Quality Adjusted Life Years

Mark Reid
Class of 2007/2008
24/03/08

Quality Adjusted Life Years (QALYs) are one method used by health

economists to measure the quantity and quality of life gained from various

forms of health technologies, procedures or resources. QALYs can be used

to determine the efficacy of drugs, treatments and technologies and can

therefore be used to benchmark these against comparator interventions for

the purpose of cost or utility effectiveness analysis. QALYs are measured on

a score between 0 and 1 to determine the number of years of perfect health

gained from each different intervention. For example; cancer drug A may

provide a patient suffering from liver cancer with 0.25 QALYs per treatment

whereas surgery could provide the same patient with 0.5 QALYs. If the cost

of the drug was £200 per treatment and the cost of surgery was £600 per

operation then the more cost effective option would be the drug (0.25 X £200

= £800 per QALY vs. 0.5 X £600 = £1200 per QALY).

Weightings

There are a variety of ways weighting different QALY assessments, each with

their own advantages and disadvantages to the economist. These methods

are Time Trade Off (TTO), Standard Gamble (SG), Person Trade Off (PTO)

and Visual Analogue Scale (VAS).

The TTO method of weighting suggests that there are negative or positive

effects on the length of time that a patient can live in perfect health based on
the options available to them. For example; a patient with an illness or

disability could choose to live five years in their current condition of less than

perfect health or could trade off some length of their life to live at a higher

quality of life, for instance by choosing an operation that may improve their

current condition but shorten their life expectancy. This method is particularly

effective when looking at cancer drugs that often can cause remission for a

period of time but may cause the cancer to return and progress at a greater

rate than if they had not had the drug. This method is a good system in terms

of being based on patient wishes, or the assessed wishes of a sample group

of patients, but has some drawbacks which are covered in greater detail later

in this paper.

The second methodology is the SG method. This system asks the patient

whether or not the options of intervention is weighed more valuably than the

option of doing nothing. The choice becomes whether or not to choose to

continue life in their existing condition or whether they should take the chance

on the intervention, almost all of which carry some degree of risk of making

the patient poorer. An example of this may be to offer a paraplegic patient a

risky operation that could allow them to walk again but carries with it a thirty

percent chance that they could die on the operating table. If the patient

weighs the possibility of being able to walk greater than the risk that the

operation could result in their death then they may choose to have the

operation. If they decide that life in a wheelchair is not as bad as the

possibility of death then they may choose not to “gamble” their utility on the

procedure.
The third methodology is the PTO. This in essence says that it is up to the

society or health planners to decide whether the value of providing a person

with a disease with an intervention that costs a certain amount is more

important than providing two or more people with a different disease the

treatment for their malady with a cumulative value equivalent to the cost of the

first disease. An example here may be looking at the treating cataract

patients versus hip replacements. If you are able to carry out five cataract

operations for the cost of two hip replacements, then where would it be most

effective, or palatable, to societies values to invest their resources. In my

opinion this is the most politically driven and least clinically driven of all of the

methodologies.

Lastly is the VAS methodology. With this style of assessing need patients are

asked to value their health on a scale of zero to one hundred, with zero being

dead (admittedly, few patients often value themselves at this level) and one

hundred being perfect health. This methodology has the flaw that it is

probably the most subjective of all of the methods. What one person may

consider to be perfect health may, in fact, be considerably lower than what

another patient would say. Additionally, patients are rarely in the position

intellectually to make this call. A person with high blood pressure or other

undiagnosed condition could value themselves considerably higher than they

actually are. This is however the simplest of methods for frontline clinicians to

use when determining how best to prioritise their individual rationing. If a

patient presents at their GP for an injured hand but no other conditions or

complaints, then it would be irresponsible for the GP to order up a bunch of

other tests unless there was some reason behind their thinking.

EUROQOL EQ-5D

Another method for determining a patient, or patient group’s, health status

and subsequent quality of life, is the EUROQOL EQ-5D index. This simple

system measures a patient’s condition against five metrics to determine

health status and then scores them out of three. The various metrics on this

index are Mobility, Self Care, Usual Activities, Pain/Discomfort, and

Anxiety/Depression. The resulting assessment provides a five digit score

consisting of numbers ranked one to three, such as 12132 or 11231, which in

turn is related to the indexes weighting table and subtracted from 1 to

determine the final quality of life score. The perfect score for a person in

perfect health is 11111 and a score of 33333 would indicate that the patient

was dead or their condition would be classified as not worth living.

This system has been developed and tested using a very large control group

to develop what is believed to be a fairly representative figure for society

however there are several drawbacks to this method that would make it

somewhat less effective on its own right. In fact, it is usually used in

conjunction with another methodology in order to ensure that the results are

accurately reflecting the patient’s quality of life rather than using it on its own.

The biggest drawback to the EUROQOL EQ-5D index is the simplicity of it.

With scores of only one to three there is a considerable amount of space for
interpretation and many of the questions and weightings reflect that. When

assessing a patient’s condition against this index at the macro level it could be

suggested to be reasonably effective however in almost all of the metrics

there is room to manoeuvre. As an example; an able bodied person may

weigh being in a wheelchair considerably worse than a paraplegic would or a

person with one form of cancer may have a lower tolerance to pain than

another patient and yet this is not accurately reflected in the scores. The

weightings also make no differentiation between walking with a cane and

being in a wheelchair yet most people would certainly see a considerable

difference in what they would consider as quality of life. Several of the

weighting scores reflect what the sample group that was involved in the

development of the index may have thought however they may not reflect

what an individual patient thinks.

From my own personal experience of breaking my ribs recently, one GP I saw

suggested that I take ibuprofen and another gave me codeine. Neither my

GPs, nor I, considered that my pain was non-existent however none of us

would consider it to be severe yet there was a disparity in what the GPs

thought was sufficient pain relief. The EQ-5D would have ranked my pain as

a two out of a possible three yet I would have ranked it somewhere around a

three or four out of a possible ten. The EQ-5D therefore cannot accurately

reflect the degrees of difference between no pain, some pain (headache,

broken bone, etc.), and severe pain (migraine, cancer, post-operative pain,

etc.) and cannot be used to accurately determine whether the correct

prescription should be nothing, mild to moderate analgesics (i.e.: codeine,

high strength NSAIDs, etc.), or high strength analgesics (morphine, et al).

Without using a further methodology to assess the intervention the

recommended treatment could be quite inappropriate.

The Drawbacks

There is no denying that there is some value in the various methods of

achieving a QALY rating for an intervention however each method has a

variety of drawbacks, some of which I’ve discussed already. One of the

biggest complaints that exists with QALY assessment at the macro economic

level is that it doesn’t take externalities into account. When health planners

are making determinations on which interventions should become guidelines,

it is difficult, or impossible, to assess the full effect that the various treatments

will have on the families and friends of the patients or on society as a whole.

An intervention such as an inoculation can have wider implications on society

as a whole if that inoculation prevents an increase in the spread of an illness

and having a respite care bed available in a community can make a huge

difference to the lives of families and carers that have to take care of elderly,

or complex, patients. These environmental impacts are incredibly difficult to

measure in terms of value however they can make a large difference to the

quality of the lives of the