“Introduction to Patient Preference Methods used for QALYs” Presented by: Jan Busschbach, PhD, Chair Section Medical Psychology and Psychotherapy, Department of Psychiatry, Erasmus MC, Rotterdam The Netherlands Saturday, 2 November 2013

Utility Measurements Preference-based Techniques  Prof. Dr. Jan J.V. Busschbach  Erasmus MC  Department for Medical Psychology and Psychotherapy  Saturday, 2 November 2013: 14: :00 2

Program before the break  14:00 – 14:30 Introduction + questions  (Presentation 1)  14:30 – 15:30 Indirect utility measurement  Lecture: Introduction EQ-5D, HUI and SF-36 in QALYs (Presentation 2)  Exercise: Indirect utility measurement (Exercise 1)  Lecture continued: EQ-5D, HUI and SF-36 in QALYs (Presentation 2 continued)  The difference between patient and social perspective (Presentation 3)  15:30 – 16:00 Direct utility measurement  Lecture: Direct utility measurement: The validity of Standard Gamble, Time Trade-Off and Visual Analogue Scale (Presentation 4)  16:00 – 16:15 Break 3

Program after the break  16:15 – 17:00 Direct utility measurement  Exercise: Direct utility measurement (Exercise 2)  Discussion: which instrument when to use?  17:00 – 17:15 Disease specific utility measurement  Lecture: Disease specific instruments for QALY-analysis + Person Trade-Off (Presentation 5)  17:15 – 17:45 Cultural differences  (Presentation 7)  17:45 – 18:00 Round up 4

Citations in PubMed

Identification of major problems  Issues ed by participants  What topics in quality of life research are most relevant/interesting for you and/or your work? 6

Health Economics  Comparing different allocations  Should we spent our money on Wheel chairs Screening for cancer  Comparing costs  Comparing outcome  Outcomes must be comparable  Make a generic outcome measure 7

Outcomes in health economics  Specific outcome are incompatible  Allow only for comparisons within the specific field Clinical successes: successful operation, total cure Clinical failures: “events” “Hart failure” versus “second psychosis”  Generic outcome are compatible  Allow for comparisons between fields Life years Quality of life  Most generic outcome  Quality adjusted life year (QALY) 8

 Example  Blindness  Time trade-off value is 0.5  Life span = 80 years  0.5 x 80 = 40 QALYs Quality Adjusted Life Years (QALY) X Life years x 80 = 40 QALYs

Area under the curve

Which health care program is the most cost-effective?  A new wheelchair for elderly (iBOT)  Special post natal care 11

12 SegwayDean Kamen

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: $ 4,000 per life year  QALY = Y x V(Q) = 10 x 0.1 = 1 QALY  Costs are 10 x $3,000 = $30,000  Cost/QALY = 40,000/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 13

QALY league table 14

 QALYs are measured in an invalid way  Life years is not the problem, thus…  It must be the validity of quality of life assessment…  One should not use cost effectiveness  Often referred to as ‘ethics’ Two points of critique 15

16 CB Utility of Health Eric Nord: Egalitarian concerns AB

Burden as criteria 17 Pronk & Bonsel, Eur J Health Econom 2004, 5:

80 0 ABC Levensjaen Costs/QALY as indicator of solidarity € € €

Costs/QALY versus Burden of disease 19 € € € € € 0 Burden of disease X X X X X

Dutch Council for Public Health and Health Care (RvZ, 2006) 20

Burden of disease: QALY lost = DALY (Disability adjusted life year) DALY QALY

Burden of disease expressed as “QALY lost” = DALY  Disability adjusted life years  The inverse of QALY  Used by the WHO  Expresses burden of disease  Measure of priority  More burden, more investment  QALY lost (DALY) = Measure of solidarity 22

QALY: both for effectiveness and solidarity  Evaluations assess cost-effectiveness in term of cost/QALY  But many decisions can not be explained by cost/QALY  Explanation in terms of fairness  People disagree with distributional implications of QALY maximisation  Fairness is burden of disease  Burden of disease is QALY lost (DALY) 23

QALY debate  Fairness is the issue in the QALY debate  QALY measurement is the straw man  Complex metric discussion  QALYs are needed to operationalize fairness  Most debate about quality of life assessment  That debate = rest of the course 24

Most debate about the QoL estimates  Unidimensional QoL  In QALY we need a unidimensional assessment of Quality of life  Rules out multidimensional questionnaires  SF-36, NHP, WHOQOL 25

Direct utility assessment  SG, TTO, PTO, VAS 26

Indirect utility assessment  HUI, EQ-5D, AQoL, 15D, Rosser index 27 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