QALYs

With adult smoking prevalence rates declining too slowly to reach national objectives, opinion leaders are considering policies to improve tobacco-related outcomes by regulating the composition of cigarettes to be (1) less harmful and/or (2) less addictive. Because harm reduction efforts may actually encourage higher cigarette consumption by promoting a safer image, and addictiveness reduction may increase the harmfulness of cigarettes by encouraging compensatory smoking behaviors, policymakers must consider the tradeoffs ...

Diabetic foot ulcers (DFU), infections and amputations are associated with high costs of care and loss of health. To evaluate new treatments, both the extra costs incurred and the health utility gained need to be examined. However, evaluations of treatments in diabetes are hampered by the lack of utility values for health states such as DFU. We estimated utility values for health states seen amongst DFU patients.We identified 13 unique health states based on presence/type of DFU and amputation. Members of the general public (n = 107) received a description of each health state. They were then asked to indicate how undesirable each health state was (using the time trade-off method). Each answer was then transformed to create a value representing the “utility” of the health state, the utility value represented on a 0-1 scale.Valid responses could be obtained from 96 persons. Mean values included: 0.84 (diabetes with no DFU or amputation), 0.75 (uninfected DFU, no amputation), 0.68 (no DFU, previous foot amputation), and 0.63 (uninfected DFU, previous amputation of other foot). The impact of an ulcer depended on amputation status.Our values correspond with previously published results but are more detailed. In addition, since our values were derived from the general public, economic evaluations that incorporate them will use the generally preferred societal perspective. Therefore, these values are appropriate, practical and sensitive weights to calculate QALYs for cost-effectiveness analyses of foot ulcer treatments.Ulcères de pieds et amputations, estimation de l'utilité d'un système d'analyse coût efficacité des nouveaux traitementsLes ulcères de pieds chez les diabétiques (UPD), les infections et les amputations sont associés à des coûts de santé élevés et une “perte” de l'état de santé. Évaluer de nouveaux traitements est à la fois en estimer les surcoûts induits et leur utilité en gain de santé. Toutefois, de telles évaluations thérapeutiques sont pénalisées, chez des patients diabétiques, par l'absence d'indicateurs fiables d'utilité dans le domaine des UPD. Ce travail a pour but d'estimer telles “valeurs d'utilité” dans ce domaine.Nous avons identifié 13 situations de perception de santé selon la présence et le type d'un UPD et/ou d'une amputation. Des sujets non diabétiques recrutés dans la population générale (n = 107) tirés au sort reçurent une information sur ces états pathologiques. Ils furent ensuite questionnés sur leur perception de la nuisance engendrée par chacun de ces états (technique de l' “échange” de cet état contre “des années de vie” que le sujet serait prêt à perdre pour l'éviter). Chaque réponse était ensuite transformée en une valeur dite “d'utilité” de cet état de santé, rapportée à une échelle de 0 à 1 (de moins grave 1 à pire 0).Des réponses fiables furent obtenues chez 96 personnes. La moyenne pour l'état de diabète sans UPD fut de 0,84, UPD sans infection ni amputation 0,75, antécédent d'amputation sans UPD 0,68, antécédent d'amputation et UPD sur l'autre pied 0,63. L'impact d'un UPD dépend de l'existence d'une d'amputation antérieurement.Nos valeurs confirment celles de travaux antérieurement publiés mais sont beaucoup plus détaillés. De plus nos données étant obtenues à partir d'un échantillon de la population générale elle seront plus pertinentes pour des évaluations économiques dans une perspective sociétale. Par conséquent ces valeurs sont appropriées, pratiques et sensibles comme élément de calcul de la balance coût-efficacité pour des analyses d'impact des traitements d'ulcères de pied chez des diabétiques (calcul de QALYs = quality-adjusted life years).

One way of evaluating health is in terms of its impact on well-being. It has been shown, however, that evaluating health this way runs into difficulties, since health and other aspects of well-being are not separable. At the same time, the practical implications of the inseparability problem remain unclear. This paper assesses these implications by considering the relations between theories, components, and indicators of well-being.

Decision analysis (DA) and value-of-information (VOI) analysis provide a systematic, quantitative methodological framework that explicitly considers the uncertainty surrounding the currently available evidence to guide healthcare decisions. In medical decision making under uncertainty, there are two fundamental questions: 1) What decision should be made now given the best available evidence (and its uncertainty)?; 2) Subsequent to the current decision and given the magnitude of the remaining uncertainty, should we gather further evidence (i.e., perform additional studies), and if yes, which studies should be undertaken (e.g., efficacy, side effects, quality of life, costs), and what sample sizes are needed? Using the currently best available evidence, VoI analysis focuses on the likelihood of making a wrong decision if the new intervention is adopted. The value of performing further studies and gathering additional evidence is based on the extent to which the additional information ...

Cost effectiveness analysis is a tool for evaluating the aggregate benefits of medical treatments, health care services, and public health programs. Its opponents often claim that its use leads to unfair discrimination against people with disabilities. My aim in this paper is to clarify the conditions under which this might be so. I present some ways in which the use of cost effectiveness analysis can lead to discrimination and suggest why these forms of discrimination may be unfair. I also discuss some proposals for avoiding discrimination without rejecting cost effectiveness analysis altogether. I argue that none of these proposals is ultimately convincing. I describe a different approach to the problem and conclude by answering the question in the title.

This paper investigates why economic approaches to priority setting have had only limited impact in practice. It argues that obstacles to the take-up of the economic approach centre on (1) limitations in the theory and practice of economic evaluations, and (2) the nature of the wider context ...

The Affordable Care Act (ACA) may be the most important health law statute in American history, yet much of the most prominent legal scholarship examining it has focused on the merits of the court challenges it has faced rather than delving into the details of its priority-setting provisions. In addition to providing an overview of the ACA’s provisions concerning priority setting and their developing interpretations,this Article attempts to defend three substantive propositions.

First, I argue that the ACA is neither uniformly hostile nor uniformly friendly to efforts to set      priorities in ways that promote cost and quality.

Second, I argue that the ACA does not take a single, unified approach to priority setting; rather, its guidance varies depending on the aspect of the health care system at issue (Patient Centered Outcomes Research Institute, Medicare, essential health benefits) and the factors being excluded from priority setting (age, disability, life expectancy).

Third, I argue that cost-effectiveness can be achieved within the ACA's constraints, but that doing so will require adopting new approaches to cost-effectiveness and priority setting. By limiting the use of standard cost-effectiveness analysis, the ACA makes the need for workable rivals to cost-effectiveness analysis a pressing practical concern rather than a mere theoretical worry.

QALY based decision-making in health care does not seem to encompass any broad-scale increase in utility to the community. Given that a properly formed Utilitarian response should base the cost-effectiveness of health care distributions upon the total increase in utility it follows that the increase in utility to the individual should be considered in conjunction with the increase in utility to the society or community. Consequently, the QALY cannot be a strict Utilitarian response to issues of healthcare distribution nor is it able to evaluate such distributions in terms of the benefit (increase in utility) to the community.

Objectives: The impact of Type 2 diabetes mellitus (T2DM) on health-related quality-of-life (HRQoL) is complex due to the burden of disease, lifelong treatment requirements, and comorbidities. This study aimed to capture UK societal utility values for health states associated with T2DM and treatment-related adverse events (AEs) to assess the burden of the disease and common AEs.

Methods: Nine health state descriptions were developed (from a literature review and patient and clinician qualitative input) depicting the burden associated with T2DM and treatment-related AEs. These were mild/moderate urinary tract infection (UTI); severe UTI; mycotic infection; moderate hypoglycemic events; severe hypoglycemic events; fear of hypoglycemia; gastrointestinal symptoms; and hypovolemic events. Members of the UK general public (n ¼ 100) valued these states using the time trade-off (TTO) methodology to elicit utility values (between 0 ¼ dead, 1 ¼ full health). Regression analysis was conducted to understand the influence of age and gender.

Results: All treatment-related AEs were found to have a significant effect on utility. From the T2DM baseline state (0.92), the experience of AEs was associated with the following disutility: T2DM with hypovolemic events (0.08); T2DM with mild/moderate UTIs (0.09); T2DM with moderate hypoglycemic events (0.11); T2DM with severe hypoglycemic events (0.15); T2DM with fear of hypoglycemia (0.15); T2DM with severe UTIs (0.19); T2DM with GI symptoms (0.24); and T2DM with mycotic infection (0.25); Males consistently scored the states with significantly lower utility values, but no significant age effects emerged.

Conclusions: Findings suggest that adverse events in T2DM can be a burden for some individuals. The study indicates the potential importance of including information regarding AEs in economic evaluations. Although some states were rated severely in terms of utility; in reality, many of these only last a few days, therefore having a minimal quality-adjusted life year (QALY) impact.

This paper explores the role of knowledge, standards, and metrics in global health. Our point of departure is the observation that the emergence of ‘global health’ as a domain of research, policy, and practice in the last three decades or so has coincided with an increased interest in the validation and use of measures of health, such as the
Disability Adjusted Life Year (DALY), in monitoring and assessing health equity across territories and populations. This ‘elective affinity’ between global health and health metrics has become the focus of scholarly debate in the social sciences. In this paper, we seek to contextualise and critically discuss the different positions in this debate. We suggest that emplacing health metrics within the neo-liberal logic of health production –one where the ‘mechanisms of life’ are
aligned with the maximisation of economic productivity- does not fully capture the interactive relationship between health measurement and the politics of health. Instead, we argue that this relationship has been characterised by controversy and uncertainty about how to interlock normative ideals and approaches to knowledge-making about health.

In the Global Burden of Disease study, disease burden is measured as disability-adjusted life years (DALYs). The paramount assumption of the DALY is that it makes sense to aggregate years lived with disability (YLDs) and years of life lost (YLLs). However, this is not smooth sailing. Whereas morbidity (YLD) is something that happens to an individual, loss of life itself (YLL) occurs when that individual's life has ended. YLLs quantify something that involves no experience and does not take place among living individuals. This casts doubt on whether the YLL is an individual burden at all. If not, then YLDs and YLLs are incommensurable. There are at least three responses to this problem, only one of which is tenable: a counterfactual account of harm. Taking this strategy necessitates a re-examination of how we count YLLs, particularly at the beginning of life.

This research develops an Excel spreadsheet for The Backbone of History, Cambridge University Press, pp.61-93 Steckel Sciulli and Rose (2002) Health Index and applies it to three modern cases of trauma and disability. The health index was developed to compare the overall health of past societies. The present research was applied to three individuals from the Documented Collection of the Maxwell Museum of Anthropology. The first, individual #154 (85.26.2), reached fifty-two years of age with many signs of poor health. This individual has traumatic injuries, dental loss, osteoporosis, degenerative joint disease, and infection. Computation of the Health Index produced a health index quality-adjusted-life-years (QALY) score of 21.82. This QALY score places the individual's sets of pathological conditions in a broader context. This score also emphasizes how difficult life was in ancient societies with similar average QALY scores. Site 61 WO7 is a 1075year-old coastal California site Skeletal Health Index from (Steckel et al. 2002) was equivalent to the individual #154. The modern individual #154 (85.26.2.) QALY scores within the top seven sites a 1075 BP Coastal Southern California site with a 21.75 QALY at 82.4% of the maximum QALY obtainable for quality of life on Skeletal Health Index. The lowest average QALY site score in the Skeletal Health Index is 14.12 at 54% of the maximum QALY obtainable at protohistoric Hawikku, New Mexico. The two other modern cases are #290 (2016.23.1) and #201(94.121.1), with QALY scores of 31.14 and 25.71, respectively. When comparing the QALY scores of the three recent individuals to Steckel et al.'s list of QALY scores by sites listed by Steckel at. al. (2002) (their table 3.2), the scores of #290 and #201 are substantially higher and have no archaeological correlation to any of the sites listed by Steckel et al. (2002).

Objectives: To elicit a willingness-to-pay (WTP) per quality-adjusted life-year (QALY) estimate for the general Greek population and assess the impact of individuals' socio-demographic characteristics and motives on this estimate. Methods: A telephone-based survey was carried out employing a representative sample of the general Greek population (n = 1342). A computer-assisted telephone-interview method was adopted to ensure random sampling. A total of 528 participants reported a WTP value for a utility improvement from their current health to perfect health. Those individuals' motives were assessed through predefined statements. Test-retest reliability was assessed using intraclass correlation coefficient (ICC). Multiple linear regression (MLR) and one-way analysis of variance (ANOVA) tests were conducted to assess the effect of socioeconomic/demographic determinants and motive statements, respectively, on WTP/QALY. MLR was re-estimated considering as dependent variable the WTP/QALY estimate calculated for participants: (1) stating a WTP value # their household income and (2) presenting higher certainty regarding stated WTP value (sensitivity analysis). Results: Analysis revealed good reliability for WTP/QALY estimates and motive statements (ICC values. 0.8). Mean WTP/ QALY was V26 280. The respective 5% trimmed value was V14 862. Being a student and household income affected WTP/ QALY. Sensitivity analysis did not produce markedly different WTP/QALY predictors, implying the robustness of results, irrespective of the participant group considered. Individuals who indicated the inability to cover basic family needs or pay tax claims as motives reported lower WTP/QALY values compared with those not viewing these aspects as motives. Conclusions: Findings confirm that the World Health Organization's criterion used currently in Greek cost-effectiveness studies is not unreasonable. Additional research is essential to further explore WTP/QALY estimates in the Greek setting and facilitate informed decision making.

Background: The return of public health to local government in England in 2013 created an opportunity to integrate preventive services with agencies that act on the wider determinants of health. A number of local authorities subsequently developed integrated health and wellbeing approaches, in recognition that the previous ‘silo’ approach to the provision of single-issue lifestyle services had made little impact on inequalities. These integrated services often involve targeting the most disadvantaged geographical and non-geographical communities locally. One example is the Wellbeing for Life (WFL) service in County Durham.

Methods: The impact of WFL was evaluated using a mixed methods study design, involving: i) ethnographic observations plus interviews and focus groups with clients (n=58), staff (n=47), volunteers (n=15) and external stakeholders (n=10); ii) secondary analysis of intervention monitoring data at baseline (n=1461 clients), three (n=1201), six (n=380) and 12 months (n=133); and iii) a value for money assessment. Primary outcome measures were the EQ-5D and short Warwick Edinburgh Mental Wellbeing Scale (SWEMWBS). Secondary outcome measures were BMI, fruit and vegetable intake, physical activity, alcohol consumption, smoking and self-efficacy.

Results: Clients reported positive experiences of engaging with the service and described making lifestyle changes, such as reducing portion sizes or trying new activities. Many would have liked a longer intervention (usually 8–12 weeks) and staff agreed that the duration was often insufficient for those with more complex physical, mental and/or social needs. Pre/post analysis of the intervention data revealed significant improvements across all outcome measures, with the largest changes observed in clients with the least positive results at baseline. These changes were largely maintained at both follow-up periods. Furthermore, reductions in the differences in EQ-5D and SWEMWBS scores between clients from the 30% most deprived communities and all other clients at the six-month follow-up stage implied that inequalities had narrowed over time. The value for money assessment indicated an estimated cost per quality-adjusted life year (QALY) of £3900 and a social return on investment of around £3.59 for every £1 spent on WFL.

Discussion: An integrated health and wellbeing approach can be acceptable to members of the target communities, encourage them to make and maintain lifestyle changes, and potentially reduce health inequalities. The WFL service appeared to represent good value for money, although the reliance on self-report data and lack of a control group were limitations of the study design. Further research is needed to establish the effectiveness of this approach over other intervention models.