Cadth 2015 d4 lidia engel final

Challenges associated in going beyond health-relatedquality of life in cost-utility analysis

Lidia Engel, MSc

Saskatoon, April 14th, 2015

PhD Candidate

David GT Whitehurst, PhDStirling Bryan, PhD

Scott A Lear, PhD

Background Theoretical issues Normative issues Conceptual issues Methodological issues Practical issues

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Background

Background

• Policy decisions are often being informed by economic evaluations that measure outcomes using quality-adjusted life years (QALYs)

• The utility values are often estimated using preference-based measures of HRQoL, such as EQ-5D, SF-6D, or HUI

Source: Whitehead SJ & Ali S (2010).


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Health-related quality of life (HRQoL)

HRQoL focuses on domains of QoL that can be expected to be affected by health alone (health-related)

Background

Adapted from Brazier J. (2007).


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Health care services may result in outcomes other than health and may impact broader aspects of QoL, for example:

- Independence - Dignity - Self-respect- The ability to cope- Etc.

These outcomes are not only affected by health alone (non-health outcomes)

Individuals may derive value from the actual processes of providing care (process utility)

Problem

Background

Ignoring these broader outcomes can lead to a misallocation of scarce resources


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Instruments that go beyond HRQoL – ICECAP & ASCOT

Background

http://www.birmingham.ac.uk/research/activity/mds/projects/HaPS/HE/ICECAP/ICECAP-A/index.aspx http://www.pssru.ac.uk/ascot/domains.php.


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Influence on the conclusion of an economic evaluation

“All results suggest that, using the ICECAP-O, the intervention has a higher probability of cost-effectiveness than with the EQ-5D at the same level of WTP.”

Background

Makai P. et al. (2014).


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Types of economic evaluation and the evaluative space

Background

Cost-benefit analysis:

Costs: Monetary units ($)Benefits: Monetary units ($)

Cost-utility analysis:

Costs: Monetary units ($)Benefits: QALYs

All kinds of benefits

Outcomes beyond health ✔

HRQoL

Outcomes beyond health

Challenges?

?


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Theoretical issues

Theoretical issues

WelfarismNarrow

Extra-welfarism(Culyer 1991)

Broad Extra-welfarism

(Brouwer et al. 2008)

Maximization rule

→ Maximize social welfare

→ Maximize health (expressed in QALYs)

→ Maximization rule is context-dependent

Non-health outcomes?

→ Yes, if individuals derive utility from it

→ Indirect (only if they contribute to health)

→ Yes, if a decision-maker with authority decides to include them

• In theory, non-health outcomes can be included within the QALY framework• One of the ‘extras’ in extra-welfarism allows to broaden the evaluative space


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Normative issues

Why should we go beyond health?

Interventions provide benefits beyond health

Can influence the conclusion of an economic evaluation

To enable comparisons across a broader range of interventions

(e.g., drugs and public health services)

To judge whether interventions offer ‘value for money’


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Normative issues

Societal preferences

What does the society value most in health care priority setting?

The perspective from a representative sample in British Columbia

Source: Bansback N. et al. (2014).

…right term?


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Defining non-health outcomes

Conceptual issues

“Non-health outcomes were not strictly defined a priori, but included features

of the intervention (e.g. invasiveness), features of the healthcare process

(discomfort, duration, healthcare professional), or subjective/perceived impact

on patients (embarrassment, uncertainty, cosmetic).” Opmeer BC. et al. (2010).

Goebbels AFG. et al. (2012).

“Non-health outcomes were defined as all outcomes not captured by EQ5D-

based QALYs.”


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Conceptual issues

Health outcomes vs. non-health outcomes

Usual activities

Self care

Mobility

Anxiety/ depression

Pain/discomfort

Attachment

Enjoy

ment

Security

EQ-5D-5LHealth outcomes?

ICECAP-A/ONon-health outcomes?

Role

Control

Stability

Achievement

Autonomy


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Conceptual issues

http://www.aqol.com.au/documents/AQoL-8D/AQoL8D_structure_superdimensions.png


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Methodological issues

Measuring non-health outcomes

Developing new measures• ICECAP instruments

• ASCOT instruments

Bolt-ons/add-ons/dimension extension• NICEQoL Project

• EQ-5D-dignity (Dixon S. et al. (2013)

Which additional dimensions?• More generic? More specific?

• Are non-health outcomes relevant for all clinical areas?

Double counting might occur if instruments measuring non-health outcomes are applied alongside preference-based HRQoL instruments


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Valuation of non-health outcomes

1)

2)


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1. Selection of the valuation technique

• Choices that involve trade-offs

• Risk of immediate death

• Should be practical, reliable and valid

• Discrete-choice experiment seems to be a promising technique

2. Full health-dead scale

3. Worse than dead health states

4. Duration: non-health outcomes are of temporary nature

5. Who should value?

Considerations for valuing non-health outcomes


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Practical issues

Practical issues

Pragmatism

Comparability

Consistency

Going beyond health-related QoL will

increase the complexity of health-care

decision making!


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Perspectives in HTA

Health care perspective

- Resources are insufficient to meet all demands

Health is the appropriate maximand that should be used

in resources allocation decisions

- Example: NICE (UK), CADTH (CA)

Societal perspective

- All costs and benefits are taken into account, regardless

of where these costs and benefits occur

- Example: CVZ (NL)

Practical issues


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HTA process and non-health outcomes

Practical issues

Assessment stage:

Clinical and cost-effectiveness

evidence is gathered

Appraisal stage:

Recommendations are made

Cost-utility analysis:

What is the outcome?1. Quality-adjusted life years (QALYs)

2. Wellbeing-adjusted life years (WALYs)

3. Social-care QALYs

4. Capability QALYs

5. Process-adjusted QALYs

6. Super QALY (health and non-health)

7. ?

Comparability?

NICE: ICER > £20,000 per QALY gained• Degree of certainty around ICER

• Change in QoL inadequate captured

• Innovation

“Social value judgments”

Solve conceptual issues first• Conceptual framework is needed

• How do we define non-health outcomes?

• What can be considered as process-related what is an outcome?

Examine existing preference-based HRQoL measures• To what extent do they already capture outcomes that go beyond health?

• Avoid double-counting

Communicate the results with decision makers early on

Conclusion and next steps

Thank you for your attention!

[email protected]

Acknowledgements:

Supervisory Committee:

David GT Whitehurst, PhD Stirling Bryan, PhD Scott Lear, PhD

References:1. Bansback N, Pollard S, Bryan S. Eliciting Public Values To Support Health Care Priority Setting: A Novel

Approach. 2014 CADTH Symposium, Gatineau, Quebec. 2. Brazier J, Ratcliffe J, Tsuchiya A, Salomon J. Measuring and Valuing Health Benefits for Economic Evaluation.

New York: Oxford University Press 2007.3. Brennan VK, Dixon S. Incorporating process utility into quality adjusted life years: a systematic review of

empirical studies. PharmacoEconomics. 2013; 31(8):677-91.4. Brouwer WBF, Culyer AJ, van Exel NJA, Rutten FFH. Welfarism vs. extra-welfarism. J Health Econ. 2008;

27(2):325-38.5. Culyer AJ. The normative economics of health care finance and provision. In: McGuire A, Fenn P, Mayhew K,

eds. Providing Healthcare: The Economics of Alternative Systems of Finance and Delivery: Oxford, Oxford University Press 1991:34-58.

6. Dixon S, Shackley P, Brazier J: What is dignity? A literature review and conceptual mapping. HEDS Discussion Paper 11/13.

7. Goebbels AFG, Lakerveld J, Ament AJHA, Bot SDM, Severens JL. Exploring non-health outcomes of health promotion: The perspective of participants in a lifestyle behaviour change intervention. Health Policy. 2012; 106(2):177-86.

8. Makai P, Looman W, Adang E, Melis R, Stolk E, Fabbricotti I. Cost-effectiveness of integrated care in frail elderly using the ICECAP-O and EQ-5D: does choice of instrument matter? The European journal of health economics, 2014, DOI 10.1007/s10198-014-0583-7.

9. Opmeer BC, de Borgie CA, Mol BW, Bossuyt PM. Assessing Preferences Regarding Healthcare Interventions that Involve Non-Health Outcomes: An Overview of Clinical Studies. Patient. 2010; 3(1):1-10.

10. Porter ME. What is value in health care? The New England journal of medicine. 2010; 363(26):2477-81.11. Whitehead SJ, Ali S. Health outcomes in economic evaluation: the QALY and utilities. Br Med Bull. 2010;

96:5-21.

Cadth 2015 d4 lidia engel final

Health & Medicine

health hrqol outcomes

health challenges

health care services

nonhealth outcomesindividuals

broader outcomes

kinds of benefits outcomes

monetary units

benefits beyo