“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 (Presentation 1)

14:30 – 15:30 Indirect utility measurement 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?

17:00 – 17:15 Disease specific utility measurement Lecture: Disease specific instruments for QALY-

analysis + Person Trade-Off (Presentation 5)

17:15 – 17:45 Cultural differences (Presentation 7)

17:45 – 18:00 Round up

4

5

7000 Citations in PubMed

1980[pdat] AND (QALY or QALYs)

0100200300400500600700800900

1000

1975 1980 1985 1990 1995 2000 2005 2010 2015

Pu

blic

ati

on

s

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)

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Example Blindness

Time trade-off value is 0.5

Life span = 80 years

0.5 x 80 = 40 QALYs

Quality Adjusted Life Years (QALY)

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0.00

1.00

X

Life years40 80

0.5 x 80 = 40 QALYs

Area under the curve

Which health care program is the most cost-effective?

A new wheelchair for elderly (iBOT) Special post natal care

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www.ibotnow.com

12

Segway Dean Kamen

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

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QALY league table

Intervention $ / QALYGM-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

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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’

Two points of critique

15

16

CB0.0

1.0

Uti

lity

of

Hea

lth

Eric Nord: Egalitarian concerns

A B

Burden as criteria

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0

5

10

15

20

25

30

Accepted Rejected

High burden Low burden

Pronk & Bonsel, Eur J Health Econom 2004, 5: 274-277

80

0A B C

Lev

ensj

aen

Costs/QALY as indicator of solidarity

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60

40

20

€ 50.000

€ 30.000

€ 40.000

Costs/QALY versus Burden of disease

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€ 80.000

€ 60.000

€ 40.000

€ 20.000

€ 0

Burden of disease

X

XX

XX

Dutch Council for Public Health and Health Care (RvZ, 2006)

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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

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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

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10

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60

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80

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Physic

al fu

nctio

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Social

Functio

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Role P

hysi

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Role e

motio

nal

Men

tal h

ealth

Vitalit

y

Bodily p

ain

Genera

l Hea

lth

Sc

ore

s o

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F-3

6

General pop.

Diabetes II

Growth hormon def.

Depression

Direct utility assessment

SG, TTO, PTO, VAS

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Indirect utility assessment

HUI, EQ-5D, AQoL, 15D, Rosser index

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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