1. Justice and Economic Evaluation Prof. Dr. Jan Busschbach j.vanbusschbach@erasmusmc.nl +31 10 7043807 1

2. Equity concerns  In cost per QALY…  Patients with low cost, high gains win…  But the general public wants that …  Patients with the highest need win …  Irrespectively the capacity to benefit….  A higher burden relates to more health care 2 Erik Nord on the fairness in distributing health care resources ISPOR Berlin 2012

3. Only Equity?  All resources to the highest burden?  What about the others?  What about waste resources?  Doesn’t effectiveness count?  “It should be a combination”  Erik Nord: Obviously,….. of course! 3

4. What does ‘need’ mean?  Need can mean:  The availability of a (cost-)effective treatment  “Burden”  Low life expectancy  Low quality of life  WHO  The Burden of Disease Project  Which people have the highest ‘need for health care’ Low life expectancy Low quality of life 4

5. WHO: Burden of disease  DALY  “Need” for health care  Disability adjusted life year  = QALY lost  Need defined by  Fixed lifespan  Max QoL  Lost in lifespan and QoL  “Fair innings” 5 DALY QALY

6. 1.0 0.0 ABC Kwaliteit van leven Falsification QALY 6 Efficiency Equity Life years

7. ABC Falsification of life years 7 80 0 Life years 60 40 20

8. 8 80 0 ABC Life Years & QoL Threshold costs/QALY: indicator of solidarity 8 60 40 20 € 50.000 € 30.000 € 40.000

9. 9 Costs/QALY versus Burden of disease 9 € 80.000 € 60.000 € 40.000 € 20.000 € 0 Burden of disease X X X X X

10. 10 Dutch Council for Public Health and Health Care (RvZ, 2006) 10

11. 11 Does this make Erik a happy man?

12. Rule of rescue  What if cancer occurs at 80 years of age?  “Fair innings” foregone?  No treatment?  Age discrimination?  QALY was already suspected  Rule of rescue  Severity of illness  More severe…. …. More priority 12 DALY QALY

13. 13 Fair Innings vs Rule of Rescue  Fair innings  What have you already got?  How good has it been?  Loss in QALYs  Rule of Rescue  Severity of illness  How bad is it now?  Expected QALYs Life expectancy…. But what if the severity of illness is a result of old age? Discriminate the old?

14. 14  Compares loss in QALY with expected QALY  Combines fair innings with rule of rescue  The more you loss of what you had expected…  André Ament Proportional short fall Prop. Short Fall = 25%Prop. Short Fall = 50%Prop. Short Fall = 60% QALY lostQALY gain Life expectancy QoL  Prop. Short Fall = 50% Now Life expectancy

15. the old and disabled 15

16. Implementation 16

17. Strengths and limitation  Combines two definitions of equity  Fair innings  Rule of rescue  Little data necessary  Might overcompensate  The old  The severe ill  Seen as complex…  Might not capture everything… 17

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