1. 1 Interactive Introduction cost effectiveness Jan J. v. Busschbach, Ph.D. Psychotherapeutic Centrum ‘De Viersprong’, Halsteren –Jan.Busschbach@deviersprong.net –+31 164 632200 Department of Medical Psychology and Psychotherapy, Erasmus MC –j.vanbusschbach@erasmusmc.nl –+31 10 4087812

2. 2 New cancer therapy (1)

3. 3 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

4. 4 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

5. 5 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?

6. 6 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 –I am extremely anxious or depressed

7. 7 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

8. 8 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

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 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

11. 11 QALY league table

12. 12 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

13. 13 Car league table

14. 14 1.0 0.0 ABC Utility of Health Egalitarian Concerns

15. 15 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

16. 16 CE-ratio by equity

17. 17 Burden of disease based on STEP-data (N = 641)

18. 18 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/cuadatabase/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….

19. 19 Health economic are used next to other criteria Burden of disease Ethical constrains Financial constrains

20. 20 Reimbursement arguments Dunning’s Funnel –1990 –Government declaration 2002 –Necessary care »Need »Equity elements –Efficacy –Cost effectiveness –Own account and responsibility

21. 21 Reimbursement arguments Impact on QoL Effect on QoL Cost effectiveness ? QALYs