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The Future of Quality of Life Assessment

in Cost-Effectiveness Research

Prof. Jan J. v. Busschbach, Ph.D.Erasmus MC

Medical Psychology and PsychotherapyViersprong Institute for studies on Personality Disorders

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)…

But QALY rules…

1980[pdat] AND (QALY or QALYs)

0100200300400500600700800900

1000

1975 1980 1985 1990 1995 2000 2005 2010 2015

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bli

cati

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s

From 1980 till 2010: 7049 publications in PubMed

There is not yet an alternative…

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Raad voor de Volksgezondheid en Zorg

Weight QALYs by severity of illness QALYs determine “severity”

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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

Efficiency frontier

Germany IQWiG Still discussion

whether it is possible ‘in theory’ to make such value judgments, let alone in practice

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 dominates Discrete choice coming up SG slips aside VAS not in favor in health economics WTP 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 But QALY is ok for big issues in care No care = dead

QALY might not be sensitive Care might be involve other aspects than health For instance: does not measure autonomy

Same issues as in cure? Disease specific instrument Involve need and innovation

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Discrete choice in care

New instrument for care ICECAP ASCOTT Several other initiatives

What is the relation with QALY? Why go for another scale?

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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

Future questionnaires

Cheap EQ-5D SF-6DHUI Sensitive SF-6DHUI EQ-5D (3L) Simple to use EQ-5D SF-6DHUI Many translations SF-6DEQ-5D HUI Many value sets EQ-5D HUI SF-6D

Will EQ-5D-5L dominate? There must be room for more instruments…