HEALTH ECONOMICS

HEALTH ECONOMICS

HEALTH ECONOMICS

Sponsored by a Grant TÁMOP-4.1.2-08/2/A/KMR-2009-0041 Course Material Developed by Department of Economics,

Faculty of Social Sciences, Eötvös Loránd University Budapest (ELTE) Department of Economics, Eötvös Loránd University Budapest

Institute of Economics, Hungarian Academy of Sciences Balassi Kiadó, Budapest

HEALTH ECONOMICS

Authors: Éva Orosz, Zoltán Kaló and Balázs Nagy Supervised by Éva Orosz

June 2011

ELTE Faculty of Social Sciences, Department of Economics

Week 9

Measurement of health gain in economic evaluations

Authors: Zoltán Kaló and Balázs Nagy Supervised by Éva Orosz

HEALTH ECONOMICS

Meaningful health benefit for patients

• Life years (not only 5 year survival)

• Quality of life

• Combinations

– QALY (Quality Adjusted Life Years) – HYE (Healthy Year Equivalents)

– DALY (Disablity Adjusted Life Years)

Chlebowski RT et al: JAMA, 289, 24, 2003, 3243-53

Hormone replacement therapy Women Health Initative study

Outcome oestrogen + progesterin (n

= 8506)

placebo (n = 8102)

Relative risk mean follow-up (month) 62.2 (16.1%) 61.2 (15.0%)

hip fracture 44 (0.10%) 62 (0.15%) 0.66

vertebral fracture 41 (0.09%) 60 (0.15%) 0.66

coronary disease 164 (0.37%) 122 (0.30%) 1.29

stroke 127 (0.29%) 85 (0.21%) 1.41

venous thromboembolic disease

151 (0.34%) 67 (0.16%) 2.11

deep vein thrombosis 115 (0.26%) 52 (0.13%) 2.07

pulmonary embolism 70 (0.16%) 31 (0.08%) 2.13

total cardiovascular disease 694 (1.57%) 546 (1.32%) 1.22

invasive breast cancer 166 (0.38%) 124 (0.30%) 1.26

endometrium cancer 22 (0.05%) 25 (0.06%) 0.83

colon and rectal cancer 45 (0.10%) 67 (0.16%) 0.63

cancer total 502 (1.14%) 458 (1.11%) 1.03

Hormon replacement: WHI results reflect previous study results?

Col N et al: Arch Intern Med. 2004;164:1634-1640.

Hormone replacement: QoL gain compensate for increased risks?

Combined hormone replacement:

• No significant impact on: general health, vitality, mental health, depressive symptoms, sexual

satisfaction

• Statistically significant, but clinically not

relevant improvement after 1 year: sleeping disorder (0.4 points out of 20 points), physical functioning (0.8 out of 100 points), pain (1.9 out of 100 points)

• After 3 year no significant improvement in any parameter.

Hays J et al. N Engl J Med, 348, 19, 2003, 1839-54.

“We should set the highest value not on living but on living well.”

Socrates

Determinants of QoL

Society

Quality of life

Culture

Economy

Environment Other

Health status

Health related quality of life

• Exclude factors not influenced by health care services and providers

• Solution: validated and standardized QoL instruments in randomized

controlled trials

Examples of impairments, disabilities and handicaps

HRQoL

Impairments

Pain Fatigue Anxiety Depression Incontinence

Handicaps

Physical independence Mobility

Social integration Orientation

Economic self-sufficiency Disabilities

Bathing Dressing

Climbing stairs Ability to work

Partnership problems

Attributes of HRQoL

Disease, disorder Impairment Disability Handicap Intrinsic situation exteriorisation objectivisation social impact

Vision loss blindness unable to drive

car social isolation

Health Related Quality of Life

Assessment of QoL instruments (I)

• Validity: ability to distinguish QoL of patients with different levels of health status

• Interpretability: measurement

expresses small, moderate, serious change or improvement in QoL

Assessment of QoL instruments (II)

• Reliability / reproducability: same results for repeated measurement

• Sensitivity / Responsiveness: ability to detect small but clinically significant changes in QoL

Validation phases

Outlook (qualitative)

• face validity

– language

– outlook, letter size – simplicity

• content validity

Content

(quantitative)

• criteria validity

• construct validity

– convergence – divergence

• reliability

– internal consistency – reproducability

• validity of different language versions has to be equal with the validity of the original version

• mirror translation is not recommended

Local adaptation of QoL

instruments

Attributes of health state classification system

Breadth of coverage

Depth of coverage

Health

physical function

emotional function

sensory function

pain cognitive ability

mobility physical activity

self-care role

performance

dressing bathing continence eating

Torrance, JHE 1986

Classification of QoL instruments

General Disease specific

Index • Rosser-Kind matrix

• Quality of Well-being

• EQ-5D

• Arthritis Impact

Measurement Scale

• General Health Questionnaire

Profil • Nottingham Health Profile

• SF-36 (Short Form 36)

• Sickness Impact Profile

• Kidney Disease Questionnaire

• RAQoL

QALY measurement

• QALYs - duration of time weighted by a health status preference score,

discounted

• “The policy objective underlying the

QALY literature is the maximization of the community’s health. An individual’s

“health” is measured in terms of QALYs and the community’s health is measured as the sum of QALYs”

Source: Wagstaff A, JHE, 1991

QALY gain by oncology treatment

0 0,2 0,4 0,6 0,8 1

life years

utility weights

surgery + medical therapy palliative care

Why measuring QALYs?

• main attributes of efficacy could be different for assessed health technologies, therefore

comparison is difficult

• outcome attributes of a single health technology can be different, therefore overall assessment of health gain is difficult:

– life years gain,

– long-term QoL benefit, – serious adverse events

– short term adverse events, – short term QoL