third plenary session ispor 14 th annual international meeting

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  • Slide 1
  • Third Plenary Session ISPOR 14 th Annual International Meeting
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  • Life expectancy multiplied by health-related quality of life: Quality-adjusted life years
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  • If, HRQL= 0.7 And, A treatment gives 10 extra years of life (@ 0.7 per year) Then. People receiving the treatment gain an average of 7 QALYs each
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  • #People HRQL LE = QALYs Saves 100 x 0.8 x 50 = 4000 Lives Improves10,000 x 0.1 x 4 = 4000 HRQL
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  • Cost treatment 1 Cost treatment 2 Effectiveness treatment 1 Effectiveness treatment 2 = COST per QALY
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  • Cost Life Expectancy HRQLQALYS Group A$80,0002 Years X.6 = 1.2 Group B $ 8,000 1 Year X.8 = 0.8 Cost-effectiveness: $80,000 - $8,000 = $72,000 = $180,000/QALY 1.2 0.8 0.4
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  • The QALY is a widely used measure of health gain. Long-standing criticism of the theoretical basis, and practical application of, QALYs.
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  • Plenary session, 10 th Annual International Meeting (Kahneman), May 2005. Issues panel, 11 th Annual International Meeting (Fryback, Kahneman, McGuire), May 2006. Two-day invitational consensus development workshop, November 2007.
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  • Funding from AHRQ and NCI. 25 participants. Discussion of: - the basics of QALYs; - the main challenges surrounding QALYs; - retaining and enhancing QALYs; - the use of QALYs in decision-making; - towards a consensus on the QALY
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  • Milton C. Weinstein PhD Harvard School of Public Health, Boston MA, USA George Torrance PhD McMaster University, Hamilton, ON, Canada Alistair McGuire PhD London School of Economics, London, UK
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  • Method for valuing health effectiveness in cost-effectiveness analysis for resource allocation decisions Values health based on time spent in health states Endorsed by US Panel and NICE for reference case
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  • Represent individual patient preferences Reflect equity, fairness, or political goals
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  • Grounded in decision science (based on expected utility theory) Individuals move through health states over time. Each health state has a value Health = value-weighted time (QALYs)
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  • Perfect health = 1.0, dead = 0.0 Interval scale properties e.g., 0.2 0.4 = 0.6 0.8 States worse than dead have negative value
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  • Value = preference (desirability) Valued by whom? individuals experiencing a health state or illness individual who may or may not experience that health state in the future individuals considering the health of a community (Values are for health states, not for changes in health states)
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  • What is being valued? Whom do we ask? What do we ask? How are health outcomes defined?
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  • What is being valued? Whom do we ask? How are health outcomes defined? Conventional QALYs allow for different answers to these questions The answer depends on the question being asked
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  • Societal resource allocation: priority setting across proposed programs or interventions Societal (programmatic) audit: evaluation of ongoing activities/programs Personal clinical decisions or decisions about insurance coverage
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  • Personal clinical/insurance choice desirability of health outcomes to the individual ex ante perspective
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  • Societal/program audit current health of affected population members, as valued by themselves ex post perspective (i.e. patient preferences/experience utility)
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  • Societal resource allocation individual health (aggregated) or community health ex ante or ex post
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  • Personal clinical/insurance the individual, +/- informed by patients/disabled people
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  • Societal/program audit members of the affected population
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  • Societal/individual health (aggregated) or Societal/community health representative sample of population including patients/disabled people informed by patients/disabled people
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  • HUI-2 HUI-3 SF-6D QWB EQ-5D 15D AQOL patient health state community survey value score US Panel and NICE reference case method different instruments give different results value scores may be population-specific
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  • Health states valuation independent of duration or sequence
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  • Health states conventional QALY approach valuation independent of duration or sequence Health paths (profiles) theoretically superior practical problem: large number of paths Health changes can incorporate equity or fairness practical problem: large number of changes order of changes matters
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  • QALYs should be discounted at the same rate as costs (US Panel, NICE)
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  • Erik Nord PhD Norwegian Institute of Public Health, Oslo, Norway Norman Daniels PhD Department of Population and International Health, Harvard School of Public Health, Boston, MA, USA Mark Kamlet PhD Heinz School of Public Policy and Management, Carnegie Mellon University, Pittsburgh, PA,USA
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  • Defined as expressing the personal utility of health outcomes as judged ex ante, on average, by the general public, from behind a veil of ignorance, about future health, based on self interest.
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  • (i) Substantial, empirical inter-method variation in ex ante assessment SG yields higher values than TTO and greater in turn than rating scale Which one is right? (ii) Empirical unwillingness to trade-off lifetime Means that less is invested in preventing the outcome confined to a wheel chair Use of experience utility disfavors prevention, use of ex-ante utility doesnt capture adaptation/foregone opportunities
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  • No consideration for pretreatment health state At odds with ethical theory/public opinion that suggests that in setting priorities societies often emphasize how bad off individuals would be without intervention i.e. concern for severity
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  • Conventional QALY model implies that the value of an intervention is proportional to the beneficiarys capacity to benefit At odds with theory/public opinion that it should not be held again people that they have conditions for which there are no complete cures or whose remaining lifetime is shorter Similarly, life years gained for those at full health valued more than life years gained for those at less than full health Conflicts with equal right to protection of life by all
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  • Standard QALYs measure differences in health states, not gains in health Ex ante preference elicitation on health states and subsequent subtraction of health state values from one another Decreases data requirements, i.e. the number of possible changes is much highter than the number of possible states Nonetheless, this is a proxy approach, yet to be validated in the health economics literature
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  • Count as 1 all gained life years if good enough to be desired by affected persons Leads to inconsistencies with individual preferences Place less weight on the duration of health benefits in comparisons of programs for patients with different life expectancies Add explicit equity weights Overload the model? Different priority classes for QALYS with different ratio cut-offs Treat prevention differently than treatment
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  • Joseph Lipscomb PhD Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA Dennis Fryback PhD University of York, York, UK Marthe Gold MD, MPH University of Wisconsin, Madison, WI, USA Dennis Revicki PhD City University of New York Medical School, New York, NY, USA
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  • For analyses requiring a summary measure of health that integrates quantity of life and quality of life, QALY is arguably the gold standard. But should it truly be the coin of the realm? Substantive concerns have been raised Our conclusion (in preview): These conceptual and methods issues signal opportunities for making important incremental improvements in the QALY rather than abandoning the construct.
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  • Conceptualization and construction of health states - Which domains? - Which health levels within each domain? Psychometric approaches for eliciting preferences Statistical strategies for deriving overall value weights for QALY conv
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  • For example Highly simple model structure: QALY conv linearly additive function of time in health states, with an exponential discounting factor to reflect time preference Distributional and other ethical issues not formally integrated into model Some suggest that the value component of QALY should be experience-based (from real-time perspective) rather than ex ante
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  • In fact, QALY conv plays important role in regulatory and purchasing decisions in many industrialized nations But push back with NICE Non-QALY approaches being taken in France/Germany Much less in U.S: Not (yet) by FDA Not (yet) by Cente


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