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Interactive Introduction cost effectiveness

• Jan J. v. Busschbach, Ph.D.

• Psychotherapeutic Centrum ‘De Viersprong’, Halsteren

– Jan.Busschbach@deviersprong.net

– +31 164 632200

• Department of Medical Psychology and Psychotherapy, Erasmus MC

– j.vanbusschbach@erasmusmc.nl

– +31 10 4087812

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New cancer therapy (1)

Symptoms of illnessDrug x

(days)Drug Y

(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

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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

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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

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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?

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EuroQol EQ-5D

• 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

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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

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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

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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”

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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

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QALY league tableIntervention $ / 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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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

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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)

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1.0

0.0A B C

Uti

lity

of

Hea

lth

Egalitarian Concerns

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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

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CE-ratio by equity

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0.0

0.2

0.4

0.6

0.8

1.0

Hooikoorts

Kalknagel

Osteoporosis

Prostaat klachten

Hypertensie

Hoog cholesterol

Vaatafsluiting in been

Diabetes met complicaties

Begin lang. Psychotherapie

Arteriosclerosis

COPDPulmonaire hypertensie

Non-Hodgkin

Burden of disease based on STEP-data (N = 641)

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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….

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Health economic are used next to other criteria

• Burden of disease

• Ethical constrains

• Financial constrains

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Reimbursement arguments

• Dunning’s Funnel– 1990

– Government declaration 2002

– Necessary care

» Need

» Equity elements

– Efficacy

– Cost effectiveness

– Own account and responsibility

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Reimbursement arguments

Impact on QoL

Effect on QoL

Cost effectiveness ?

0.5

0.6

0.7

0.8

0.9

1.0

Intake 1 year after 2 years

QALYs

00.10.20.30.40.50.60.70.80.9

1

EQ-5D utilities

Patent graft

Symptomatic occlusion

Primary amputation

Secondary amputation

Cerebrovascular accident

Myocardial infarction

Intake clinic psychotherapy