1. Big Q and Little Q revisited Christopher McCabe PhD Capital Health Endowed Research Chair in Emergency Medicine Research

2. Acknowledgements Capital Health Research Chair Endowment, UK National Institute for Health Research. Co-authors: D.Meads, C Czoski-Murray, C. Rutherford, C. Dealey, E. McGinnis, N. Stubbs, L. Wilson, J. Nixon, C. Hulme (Universities of Leeds and Sidney, Leeds Community Health Care NHS Trust)

3. Overview PROs and Value Based Reimbursement Decisions Generic vs. Condition specific PROs Q from EQ-5D or Q from PuQol_UI Implications for Reimbursement Conclusion

4. PROs in Reimbursement Preference-based PROs = Q in the QALYs. QALYs = value in value based decision making. Value = index used to choose what to pay for.

5. 0 Health care expenditures QALYs per $1,000 A model of CEA based reimbursement Current treatments covered by health care system Budget Treatments not covered by the health care system Better value Worse value Willingness to Pay

6. 0 Budget Willingness to Pay New Willingness to Pay QALYs per $1,000 Health care expenditures A model of CEA based reimbursement

7. Condition Specific PRO: PuQol_UI

8. Generic: EQ-5D-3L Five Dimensions: Mobility, Self Care, Usual Activities, Pain, Anxiety and Depression Three response levels No problems Some problems Sever problems/unable

9. PuQol_UI vs EQ-5D N= 100 Sex49% Female Mean age (range)77.2 (22.7-101.7) Wheelchair users50% PU Grade Superficial (grades 1-2)54% Severe (grades 3-4)46%

10. Mean Utilities by Pressure Ulcer Severity Mean (SD) SuperficialSevere PUQoL-UI0.72 (0.17)0.67 (0.17) EQ-5D0.24 (0.36)0.15 (0.38)

11. Big Q and Little Q EQ-5D Best Health State No problems walking about No problems with self care No problems with performing my usual activities I have no pain or discomfort I am not anxious or depressed PUQol_UI Best Health State I have no bother at with annoying pain and discomfort I have no bother adjusting myself in bed I have no bother with washing myself I have no bother with reduced energy levels I have no bother with feeling depressed I have no bother with feeling like a burden or a nuisance I have no bother with going out

12. Big Q and Little Q EQ-5D Worst Health State Confined to bed I am unable to wash or dress myself I am unable to perform my usual activities I have extreme pain or discomfort I am extremely anxious or depressed PUQol_UI Best Worst State I have a lot of bother at with annoying pain and discomfort I have a lot of bother adjusting myself in bed I have a lot of bother with washing myself I have a lot of bother with reduced energy levels I have a lot of bother with feeling depressed I have a lot of bother with feeling like a burden or a nuisance I have a lot of bother with going out

13. Question Does anyone think these are equivalent scales?

14. Valued Effect per $1,000 0 Health care expenditures QALYs per $1,000 Changing the Value Index: Implications for Reimbursement Current treatments covered by health care system Budget Treatments not covered by the health care system Better value Worse value Willingness to Pay

15. Valued Effect per $1,000 0 Health care expenditures Current treatments covered by health care system Budget Treatments not covered by the health care system Better value Worse value Willingness to Pay Changing the Value Index: Implications for Reimbursement

16. Valued Effect per $1,000 0 Health care expenditures Changing the Value Index: Implications for Reimbursement Current treatments covered by health care system Budget Treatments not covered by the health care system Better value Worse value Willingness to Pay

17. Valued Effect per $1,000 0 Health care expenditures Changing the Value Index: Implications for Reimbursement Current treatments covered by health care system Budget Treatments not covered by the health care system Better value Worse value Willingness to Pay

18. Valued Effect per $1,000 0 Health care expenditures Changing the Value Index: Implications for Reimbursement Current treatments covered by health care system Budget Treatments not covered by the health care system Better value Worse value Willingness to Pay

19. Equity and PROs in Reimbursement Vertical – Treating unequals Unequally Horizontal – Treating equally Equally

20. Conclusion Using PROs in Reimbursement Decision Process – Promote ‘apples vs oranges’ decisions – Impede both vertical and horizontal equity HANDLE WITH CARE