Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 Days sick of chemotherapy Days sick of disease TWiST 300 10 100 190 400 150 30 220 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 3 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? 5 Visual Analogue Scale Normal health Does the scale fit Q-TWIST? Is 2 days 0.5 = 1 day 1.0? ? X = Dead 6 Quality Adjusted Life Years (QALY) Example Blindness Time trade-off value is 0.5 Life span = 80 years 0.5 x 80 = 40 QALYs 1.00 X 0.5 x 80 = 40 QALYs 0.00 40 80 Life years 7 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 8 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 10 Area under the curve Which health care program is the most cost-effective? A new wheelchair for elderly (iBOT) Special post natal care www.ibotnow.com Dean Kamen Segway 13 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 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 Publications Key words: 1980[pdat] AND (QALY or QALYs) 900 800 700 600 500 400 300 200 100 0 1980 1985 1990 1995 2000 2005 2010 2015 16 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 17 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 20 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 per effect Cost utility analysis Makes comparisons possible between diseases Cost effectiveness Like: Cost per cure Stays within one disease Improve cost effectiveness Other ways to improve cost effectiveness Insight in costs Stop rules 22 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 24 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 25 Weighting components Which components of therapy contribute most to the cost price? Does this ranking relates to the indented effects? Benchmark 26 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% 28 Monitor the patient ….frequently during therapy Looks like Routine Outcome Measure but with a high frequency 29 Position patients versus normal population 30 Monitoring reduces the number of treatments Michael N = 400 Lambert Kim de Jong et al in press Erasmus MC …and gives better results Feed back Non feed back 32 Conclusion Holy grail Holy grail might be too expensive Formal cost effectiveness analysis (CEA) Costs per QALY 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