Adrian TowseDirector of the Office of Health EconomicsVisiting Professor London School of Economics

AES, June 2016

Equity Adjusted QALYs? QALYs and Equity

AES June 2016

Agenda: QALYs and equity

• What do we mean by equity?• Who gets treated? Lessons from the England

VBP saga• Are we picking up what matters to patients and

society?• What else should be in the “Value Framework”?

• Ill and impoverished? Extended CEA and income inequality in MLICs

• Summary

AES June 2016

What do we mean by equity?

Are we being fair?1. QALY = QALY = QALY? Do some

outcomes matter more?2. Opportunity cost. Are we being fair to

the patients with other conditions?3. How are we making decisions? Is the

process fair?4. Does the QALY pick up all of the

outcomes that matter?

AES June 2016

Agenda: QALYs and equity

• What do we mean by equity?• Who gets treated? Lessons from the

England VBP saga• Are we picking up what matters to patients and

society?• What else should be in the “Value Framework”?

• Ill and impoverished? Extended CEA and income inequality in MLICs

• Summary

AES June 2016

Lessons from the England VBP saga

VBP in England (as proposed by DH) aimed to do three things:1. Be very clear about which elements of

distributive justice that are included2. Weight QALYs and get rid of deliberation

• A disease severity adjustment to weight QALYs• A societal impact weighting converted into

QALYs at the citizen WTP for a QALY (£60K)3. Have weights ‹1 as well as ›1

AES June 2016

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But we have different meanings and therefore measures of equity (Culyer 2015)

a = equity = equal health (45o line from 0)b = equal health gain (45o line from E)c = QALY = QALY = QALY, i.e. QALY maximisationd = maintaining initial distribution of disease

burden (line through 0 and E) e = distribution in proportion to need (inverse of d) f = equal shares of resource

AES June 2016

AES June 2016

Extract from Table II. Disease weightings using different measures of burden and wider social benefits: top 3, displaced rate, and bottom three diseases

Proportionate shortfall

(% QALY loss) Absolute shortfall

(QALY loss)

Wider social benefits (net production)

C22 Liver cancer 73% C22 Liver cancer 10.7 M05 Rheumatoid arthritis

£30,034 

C25 Pancreatic cancer 73% C25 Pancreatic

cancer 9.97 E11 Diabetes £27,421 

C34 Lung cancer 71% C34 Lung cancer 9.68 M45 Ankylosing spondylitis £26,190

DisplacedAverage of displacedQALYs

8% DisplacedAverage of displacedQALYs

2.07 DisplacedAverage of displaced QALYs

£11,611

K50 Irritable Bowel Syndrome 1% L40 Psoriasis 0.19 C22 Liver cancer -£32,709

E66 Obesity 0% E66 Obesity 0.18 C34 Lung cancer -£36,067

M45 Ankylosing spondylitis 0% M45

Ankylosing spondylitis 0.11 C25 Pancreatic

Cancer -£53,860

Source: Claxton et al., 2015

AES June 2016

The impact of different “equity” weights

• We can see from the previous two slides that different equity adjustments can have very different impacts on weights;

• This may be entirely appropriate – society has a complex set of equity considerations

• However, it creates a highly contested terrain – criteria included and choice of measurement really matter

• This raises the question as to how explicit and algorithmic should the weighting be?

AES June 2016

In the absence of a specified (agreed) social welfare function (SWF) we need a fair process

Accountability for Reasonableness (Daniels 2000) • ”In the absence of a consensus on principles [or

measurement], a fair process allows us to agree on what is legitimate and fair.”

• Key elements of a fair process will involve:• “Transparency about the grounds for decisions• Appeals to rationales .. that all can accept as

relevant..• Procedures for revising decisions in the light of

challenges to them..”

AES June 2016

Weighting QALYs versus a deliberative process versus MCDA?• Weighting QALYs using pre-set weights requires agreement on:

• Measurement issues• The things that matter and the binding weights to be applied -

this part of the SWF is known• Measurement of the things that matter is essential to support a

deliberative process• Given hard data on health system costs and on health gain, but

on nothing else, the Appraisal Committee will focus on incremental system cost per unit of health gain

• MCDA offers a route to structured deliberation that meets the criteria of “Accounting for Reasonableness”

• It can combine pre-set weights with deliberation on other measured and unmeasured things that matter

• The challenges are methodological (in particular opportunity cost) and practicality (how much time will it take?)

AES June 2016

Lessons from the VBP saga• Moving from listing the things that matter to measuring

them to weighting them are three very different steps• But we know that listing but not measuring means it is

very hard for Appraisal Committees to take things into account – so we need to measure

• Weighting in any form makes the Social Welfare Function explicit and will generate a backlash

• A fair process is therefore required which combines elements of societal weighting and a structured deliberative decision making process

• We have to recognise that this makes it harder to be fair to the patients not in the room if we have a fixed budget

AES June 2016

Agenda: QALYs and equity

• What do we mean by equity?• Who gets treated? Lessons from the England

VBP saga• Are we picking up what matters to

patients and society?• What else should be in the “Value

Framework”? • Ill and impoverished? Extended CEA and income

inequality in MLICs• Summary

AES June 2016

What else could or should be in the “Value Framework”?

To go beyond QALYs one could have • Better measure of health, disease/condition-

specific, EQ-5D bolt-ons (Yang et al. 2015)• Broader measure of benefit• Societal perspective, e.g. productivity losses

and carer effects

AES June 2016

Capability ApproachAmartya Sen awarded the Nobel prize in economics, 1998When assessing quality of life, the object of the assessment should be people’s capabilities, intended as the real freedom that people have to live the life they valueA crucial normative argument that quality of life should not be measured as opulence or utility and should not be assessed using people’s preferences or desires but should concern people’s capabilities

• the abilities to achieve those ‘beings and doings’ that people have reason to value in life (Sen 1993)

AES June 2016

Sen (1998) view of “the Standard of Living”

GoodsCharacter- istics, attributes

Environment (physical, political, social)

CapabilitiesImpact

Utility

AES June 2016

Operationalising the Capability Approach

• Early work by Sen on the Human Development Index• Wide adoption in development and gender studies• Informed Tony Culyer’s contribution to the progress of

extra-welfarism and the subsequent development of the QALY framework (Culyer, 1990)

• Most recently operationalised as an outcome measure (Lorgelly, 2015)

• ICECAP suite of instruments• ASCOT• OCAP, OCAP-18, OxCAP-MH• Targeted instrument development

AES June 2016

Empowerment: Payne, McAllister, Davies 2012

AES June 2016

Garrison, L., Mestre-Ferrandiz, J. and Zamora, B., OHE and EPEMED, Forthcoming, June, 2016

AES June 2016

What has this got to do with equity?• If a QALY ≠ QALY ≠ QALY, then other outcomes

will also impact on equity considerations• We need to keep all of this in context – there is a

proportionality test. As Payne and Thompson (2013) state:• The “availability of other approaches to value benefit

is a necessary but not sufficient requirement for moving beyond the QALY. It is not controversial to suggest that the alternatives to the QALY should only be used if they offer sufficient improvements to the existing valuation metric’’

AES June 2016

Agenda: QALYs and equity

• What do we mean by equity?• Who gets treated? Lessons from the England

VBP saga• Are we picking up what matters to patients and

society?• What else should be in the “Value Framework”?

• Ill and impoverished? Extended CEA and income inequality in MLICs

• Summary

AES June 2016

Extended CEA (ECEA) • Builds on earlier work by Peter Smith • Particular application in the context of moves to universal

health coverage (UHC) in Middle and Low Income Countries (MLICs) in which HTA plays an important role

• Adds to incremental cost / health gain with:• Value of insurance against financial risks• Crowding out private out-of-pocket expenditure (saving

people money) • Distributional consequences of the health gain

• But does not aggregate (no weightings) and does not include societal impact including productivity effects

• Examples: Verguet et al. (2015) and Levin et al. (2015)

AES June 2016

Agenda: QALYs and equity

• What do we mean by equity?• Who gets treated? Lessons from the England

VBP saga• Are we picking up what matters to patients and

society?• What else should be in the “Value Framework”?

• Ill and impoverished? Extended CEA and income inequality in MLICs

• Summary

AES June 2016

Summary• Moving from listing the things that matter to measuring

them to weighting them are three very different steps• Weighting in any form makes the Social Welfare Function

explicit and will generate a backlash• A fair process is therefore required which combines

elements of societal weighting and a structured deliberative decision making process

• Moving “beyond QALYs” is inevitable but (i) we have to apply a proportionality test and (ii) it will compound the weighting problem:

• Extended CEA is an example where the elements of additional benefit can be measured but there is no easy way to generate weights

AES June 2016

ReferencesClaxton K, Sculpher M, Palmer S, Culyer AJ (2015). Causes for concern: is nice failing to uphold its responsibilities to all NHS patients? Health Economics. 2015 Jan 7;24(1):1-7.

Culyer AJ (1990). Commodities, characteristics of commodities, characteristics of people, utilities, and the quality of life, Routledge: London.

Culyer A (2015). Equity and Efficiency. http://www.ispor.org/Event/ReleasedPresentations/2015Santiago

Daniels N (2000). Accountability for reasonableness. British Medical Journal 2000;321:1300–1

Levin C, Sharma M, et al. (2015). An extended cost-effectiveness analysis of publicly financed HPV vaccination to prevent cervical cancer in China. Vaccine 33 (2015) 2830–2841

Lorgelly P (2015). Choice of Outcome Measure in an Economic Evaluation: A Potential Role for the Capability Approach. PharmacoEconomics. 2015 Aug 1;33(8):849-55.

McAllister M, Dunn G, Payne K, Davies L, Todd C (2012). Patient empowerment: The need to consider it as a measurable patient-reported outcome for chronic conditions. BMC health services research. 2012;12(1). 157

Payne & Thompson (2013). Economics of pharmacogenomics: rethinking beyond QALYs? Curr Pharmacogenomics Pers Med. 2013;11(3):187–95.

Sen A (1993). Capability and well-being. In: Nussbaum, MC, Sen A (eds.), The Quality of Life. Clarendon Press: Oxford

Sen A (1988) The Standard of Living. Cambridge University Press

Towse A and Barnsley P (2013) Clarifying meanings of absolute and proportional shortfall with examples. Available at https://www.nice.org.uk/Media/Default/About/what-we-do/NICE-guidance/NICE-technology-appraisals/OHE-Note-on-proportional-versus-absolute-shortfall.pdf

Verguet S, Laxminarayan R, Jamison DT (2015). Universal public finance of tuberculosis treatment in India: an extended cost-effectiveness analysis. Health Economics 2015; 24(3):318-332.

Yang et al. (2015). An exploratory study to test the impact on three “Bolt-On" items to the EQ-5D. Value in Health, 2015; 18(1): 52-60.

Adrian TowseThe Office of Health Economics

Registered address Southside, 7th Floor, 105 Victoria Street, London SW1E 6QT

Website: www.ohe.org  Blog: http://news.ohe.orgEmail: atowse@ohe.org

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