Moving the QALY Forward: Rationale for Change

Abstract

In November 2007, ISPOR convened the “Building a Pragmatic Road: Moving the QALY Forward” Consensus Development Workshop where thought leaders presented and discussed the following: 1) defining and refining the quality-adjusted life-year (QALY) by analyzing the underlying assumptions; 2) developing alternative paradigms and measures; 3) retaining the QALY and enhancing it with additional methods; and 4) incorporating a variety of decision-makers’ needs. The goal of this workshop on the QALY was to reach consensus among the thought leaders on these broad categories, with recommendations for specific, applicable actions. Workshop participants are listed below. Before this workshop, participants were divided into five groups and each group met via teleconference to develop their arguments on one of the following topics: 1) defining the QALY; 2) considering alternate definitions of the QALY and defining the issues; 3) incorporating an experience-based approach to the QALY; 4) defining the importance of bridging past QALY information to future QALY information; and 5) defining the value of the QALY from a health-care decision-makers’ perspective. Using a modified “forming–storming–norming–performing” model [1] for consensus development during the 2-day workshop, each group presented arguments about the QALY, received feedback on their arguments and modified, if needed. Then a group of representatives from each group was convened to develop consensus statements on “moving the QALY forward” based on the arguments presented. These consensus statements were then debated, and agreed upon by workshop participants, and then formulated into the final article in this Special Issue. This Value in Health Special Issue describes the arguments presented during the consensus development workshop on the QALY. Articles 2–6, “QALYs: The Basics,” “QALYs: Some Challenges,” “A Different Approach to Health State Valuation,” “Retaining, and Enhancing, the QALY,” and “The Use of QALYs in Clinical and Patient Decision-Making: Issues and Prospects,” present the arguments. Article 7, “Towards a Consensus on the QALY,” defines eight consensus statements developed by the “consensus developing group” and presents a way forward. The last two articles in this Special Issue, “Editorial: On The Benefits of Modeling Using QALYs for Societal Resource Allocation: The Model Is the Message” and “Editorial: Moving The QALY Forward or Just Stuck in Traffic?” are provided by two guest editors, selected by the Value in Health Editor-in-Chief to critique this Special Issue. The appointment of guest editors is an important component of Value in Health’s policy on Special Issues and is intended to ensure that a broad range of views is expressed. The guest editors did not participate in the QALY Consensus Development Workshop, so their reactions are based on the written articles alone. Garrison is broadly welcoming of this initiative and considers that the articles in this Special Issue are a fair and useful representation of the current debate about health state utilities and preferences. Nevertheless, he also points out that several important issues were not discussed, or not resolved satisfactorily. He also points out that the relevance of QALYs for resource allocation may depend crucially on the values underlying the organization of the health-care system in a given country. For example, QALYs may have a different relevance in a country like the United Kingdom, with a government-funded national health service, than they may have in a country like the United States. On the other hand, Reed Johnson is much more frustrated with the lack of progress with research within the QALY paradigm and feels that more progress would be made if we looked for alternatives. These could be alternative methods for elucidating preferences, such as contingent valuation and discrete choice experiments, or different decision-making approaches, such as that currently being proposed by the Institute for Quality and Efficiency in Health Care in Germany. We support further research into, and experimentation with, alternatives to the QALY. As these approaches become more often used in practice, their difficulties will become better known and, hopefully, resolved. Nevertheless, the focus on this workshop was on experience with the QALY. Perhaps, similar workshops, discussing experiences with using alternative measures, will be possible in the future. We hope that this Value in Health Special Issue on “Moving the QALY Forward: Building a Pragmatic Road” is both informative and serves as a platform for future debate and consensus development on the QALY.