Quality of life in relation to costs

1. Quality of life in relation to costs Prof. Dr. Jan van Busschbach Medische Psychologie en Psychotherapie

2. Budget 2012 government NL

3. Raising costs in NL: 87 billion

4. More than growth national income

6. How much money is it worth? • Willingness to pay • Non familiarity with payment in health care • Starting point error • Strong relation with income • Does not do the job

7. Framing the question helps… Remove large scar Involve painful operation Cost € 500,- Remove large scar Involve painless operation Cost € 1000,- OR • Pair comparisons • DCE, conjoint analysis • Comparisons between health care interventions remain difficult

8. 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 8

9. 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) 9

10. Quality Adjusted Life Years (QALY) 1.00 X 0.00 0.5 x 80 = 40 QALYs 80 40 Life years • Example • Blindness • Time trade-off value is 0.5 • Life span = 80 years • 0.5 x 80 = 40 QALYs 10

11. Area under the curve

12. Which health care program is the most cost-effective? A new wheelchair for elderly (iBOT) Special post natal care 12

13. www.ibotnow.com Dean Kamen Segway 13

14. 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: $ 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 14

15. QALY league table 15

16. 7000 Citations in PubMed

17. Direct valuation

18. Time Trade-Off • Rolstoel • 50 jaar levensverwachting • Hoeveel jaar zou je maximaal willen inleveren? • Max. trade-off: 10 jaar • QALY(wiel) = QALY(voet) • Y * V(wiel) = Y * V(voet) • 50 V(wiel) = 40 * 1.00 • V(wiel) = 0.80

19. …or use validated questionnaires 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

20. Healthy Death A problem in the patient perspective…. • Stensman • Scan J Rehab Med 1985;17:87-99. • Scores on a visual analogue scale • 36 subjects in a wheelchair • 36 normal matched controls • Mean score • Wheelchair: 8.0 • Health controls: 8.3

21. Validated questionnaires

22. EQ-5D-3L versus EQ-5D-5l

23. Validating disease specific questionnaires • International Symptom Prostate Score (IPSS) • BPH • Enlargement of the prostate • Causes voiding problems in elderly men • Difficulties to pee • 7 questions: How often have you • had to push or strain to begin urination? • had a sensation of not emptying your bladder completely? • had to urinate again less than two hours after you finished urinating? • found you stopped and started again several times when you urinated? • you find it difficult to postpone urination? • had a weak urinary stream? • How many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?

24. Can we convert the IPSS outcomes into utilities? Attribute TTO values to the IPSS health states Problem: IPSS has 279.936 health states 7 items, 6 answer levels = 6x6x6x6x6x6x6 = 279.936 health states Too many to value with TTO Reduce number of health states Reduce items Factor analysis Reduce answer levels Combine answer levels

25. Factor analysis on patients IPSS responses N = 1414 Two main factors Obstructive (alpha= 0.8018) Irritative (alpha= 0.7165) Confirmed in literature Factors divided in 3 levels Number of health states reduced to 33 = 9 Can be valued directly TTO General public, representative for gender/age (N=170) Reduce number of health states

26. QALY weights for BPH

27. Conclusions • QALY can help to related quality of life to cost • QALYs are the most accepted for of cost effectiveness analysis • At least in the Netherlands • Might not be true in the US and Germany • QALY often need new validation of disease specific questionnaires.