“Introduction to Patient Preference
Methods used for QALYs”
Presented by:
Jan Busschbach, PhD, Chair Section Medical Psychology and
Psychotherapy, Department of Psychiatry, Erasmus MC, Rotterdam
The Netherlands
Saturday, 2 November 2013
Utility Measurements
Preference-based Techniques
 Prof.
Dr. Jan J.V. Busschbach
 Erasmus MC
 Department for Medical Psychology and Psychotherapy
 Saturday,
2 November 2013: 14:00 - 18:00
2
Program before the break

14:00 – 14:30 Introduction + email questions

14:30 – 15:30 Indirect utility measurement
 (Presentation 1)
 Lecture: Introduction EQ-5D, HUI and SF-36 in QALYs




(Presentation 2)
Exercise: Indirect utility measurement (Exercise 1)
Lecture continued: EQ-5D, HUI and SF-36 in QALYs (Presentation 2
continued)
The difference between patient and social perspective
(Presentation 3)
15:30 – 16:00 Direct utility measurement
 Lecture: Direct utility measurement: The validity of Standard Gamble,
Time Trade-Off and Visual Analogue Scale (Presentation 4)

16:00 – 16:15 Break
3
Program after the break
 16:15
– 17:00 Direct utility measurement
 Exercise: Direct utility measurement (Exercise 2)
 Discussion: which instrument when to use?
– 17:15 Disease specific utility
measurement
 17:00
 Lecture: Disease specific instruments for QALY-analysis +
Person Trade-Off (Presentation 5)
 17:15
– 17:45 Cultural differences
 17:45
– 18:00 Round up
 (Presentation 7)
4
7000 Citations in PubMed
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
2015
5
Identification of major problems
 Issues
emailed by participants
 What topics in quality of life research are most
relevant/interesting for you and/or your work?
6
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
7
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”
“Hart failure” versus “second psychosis”
 Generic
outcome are compatible
 Allow for comparisons between fields
• Life years
• Quality of life
 Most
generic outcome
 Quality adjusted life year (QALY)
8
Quality Adjusted Life Years
(QALY)
 Example
 Blindness
 Time trade-off value is 0.5
 Life span = 80 years
 0.5 x 80 = 40 QALYs
1.00
X
0.5 x 80 = 40 QALYs
0.00
40
80
Life years
9
Area under the curve
1
QALY weights
0.9
0.8
0.7
0.6
Co-morbidity
0.5
Psychotherapy
0.4
No psychotherapy
0.3
0.2
0.1
0
0
10
20
30
40
50
Life years
60
70
80
Which health care program is
the most cost-effective?

A new wheelchair for elderly (iBOT)
 Special post natal care
11
www.ibotnow.com
Dean Kamen
Segway
12
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: $ 4,000 per life year
QALY = Y x V(Q) = 10 x 0.1 = 1 QALY
Costs are 10 x $3,000 = $30,000
Cost/QALY = 40,000/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
13
QALY league table
Intervention
$ / QALY
GM-CSF in elderly with leukemia
235,958
EPO in dialysis patients
139,623
Lung transplantation
100,957
End stage renal disease management
53,513
Heart transplantation
46,775
Didronel in osteoporosis
32,047
PTA with Stent
17,889
Breast cancer screening
5,147
Viagra
5,097
Treatment of congenital anorectal malformations
2,778
14
Two points of critique
 QALYs
are measured in an invalid way
 Life years is not the problem, thus…
 It must be the validity of quality of life assessment…
 One
should not use cost effectiveness
 Often referred to as ‘ethics’
15
Eric Nord: Egalitarian concerns
1.0
A
B
C
0.0
16
Burden as criteria
30
25
20
15
10
5
0
Accepted
High burden
Rejected
Low burden
Pronk & Bonsel, Eur J Health Econom 2004, 5: 274-277
17
Costs/QALY as indicator of solidarity
€ 40.000
80
€ 30.000
60
€ 50.000
40
20
0
A
B
C
18
Costs/QALY versus Burden of disease
X
€ 80.000
X
€ 60.000
X
€ 40.000
X
€ 20.000
€
X
0
Burden of disease
19
Dutch Council for Public Health and
Health Care (RvZ, 2006)
20
Burden of disease:
QALY lost = DALY (Disability adjusted life year)
DALY
QALY
Burden of disease expressed as
“QALY lost” = DALY
 Disability
adjusted life years
 The inverse of QALY
 Used by the WHO
 Expresses
burden of disease
 Measure of priority
 More burden, more investment
 QALY
lost (DALY) = Measure of solidarity
22
QALY: both for effectiveness
and solidarity
 Evaluations
assess cost-effectiveness in term
of cost/QALY
 But many decisions can not be explained by
cost/QALY
 Explanation in terms of fairness
 People disagree with distributional implications of QALY
maximisation
 Fairness
is burden of disease
 Burden of disease is QALY lost (DALY)
23
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
 That debate = rest of the course
24
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
100
90
Scores on SF-36
80
70
General pop.
60
Diabetes II
50
Growth hormon def.
40
Depression
30
20
10
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Bo
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So
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Ro
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Ph
ys
ic
Ro
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na
M
l
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0
25
Direct utility assessment
 SG,
TTO, PTO, VAS
26
Indirect utility assessment
 HUI,
EQ-5D, AQoL, 15D, Rosser index
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
27