1. QALYs and Ethics Is there an ethical / valid alternative?
Prof. dr. Jan van Busschbach 1

2. Arguments reimbursement
Pro
Contra
Effectiveness
Compassion
Solidarity
Empathy
Costs
Cost effectiveness

3. Health Economics Comparing different allocations
Should we spend our money on
Wheel chairs
Screening for cancer
Comparing costs
Comparing outcome
Outcomes must be comparable
Make a generic outcome measure

4. Outcomes in health economics
Specific outcomes 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)

5. Quality Adjusted Life Years (QALY)
Example
Blindness
Time trade-off value is 0.5
Life span = 80 years
0.5 x 80 = 40 QALYs
0.00
1.00 X
0.5 x 80 = 40 QALYs
Life years 40 80

6. Area under the curve

7. Cost per QALY 20 QALY gained €100.000 Cost per QALY
€ /20 QALYs = €5000/QALY

8. I want to live in… Country A Country B Life expectancy 80
Quality of life 0.8
Focus on common diseases
Life expectancy 78.8
Quality of life 0.75
Focus on rare catastrophic diseases

9. QALY league table

10. The QALY straw man How can quality of life be ‘objective’?
How can you validly measure it?

11. In the past, much criticism
Cohen CB.
Quality of life and the analogy with the Nazis.
Journal of Medicine and Philosophy 8: , 1983.

12. Criticism remains
….the strictly fascist essence of those QALYs (so-called Quality-Adjusted Life Years)…

13. QALY publications

14. Three problems with the criticism …..
Arguments represent aversion toward a limited budget
Proposed alternatives turn out to be the same
Even equity concerns are in need of QALY

15. 1. Arguments often represent aversion limited budget
“…Wij hebben duidelijk aangegeven dat een discussie over "wat maatschappelijk nog aanvaardbaar is" [kosten per QALY] alleen gevoerd mag worden als geldverslindende "frivoliteiten" door de maatschappij […] zijn uitgebannen. Bijvoorbeeld "joint strike fighters“…
Kees van Bezooijen in his roll as Patient representative, 2007

16. Three problems with the criticism …..
Arguments represent aversion toward a limited budget
Proposed alternatives turn out to be the same
Even equity concerns are in need of QALY

17. 2. Proposed alternative turns out to be the same…
TWiST
Time Without Symptoms of disease and subjective Toxic effects of treatment
HYE
Health Years Equivalent
SAVE
Saved Young Life Equivalent
DALY
Disability Adjusted Life Years
Capabilities
Amartya Sen

18. Burden of Disease Project
WHO Global Burden of Disease (GBD)
Impact of diseases world wide
Estimates of epidemiology per disease
Mortality
Quality of life losses
In need of one measure of health
But WHO disliked QALY… 18

19. Chris Murray Harvard Worked outside DALY School of Public Health
Health economics
Med Decision Making
DALY
Disability Adjusted Life Years
Lost life years
Lost Quality of life 19

20. DALY / QALY
DALY
QALY 20

21. Two points of critique 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’

22. Falsification QALY Life years 1.0 Kwaliteit van leven Efficiency
Equity
0.0 A B C

23. Falsification of life years80
Life years 60 40 20 A B C 23

24. Efficiency/equity debate
Cost per QALY represents efficiency
But is our health care system based on efficiency?
In health care, next to efficiency…
Compassion
Solidarity
Empathy

25. Is (should) burden (be) a criterion?
Pronk & Bonsel, Eur J Health Econom 2004, 5:

26. Costs/QALY as indicator of solidarity€ 80 € 60 €
Levensjaen 40 20 A B C 26

27. Costs/QALY versus Burden of diseaseX € € € € €
Burden of disease

28. Three problems with the criticism …..
Arguments represent aversion toward a limited budget
Proposed alternatives turn out to be the same
Even equity concerns are in need of QALY

29. Dutch Council for Public Health and Health Care (De Raad voor de Volksgezondheid en Zorg, 2006)

30. QALYs moderate NICE’s decisions
At average levels for all covariates, a decision would have a 50% chance of rejection if its ICER were £45,118/QALY
Dakin, Devlin, Rice, Parkin, O’Neill, Feng (2014) The influence of cost effectiveness and other factors on NICE decisions. Health Economics, 2014

31. Conclusion Quality of life can be measured
Usual multidimensional
Unidimensional: QALYs
QALYs can validly be use in cost effectiveness research
Burden of disease is also a criterion
On need QALYs to measure burden