The QALY is ableist: on the unethical implications of health states worse than dead

Quality of Life Research ◽

10.1007/s11136-021-03052-4 ◽

2021 ◽

Author(s):

Paul Schneider

Keyword(s):

Economic Evaluation ◽

Health Economic Evaluation ◽

Health State ◽

Worth Living ◽

Allocation Of Resources ◽

Health It ◽

Healthy Individuals ◽

Ethical Aspects ◽

Health States ◽

The Times

Abstract Introduction A long-standing criticism of the QALY has been that it would discriminate against people in poor health: extending the lives of individuals with underlying health conditions gains fewer QALYs than extending the lives of ‘more healthy’ individuals. Proponents of the QALY counter that this only reflects the general public’s preferences and constitutes an efficient allocation of resources. A pivotal issue that has thus far been overlooked is that there can also be negative QALYs. Methods and results Negative QALYs are assigned to the times spent in any health state that is considered to be worse than dead. In a health economic evaluation, extending the lives of people who live in such states reduces the overall population health; it counts as a loss. The problem with this assessment is that the QALY is not based on the perspectives of individual patients—who usually consider their lives to be well worth living—but it reflects the preferences of the general public. While it may be generally legitimate to use those preferences to inform decisions about the allocation of health care resources, when it comes to states worse than dead, the implications are deeply problematic. In this paper, I discuss the (un)ethical aspects of states worse than dead and demonstrate how their use in economic evaluation leads to a systematic underestimation of the value of life-extending treatments. Conclusion States worse than dead should thus no longer be used, and a non-negative value should be placed on all human lives.

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Health Utility Measurement

The Oxford Handbook of Health Economics ◽

10.1093/oxfordhb/9780199238828.013.0033 ◽

2011 ◽

pp. 787-813 ◽

Cited By ~ 2

Author(s):

Donna Rowen ◽

John Brazier

Keyword(s):

Economic Evaluation ◽

Health Utility ◽

Health State ◽

Health States ◽

Health State Description ◽

Utility Measurement ◽

Current State ◽

Increasing Demand ◽

Demand For Health

Measuring and valuing health is a major component of economic evaluation, meaning that health utility measurement has been growing in popularity in recent years due to the increasing demand for health state values in economic models and evaluations. The main issues in health utility measurement are how to describe health states, how to value the health state description and whose values should be used. This article briefly outlines these main issues and then focuses on recent methodological developments in health utility measurement. It assesses the current state of health utility measurement and discusses the question of assessment of a health state to be used in economic evaluation. The discussion whether experience utility should be used rather than conventional preference-based utility raises important issues about perspective and the role of various factors.

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Conclusions: measurement and valuation of health

10.1093/med/9780198725923.003.0012 ◽

2016 ◽

Author(s):

John Brazier ◽

Julie Ratcliffe ◽

Joshua A. Salomon ◽

Aki Tsuchiya

Keyword(s):

Economic Evaluation ◽

Policy Making ◽

Health State ◽

Health It ◽

Reference Case ◽

Policy Makers ◽

The World ◽

Health State Utility Values ◽

Intellectual Challenge ◽

Health Valuation

This book addresses the main questions surrounding the measurement and valuation of health. It shows that there are many different answers to to questions regarding how to describe health, valuation methods, whose values, what instruments to use, how to aggregate QALYs, and how to use the health state utility values in economic evaluation. This chapter examines the implications of this diversity for policy making, the use of a reference case, and briefly reviews the guidelines used by major policy makers (e.g. NICE) around the world. We cannot predict how the field is likely to develop over the next decade, but we are sure it will lose none of its intellectual challenge and controversy.

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LIVES WORSE THAN DEATH: ADULT CHILDREN ARE POOR AT ESTIMATING PARENTS’ QUALITY-OF-LIFE VALUATIONS

Innovation in Aging ◽

10.1093/geroni/igz038.2368 ◽

2019 ◽

Vol 3 (Supplement_1) ◽

pp. S636-S636

Author(s):

Matthew Pichiello ◽

Meghan McDarby ◽

Elissa K Kozlov ◽

Brian Carpenter

Keyword(s):

Quality Of Life ◽

Adult Children ◽

Adult Child ◽

Feeding Tube ◽

Health State ◽

Worth Living ◽

Health States ◽

Older Parents ◽

The Impact

Abstract Adult children often help older parents make medical decisions when their health is compromised. To do so in a way that respects parent values requires children to know how their parent views health states and consequent quality of life. The current study compared older parent and adult child valuations of quality of life in different health contexts. Families consisted of older parents (n = 37) and their adult children (n = 66). Parents rated perceived quality of life in 14 compromised health states on a scale from 1 (difficult but acceptable) to 5 (not worth living). Children estimated how their parent responded to each health state, yielding an index of their knowledge of parent perceptions. Overall, parents described all compromised health states as less acceptable than adult children thought they would, t(99) = 2.19, p < .05. Notably, parents believed situations that caused financial or emotional burden to their family were much less acceptable than their children estimated. Children were more knowledgeable about parent valuations for more extreme circumstances, such as living with a feeding tube. Within families, children demonstrated only slight knowledge about parent quality of life valuations (kappa = .081). Across the entire sample of families, there was a broad range of knowledge (kappas = -.181 – .351), but at best, knowledge was still only fair. Results from this study suggest that adult children may underestimate the impact of compromised health states on parent estimations of quality of life, which could affect collaborations on healthcare decisions.

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Estimation of Input Costs for a Markov Model in a German Health Economic Evaluation of Newer Antidepressants

MDM Policy & Practice ◽

10.1177/2381468317751923 ◽

2018 ◽

Vol 3 (1) ◽

pp. 238146831775192

Author(s):

Astrid Seidl ◽

Marion Danner ◽

Christoph J. Wagner ◽

Frank G. Sandmann ◽

Gaby Sroczynski ◽

...

Keyword(s):

Health Economic ◽

Economic Evaluation ◽

Societal Perspective ◽

Selective Serotonin Reuptake Inhibitors ◽

Health Economic Evaluation ◽

Mental Illnesses ◽

Economic Evaluations ◽

Decision Analytic Model ◽

Health State ◽

German Health

Background: Estimating input costs for Markov models in health economic evaluations requires health state–specific costing. This is a challenge in mental illnesses such as depression, as interventions are not clearly related to health states. We present a hybrid approach to health state–specific cost estimation for a German health economic evaluation of antidepressants. Methods: Costs were determined from the perspective of the community of persons insured by statutory health insurance (“SHI insuree perspective”) and included costs for outpatient care, inpatient care, drugs, and psychotherapy. In an additional step, costs for rehabilitation and productivity losses were calculated from the societal perspective. We collected resource use data in a stepwise hierarchical approach using SHI claims data, where available, followed by data from clinical guidelines and expert surveys. Bottom-up and top-down costing approaches were combined. Results: Depending on the drug strategy and health state, the average input costs varied per patient per 8-week Markov cycle. The highest costs occurred for agomelatine in the health state first-line treatment (FT) (“FT relapse”) with €506 from the SHI insuree perspective and €724 from the societal perspective. From both perspectives, the lowest costs (excluding placebo) were €55 for selective serotonin reuptake inhibitors in the health state “FT remission.” Conclusion: To estimate costs in health economic evaluations of treatments for depression, it can be necessary to link different data sources and costing approaches systematically to meet the requirements of the decision-analytic model. As this can increase complexity, the corresponding calculations should be presented transparently. The approach presented could provide useful input for future models.

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Economic evaluation of process utility: elucidating preferences for a non-invasive procedure to treat restenosis

Health Economics Review ◽

10.1186/s13561-021-00327-x ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Maria V. Aviles-Blanco

Keyword(s):

Economic Evaluation ◽

Health Economic Evaluation ◽

Invasive Procedure ◽

Health Programs ◽

Drug Eluting Stent ◽

Health State ◽

Non Invasive ◽

Monetary Value ◽

Process Utility ◽

The Cost

Abstract Background In health economic evaluation, utility associated with a health state is outcome-oriented and usually measured using the QALY methodology. Even though there is consistent evidence of utility not only being derived from outcomes but also from procedures, process utility has not been fully integrated in QALY calculations. The aim of this paper is twofold: first, to provide evidence of process utility associated with an alternative treatment to angioplasty, and second, to estimate a monetary value of such process utility using the willingness to pay (WTP) approach. Methods A total of 1514 people were polled on their WTP to avoid angioplasty to have a drug-eluting stent (DES) implanted. WTP is estimated with a contingent valuation (CV) survey. Individuals are also asked if they would be WTP for a non-invasive procedure with similar results being achieved. WTP responses were analyzed using a double bounded (DB) logit model. Results Most of the participants showed positive preferences for avoiding angioplasty, with an estimated mean WTP of €5692.87. Using QALY gains for avoiding angioplasty, varying from 0.0035 to 0.08 QALYs, our WTP estimate imply monetary values per QALY that range from €71,160.87 to €1,626,534.28. Discussion A WTP of €5692.87 to avoid angioplasty imply a monetary value per QALY that greatly exceed the cost per QALY thresholds established in different countries to consider health programs as beneficial to society. Our results reflect how different methodologies for HTA may lead to different conclusions. From the ICER perspective, the cost that would make the treatment with pills option cost-effective, using a threshold of €40,000/QALY, would be €224. However, a cost-benefit approach could support health programs even with a higher cost. Conclusion WTP methodology captures outcome and process factors related to angioplasty as our WTP estimations are non-significantly different for the costs of angioplasty. WTP approach must be considered as a genuine alternative to QALY approaches to value process utility.

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From Clinical Outcomes to Health Utilities: The Role of Mapping to Bridge the Evidence Gap

Oxford Research Encyclopedia of Economics and Finance ◽

10.1093/acrefore/9780190625979.013.86 ◽

2019 ◽

Author(s):

Mónica Hernández Alava

Keyword(s):

Quality Of Life ◽

Decision Making ◽

Economic Evaluation ◽

Health Utility ◽

Health State ◽

Health States ◽

Descriptive System ◽

Healthcare Technologies ◽

Health State Utility Values

The assessment of health-related quality of life is crucially important in the evaluation of healthcare technologies and services. In many countries, economic evaluation plays a prominent role in informing decision making often requiring preference-based measures (PBMs) to assess quality of life. These measures comprise two aspects: a descriptive system where patients can indicate the impact of ill health, and a value set based on the preferences of individuals for each of the health states that can be described. These values are required for the calculation of quality adjusted life years (QALYs), the measure for health benefit used in the vast majority of economic evaluations. The National Institute for Health and Care Excellence (NICE) has used cost per QALY as its preferred framework for economic evaluation of healthcare technologies since its inception in 1999. However, there is often an evidence gap between the clinical measures that are available from clinical studies on the effect of a specific health technology and the PBMs needed to construct QALY measures. Instruments such as the EQ-5D have preference-based scoring systems and are favored by organizations such as NICE but are frequently absent from clinical studies of treatment effect. Even where a PBM is included this may still be insufficient for the needs of the economic evaluation. Trials may have insufficient follow-up, be underpowered to detect relevant events, or include the wrong PBM for the decision- making body. Often this gap is bridged by “mapping”—estimating a relationship between observed clinical outcomes and PBMs, using data from a reference dataset containing both types of information. The estimated statistical model can then be used to predict what the PBM would have been in the clinical study given the available information. There are two approaches to mapping linked to the structure of a PBM. The indirect approach (or response mapping) models the responses to the descriptive system using discrete data models. The expected health utility is calculated as a subsequent step using the estimated probability distribution of health states. The second approach (the direct approach) models the health state utility values directly. Statistical models routinely used in the past for mapping are unable to consider the idiosyncrasies of health utility data. Often they do not work well in practice and can give seriously biased estimates of the value of treatments. Although the bias could, in principle, go in any direction, in practice it tends to result in underestimation of cost effectiveness and consequently distorted funding decisions. This has real effects on patients, clinicians, industry, and the general public. These problems have led some analysts to mistakenly conclude that mapping always induces biases and should be avoided. However, the development and use of more appropriate models has refuted this claim. The need to improve the quality of mapping studies led to the formation of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Mapping to Estimate Health State Utility values from Non-Preference-Based Outcome Measures Task Force to develop good practice guidance in mapping.

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2200-PUB: Application of Data Envelopment Analysis in Health Economic Evaluation of Insulin Pump Treatment during Perioperative Period

Diabetes ◽

10.2337/db20-2200-pub ◽

2020 ◽

Vol 69 (Supplement 1) ◽

pp. 2200-PUB

Author(s):

WEI SONG ◽

JIANXUAN WEN ◽

LING ZHAO ◽

GUANJIE FAN ◽

MENG LUO ◽

...

Keyword(s):

Health Economic ◽

Economic Evaluation ◽

Data Envelopment Analysis ◽

Insulin Pump ◽

Health Economic Evaluation ◽

Perioperative Period ◽

Data Envelopment

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Estimating Utility Values for Health States of DFU Patients Using EQ-5D-5L and cTTO

The International Journal of Lower Extremity Wounds ◽

10.1177/15347346211014392 ◽

2021 ◽

pp. 153473462110143

Author(s):

Morteza Arab-Zozani ◽

Hossein Safari ◽

Zoha Dori ◽

Somayeh Afshari ◽

Hosein Ameri ◽

...

Keyword(s):

Foot Ulcer ◽

Diabetic Foot Ulcer ◽

Economic Modeling ◽

Health State ◽

Health States ◽

Utility Values ◽

The Mean ◽

The Difference ◽

Diabetes Center ◽

Health State Utility Values

Health-state utility values of diabetic foot ulcer (DFU) patients are necessary for clinical praxis and economic modeling. The purpose of this study was to estimate utility values in DFU patients using the EuroQol-5-dimension-5-level (EQ-5D-5L) and composite time trade-off (cTTO). The EQ-5D-5L and cTTO were used for estimating utility values. Data were collected from 228 patients referred to the largest governmental diabetes center in the South of Iran, Yazd province. When appropriate, independent sample t-test or analysis of variance test was used to test the difference in the utility values in each of the demographic and clinical characteristics of the patients. Finally, the BetaMix was used to identify predictors of the utility values. The means of EQ-5D-5L and cTTO values were 0.55( SD 0.21) and 0.67( SD 0.23), respectively. Anxiety and pain were the most common problems reported by the patients. The difference between the mean EQ-5D-5L values was significant for age, grade of ulcer, number of comorbidities, and having complications. In addition, variables of gender, age, grade of ulcer, and having complications were significant predictors of the EQ-5D-5L. The difference between the mean cTTO values was significant for age, employment status, grade of ulcer, number of comorbidities, and having complications. Moreover, variables of gender, age, grade of ulcer, number of comorbidities, and developing complications were significant predictors of cTTO. The current study provided estimates of utility values for DFU patients for clinical praxis and economic modeling. These estimates, similar to utilities reported in other studies, were low. Identifying strategies to decrease anxiety/depression and pain in patients is important to improve the utility values.

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