Abstract
The objective of this paper is to examine how well the QALY captures the health gains generated by cancer treatments, with particular focus on the methods for constructing QALYs preferred by the UK National Institute for Health and Clinical Excellence (NICE). Data were obtained using a keyword search of the MEDLINE database and a hand search of articles written by leading researchers in the subject area (with follow up of the references in these articles). Key arguments were discussed and developed at an oncology workshop in September 2009 at the Office of Health Economics.
Three key issues emerged. First, the EQ-5D, NICE’s preferred measure of health-related quality of life (QOL) in adults, has been found to be relatively insensitive to changes in health status of cancer patients. Second, the time trade-off, NICEs preferred technique for estimating the values of health states, involves making assumptions that are likely to be violated in end-of-life scenarios. Third, the practice of using valuations of members of the general population, as recommended by NICE, is problematic because such individuals typically display a misunderstanding of what it is really like for patients to live with cancer.
Because of the way in which it is constructed, the QALY shows important limitations in terms of its ability to accurately capture the value of the health gains deemed important by cancer patients. A research agenda for addressing these limitations is proposed.
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Boersma C, Broere A, Postma MJ. Quantification of the potential impact of cost-effectiveness thresholds on Dutch drug expenditures using retrospective analysis. Value Health 2010; 13: 853–6
Weinstein MC, Skinner JA. Comparative effectiveness and health care spending: implications for reform. N Engl J Med 2010; 362 (19): 460–5
NICE. Guide to the methods of technology appraisal. London: NICE, 2008 [online]. Available from URL: http://www.nice.org.uk/media/B52/A7/TAMethodsGuideUpdatedJune2008.pdf [Accessed 2009 Nov 16]
Brazier J, Ratcliffe J, Salomon J, et al. Measuring and valuing health benefits for economics evaluation. Oxford: Oxford University Press, 2007
Department of Health. Cancer reform strategy; 2007 [online]. Available from URL: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081013 [Accessed 2009 Nov 16]
National Institute for Health and Clinical Excellence. Technology appraisal guidance 178: bevacizumab (firstline), sorafenib (first- and second-line), sunitinib (secondline) and temsirolimus (first-line) for the treatment of advanced and/or metastatic renal cell carcinoma. London: NICE, 2009 [online]. Available from URL: http://guidance.nice.org.uk/TA178/Guidance/pdf/English [Accessed 2009 Nov 16]
Hawkes N. d35,000-a-year kidney drugs too costly for NHS: veto on basis of price is outrage to kidney patients, says specialist. The Times 2008 Aug 7 [online]. Available from URL: http://www.timesonline.co.uk/tol/life_and_style/health/article4474425.ece [Accessed 2009 Nov 16]
National Institute for Health and Clinical Excellence. Appraising life-extending, end of life treatments. London: NICE, 2009 [online]. Available from URL: http://www.nice.org.uk/aboutnice/howwework/devnicetech/endoflifetreatments.jsp?domedia=1&mid=88ACDAE5-19B9-E0B5-D422589714A8EC6D [Accessed 2009 Nov 16]
National Institute for Health and Clinical Excellence. Update report on the application of the ‘end-of-life’ supplementary advice in health technology appraisals. London: NICE, 2009 [online]. Available from URL: www.nice.org.uk/media/835/8E/ITEM7EndOfLifeTreatments.pdf [Accessed 2009 Nov 16]
Rabin R, de Charro F. EQ-5D: a measure of health status from the EuroQol Group. Ann Med 2001; 33: 337–43
Brazier J, Deverill M, Green C, et al. A review of the use of health status measures in economic evaluation. Health Technol Assess 1999; 3 (9): i-iv, 1–164
Dolan P. Modelling valuations for EuroQol health states. Med Care 1997; 35: 1095–108
Dolan P. The measurement of health related quality of life for use in resource allocation in health care. In: Culyer AJ, Newhouse JP, editors. Handbook of health economics. Vol. 1. Amsterdam: Elsevier Science, 2000
Drummond MF, Sculpher MJ, Torrance GW, et al. Methods for the economic evaluation of health care programmes. 3rd ed. New York: Oxford University Press, 2005
Williams A. The role of the EuroQoL instrument in QALY calculations [CHE discussion paper 130]. York: Centre for Health Economics, University of York, 1995
Grieve R, Grishchenko M, Cairns J. SF-6D versus EQ-5D: reasons for differences in utility scores and impact on reported cost-utility. Eur J Health Econ 2009; 10: 15–23
Broeckel A, Jacobsen PB, Horton J, et al. Characteristics and correlates of fatigue after adjuvant chemotherapy for breast cancer. J Clin Oncol 1998; 16: 1689–96
Stone P, Ream E, Richardson A, et al. Cancer-related fatigue: a different of opinion? Eur J Cancer Care 2003; 12: 20–7
Esbensen BA, Osterlind K, Roer O, et al. Quality of life of elderly persons with newly diagnosed cancer. Eur J Cancer Care 2004; 13: 443–53
Hofman M, Ryan JL, Figueroa-Moseley CD, et al. Cancerrelated fatigue: the scale of the problem. Oncologist 2007; 12: 4–10
Dobrez D, Cella D, Pickard S, et al. Estimation of patient preference-based utility weights from the functional assessment of cancer therapy: general. Value Health 2007; 10: 266–72
Kröz M, Büssing A, von Laue HB, et al. Reliability and validity of a new scale on internal coherence (ICS) of cancer patients. Health Qual Life Outcomes 2009 Jun 24; 7: 59
Feeny DH. The roles for preference-based measures in support of cancer research and policy. In: Lipscomb J, Gotay CC, Snyder C, editors. Outcomes assessment in cancer: measures, methods and applications. NewYork: Cambridge University Press, 2005
Bharmal M, Thomas J. Comparing the EQ-5D and the SF-6D descriptive systems to assess their ceiling effects in the US general population. Value Health 2006; 9: 262–71
Barton G, Sach T, Doherty M, et al. An assessment of the discriminative ability of the EQ-5D, SF-6D, and EQ VAS, using sociodemographic factors and clinical conditions. Eur J Health Econ 2008; 9: 237–49
van Agt H, Bonsel G. The number of levels in the descriptive system. In: Kind P, Brooks R, Rabin R, editors. EQ-5D concepts and methods: a developmental history. Dordrecht: Springer, 2005
Horsman J, Furlong W, Feeny D, et al. The Health Utilities Index (HUI): concepts, measurement properties and applications. Health Qual Life Outcomes 2003; 1 [online]. Available from URL: http://www.hqlo.com/content/1/1/54 [Accessed 2009 Nov 16]
Pickard AS, De Leon MC, Kohlmann T, et al. Psychometric comparison of the standard EQ-5D to a 5 level version in cancer patients. Med Care 2007; 45: 259–63
Pickard AS, Kohlmann T, Janssen MF, et al. Evaluating equivalency between response systems: application of the Rasch model to a 3-level and 5-level EQ-5D. Med Care 2007; 45: 812–9
Kind P. Size matters: EQ-5D in transition. Med Care 2007; 45: 809–11
Janssen MF, Birnie E, Haagsma JA, et al. Comparing the standard EQ-5D three-level system with a five-level version. Value Health 2008; 11: 275–84
Kind P, Macran S. Eliciting social preferences weights for functional assessment of cancer therapy-lung health states. Pharmacoeconomics 2005; 23 (11): 1143–53
Krahn M, Bremner KE, Tomlinson G, et al. Responsiveness of disease-specific and generic utility instruments in prostate cancer patients. Quality Life Res 2007; 16: 509–22
Neyt M. Towards more consistent use of generic quality-oflife instruments. Pharmacoeconomics 2010; 28 (4): 345–6
Brazier J, Yang Y, Tsuchiya A. Review of methods for mapping between condition specific measures onto generic measures of health. Report of the Office of Health Economics Commission on NHS outcomes, performance and productivity; 2008 [online]. Available from URL: http://www.ohe.org/page/Commissionreport.cfm [Accessed 2009 Nov 16]
Brazier J, Tsuchiya A. Preference-based condition-specific measures of health: what happens to cross programme comparability? Health Econ 2010; 19: 125–9
Brazier J, Czoski-Murray C, Roberts J, et al. Estimation of a preference-based index from a condition-specific measure: the Kings Health Questionnaire. Med Decis Making 2008; 28: 113–26
Rowen D, Brazier JE, Young TA, et al. Deriving a preference-based measure for cancer using the EORTC QLQC30. HEDS Discussion Paper 10/01; 2010 [online]. Available from URL: http://eprints.whiterose.ac.uk/10872/ [Accessed 2010 Jul 23]
Torrance GW, Thomas W, Sackett D. A utility maximization model for evaluation of health care programs. Health Serv Res 1972; 7: 118–33
Dolan P, Stalmeier P. The validity of time trade-off values in calculating QALYs: constant proportional time trade-off versus the proportional heuristic. J Health Econ 2003; 22: 445–58
Gudex C. Time trade-off user manual: props and self-completion methods. Centre for Health Economics Working Paper No 020cheop [online]. Available from URL: http://www.york.ac.uk/media/che/documents/papers/occasionalpapers/CHE%20Occasional%20Paper%2020.pdf [Accessed 2011 Mar 22]
Robinson A, Spencer A. Exploring challenges to TTO utilities: valuing states worse than dead. Health Econ 2006; 15: 393–402
Stalmeier P, Bezembinder T, Unic I. Proportional heuristics in time tradeoff and conjoint measurement. Med Decis Making 1996; 16: 36–44
Stalmeier PFM, Chapman GB, de Boer AGM, et al. A fallacy of the multiplicative QALY model for low quality weights in students and patients judging hypothetical health states. Int J Technol Assess Health Care 2001; 17: 488–96
Stalmeier PFM, Lamers LM, Busschbach JJV, et al. On the assessment of preferences for health and duration:maximal endurable time and better than dead preferences. Med Care 2007; 45: 835–41
Miyamoto JM, Eraker SA. A multiplicative model of the utility of survival duration and health quality. J Exp Psychol 1988; 117: 3–20
Attema AE, Brouwer WBF. On the (not so) constant proportional trade-off in TTO. Qual Life Res 2010; 19: 489–97
Sutherland HJ, Llewelyn-Thomas H, Boyd NF, et al. Attitudes towards quality of survival: the concept of ‘maximum endurable time’. Med Decis Making 1982; 2: 299–309
Dolan P. Modelling valuations for health states: the effect of duration. Health Policy 1996; 38: 189–203
Stiggelbout AM, Kiebert GM, Kievit J, et al. The ‘utility’ of the time trade-off method in cancer patients: feasibility and proportional trade-off. J Clin Epidemiol 1995; 48: 1207–14
van Nooten FE, Koolman X, Brouwer WBF. The influence of subjective life expectancy on health state valuations using a 10 year TTO. Health Econ 2008; 18: 548–58
Buckingham K, Devlin N. A note on the nature of utility in time and health and implications for cost utility analysis. Soc Sci Med 2009; 68: 362–7
Sharma R, Stano M. Implications of an economic model of health states worse than dead. J Health Econ 2010; 29: 536–40
Gold MR, Siegel JE, Russell LB, et al. Cost-effectiveness in health andmedicine. New York: Oxford University Press, 1996
Ubel PA, Loewenstein G, Jepson C. Whose quality of life? A commentary exploring discrepancies between health state evaluations of patients and the general public. Qual Life Res 2003; 12: 599–607
Insinga RP, Fryback DG. Understanding differences between self-ratings and population ratings for health in the EuroQOL. Qual Life Res 2003; 12: 611–9
Schkade DA, Kahneman D. Does living in California make people happy? A focusing illusion in judgments of life satisfaction. Psychol Sci 1998; 9: 340–6
Kahneman D, Tversky A. Prospect theory: an analysis of decision under risk. Econometrica 1979; 47: 263–91
Dolan P, Kahneman D. Interpretations of utility and their implications for the valuation of health. Econ J 2008; 118: 215–34
Menzel P, Dolan P, Richardson J, et al. The role of adaptation to disability and disease in health state valuation: a preliminary normative analysis. Soc Sci Med 2002; 55: 2149–58
de Wit GA, Busschbach JJ, de Charro FT. Sensitivity and perspective in the valuation of health status: whose values count? Health Econ 2000; 9 (2): 109–26
Giesinger JM, Golser M, Erharter A, et al. Do neurooncological patients and their significant others agree on quality of life ratings? Health Qual Life Outcomes 2009; 7: 87
Polsky D, Willke RJ, Scott K, et al. A comparison of scoring weights for the EuroQol derived from patients and the general public. Health Econ 2001; 10 (1): 27–37
Ratcliffe J, Brazier J, Palfreyman S, et al. A comparison of patient and population values for health states in varicose veins patients. Health Econ 2007; 16: 395–405
Mann R, Brazier J, Tsuchiya A. A comparison of patient and general population weightings of EQ-5D dimensions. Health Econ 2008; 18: 363–72
Lacey HP, Fagerlin A, Loewenstein G, et al. It must be awful for them: perspective and task context affects ratings for health conditions. Judgm Decis Mak 2006; 1: 146–52
O’Leary JF, Fairclough DL, Jankowski MK, et al. Comparison of time-tradeoff utilities and rating scale values of cancer patients and their relatives: evidence for a possible plateau relationship. Med Decis Making 1995; 15: 132–7
Tang ST, McCorkle R. Use of family proxies in quality of life research for cancer patients at the end of life: a literature review. Cancer Investig 2002; 20: 1086–104
Ditto PH, Hawkins NA, Pizarro DA. Imagining the end of life: on the psychology of advance decision making. Motiv Emot 2005; 29: 481–502
Harris J. QALYfying the value of human life. J Med Ethics 1987; 13: 117–23
Brazier J, Akehurst R, Brennan A, et al. Should patients have a greater role in valuing health states? Appl Health Econ Health Policy 2005; 4 (4): 201–8
Slevin ML, Stubbs L, Plant JJ, et al. Attitudes to chemotherapy: comparing views of patients with cancer with those of doctors, nurses, and general public. BMJ 1990; 300: 1458–60
Roberts T, Bryan S, Heginbotham C, et al. Public involvement in health care priority setting: an economic perspective. Health Expect 1999; 2: 235–44
Dolan P, Lee H, King D, et al. How does NICE value health? BMJ 2009; 339: 371–3
Tengs TO. Cost-effectiveness versus cost-utility analysis of interventions for cancer: does adjusting for health-related quality of life really matter? Value Health 2004; 1: 70–8
EuroQol. What is EQ-5D [online]. Available from URL: http://www.euroqol.org/home.html [Accessed 2010 Mar 8]
Shah KK, editor. Assessing and appraising oncology medicines: what are the key areas of methodological research to pursue? OHE workshop summary; 2009 [online]. Available from URL: http://www.ohe.org/fileadmin/user_upload/Other_materials/OncologyWorkshop_Dec2009.pdf [Accessed 2011 May 12]
Acknowledgements
The authors are grateful for the contributions of Claire Devaney, Nancy Devlin, the anonymous reviewers and participants at the Office of Health Economics oncology workshop in September 2009.
This paper is based on part of a consulting project commissioned and funded by the Pharmaceutical Oncology Initiative (POI) group. The material presented in this paper is independent of the funders. There are no conflicts of interest to declare.
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Garau, M., Shah, K.K., Mason, A.R. et al. Using QALYs in Cancer. Pharmacoeconomics 29, 673–685 (2011). https://doi.org/10.2165/11588250-000000000-00000
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DOI: https://doi.org/10.2165/11588250-000000000-00000