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ARCC
Canadian Centre for Applied Research in Cancer Control
Cancer care decision-makers’ perspectives on
quality-adjusted life years (QALYs)
for decision-making and resource allocation
Elena Papadakis
Vancouver, BC
Presentation Outline
1.
2.
3.
4.
5.
6.
7.
Evidence-based Marginal Analysis (EBMA)
Quality-adjusted Life Years (QALYs)
Objectives
Methods & Perspective Types
Results
Discussion
Summary
Evidence-Based Marginal Analysis (EBMA)
PBMA
Five Program Areas
Define aim and
scope
1. Adjuvant trastuzumab
(Herceptin) in breast cancer
Determine current
program budget
Form Steering
Committee
2. Bevacizumab (Avastin) in
metastatic colorectal cancer
EBMA
For each area identified:
Establish decisionmaking criteria
Identify areas
for new
resource use
Identify areas
for resource
release
Form Advisory
Panel
3. Mammography for women
with dense breast tissue
4. PET-CT for NSCLC staging
Collect local
costs/outcomes
Make allocation
recommendations
Build Markov
model
Validity check and
final decisions
CEA using
QALYs
5. MRI for breast cancer
screening
Quality-adjusted Life Years (QALYs)
A QALY is a health outcome
measure that combines survival
and quality-of-life into a single
metric
Today’s Presentation
Objective: To explore decisionmakers’ views and attitudes towards
QALYs for decision-making and
resource allocation in cancer care
Methods
Data Collection
Purposeful sampling strategy
20 decision-makers
Hour-long, semi-structured interviewing
Data Analysis
Transcribe interviews verbatim
Code interview transcripts manually
Organize codes into themes and subthemes
Upload codes onto NVivo 2008
Perspective Types
Gender
Years Exp. Health
Care
Years Exp. Prioritysetting
Age
16 +
6 - 15
0-5
16 +
6 - 15
Type
No.
0-5
Clinical
9
5M
4F
35-65
7
2
-
2
2
5
Managerial
8
3M
5F
35-65
3
5
-
-
5
3
Scientific
3
3M
0F
35-65
3
-
-
1
2
-
Total
20
11M/9F
35-65
13
7
-
3
9
8
Results:
Familiarity with QALYs
EP: On a scale from one to five, what was your understanding
of a QALY prior to the advisory panel meetings?
DM 116: A QALY?
EP: Yes a QALY.
DM 116: Oh you’re attacking my memory. Managerial
Understanding of QALYs Prior to EBMA Program Areas
Low
Average
High
→
→
→
40%
15%
45%
Results:
Relevance of QALYs
“On a scale from one to five, one being the lowest, five being the
highest, how relevant are QALYs to decision makers at BCCA?”
Unaware
Low
Average
High
→
→
→
→
15%
20%
25%
40%
“What counts as evidence when setting priorities in decisionmaking and resource allocation?”
One decision-maker cited “quality-of-life” data as
evidence
Results:
Emergent Themes
EP: How relevant are QALYs to decision-makers
at the BC Cancer Agency?
DM 123: My own concern is the quality
adjustment is often based on some pretty flimsy
data … The quality-adjustment is not exactly
flaky but certainly it’s very imprecise … It’s often
based on small samples in fairly restricted
situations. Managerial w/ scientific exp.
Results:
Emergent Themes
DMs’ attitudes towards QALYs linked to perspectives on QoL
data
QoL data are not as robust as they could be (4)
Results:
Emergent Themes
EP: How relevant are QALYs to decision-makers
at the BC Cancer Agency?
DM 117: For curative I don’t think it’s a big deal.
People are willing to go through hell to get cured.
Now for palliative, it’s really all about QALY.
Managerial w/scientific exp.
Results:
Emergent Themes
DMs’ attitudes towards QALYs linked to perspectives on the
value of longevity versus the value of quality-of-life
Longevity valued above quality-of-life (14)
1. Curative interventions take precedence over palliative ones (8)
2. People who have curable conditions are willing to suffer (1)
3. Clinicians are not convinced that quality-of-life is the most valuable endpoint (5)
Results:
Emergent Themes
EP: Your thoughts on pain management drugs as
a part of BC Cancer Agency’s budget?
DM 129: I think that the BC Cancer Agency has
been very, very narrow-minded in terms of its role
… I think we could do better with end-of-life … If
we are cancer doctors, we look after the whole
spectrum, we don’t just look after the narrow
spectrum. Clinical
Results:
Emergent Themes
Decision-makers recognize that QoL is an important part of
cancer care
QoL is very important (36)
1. Symptomatic relief and palliation are highly valuable in cancer care (12)
2. Since the majority of cancers are incurable, it would be unreasonable not to
be involved in palliative care (3)
3. QoL is part of the cancer spectrum & should be factored into D-M (8)
4. Conventional cancer care could put more emphasis on palliation (4)
5. Curative interventions only valued higher than palliative ones provided they
improve QoL at the same time (1)
6. An element of humanity and compassion must be accounted for in D-M (4)
7. It doesn’t matter whose budget palliative drugs come from so long as they
are available to the people who need them (4)
Discussion
 Scholarship suggests that health care decision-makers have
limited training in economic methods.
 The perception that quality-of-life data are not as robust as
they could be means that QALYs are perceived by some as
being a poor source of evidence.
 The tendency among decision-makers to value longevity
above quality-of-life means that the applicability of QALYs to
cancer care may not be fully appreciated at this time.
Discussion
 Decision-makers recognize that conventional cancer care
does not put as much emphasis on palliative care as it does
on treatment.
 Psychological, emotional and spiritual dimensions of
human health are not central to biomedical explanations of
cancer.
 Palliative interventions might fare better in decisionmaking and resource allocation contexts if a more balanced
approach to cancer care was more pervasive.
Summary
 Quality-of-life is an important part of cancer care but some
decision-makers are reluctant to embrace QALYs because of the
perception that quality-of-life data are not as robust as they could
be.
 Efforts to improve decision-makers’ perceptions of quality-of-life
data could bolster their confidence in QALYs, however competing
judgments about the value of longevity versus the value of qualityof-life are likely to persist.
 A more balanced approach to cancer care could potentially boost
the perceived value of quality-of-life and ultimately the
applicability of QALYs to cancer care.
Acknowledgements
Co-authors
Dr. Stuart Peacock
Decision-makers and content experts
EBMA Steering Committee
EMBA Screening Mammography, Trastuzumab, PETCT, MRI, and Bevacuzimab Advisory Panels
Funding agencies
Canadian Institutes of Health Research
Michael Smith Foundation for Health Research