Transcript Quality of life Assessment

Interactive Introduction
cost effectiveness
• Jan J. v. Busschbach, Ph.D.
• Psychotherapeutic Centrum ‘De Viersprong’,
Halsteren
– [email protected]
– +31 164 632200
• Department of Medical Psychology and
Psychotherapy, Erasmus MC
– [email protected]
– +31 10 4087812
1
New cancer therapy (1)
Drug x
Drug Y
Symptoms of illness
(days)
(days)
Survival
300
400
Sick of chemotherapy
10
150
Sick of disease
100
30
TWiST *
190
220
TWiST = Time Without Symptoms of disease and Toxicity
2
Time Without Symptoms of disease and
subjective Toxic effects of treatment
• TWiST
– Developed by Gelber (statistician)
• In search for a typical “cancer” problem
– Often prolonged life but also a reductions in quality of life
» At the beginning (side effects)
» At the end
– Only count the days without symptoms of disease and
subjective toxic effects of the treatment
3
New cancer therapy (2)
• 50 patients each year (per hospital)
– Drug x: 50 x euro 1.750 = euro 87.500
– Drug y: 50 x euro 2.000 = euro 100.000
• Drug budget for x or y = euro 50.000
– Number of patient
» Drug x: euro 50.000 / 1.750 = 28.5 patients
» Drug y: euro 50.000 / 2.000 = 25.0 patients
– Survival in days
» Drug x: 28.5 patients x 300 days = 8.550 days
» Drug y: 25.0 patients x 400 days = 10.000 days
– Survival in TWiST
» Drug x: 28.5 patients x 190 TWiST = 5.415 days
» Drug y: 25.0 patients x 220 TWiST = 5.500 days
4
TWiST ignores differences in
quality of life
• TWiST
– Healthy = 1
– Sick (dead) = 0
• There is more to life than sick/health
– Make scale 0..1
» Quality of life scale
– Quality adjusted TWiST
» Q-TWiST
» Almost equal to Quality Adjusted Life Years (QALYs)
• How to scale quality of life?
5
EuroQol EQ-5D
•
MOBILITY
–
–
–
•
SELF-CARE
–
–
–
•
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 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 in walking about
I have some problems in walking about
I am confined to bed
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
6
Value a health state
• Wheelchair
–
–
–
–
–
Some problems in walking about
Some problems washing or dressing
Some problems with performing usual activities
Some pain or discomfort
No psychosocial problems
7
Time Trade-Off
• TTO
• Wheelchair
– With a life expectancy: 50 years
• How many years would you trade-off for a
cure?
– Max. trade-off is 10 years
• QALY(wheel) = QALY(healthy)
– Y * V(wheel) = Y * V(healthy)
– 50 V(wheel) = 40 * 1
• V(wheel) = .8
8
In health economics:
Q-TWiST = QALY
• Count life years
• Value (V) quality of life (Q)
– V(Q) = [0..1]
» 1 = Healthy
» 0 = Dead
– One dimension
• Adjusted life years (Y) for value quality of life
– QALY = Y * V(Q)
» Y: numbers of life years
» Q: health state
» V(Q): the value of health state Q
• Also called “utility analysis”
9
Which health care program is the
most cost-effective?
• A new wheelchair for elderly
–
–
–
–
–
–
Increases quality of life = 0.1
10 years benefit
Extra costs: $ 3,000 per life year
QALY = Y x V(Q) = 10 x 0.1 = 1 QALY
Costs are 10 x $3,000 = $30,000
Cost/QALY = 30,000/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
10
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
11
Car economics
• Should we spend our money on a
–
–
–
–
Suzuki Alto 1.0
BMW 316
Comparing costs
Comparing outcome
• Relate costs to outcome
– Cost per outcome
– Cost per kilometer
» Suzuki Alto 1.0
» BMW 316
12
Car league table
Car
€ / Km
Car
€ / Km
Suzuki Alto 1.0
0.24
Hyundai Lantra 1.5
0.47
Daihatsu Cuore 1.0
0.27
Opel Vectra 1.6
0.53
Hyundai Atos Multi 1.0
0.27
Citroën Xantia 1.8i
0.55
Renault Twingo 1.2 inj
0.28
Mazda 626 2.0
0.58
Daewoo Matiz
0.33
BMW 316
0.74
Cost per kilometre including gas, maintenance, debit, etc. Price level 2002.
Calculations based on over 2,5 years use and 40.000 km.
(Consumentenbond, Augustus 2003)
13
Egalitarian Concerns
1.0
0.0
A
B
C
14
Implications shifting threshold
• QALY are weighted
• Weighted QALYs are maximized
– Health is no longer the only thing maximized
• Health status population will drop
• Differences in health will drop
– Egalitarian consideration are incorporated
• Burden of disease becomes a criteria
– Equity
15
CE-ratio by equity
16
Burden of disease based on
STEP-data (N = 641)
1.0
0.8
0.6
0.4
0.2
0.0
Ho
oik
Ka
oo
lkn
rts
No
Os
P
Hy
Ho
Va
D
Be
Ar
CO
Pu
ter
ata iab
npe
g
teo ros
l
o
P
m
i
g
ete
nl
D
H
taa
ios
on
rte
fsl
ag
po
c
a
h
sm
tk
air odg
ns
cle
uit
ng
el
o
ro
l
l
kin
eh
ie
es
i
ac
sis
.P
ro
et
ter ng i
s
ht
s
y
c
i
y
p
s
o
nb
en
ol
ch
er
ten
ee mpli
ot
h
n
ca
sie
er
tie
ap
s
ie
17
Are health economic results
used?
• Must we be afraid of the uncontrolled use of QALY?
• QALY league table are difficult to make
– Largest at Harvard School of Public Health
– www.hsph.harvard.edu/organizations/hcra/cuadatabase/intro.html
» a comprehensive league table
» a catalogue of preference scores
• QALY league tables are not used
– At least not in The Netherlands
– There used to be a mysterious list in UK….
18
Health economic are used next
to other criteria
• Burden of disease
• Ethical constrains
• Financial constrains
19
Reimbursement arguments
• Dunning’s Funnel
– 1990
– Government declaration
2002
– Necessary care
» Need
» Equity elements
– Efficacy
– Cost effectiveness
– Own account and
responsibility
20
Reimbursement arguments
Impact on QoL
Effect on QoL
Cost effectiveness ?
1.0
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Patent graft
0.9
Symptomatic occlusion
Primary amputation
Secondary amputation
0.8
Cerebrovascular accident
QALYs
Myocardial infarction
Intake clinic psychotherapy
0.7
0.6
EQ-5D utilities
0.5
Int ake
1 year af t er
2 years
21