quality of life and cost-effectiveness an interactive introduction
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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 300 400
Days sick of chemotherapy 10 150
Days sick of disease 100 30
TWiST 190 220
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
0.0
Quality of li
fe
1.0
Visual Analogue Scale
Does the scale fit Q-TWIST? Is 2 days 0.5 = 1 day 1.0?
6
Dead
Normal health
X?=
Example Blindness
Time trade-off value is 0.5
Life span = 80 years
0.5 x 80 = 40 QALYs
Quality Adjusted Life Years (QALY)
7
0.00
1.00
X
Life years40 80
0.5 x 80 = 40 QALYs
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
A new wheelchair for elderly (iBOT) Special post natal care
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
Which health care program is the most cost-effective?
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
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0
100
200
300
400
500
600
700
800
900
1980 1985 1990 1995 2000 2005 2010 2015
Pu
blic
ati
on
s
Key words: 1980[pdat] AND (QALY or QALYs)
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 utility analysis
Makes comparisons possible between diseases
Cost per effect 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 Lambert N = 400
Kim de Jong et al in press
Erasmus MC
…and gives better results
32
Feed back
Non feed back
Conclusion
Holy grail Formal cost effectiveness analysis (CEA)
Costs per QALY
Holy grail might be too expensive 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
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