Interactive Introduction cost effectiveness

Jan J. v. Busschbach, Ph.DJan J. v. Busschbach, Ph.DViersprong Institute for studies on Personality Viersprong Institute for studies on Personality Disorders (VISPD)Disorders (VISPD)

Jan.Busschbach@deviersprong.nl+31 164 632200

Department of Medical Psychology & Department of Medical Psychology & Psychotherapy, Erasmus University Medical Center Psychotherapy, Erasmus University Medical Center

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New cancer therapy

Symptoms Drug X Drug Y

Survival days 300 400Days sick of chemotherapy 10 150Days sick of disease 100 30TWiST 190 220

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Time Without Symptoms of disease and subjective Toxic effects of treatment

• TWiST– Developed by Richard 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

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Fit new therapy in fixed budget

• 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

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TWiST: ignores differences in quality of life

• TWiST– Healthy = 1– Sick (dead) = 0

• There is more to life than sick/health– Make intermediate values– Q-TWiST

• Quality of life adjusted adjusted TWiST• How to scale quality of life?

0.0 Q

uality of lif

e 1

.0

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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

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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) = .80

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EuroQol EQ-5D: of the shelf QALY value

• 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

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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”

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• A new wheelchair for elderly (iBOT)• Special post natal care

Which health care program is the most cost-effective?

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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

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Effect psychotherapy

0.5

0.6

0.7

0.8

0.9

1.0

Intake 1 year after 2 years

EQ

-5D

soc

ial v

alue

s

Clinic 12 months

Clinic 6 months

Clinic 3 months(STIP)Out-patient clinic

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Example STIP

• Short-Term Inpatient Psychotherapy• Cost price

– Per patient day: € 210.34– 3 mouths = 91.3 day– 91.3 x 210 = € 19,194.53

• Includes overhead– Buildings, administration, etc

• Excluding– Savings elsewhere in health care system

• Effect– Assume quality of life increase of 0.25– Over 10 year

• Cost / QALY– 19,194.54 / (10 x 0.25) = € 7,677.41

Although gold standard…

Cost per QALY of

psychotherapy have never been

published

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QALY league table

Intervention $ / QALY GM-CSF in elderly with leukemia 235,958

EPO in dialysis patients 139,623

Lung transplantation 100,957

End stage renal disease management 53,513

Heart transplantation 46,775

Didronel in osteoporosis 32,047

PTA with Stent 17,889

STIP: Short-term inpatient psychotherapy 7,677

Breast cancer screening 5,147

Viagra 5,097

Treatment of congenital anorectal malformations 2,778

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1.0

0.0A B C

Util

ity o

f Hea

l th

Egalitarian Concerns:Burden of disease

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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

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CE-ratio by equity

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

0.0

0.2

0.4

0.6

0.8

1.0

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Conclusion

• Introduce state-of-the-art cost effectiveness studies– Measure costs and outcome

• Suitable for cost effectiveness studies• According to guidelines

• Establish burden of disease– State-of-the-art quality of life research

• Use an active approach on budget constrains– Anticipate on policy arguments– Look for beyond own discipline