Qu est-ce que la santé? Regard critique sur les QALYs et analyse d autres paramètres pour mesurer les gains en santé

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2 Chaire Francqui: leçon 5 Qu est-ce que la santé? Regard critique sur les QALYs et analyse d autres paramètres pour mesurer les gains en santé Lieven Annemans ULB, 17 mai 2017

3 The goal of health care systems Primary goal of health care policy = to optimise the health of the population within the limits of the available resources, and within an ethical framework built on equity and solidarity principles. Report of the Belgian EU Presidency, adopted by the EU Council of Ministers of Health in Dec

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5 Cost Cost-effectiveness Not C-EFF intervention Current care C-EFF dominant Health effect (QALYs) 5

6 QALY = Quality Adjusted Life Years INDEX ( utility level ) Perfect health Death TIME 6

7 Example diabetes complications Utility decrement at diagnosis (event) Utility decrement in subsequent years Ischemic heart disease (CHD) Myocardial infarction Heart failure Stroke Diabetes related foot amputation Diabetes related blindness End stage renal disease Based on UKPDS 7

8 gain in QALY by avoiding INDEX ( utility level ) complications Perfect health Death 0 TIME 8

9 PROBLEM: where is the threshold? Desaigues et al (2007): willingness to pay method: 40,000 per Healthy Life Year (for EU25 countries)? BUT average for EU, 10 years ago, willingness to pay depends on ability to pay BENCHMARKING e.g. cost-effectiveness of caring for a dialysis patient historically 50,000 $ per QALY BUT now 100,000 $ per QALY WHO: 1 to 3 times GDP per capita (e.g. Belgium = +/ ) BUT RECENTLY CHALLENGED BY THE WHO ITSELF 9

10 Examples (Belgium) Treatment Intensive cardiovascular rehabilitation in CHD Cost per QALY gained ( ) dominant Procoralan Chronic Heart Failure 6,000 Total Hip Replacement 10,000 Brillique Acute Coronary Syndrome 14,000 Prezista HIV 16,000 Sovaldi HCV 18,000 Velcade multiple myeloma 30,000 Tysabri MS 47,000 Annual mammography for women aged 60-70yr 70,000 Annual CT for 60 year-old heavy smokers 130,000 CTG/CRM (RIZIV) (at official prices)

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12 Health the ideal More prevention typical Based on Paffenbarger & Olsen

13 The reality: NO morbidity compression Vol 388 October 8, 2016: BELGIUM 85.0 WOMEN 80.0 MEN 75.0 Years with morbidity Healthy years

14 The reality: lost healthy life years in Belgium (DALYs) WHO 2012, data for BELGIUM

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16 Incidence of selected diseases Relative risk of disease by BMI category (overweight: kg/m²; obesity: 30 kg/m²) disease overweight men obese men overweight women Example: an overweight man has 2.25 more times risk to develop diabetes than a man with healthy weight. Source: International Association for the Study of Obesity (IASO) obese women diabetes coronary heart disease stroke colon cancer breast cancer premenopausal postmenopausal

17 Risk reductions for 1 unit BMI decrease Disease Men Women Reference Diabetes mellitus -13.0% -11.0% Schienkiewitz et al Coronary heart disease -4.7% -5.7% McGee 2005 Stroke -6.0% -8.5% Rosengren et al. 2003, Kurth et al Colon cancer -5.2% -2.0% Renehan et al Breast cancer premenopausal postmenopausal 0.0% -4.0% Green et al Green et al. 2012

18 Results per individual 18

19 Impact of 1 unit BMI decrease in the overweight and obese population in Belgium (n=3,795,026) over 20 yrs Direct savings: 3,212,129,035 Indirect savings: 783,603,473 3,995,732,509 QALYs gained: 303,602

20 EXAMPLE 2: prevention of obesity in primary schools Per 1000 children Investment Gain in productive life years Prevention program vs doing nothing Brown, International Journal of Behavioral Nutrition and Physical Activity 2007, 4:47 20

21 Prevention that acts on persons indirectly, by altering their physical or social environment, is most cost-effective Chokshi et al, NEJM 2012

22 !! Prevention not always cost-effective Cost ( ) per QALY Garret et al, British Journal of General Practice, March 2011

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24 Disability weight Utility weight QALY DALY

25 DALY YLD (Years of Life with disability) + YLL (years of life lost) YLD: how to measure the disability? 1996: panel of experts 2010: >30,000 people from 167 countries were asked to value paired comparisons of health states update of these DWs was generated for the Global Burden of Disease 2013 Study (GBD 2013) by incorporating results of new surveys in four European countries (Hungary, Italy, the Netherlands, and Sweden). The two studies combined resulted in a set of DWs based on 60,890 participants (Maertens et al 2017) 25

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27 Example Mean 2.5% 97.5% 27

28 How to measure the Utility level in QALYs? NOT straightforward! direct VAS: Visual Analogue Scale SG: Standard Gamble TTO: Time Trade Off indirect EQ 5D SF IMAGINE you stay 10 years in X OR 8 years in perfect health (= 1 ) 28

29 TTO: example of scenario I. 10 years in X II. OR? OR? 8 years in perfect health (= 1 ) 10 years in X 6 years in perfect health (= 1 ) III. 10 years in X OR? 7 years in perfect health (= 1 ) = 7*1 = 10*X X =

30 Indirect method: via EuroQol 5D (EQ 5D) Mobility 1. I have no problems in walking about x 2. I have some problems in walking about 3. I am confined to bed Self-Care 1. I have no problems with self-care x 2. I have some problems washing or dressing myself 3. I am unable to wash or dress myself Usual Activities (e.g. work, study, housework, family or leisure activities) 1. I have no problems with performing my usual activities 2. I have some problems with performing my usual activities x 3. I am unable to perform my usual activities Pain/Discomfort 1. I have no pain or discomfort 2. I have moderate pain or discomfort x 3. I have extreme pain or discomfort Anxiety/Depression 1. I am not anxious or depressed 2. I am moderately anxious or depressed 3. I am extremely anxious or depressed x

31 Linking EQ5D with TTO via de general population 2. Imaging now you can become perfectly healthy, but with less years. (TTO) utility value for these health states Imaging you are: (described) (described) 12311(described).. Multivariate equation: TTO = f(five dimensions) TTO = 1 - b1*dim1 - b2*dim2 -. b5*dim5 coefficients 31

32 EQ-5D UK tariff (score = 2) (score = 3) 32

33 Transformation from EQ 5D applied in Belgium status index status index status index status index status index

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35 ISP ENQUÊTE DE SANTÉ 2013 RAPPORT 1 : SANTÉ ET BIEN-ÊTRE

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38 Q: Is a QALY a QALY? Same life expectancy Same cost of treatment Same prevalence Treatment X Disease A Treatment Y Disease B E. Nord, person trade off method

39 Is a QALY a QALY? No! Plus number, own responsibility, mortality? E. Nord, person trade off method 39

40 Health status Social reference point (Scitovsky) maximal minimal Striving above SRP Pleasure seeking Not necessary No funding Striving towards SRP Necessity depends on severity Accept higher cost/qaly in worst conditions Social reference point Age related?? First cited in Stolk et al, Health Policy 59 (2002)

41 Extra problem: Current QALY approach is not sufficiently patient oriented Universal concepts are sometimes omitted from generic health utility measures (EQ5D, SF36) Sleep adequacy Impact of disease and treatment on appearance Impaired memory/cognition Threats to dignity Fear/concern of worsening disease 41

42 Discussion Health policy makers need to allocate the money accounting for efficiency and equity To make good decisions they need to value health DALYs underestimate the true burden of disease Gaining QALYs seems to have higher value in case the starting health is worse Regardless of the measure, investring in prevention that acts on the environment of people is the best investment in health

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