1. Interactive Introduction cost effectiveness Jan J. v. Busschbach, Ph.D Viersprong Institute for studies on Personality Disorders (VISPD) Jan.Busschbach@deviersprong.nl +31 164 632200 Department of Medical Psychology & Psychotherapy, Erasmus University Medical Center

2. 2 New cancer therapy SymptomsDrug XDrug Y Survival days 300 400 Days sick of chemotherapy 10 150 Days sick of disease 100 30 TWiST 190 220

3. 3 Time Without Symptoms of disease and subjective Toxic effects of treatment TWiST –Developed by Richard 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

4. 4 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

5. 5 TWiST: ignores differences in quality of life TWiST –Healthy = 1 –Sick (dead) = 0 There is more to life than sick/health –Make intermediate values –Q-TWiST Quality of life adjusted adjusted TWiST How to scale quality of life? 0.0 Quality of life 1.0

6. 6 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

7. 7 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) =.80

8. 8 EuroQol EQ-5D: of the shelf QALY value 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

9. 9 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”

10. 10 A new wheelchair for elderly (iBOT) Special post natal care Which health care program is the most cost-effective?

11. 11 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

12. 12 Effect psychotherapy

13. 13 Example STIP Short-Term Inpatient Psychotherapy Cost price –Per patient day: € 210.34 –3 mouths = 91.3 day –91.3 x 210 = € 19,194.53 Includes overhead –Buildings, administration, etc Excluding –Savings elsewhere in health care system Effect –Assume quality of life increase of 0.25 –Over 10 year Cost / QALY –19,194.54 / (10 x 0.25) = € 7,677.41 Although gold standard… Cost per QALY of psychotherapy have never been published

14. 14 QALY league table

15. 15 1.0 0.0 ABC Utility of Health Egalitarian Concerns: Burden of disease

16. 16 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

17. 17 CE-ratio by equity

18. 18 Burden of disease based on STEP-data (N = 641)

19. 19 Conclusion Introduce state-of-the-art cost effectiveness studies –Measure costs and outcome Suitable for cost effectiveness studies According to guidelines Establish burden of disease –State-of-the-art quality of life research Use an active approach on budget constrains –Anticipate on policy arguments –Look for beyond own discipline