Transcript HEAD 2012

Quality of life and Cost-Effectiveness
An Interactive Introduction
Prof. Jan J. v. Busschbach, Ph.D.
Erasmus MC
Medical Psychology and Psychotherapy
Viersprong Institute for studies on Personality Disorders
New cancer therapy
Symptoms
Drug X
Drug Y
Survival days
Days sick of chemotherapy
Days sick of disease
TWiST
300
10
100
190
400
150
30
220
Time Without Symptoms of disease and
subjective Toxic effects of treatment: TWiST
 Richard
Gelber
 statistician
 Count
…
 Days not sick from treatment
 Days not sick from disease
3
Fit new therapy in fixed budget


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
TWiST: ignores differences
in quality of life
 TWiST
 Healthy = 1
 Sick (dead) = 0
 Q-TWiST

• Quality of life adjusted TWiST
Make intermediate values
• 1.0; 0.75; 0.50; 0.25; 0.00
 How
to scale quality of life?
5
Visual Analogue Scale
Normal
health
 Does
the scale fit Q-TWIST?
 Is 2 days 0.5 = 1 day 1.0?
?
X
=
Dead
6
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
7
Time Trade-Off
 Wheelchair
 With a life expectancy: 50 years
 How
many years would you trade-off for a
cure?
 Max. trade-off: 10 years
 QALY(wheel)
= QALY(healthy)
 Y * V(wheel) = Y * V(healthy)
 50 V(wheel) = 40 * 1.00
 V(wheel)
= 0.80
8
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”
Q-TWiST = QALY
 Several
initiatives early seventies
 Epidemiologist and health economists
 Part
of QALY concept
 Quality Adjusted Life Years
 QALY = Q-TWiST
10
Area under the curve
Which health care program is
the most cost-effective?

A new wheelchair for elderly (iBOT)
 Special post natal care
www.ibotnow.com
Dean Kamen
Segway
13
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: $ 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
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
STIP: Short-term inpatient psychotherapy
7,677
Breast cancer screening
5,147
Viagra
5,097
Treatment of congenital anorectal malformations
2,778
6000 Citations in 2009
Publications
Key words: 1980[pdat] AND (QALY or QALYs)
900
800
700
600
500
400
300
200
100
0
1980
1985
1990
1995
2000
2005
2010
2015
16
Orphan drugs
 Pompe
disease
 Classical form: € 300.000 – 900.000 per QALY
 Non classical form: up to € 15.000.000 per QALY
 If maximum = € 80.000
• Ration is almost 1:200
 Low
cost effectiveness but…
 High burden
 Low prevalence
 Little own influence on disease
 High consensus in the field
• Coalition patient, industry, doctors and media
• Low perceived incertainty
17
Light version cost effectiveness
 Formal
cost effectiveness is expensive
 Is there a light version?
What do we have?
 Costs
 Patient
count
 Costs per Patient
 DBC
/ DOT
 Cost per DBC
 TWiST
 Costs per Time without psychosis
 Costs per Time in normal health
 Cost per Recovered patient
 Routine
Outcome Monitoring (ROM)
 Could be of help here
Routine Outcome Monitoring
 ROM
has the potential of
 Cost per ‘outcome’ ratio
 Difficulties
getting data at end of treatment
20
Cost effectiveness
 Cost
benefit
 Benefit in monetary terms minus cost
 Can seldom be done in health care
• What is the value of a life year
 Cost
per QALY
 Cost
per effect
 Cost utility analysis
 Makes comparisons possible between diseases
 Cost effectiveness
 Like: Cost per cure
 Stays within one disease
Improve cost effectiveness
 Other
ways to improve cost effectiveness
 Insight in costs
 Stop rules
22
Costs often unknown…
 Cost
price therapy is mostly unknown in
metal health
 No insight in costs of components therapy
 Typically salary + fixed overhead (for instance 37%)
Activity Based Costing can help
24
Insights in costs will allow for…
 Informal
cost effectiveness analysis
 Which therapy is most cost effective?
 Assumes that outcomes / patients are sufficient comparable
 Effects
 Cost per ‘cure’
 Cost per increase on a specific scale
 Cost per DBC
25
Weighting components
 Which
components of therapy contribute
most to the cost price?
 Does this ranking relates to the indented
effects?
 Benchmark
26
Stop rules
 We
seem to know when a therapy is needed
 But do we know when to stop?
 If all the ‘potential’ of the patient is reached?
Within social health insurance
 Reasonable
stop rules might be:
 When no progress is made anymore
 When the patient is comparable with the general population
• > 5 – 10%
28
Monitor the patient
 ….frequently
during therapy
 Looks like Routine Outcome Measure
 but with a high frequency
29
Position patients versus
normal population
30
Monitoring reduces the number
of treatments
 Michael
N
= 400
Lambert
 Kim de Jong et al in press
 Erasmus MC
…and gives better results
Feed back
Non feed back
32
Conclusion
 Holy
grail
 Holy
grail might be too expensive
 Formal cost effectiveness analysis (CEA)
 Costs per QALY
 Formal cost effectiveness is indeed expensive
 Informal
CEA might already reveal much
 Cost per treatment
 Cost per successful treatment
 There
is a need for real cost prices
 Especially price of components
 To start bench mark procedure