Quality of life and Cost-Effectiveness

An Interactive Introduction

Prof. Jan J. v. Busschbach, Ph.D.Erasmus MC

Medical Psychology and Psychotherapy

Viersprong Institute for studies on Personality Disorders

New cancer therapy

Symptoms Drug X Drug Y

Survival days 300 400

Days sick of chemotherapy 10 150

Days sick of disease 100 30

TWiST 190 220

Time Without Symptoms of disease and subjective Toxic effects of treatment: TWiST

Richard Gelber statistician

Count … Days not sick from treatment

Days not sick from disease

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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

TWiST: ignores differences in quality of life

TWiST Healthy = 1

Sick (dead) = 0

Q-TWiST• Quality of life adjusted TWiST

Make intermediate values

• 1.0; 0.75; 0.50; 0.25; 0.00

How to scale quality of life?

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0.0

Quality of li

fe

1.0

Visual Analogue Scale

Does the scale fit Q-TWIST? Is 2 days 0.5 = 1 day 1.0?

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Dead

Normal health

X?=

Example Blindness

Time trade-off value is 0.5

Life span = 80 years

0.5 x 80 = 40 QALYs

Quality Adjusted Life Years (QALY)

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0.00

1.00

X

Life years40 80

0.5 x 80 = 40 QALYs

Time Trade-Off

Wheelchair With a life expectancy: 50 years

How many years would you trade-off for a cure? Max. trade-off: 10 years

QALY(wheel) = QALY(healthy) Y * V(wheel) = Y * V(healthy)

50 V(wheel) = 40 * 1.00

V(wheel) = 0.80

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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”

Q-TWiST = QALY

Several initiatives early seventies Epidemiologist and health economists

Part of QALY concept Quality Adjusted Life Years

QALY = Q-TWiST

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Area under the curve

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

Which health care program is the most cost-effective?

www.ibotnow.com

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Segway Dean Kamen

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

Which health care program is the most cost-effective?

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

6000 Citations in 2009

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1980 1985 1990 1995 2000 2005 2010 2015

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Key words: 1980[pdat] AND (QALY or QALYs)

Orphan drugs

Pompe disease Classical form: € 300.000 – 900.000 per QALY Non classical form: up to € 15.000.000 per QALY If maximum = € 80.000

• Ration is almost 1:200

Low cost effectiveness but… High burden Low prevalence Little own influence on disease High consensus in the field

• Coalition patient, industry, doctors and media• Low perceived incertainty

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Light version cost effectiveness

Formal cost effectiveness is expensive Is there a light version?

What do we have?

Costs Patient count

Costs per Patient

DBC / DOT Cost per DBC

TWiST Costs per Time without psychosis

Costs per Time in normal health

Cost per Recovered patient

Routine Outcome Monitoring (ROM) Could be of help here

Routine Outcome Monitoring

ROM has the potential of Cost per ‘outcome’ ratio

Difficulties getting data at end of treatment

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Cost effectiveness

Cost benefit Benefit in monetary terms minus cost

Can seldom be done in health care

• What is the value of a life year

Cost per QALY Cost utility analysis

Makes comparisons possible between diseases

Cost per effect Cost effectiveness

Like: Cost per cure

Stays within one disease

Improve cost effectiveness

Other ways to improve cost effectiveness Insight in costs

Stop rules

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Costs often unknown…

Cost price therapy is mostly unknown in metal health

No insight in costs of components therapy Typically salary + fixed overhead (for instance 37%)

Activity Based Costing can help

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Insights in costs will allow for…

Informal cost effectiveness analysis Which therapy is most cost effective?

Assumes that outcomes / patients are sufficient comparable

Effects Cost per ‘cure’

Cost per increase on a specific scale

Cost per DBC

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Weighting components

Which components of therapy contribute most to the cost price?

Does this ranking relates to the indented effects?

Benchmark

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Stop rules

We seem to know when a therapy is needed But do we know when to stop?

If all the ‘potential’ of the patient is reached?

Within social health insurance

Reasonable stop rules might be: When no progress is made anymore

When the patient is comparable with the general population

• > 5 – 10%

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Monitor the patient

….frequently during therapy Looks like Routine Outcome Measure

but with a high frequency

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Position patients versus normal population

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Monitoring reduces the number of treatments

Michael Lambert N = 400

Kim de Jong et al in press

Erasmus MC

…and gives better results

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Feed back

Non feed back

Conclusion

Holy grail Formal cost effectiveness analysis (CEA)

Costs per QALY

Holy grail might be too expensive Formal cost effectiveness is indeed expensive

Informal CEA might already reveal much Cost per treatment

Cost per successful treatment

There is a need for real cost prices Especially price of components

To start bench mark procedure