EBM VBM

Evidence-based CardiologyEvidence-based PediatricsEvidence-based GynecologyEvidence-based Dentistry Evidence-based Nursing Evidence-based Health PolicyEvidence-based Health Technology AssessmentEvidence-based Decision MakingEvidence-based Health Performance IndicatorsEvidence-based Clinical AuditEvidence-based Risk Management & Patient SafetyEvidence-based Everything!!!

Patient with problem

Hierarchy of evidenceMeta-analysis of RCT

Large RCT

Small RCT

Non-Randomized trials

Observational studies

Case series / reports

Anecdotes, expert, consensus

What is value?Doctors value

Patients value

What is value?Value CostValue BenefitValue EffectivenessValue Utility

What is value?Quality of life

Length of lifeOur service should provide value: either lengthof life or quality of life, or bothInterventions which do not provide any of the 2 should be ignored

How do we measure value?Length of life can usually be found in EBM literatureQuality of life is equally important but difficult to measure

How do we measure quality of life?Quality of life instrumentsFunction-based instrumentsPreference-based instrumentsBoth measures are not always interchangeable Patient-preference based utility analysis is better

Functional utility analysisNYHA classification of cardiac functionStroke functional classificationArthritis functional classification and other specialty measuresFunctional utility analysis Objective

Patient-preference utility analysisStandard gamble utility analysisWillingness to pay utility analysisTime trade-off utility analysisPreference utility analysis Subjective

Standard gamble utility analysisExample: for essential hypertensionSuppose there is a treatment that permanently cures your disease. But it does not always work. If it does not, you will die. What is the highest percent risk of death you would be willing to accept?If the patient chooses 2%, then the utility value is 0.98

Willingness-to-pay utility analysisExample: for chronic arthritisWhat proportion of your income you would to give in order you are free from your disease?If it is asked to patient with chronic arthritis and the answer is 20%, then the utility value is 0.8

Time trade-off utility analysisExample: for cardiac failureHow many additional years do you expect to live?Suppose there is a treatment that makes you completely free from your disease for as long as you live. The treatment always works but decreases your survival. It means it increases your quality of life but decreases your length of life.What is the max. of time you would be willing to give up in order you will be free from your disease for the rest of life?If the patient expect to live 20 more years and agree to give up 4 years in order to have perfect health, utility is 1-0.2 = 0.8

Among the 3, time-trade utility analysis is the best:It is applicable in all health statesGood to excellent reproducibilityReadily understood by the patientsLow burden of administrationGenerally unaffected by age, sex, ethnicity, education, incomeGood construct validity (it measures what actually should be measured)

QALYQuality-adjusted life yearsRepresents quality of life and length of lifeBy convention: QALY = 0 means deathQALY = 1 means perfect healthExample: A patient with utility value of 0.8 and live for 5 years has 0.8 x 5 = 4 QALYs

QALYs gained by an intervention: exampleA man with coronary heart disease has utility value of 0.70, and the expected survival without surgery is 5 years.If surgery could improve the length of life from 5 to 15 years, and in addition it improves the utility value from 0.70 to 0.90, then the QALY gained can be calculated:In quality of life: (0.900.70) x 5 yrs = 1.0 QALYIn length of life: 0.90 x (15-5 yrs) = 9.0 QALYsThe total value gained = 1.0 + 9.0 = 10.0 QALYsThe cost for 1 QALY gain can be analyzed by using health economic analysis, i.e. cost-utility analysis

5 yrs10 yrs(0.9-0.7) x 5 0.9 x 10QoLLoLSurgery

Economic health care analysisCost minimization analysis: comparing 2 equally effective interventions to determine which is less costlyCost benefit analysis: measures money saved by an intervention for the money expendedCost effectiveness analysis: measure the money expended on an intervention for certain outcome (life years, work years, vision years, etc)Cost utility analysis: measures the money expended on an intervention for the value (improvement of length of life and/or quality of life) gained. The outcome is Rp./QALY (money spent per quality adjusted life years gained).

ConclusionsEBM paradigm should be the gold standard of health care, both for individual or public areaVBM should be utilized for healthcare strategyValue = length of life and / or quality of lifeValues can be measured objectively or subjectivelyQALY incorporates quality and length of life

Conclusions (cont)Economic health care analysis consists of cost minimization, cost benefit, cost effectiveness analysis, cost utilization analyses; the latter is the bestUtility analysis (money spent/1 QALY obtained) may direct physicians and health administrators to provide best health care in the shortcoming of health expenditure

EpidemiologyClinicalEpidemiologyEBMVBMCommunityPatientPatientPatient

ClinicalEpidemiologyEBMEpidemiologyVBM

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