Use Of Quality-adjusted Life-year Research Articles

Ethical Shortcomings of QALY: Discrimination Against Minorities in Public Health.

Despite progress, discrimination in public health remains a problem. A significant aspect of this problem relates to how medical resources are allocated. The paradigm of quality-adjusted-life-year (QALY) dictates that medical resources should be allocated on the basis of units measured as length of life and quality of life that are expected after the implementation of a treatment. In this article, I discuss some of the ethical shortcomings of QALY, by focusing on some of its flawed moral aspects, as well as the way it relates to discrimination on the basis of age, race, and disability status. I argue that while this approach seeks to maximize efficiency, it does not place sufficient value on the preservation of life itself. Even more concerning is the fact that the use of QALY disproportionately harms minorities. While QALY is a well-intentioned approach to the allocation of scarce healthcare resources, new alternatives must be sought.

QALY Maximization and the Social Optimum

The quality-adjusted life year (QALY) approach as a paradigmatic measure of health outcomes is widely used in the economic evaluation of health policies and is even trying to be emulated in other public policy areas. The objective of this paper is to structure the arguments underlying the use of QALYs in cost-effectiveness analyses, which condition its applicability. To this effect, the paper intervenes in the unreasonable use of the approach in terms of its limitations when prioritizing health services. In short, the authors are generally in favor of the instrument but do not have blanket enthusiasm in support of it.

THE USE OF QALY AS AN INTEGRAL MEASURE OF EFFECTIVENESS IN THE EVALUATION OF MEDICAL TECHNOLOGIES

This report addresses the ways of calculating QALY (Quality-adjusted life-year). OutsideRussia, a standardized methodology to calculate QALY is in use; such an approach makes it possible to apply this universal criterion of effectiveness to the evaluation of new health technologies. Its versatility enables better decision-making on financing the medical treatment within a limited budget. With this algorithm, the financial resources are allocated in such a way as to maximize the levels of QALY. InRussiato date, the use of QALY as a measure of drug effectiveness is not yet possible because of the lack of standardized calculating methods, as well as the absence of uniform tariffs for assessing the medical status of the patient in terms of health utility. Here, we present a number of methods for estimating the health utility, which are used to calculate the QALY, and describe advantages and disadvantages of these methods.

Using QALYs in telehealth evaluations: a systematic review of methodology and transparency.

BackgroundThe quality-adjusted life-year (QALY) is a recognised outcome measure in health economic evaluations. QALY incorporates individual preferences and identifies health gains by combining mortality and morbidity into one single index number. A literature review was conducted to examine and discuss the use of QALYs to measure outcomes in telehealth evaluations.MethodsEvaluations were identified via a literature search in all relevant databases. Only economic evaluations measuring both costs and QALYs using primary patient level data of two or more alternatives were included.ResultsA total of 17 economic evaluations estimating QALYs were identified. All evaluations used validated generic health related-quality of life (HRQoL) instruments to describe health states. They used accepted methods for transforming the quality scores into utility values. The methodology used varied between the evaluations. The evaluations used four different preference measures (EQ-5D, SF-6D, QWB and HUI3), and utility scores were elicited from the general population. Most studies reported the methodology used in calculating QALYs. The evaluations were less transparent in reporting utility weights at different time points and variability around utilities and QALYs. Few made adjustments for differences in baseline utilities. The QALYs gained in the reviewed evaluations varied from 0.001 to 0.118 in implying a small but positive effect of telehealth intervention on patient’s health. The evaluations reported mixed cost-effectiveness results.ConclusionThe use of QALYs in telehealth evaluations has increased over the last few years. Different methodologies and utility measures have been used to calculate QALYs. A more harmonised methodology and utility measure is needed to ensure comparability across telehealth evaluations.

QALYs, euthanasia and the puzzle of death

This paper considers the problems that arise when death, which is a philosophically difficult concept, is incorporated into healthcare metrics, such as the quality-adjusted life year (QALY). These problems relate...

Cost-effectiveness in Orthopedics

Cost-effective analysis has become an important tool in helping determine what procedures are both cost-effective and appropriate in today's cost control health care. The quality-adjusted life-year (QALY) is a standard measure for health-related quality-of-life in medical cost-effectiveness research. It can be used to compare different interventions to determine the cost-effectiveness of each procedure. Use of QALY to compare health care interventions has become the new gold standard. The key words arthroscopy, cost-effectiveness analysis, QALY, shoulder, hip, knee, ankle, elbow, wrist, and pubic symphysis were searched utilizing PubMed and an internet search engine. Cost/QALY ratios were determined and compared with other surgical procedures using techniques other than arthroscopy. Cost/QALYs were found for the shoulder, hip, knee, and elbow. The QALY for the shoulder was $13,092, for a simple knee was $5783, for a hip $21,700, and for an elbow $2031. General costs were found for the ankle, wrist, and pubic symphysis, that could be used to estimate QALYs without the complex formal calculation. On the basis of our findings, arthroscopy is an extremely cost-effective allocation of health care resources.

Palliative care for the terminally ill in America: the consideration of QALYs, costs, and ethical issues

The drive for cost-effective use of medical interventions has advantages, but can also be challenging in the context of end-of-life palliative treatments. A quality-adjusted life-year (QALY) provides a common currency to assess the extent of the benefits gained from a variety of interventions in terms of health-related quality of life and survival for the patient. However, since it is in the nature of end-of-life palliative care that the benefits it brings to its patients are of short duration, it fares poorly under a policy of QALY-maximization. Nevertheless, we argue that the goals of palliative care and QALY are not incompatible, and optimal integration of palliative care into the calculation of QALY may reveal a mechanism to modify considerations of how optimal quality of life can be achieved, even in the face of terminal illness. The use of QALYs in resource allocation means that palliative care will always compete with alternative uses of the same money. More research should be conducted to evaluate choices between palliative care and more aggressive therapies for the terminally ill. However, current limited data show that investing in palliative care makes more sense not only ethically, but also financially.

Valuing Health for Clinical and Economic Decisions: Directions Relevant for Rheumatologists

The quality-adjusted life-year (QALY) is a construct that integrates the value or preference for a health state over the period of time in that health state. The main use of QALY is in cost-utility analysis, to help make resource allocation decisions when faced with choices. Although the concept of the QALY is appealing, there is ongoing debate regarding their usefulness and approaches to deriving QALY. In 2008, OMERACT engaged in an effort to agree on QALY approaches that can be used in rheumatology. Based on a Web questionnaire and a subsequent meeting, rheumatologists questioned whether it was relevant for OMERACT (1) to investigate use of a QALY that represents the patients' perspective, (2) to explore the validity of the visual analog scale (VAS) to value health, and (3) to understand the validity of mapping health-specific instruments on existing preference instruments. This article discusses the pros and cons of these points in light of current insight from the point of view of health economics and decision-making theory. It also considers the further research agenda toward a QALY approach in rheumatology.

What Next for QALYs?

THE QUALITY-ADJUSTED LIFE-YEAR (QALY) HAS COME under fire lately. In the United States, health reform legislation prohibited use of cost-per-QALY thresholds. The United Kingdom has proposed that the National Institute for Health and Clinical Excellence (NICE), which has influenced reimbursement through cost-per-QALY ratios, will not in the future use such information to make yes or no recommendations; instead NICE’s cost-effectiveness assessments would provide an input into price negotiations for technologies. In Germany, the Institute for Quality and Efficiency in Health Care implemented a new system for evaluating the value of medical technologies but rejected the cost-per-QALY model on ethical and methodological grounds. Many countries (including France, Spain, and Italy) have opted for other approaches. Other articles have criticized use of QALYs. The drawbacks of QALYs are well known. QALYs represent health over time as a series of preference-weighted health states, for which the preference or quality weights reflect the desirability of living in the state, typically from perfect health (weighted 1.0) to death (weighted 0.0). However, the preference weights on which QALYs are based may not capture well how individuals value certain aspects of health (eg, the amount of time experienced in a health state or the order in which states are experienced). The procedure for measuring preferences for health states may exaggerate the importance of the health state in question relative to other aspects of life. Rankings based on cost-per-QALY ratios may not reflect certain preferences. For example, individuals tend to favor interventions that help those most in need or the vulnerable populations, such as children, regardless of whether these options are efficient from a QALY optimizing standpoint. It is difficult to be too enthusiastic about the QALY. Those who support the QALY emphasize its attempt to capture preferences, its convenience, and the lack of good alternatives, but also acknowledge its limitations. Nevertheless, it is unclear why such a simple metric attracts such strong objection. The QALY provides a convenient yardstick for measuring and comparing health effects of varied interventions across diverse diseases and conditions. It helps foster consistency and transparency in health care decision making. Rather than being a rule, it is intended to serve as a rough benchmark for health gains and as one of several inputs into decisions. There is not a similar debate around the concept of life expectancy even though it, too, provides a simple benchmark for health gains. Much of the opposition is unreasonable. For example, critics are particularly troubled that cost-per-QALY thresholds discriminate on the basis of age and disability by favoring younger and healthier populations who have more potential QALYs to gain. However, older and impaired populations typically fare better than younger and healthier populations in cost-effectiveness analyses because it is generally less efficient to provide care to healthier individuals. Moreover, all alternative policies for resource allocation carry their own ethical dilemmas. For example, an approach that banned the valuation of life extension would mean that spending resources to extend by a month the life of a 100-year-old person who is in a vegetative state cannot be valued differently from spending resources to extend the life of a child by many healthy years. Above all, critics conflate QALYs with rationing. They do not distinguish QALYs as an outcome measure from cost-per-QALY thresholds as a decision tool and seem to blame the QALY for revealing uncomfortable choices in health care. They fault the measure for presenting an unacceptable intrusion into the patient-physician relationship. They imply that QALYs represent an absence of clinical judgment and a loss of control, which could shift from physicians and patients to economists or bureaucrats who themselves do not provide care and who have a cost-containment agenda. Such arguments suggest deeper ideologies and agendas, not about QALYs as a metric, per se, but about the autonomy of physicians, about whether health is a private or public good, and about the appropriate role of government in health care. The QALY may effectively be a vessel into which stakeholders pour their frustrations about health care,

The Use of QALYs in Clinical and Patient Decision-Making: Issues and Prospects

The Use of QALYs in Clinical and Patient Decision-Making: Issues and Prospects

Moving the QALY Forward: Rationale for Change

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.

QALYs: The Basics

The aim of this article is to review the concept of the qualityadjusted life-year (QALY), a widely used measure of health improvement that is used to guide health-care resource allocation decisions. The QALY was originally developed as a measure of health effectiveness for cost-effectiveness analysis, a method intended to aid decision-makers charged with allocating scarce resources across competing health-care programs [1–3]. We refer to this original concept of the QALY, as defined in the early literature, as the “conventional” QALY, recognizing that alternative conceptual models have been proposed, including but not limited to so-called “equity-weighted” QALYs. The US Panel on Cost-Effectiveness in Health and Medicine [4] and the National Institute of Health and Clinical Excellence (NICE) in Britain have both endorsed the conventional QALY for their “reference case,” i.e., a standardized methodological approach to promote comparability in cost-effectiveness analyses of different health-care interventions. In using QALYs, we assume that a major objective of decisionmakers is to maximize health or health improvement across the population subject to resource constraints. The use of QALYs further assumes that health or health improvement can be measured or valued based on amounts of time spent in various health states. The conventional QALY is therefore a valuation of health benefit. We note, however, that decision-makers may also have other objectives such as equity, fairness, and political goals, all of which currently must be handled outside the conventional Special Issue [5] addresses some of these variations on the conventional QALY. The QALY was not initially developed to aid individual patient decision-making, although its use has sometimes been extended into clinical decision analyses for this purpose. The core concept of the conventional QALY is grounded in decision science and expected utility theory. The basic construct is that individuals move through health states over time and that each health state has a value attached to it. Health, which is what we are seeking to maximize, is defined as the value-weighted time—life-years weighted by their quality—accumulated over the relevant time horizon to yield QALYs. Health states must be valued on a scale where the value of being dead must be 0, because the absence of life is considered to be worth 0 QALYs. By convention, the upper end of the scale is defined as perfect health, with a value of 1. To permit aggregation of QALY changes, the value scale should have interval scale properties such that, for example, a gain from 0.2 to 0.4 is equally valuable as a gain from 0.6 to 0.8. States worse than dead can exist and they would have a negative value and subtract from the number of QALYs. These conditions, along with an assumption of risk neutrality over life-years, are sufficient to ensure that the QALY is a useful representation of health state preferences.

Hedonic Damages – One More Time: A Symposium

On January 5, 2008, the National Association of Forensic Economics (NAFE) sponsored its third symposium on “hedonic damages,” this time entitled “Hedonic Damages – One More Time.” The first symposium on hedonic damages was presented at the December 1989 Allied Social Sciences meetings in Atlanta, Georgia with the title “Hedonic Damages and the Value of Life.” Papers from that session by W. Kip Viscusi, Ted R. Miller, Stan V. Smith, and William T. Dickens were published in Volume 3, No. 3 of this journal (1990). The second symposium on hedonic damages was presented at the January 2000 Allied Social Sciences meetings in Boston, Massachusetts with the title “Hedonic Damages Ten Years Later.” Papers from that session by W. Kip Viscusi, J. Paul Leigh and Jorge A. Garcia, Ted R. Miller, Stan V. Smith and Thomas R. Ireland, along with an introduction by Peter Marks and Thomas R. Ireland were published in Volume 13, No. 2 of this journal (2000). W. Kip Viscusi and Ted R. Miller returned as presenters for a third time at the January, 2008 symposium, along with Brian McDonald and John O. Ward. Thomas Ireland acted as the organizer of the 2008 symposium and Peter Marks served as its chair. The term “hedonic damages” first entered general public consciousness on December 12, 1988 with a front page story in the Wall Street Journal by Paul M Barrett on “The Price of Pleasure,” featuring Stan V. Smith and his successful presentation of hedonic damages testimony in the case of Sherrod v. Berry (1985, 1987, and 1988). Two federal judges in Illinois had commented favorably about Smith’s testimony in the original opinion and one of the appeals decisions before the case was reversed on other grounds in 1988. The NAFE symposium in December of 1989 was designed to explore this interesting new development in the field of forensic economics. As of the 2000 symposium hedonic damages testimony had enjoyed several successes in individual states, but had been rejected by the courts in a number of reported decisions, particularly at the federal level. The threat of Daubert and Frye standards for admission of expert testimony being applied negatively to hedonic damage testimony had become one of the central features in the debate over this concept. As of 2008 hedonic damages testimony had become much more specialized. Because hedonic damages testimony had been rejected in a number of legal decisions, fewer and fewer forensic economists were involved, but Stan Smith, Robert Johnson, Brian McDonald, as well as several other economic experts

Quality‐adjusted life years: how useful in medico economic studies

Cost-effectiveness analysis has evolved as a practical response to the need to allocate limited resources for health care. It can be used to compare interventions whose effects on health are different if the measure of effectiveness captures all the important health dimensions of the effects of the interventions. Using the quality-adjusted life year (QALY) as the unit of effectiveness attempts to approach this ideal and is currently the approach recommended by many consensus groups. Conventional QALYs represent time spend in a series of "quality-weighted" health states, where the quality weights reflect the desirability of living in the state. Many challenges arise when preferences are incorporated into an economic analysis. The purpose of this paper is to highlight some of the issues surrounding the use of QALYs and to encourage researchers to present their methodology in a clear and transparent way.

Estimation of Burden of Lead for Offspring of Female Lead Workers: A Quality-Adjusted Life Year (QALY) Assessment

This study demonstrates an empirical example that uses quality-adjusted life year (QALY) as a common metric for occupational health assessment to measure the utility loss of potential lead-exposed children delivered by female lead-battery-exposed workers. A set of nationwide health examination data was used for 1726 lead workers. Among them, there were 649 female workers. The numbers of offspring from female lead workers were estimated by multiplying the age-specific fertility rate (ASFR) by the number of workers in each age stratum. The quality of life assessment for these offspring was assumed impaired by increased absorption of lead using a measure of utility for quality of life that was adapted from Rosser’s index of health-related quality of life. The total utility loss was calculated by summing up the loss of QALY for these expected offspring. Dose-response and exposure assessments were based on their mothers’ blood lead levels. It was estimated that more than 38 babies were delivered in 1 yr. There would be 19 babies born with blood lead levels over 30 µg/dl, and about 17 babies with blood lead between 10 and 29 µg/dl. The expected utility loss of the babies was estimated to be about 216 QALY, of which 51.6 QALY was attributed to the babies with moderate blood lead level, while that of high blood lead was 164.4 QALY. An effective industrial hygiene program to reduce blood lead to 5, 10, and 15 µg/dl in female lead-exposed workers would decrease the utility loss to 169.5, 126.8, and 92.3 QALY, respectively, in the offspring. An alternative policy of raising the age of female workers by 5 or 10 yr before employment would also reduce the loss to 174.6 or 107.4 QALY. Data suggest that an effective industrial hygiene program should be implemented, and the use of QALY as a common metric for comparative assessment of occupational health policy may be feasible.

QALYs, standard gambles, and the expected budget constraint

This paper shows that when quality adjustment factors for use in constructing QALY indices are established through answers to standard-gamble questions or similar methods, the assumptions that are made by respondents about the financial consequences of changing probabilities of illness and death are critically important for the use of QALYs in cost-utility analysis (CUA). It qualifies Meltzer’s [Journal of Health Economics 16 (1997) 33] result that the cost per quality-adjusted life-year (QALY) for life-saving medical interventions should include the future consumption of those who would otherwise not have survived, by showing that its validity depends on how the QALY index has been established. The paper also shows that, contrary to a widely held notion, allocation of a fixed health care budget through CUA does not generally result in a second-best efficient allocation. Another finding is that failure to specify carefully what respondents to standard-gamble questions are supposed to assume about the financial consequences of ill health may result in a bias against providing care to older individuals.

Double jeopardy and the use of QALYs in health care allocation.

The use of the Quality Adjusted Life-Year (QALY) as a measure of the benefit obtained from health care expenditure has been attacked on the ground that it gives a lower value to preserving the lives of people with a permanent disability or illness than to preserving the lives of those who are healthy and not disabled. The reason for this is that the quality of life of those with illness or disability is ranked, on the QALY scale, below that of someone without a disability or illness. Hence we can, other things being equal, gain more QALYs by saving the lives of those without a permanent disability or illness than by saving the lives of those who are disadvantaged in these ways. But to do so puts these disadvantaged people under a kind of double jeopardy. Not only do they suffer from the disability or illness, but because of it, a low priority is given to forms of health care that can preserve their lives. This, so the objection runs, is unjust or unfair. This article assesses this objection to the use of QALYs as a basis for allocating health care resources. It seeks to determine what is sound in the double jeopardy objection, and then to show that the defender of QALYs has an adequate response to it.