Justice and Economic Evaluation

Prof. Dr. Jan Busschbachj.vanbusschbach@erasmusmc.nl

+31 10 7043807

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Equity concerns

In cost per QALY… Patients with low cost, high gains win…

But the general public wants that … Patients with the highest need win … Irrespectively the capacity to benefit….

A higher burden relates to more health care

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Erik Nord on the fairness in distributing health care resourcesISPOR Berlin 2012

Only Equity?

All resources to the highest burden? What about the others? What about waste resources?

Doesn’t effectiveness count?

“It should be a combination” Erik Nord: Obviously,….. of course!

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What does ‘need’ mean?

Need can mean: The availability of a (cost-)effective treatment “Burden” Low life expectancy Low quality of life

WHO The Burden of Disease Project Which people have the highest ‘need for health care’

• Low life expectancy• Low quality of life

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WHO: Burden of disease

DALY “Need” for health care Disability adjusted life year = QALY lost

Need defined by Fixed lifespan Max QoL Lost in lifespan and QoL

“Fair innings”

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DALY

QALY

1.0

0.0A B C

Kw

alit

eit

van

lev

enFalsification QALY

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Efficiency

EquityLif

e ye

ars

A B C

Falsification of life years

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80

0

Lif

e ye

ars 60

40

20

8

80

0A B C

Lif

e Y

ears

& Q

oL

Threshold costs/QALY:indicator of solidarity

8

60

40

20

€ 50.000

€ 30.000

€ 40.000

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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

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

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Does this make Erik a happy man?

Rule of rescue

What if cancer occurs at 80 years of age? “Fair innings” foregone?

No treatment?

Age discrimination? QALY was already suspected

Rule of rescue Severity of illness More severe….

• …. More priority

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DALY

QALY

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Fair Innings vs Rule of Rescue

Fair innings What have you already got? How good has it been? Loss in QALYs

Rule of Rescue Severity of illness How bad is it now? Expected QALYs

• Life expectancy….

But what if the severity of illness is a result of old age?

Discriminate the old?

Compares loss in QALY with expected QALY Combines fair innings with rule of rescue The more you loss of what you had expected… André Ament

Proportional short fall

Prop. Short Fall = 25% Prop. Short Fall = 50% Prop. Short Fall = 60%

QALY lostQALY gain

Life expectancy

QoL

Prop. Short Fall = 50%

Now

Now Life expectancy

the old and disabled

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Implementation

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Strengths and limitation

Combines two definitions of equity Fair innings Rule of rescue

Little data necessary Might overcompensate

The old The severe ill

Seen as complex… Might not capture everything…

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