5D (3L)
HUI
HUI
SF-6D