Use Of Quality-adjusted Life Years Research Articles

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

Are Drug-Eluting Stents Cost-Effective?

Since their commercial introduction in 2003, drug-eluting stents (DES) have rapidly altered the management of coronary artery disease. Before their development, the percutaneous management of coronary artery disease was performed predominantly by implantation of bare metal stents (BMS) made of either surgical stainless steel or metal alloys. Although such stents represented a considerable advance over balloon angioplasty alone, they remained limited by restenosis resulting from neointimal proliferation. As a result, ≈15% to 20% of patients treated with BMS required ≥1 repeat revascularization procedure within the 6 to 12 months after stent implantation.1 Despite numerous attempts at systemic pharmacotherapy, device modification, and even use of ionizing radiation, the rate of restenosis after BMS implantation remained largely unaffected. Response by Eisenberg p 1744 Over the past 5 years, effective DES have become the first device to substantially reduce the incidence of restenosis after stent implantation. By delivering high concentrations of either antiproliferative or immunomodulatory compounds directly to the site of arterial injury and by controlling this delivery through polymer-based drug release, both sirolimus- and paclitaxel-eluting stents have safely and effectively inhibited the proliferative process that results in in-stent restenosis. In pivotal clinical trials, both sirolimus- and paclitaxel-eluting stents have reduced rates of angiographic restenosis by 70% to 90% compared with conventional BMS designs, with parallel reductions in the need for clinically driven target vessel revascularization (TVR).2–4 As a result, in April 2003, DES were approved for use in clinical practice in the United States. Within 9 months of their introduction, DES made up 35% of all stent implantations in the United States,5 and their use has increased rapidly since that time. At our own institution, DES comprised >85% of all stents implanted during the past year, and national estimates are that >90% of all percutaneous coronary intervention (PCI) procedures …

The use of quality‐adjusted life‐years in cost‐effectiveness studies

The use of quality‐adjusted life‐years in cost‐effectiveness studies

Use of quality-adjusted life years for the estimation of effectiveness of health care: A systematic literature review

The objectives of this study were to identify, in a systematic literature review, published studies having used quality-adjusted life years (QALYs) based on actual measurements of patients' health-related quality of life (HRQoL) and to determine which HRQoL instruments have been used to calculate QALYs. Furthermore, the aims were to characterize studies with regard to medical specialty, intervention studied, results obtained, quality, country of origin, QALY gain observed, and interpretation of results regarding cost-effectiveness. Systematic searches of the literature were made using the MEDLINE, Embase, CINAHL, SCI, and Cochrane Library electronic databases. Initial screening of identified articles was based on abstracts read independently by two of the authors; full-text articles were again evaluated by two authors, who made the final decision on which articles should be included. The search identified 3,882 articles; 624 were obtained for closer review. Of the reviewed full-text articles, seventy reported QALYs based on actual before-after measurements using a valid HRQoL instrument. The most frequently used instrument was EuroQol HRQoL instrument (EQ-5D, 47.5 percent). Other instruments used were Health Utilities Index (HUI, 8.8 percent), the Rosser-Kind Index (6.3 percent), Quality of Well-Being (QWB, 6.3 percent), Short Form-6D (SF-6D, 5.0 percent), and 15D (2.5 percent). The rest (23.8 percent) used a direct valuation method: Time Trade-Off (10.0 percent), Standard Gamble (5.0 percent), visual analogue scale (5.0 percent), or rating scale (3.8 percent). The most frequently studied medical specialties were orthopedics (15.5 percent), pulmonary diseases (12.7 percent), and cardiology (9.9 percent). Ninety percent of the studies came from four countries: United Kingdom, United States, Canada, the Netherlands. Approximately half of the papers were methodologically high quality randomized trials. Forty-nine percent of the studied interventions were viewed by the authors of the original studies as being cost-effective; only 13 percent of interventions were deemed not to be cost-effective. Although QALYs gained are considered an important measure of effectiveness of health care, the number of studies in which QALYs are based on actual measurements of patients' HRQoL is still fairly limited.

Economics of Rotavirus Gastroenteritis and Vaccination in Europe

Rotavirus is a major cause of gastroenteritis in children throughout Europe and the world. In addition to causing morbidity and mortality in children, rotavirus gastroenteritis (RVGE) creates a major economic burden on health care systems and families in Europe. The costs of hospital admissions for RVGE and nosocomial infections generate significant medical treatment costs throughout the region. Less information is available on the costs associated with less severe episodes and the costs borne by families, including lost time from work. The availability of rotavirus vaccines presents an effective opportunity to prevent RVGE and these associated economic costs, as well as providing protection to each child and hence benefiting the child's family. The adoption of rotavirus vaccine by health authorities in Europe will require a comparison of the costs and benefits. Economic evaluations that compare the costs of vaccination to the economic benefits of rotavirus vaccination will provide an estimate of its financial impact on health care systems and society. However, to provide a complete picture, economic evaluations of rotavirus vaccines will need to account for both the reduced costs and the reduced morbidity from prevented RVGE. Cost-effectiveness analyses based on quality-adjusted life years (QALYs) provide a systematic approach for assessing vaccination as a health investment, comparing the incremental costs associated with rotavirus vaccination and the reduced morbidity and mortality. QALYs provide a standardized approach for quantifying and comparing reductions in health-related quality of life and premature mortality. Although methodologic limitations exist in applying the QALY approach to childhood vaccines, their use in cost effectiveness analyses allows decision makers to consider the full health benefits of rotavirus and other vaccines.

The Validity of QALYs under Non‐Expected Utility

This paper examines applications of non-expected utility in the health domain. The most widely used utility model in health economics, the time-linear QALY model, assumes (i) separability of quality of life and life duration, and (ii) linearity of the utility for life duration. We perform new tests, which are robust to violations of expected utility, of these two assumptions. The data support separability, but show that the utility for life duration is concave rather than linear. The finding of concave utility may not be surprising in itself. The contribution of this paper is to demonstrate this empirically without being invalidated by violations of expected utility. It has by now been widely recognised that expected utility is not valid as a descriptive theory of decision under uncertainty. The descriptive violations of expected utility have led to the emergence of several non-expected utility theories. The increasing importance of non-expected utility makes it necessary to reassess applications that were previously based on expected utility. Examples of such reassessments include Karni and Safra (1989), Crawford (1990) and Dekel et al. (1991) for game theory, Machina (1995) and Wakker et al. (1997) for insurance theory and Cubitt and Sugden (1998) for the evolution of preferences. See Starmer (2000) for a review. The present paper examines applications of non-expected utility in the health domain. We focus on the main utility model in health economics, the quality-adjusted life-years (QALY) model, and present new theoretical foundations for, and empirical tests of this model under non-expected utility. QALYs provide a simple way to combine the two dimensions of health, life duration and health status, into a single utility index. They are intuitively appealing, which facilitates communication to policy makers, and analytically tractable, which explains their widespread use in practical studies. A disadvantage of QALYs is that they only represent individual preferences over health under strong assumptions. If these assumptions do not hold, then the use of QALYs may lead to incorrect policy recommendations. To gain insight into the validity of QALYs, it is necessary to assess the restrictiveness of the assumptions that the QALY model imposes. In the most common version of the QALY model, the time-linear QALY model, the utility of the health outcome of spending t years in health state q is equal to tV(g), where V is a utility function over health states. That is, in the time-linear QALY model the utility for duration is linear. It is well known that under expected utility, linearity of utility implies risk neutrality. As it turns out, risk neutrality with

QALYS and Policy Evaluation: A New Perspective

This Article presents a new, welfarist defense of the use of QALYs (quality adjusted life years) in policy evaluation. It challenges both the conventional wisdom among health economists that QALY-based analysis is dominated by traditional cost-benefit analysis (i.e., the sum of willingness-to-pay amounts) as well as the standard view of public health researchers that QALYs should function as the effectiveness metric in a cost-effectiveness analysis. Instead, the Article defends a nontraditional form of cost-benefit analysis, where QALYs are multipled by a conversion factor, for example $100,000 per QALY, and added to the monetized non-health effects of a policy. Part I of the Article surveys the current literature on QALYs. Part II shows that QALYs can be a more accurate measure of overall well-being than WTP amounts, under certain conditions, and argues that cognitive difficulties interfering with the measurement of WTP amounts can be circumvented by QALYs. Part III describes the limitations of QALYs. Part IV discusses the role that QALYs should play in welfarist policy analysis, given their strengths and limitations. In particular, it presents a pragmatic approach to determining the QALY-to-dollar conversion factor, and sheds new light on the controversy about pricing whole lives versus life-years.

Cost-Effectiveness versus Cost–Utility Analysis of Interventions for Cancer: Does Adjusting for Health-Related Quality of Life Really Matter?

Objective The US Public Health Service Panel on Cost-Effectiveness has recommended the use of quality-adjusted life-years (QALYs) as the best way to estimate outcomes in a cost-effectiveness analysis. We evaluate the importance of this recommendation by assessing whether adjusting for health-related quality of life affects the ultimate resource allocation decision implied by the cost-effectiveness ratio for interventions aimed at cancer prevention and control. Methods We identified 110 interventions in 39 articles for which both cost/life-year and cost/QALY were reported. Interventions were forms of prevention, early detection, or treatment of cancer. We calculated a Spearman correlation to assess the ordinal relationship between cost/life-year and cost/QALY. In addition, we employed various decision thresholds to assess whether the use of cost/life-year would yield different resource allocation decisions than the use of cost/QALY. Results The correlation between cost/life-year and cost/QALY is 0.96 ( P < .0001). Assuming a $50,000 decision threshold, adjustment for quality of life would affect the implied choice in 5% of cases. With a $400,000 threshold, adjustment for quality of life would affect choice for 2% of interventions. Conclusions For interventions aimed at cancer, the outcome measures of cost/life-year and cost/QALY are highly correlated with one another. Although adjusting for quality of life can make an important difference in the evaluation of alternative approaches to cancer prevention and control, it often does not.

A utility-theoretic model for QALYs and willingness to pay.

Despite the widespread use of quality-adjusted life years (QALY) in economic evaluation studies, their utility-theoretic foundation remains unclear. A model for preferences over health, money, and time is presented in this paper. Under the usual assumptions of the original QALY-model, an additive separable presentation of the utilities in different periods exists. In contrast to the usual assumption that QALY-weights do solely depend on aspects of health-related quality of life, wealth-standardized QALY-weights might vary with the wealth level in the presented extension of the original QALY-model resulting in an inconsistent measurement of QALYs. Further assumptions are presented to make the measurement of QALYs consistent with lifetime preferences over health and money. Even under these strict assumptions, QALYs and WTP (which also can be defined in this utility-theoretic model) are not equivalent preference-based measures of the effects of health technologies on an individual level. The results suggest that the individual WTP per QALY can depend on the magnitude of the QALY-gain as well as on the disease burden, when health influences the marginal utility of wealth. Further research seems to be indicated on this structural aspect of preferences over health and wealth and to quantify its impact.

Funding the New Biologics – Introduction

863 In up to 20% of cases, Crohn’s disease remains active despite conventional medical therapy. Disorders of this type are usually not fatal, but result in significant disability, and thereby incur disproportionately great indirect medical and other costs to the patient and his or her family. Because treatment options are limited and there is a desire to avoid repeated surgical procedures, new biological agents, such as infliximab, are welcomed by physicians and patients. Infliximab is expensive, however, and a recent Canadian economic analysis has suggested that its use exceeds recognized benchmarks of cost effectiveness. This analysis was rigorous, used the best available clinical data, and included sophisticated sensitivity analyses, but was subject to important limitations dictated by the available data. For example, it assessed only direct medical costs and employed a short time horizon, which might have resulted in an underestimation of the long term benefits of averting surgery. Some of the assumptions that were used in the design of the model relied on American epidemiological data and expert opinion, instead of empirical Canadian data. The use of quality-adjusted life-years in the calculation of clinical costs and benefits might not be appropriate for patients with relatively high indirect medical costs, as is the case with Crohn’s disease. It might be better to compare the benefits of a specific medical strategy with those obtained by alternative uses of the health care resources. The manner by which quality-adjusted life-years were calculated in the Canadian Coordinating Office for Health Technology Assessment report has also been discussed. Currently accepted standards of cost effectiveness, including incremental cost utility ratios, are inherently arbitrary. It is possible that, in general, new biological agents could never meet such standards and would thus be declared cost ineffective, despite the fact that they are of proven benefit for certain important subgroups of patients. It has been suggested that a new way of evaluating these agents must be devised. Because the cost of the medication itself is an important component of overall health care costs, innovative cost-sharing schemes should be considered. It would also be helpful to identify specific subgroups of patients for whom new and expensive agents are appropriate. Clinical experience with infliximab is limited, and further economic analyses will be required as new data become available. Policy makers will need to consider not only economic but also humanitarian factors when deciding whether to provide funding for medications that offer hope to patients whose prognoses are otherwise dismal.

Health-related quality of life of Colles' fracture patients.

Recent guidelines published by the National Osteoporosis Foundation (NOF) make extensive use of quality-adjusted life-years (QALYs). Crucial to these guidelines, therefore, are the assumptions that are made about the health-related quality of life (HRQoL) gained from the avoidance of osteoporotic fractures. This paper reports on a study in which 50 Colles' fracture patients were asked to describe their health at each visit during treatment using the EuroQol descriptive system and to value their own health using the visual analogue scale (VAS). By applying a set of population-derived valuations to the states reported by the patients, the QALY loss is shown to be about 2%. This is about half of the loss, based upon clinician judgement, that is contained in the NOF guidelines. In addition, the results suggest that it may be possible to use VAS scores to predict treatment requirements, since those patients who require fewer visits have, on average, higher initial VAS scores.

Preference based outcome measures for economic evaluation of drug interventions: quality adjusted life years (QALYs) versus healthy years equivalents (HYEs).

Decisions about medical treatment and health programmes involve both technical and value judgements. For the purpose of performing an economic appraisal of different health interventions (including drug interventions), a single global score is essential as the measure of outcome. This measure should enable us to compare different interventions that affect both duration and quality of life at different levels of effect. This article provides a short but critical overview of the most commonly used measure of outcome in such cases--the quality adjusted life years (QALY). We describe the measure and discuss its limitations. More specifically we discuss problems stemming from the fact that QALYs do not fully reflect individual preferences and the fact that different (not necessarily comparable) methods of measurement can be used to generate the weights. We also discuss the issue of the equity implications of the methods used to aggregate the QALY values of individuals to arrive at a community health outcome measure. Our conclusion is that the use of QALY does not coincide with achieving the stated goal of economic evaluations (i.e. efficient allocation of resources to enable maximisation of the health of the community for any given level of resources). An alternative measure of outcome--the healthy years equivalent (HYE), which does not suffer from many of the major limitations associated with the QALY measure--is described and discussed.

The use of QALYs in health service planning

There has been substantial interest in recent years, among research workers and in health service management, in the potential use of quality-adjusted life years (QALYs) as an aid to decision-making about the development of services and use of resources in health services (Gudex, 1986; Drummond, 1986). In 1986 the North Western Regional Health Authority (RHA) initiated the first large-scale attempt to use QALYs as a practical aid to planning in the National Health Service. This paper draws on the experience of the North Western RHA in examining some methodological and practical issues relating to the future of QALYs as an aid to decision-making in the Health Service.

Castigating QALYs.

The ethical problem of how to apportion limited resources amongst the needy has been forced on us by arbitrary limitation of health expenditure. Its solution would not be required if health expenditure were higher. Distribution of resources according to best value for money, assessed as Quality Adjusted Life Years (QALYs) per unit cost, has been suggested as a possible solution, but leads to absurd anomalies. In the calculation of QALYs the implied value of life is no more than the absence of suffering. The use of QALYs for the comparison of treatments that are symptomatic or life-saving therefore leads to serious undervaluation of life and treatments that prolong it. Moreover, distribution of resources by best value for money, however assessed, is inequitable since for a given degree of suffering those whose illnesses happen to be cheaper to treat will be treated in preference to those whose treatments are more expensive.

The use of QALYs in health care decision making

This paper seeks to highlight some of the critical issues concerning the use of the Quality Adjusted Life Years (QALYs) to measure the outcome of health care choices, in decisions related to both individual patient care and social resource allocation. Much of the support for the QALY is based on its simplicity as a tool for resolving complex choices. However, it may be the case that the QALY is not sufficietly refined of robust, failing perhaphs to take into account some of the critical factors which affect preferences over different health care scenarios.