Interactive Introduction cost effectiveness

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Interactive Introduction cost effectiveness

• Jan J. v. Busschbach, Ph.D.
• Psychotherapeutic Centrum De Viersprong,
  Halsteren
• Jan.Busschbach_at_deviersprong.net
• 31 164 632200
• Department of Medical Psychology and
  Psychotherapy, Erasmus MC
• j.vanbusschbach_at_erasmusmc.nl
• 31 10 4087812

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New cancer therapy (1)
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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

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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 table
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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
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Egalitarian Concerns
1.0
Utility of Health
0.0
A
B
C
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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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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/cuadatabas
  e/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

• Dunnings 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 ?
QALYs