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
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 2010 3
Cost Cost-effectiveness Not C-EFF intervention Current care C-EFF dominant Health effect (QALYs) 5
QALY = Quality Adjusted Life Years INDEX ( utility level ) Perfect health 1 0.6 0.5 +2 10 +5 +2.5 Death 0 20 25 TIME 6
Example diabetes complications Utility decrement at diagnosis (event) Utility decrement in subsequent years Ischemic heart disease (CHD) -0.09-0.046 Myocardial infarction -0.055-0.032 Heart failure -0.108-0.05 Stroke -0.164-0.061 Diabetes related foot amputation -0.280-0.13 Diabetes related blindness -0.175-0.175 End stage renal disease -0.263-0.248 Based on UKPDS 7
gain in QALY by avoiding INDEX ( utility level ) complications Perfect health 1 0.5 Death 0 TIME 8
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 = +/- 37000) http://www.who.int/choice/costs/cer_thresholds/en/ BUT RECENTLY CHALLENGED BY THE WHO ITSELF 9
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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Health the ideal More prevention typical Based on Paffenbarger & Olsen 1996 12
The reality: NO morbidity compression www.thelancet.com Vol 388 October 8, 2016: BELGIUM 85.0 WOMEN 80.0 MEN 75.0 Years with morbidity 11.1 11.2 70.0 9.0 9.1 65.0 67.2 68.6 Healthy years 70.9 72.0 60.0 2005 2015 2005 2015 13
The reality: lost healthy life years in Belgium (DALYs) 450.000 394.000 293.000 280.000 166.000 140.000 147.000 124.000 98.000 59.000 42.000 WHO 2012, data for BELGIUM
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Incidence of selected diseases Relative risk of disease by BMI category (overweight: 25-29.9 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 2.25 5.50 2.30 7.00 coronary heart disease 1.35 2.00 1.35 2.00 stroke 1.20 1.50 1.20 1.55 colon cancer 1.20 1.40 1.08 1.10 breast cancer premenopausal postmenopausal 1.00 1.12 1.00 1.25
Risk reductions for 1 unit BMI decrease Disease Men Women Reference Diabetes mellitus -13.0% -11.0% Schienkiewitz et al. 2006 Coronary heart disease -4.7% -5.7% McGee 2005 Stroke -6.0% -8.5% Rosengren et al. 2003, Kurth et al. 2002 Colon cancer -5.2% -2.0% Renehan et al. 2008 Breast cancer premenopausal postmenopausal 0.0% -4.0% Green et al. 2012 Green et al. 2012
Results per individual 18
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
EXAMPLE 2: prevention of obesity in primary schools Per 1000 children Investment Gain in productive life years Prevention program vs doing nothing 77000 750000 Brown, International Journal of Behavioral Nutrition and Physical Activity 2007, 4:47 20
Prevention that acts on persons indirectly, by altering their physical or social environment, is most cost-effective Chokshi et al, NEJM 2012
!! Prevention not always cost-effective Cost ( ) per QALY Garret et al, British Journal of General Practice, March 2011
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Disability weight Utility weight QALY 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 20 30 40 50 60 70 80 DALY 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 20 30 40 50 60 70 80
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
Example Mean 2.5% 97.5% 27
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 36... IMAGINE you stay 10 years in X OR 8 years in perfect health (= 1 ) 28
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 = 0.7 29
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 11223 30
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 0.6 0.7 0.8.. 1. Imaging you are: 22322 (described) 21123 (described) 12311(described).. Multivariate equation: TTO = f(five dimensions) TTO = 1 - b1*dim1 - b2*dim2 -. b5*dim5 coefficients 31
EQ-5D UK tariff (score = 2) (score = 3) 32
Transformation from EQ 5D applied in Belgium status index status index status index status index status index 11111 1.0000 12322 0.2602 21233 0.1121 23231 0.1536 32133-0.0142 11112 0.7444 12323 0.1568 21311 0.4555 23232 0.0502 32211 0.3291 11113 0.3847 12331 0.2799 21312 0.3521 23233-0.0532 32212 0.2257 11121 0.7641 12332 0.1765 21313 0.2487 23311 0.2902 32213 0.1223 11122 0.6607 12333 0.0731 21321 0.3718 23312 0.1868 32221 0.2455 11123 0.3010 13111 0.4262 21322 0.2684 23313 0.0834 32222 0.1421 11131 0.4241 13112 0.3228 21323 0.1650 23321 0.2065 32223 0.0387 11132 0.3207 13113 0.2194 21331 0.2881 23322 0.1031 32231 0.1618 11133 0.2173 13121 0.3425 21332 0.1847 23323-0.0003 32232 0.0584 11211 0.8170 13122 0.2391 21333 0.0813 23331 0.1228 32233-0.0450 11212 0.7136 13123 0.1357 22111 0.6907 23332 0.0194 32311 0.2984 11213 0.3539 13131 0.2588 22112 0.5873 23333-0.0840 32312 0.1950 11221 0.7333 13132 0.1554 22113 0.2276 31111 0.4426 32313 0.0916 11223 0.2702 11222 0.6299 13133 0.0520 22121 0.6070 31112 0.3392 32321 0.2147 11223 0.2702 13211 0.3954 22122 0.5036 31113 0.2358 32322 0.1113 11231 0.3934 13212 0.2920 22123 0.1439 31121 0.3589 32323 0.0079 11232 0.2900 13213 0.1886 22131 0.2670 31122 0.2555 32331 0.1310 11233 0.1866 13221 0.3117 22132 0.1636 31123 0.1521 32332 0.0276 11311 0.5300 13222 0.2083 22133 0.0602 31131 0.2752 32333-0.0758 11312 0.4266 13223 0.1049 22211 0.6599 31132 0.1718 33111 0.2773 11313 0.3232 13231 0.2280 22212 0.5565 31133 0.0684 33112 0.1739 11321 0.4463 13232 0.1246 22213 0.1968 31211 0.4118 33113 0.0705 11322 0.3429 13233 0.0212 22221 0.5762 31212 0.3084 33121 0.1936 11323 0.2395 13311 0.3646 22222 0.4728 31213 0.2050 33122 0.0902 11331 0.3626 13312 0.2612 22223 0.1131 31221 0.3281 33123-0.0132 11332 0.2592 13313 0.1578 22231 0.2362 31222 0.2247 33131 0.1099 11333 0.1558 13321 0.2810 22232 0.1328 31223 0.1213 33132 0.0065 12111 0.7651 13322 0.1776 22233 0.0294 31231 0.2444 33133-0.0969 12112 0.6617 13323 0.0742 22311 0.3728 31232 0.1410 33211 0.2465 12113 0.3020 13331 0.1973 22312 0.2694 31233 0.0376 33212 0.1431 12121 0.6815 13332 0.0939 22313 0.1660 31311 0.3810 33213 0.0397 12122 0.5781 13333-0.0095 22321 0.2892 31312 0.2776 33221 0.1628 12123 0.2184 21111 0.7733 22322 0.1858 31313 0.1742 33222 0.0594 12131 0.3415 21112 0.6699 22323 0.0824 31321 0.2974 33223-0.0440 12132 0.2381 21113 0.3102 22331 0.2055 31322 0.1940 33231 0.0791 12133 0.1347 21121 0.6897 22332 0.1021 31323 0.0906 33232-0.0243 12211 0.7344 21122 0.5863 22333-0.0013 31331 0.2137 33233-0.1277 12212 0.6310 21123 0.2266 23111 0.3517 31332 0.1103 33311 0.2157 12213 0.2713 21131 0.3497 23122 0.1646 31333 0.0069 33312 0.1123 33
5L 34
ISP ENQUÊTE DE SANTÉ 2013 RAPPORT 1 : SANTÉ ET BIEN-ÊTRE
Q: Is a QALY a QALY? 1 1.0 0.8 0.4 0.2 0 Same life expectancy Same cost of treatment Same prevalence Treatment X Disease A Treatment Y Disease B E. Nord, person trade off method
Is a QALY a QALY? No! 1 1.0 0.4 0.2 0 0.8 Plus number, own responsibility, mortality? E. Nord, person trade off method 39
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) 53 63 40
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
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