Monday, May 19, 2008

The Executioner's Axe

... the hangman's noose, the fatal injection, the guillotine ... let's introduce the QALY.

Just as the Axe and the Noose and the Fatal Drug are not responsible for Death, nor is the Quality-Adjusted Life Year.

It is their use by humans. And I suspect, in the case of QALYs, the profession known as actuaries, and to be more precise, I suspect there are specialised medical actuaries. Have you ever heard of Actuary? I hadn't. This is the profession that calculates insurance risk.

Crude examples ... if your house is worth £500,000 but happens to be in a run-down inner city area, it is more likely to be the victim of an arson attack than if it was located in a leafy suburb and thus your house insurance is greater. But if your house in the run-down inner-city area is worth only £150,000 at the same risk, your house insurance will be less. And if you live in a hovel in the countryside, your house insurance will probably be minimal.

If you are 22 and buy a second-hand sports car, your car insurance will be higher than the 45 year old with 23 years of no-claims owning a BMW estate living in a leafy suburb because the 22 year-old is more likely to have a drink above limit, not be carting around his/her kids and will want to show off to his/her mate that it can do 0-100 mph in x seconds on an inner-city ringroad.

Logical of course and the actuaries have pored over all the statistics to make this an “exact” science.

I have no problem with Quality-Adjusted Life Years. Clearly, this treatment will add a QALY to my life – ok I'm not 100% (1) but I'm not 0% (dead) nor even negative (permanent vegetative on life support – surely a good statistical argument for turning the switch off).

The executioner's axe is the value a society attaches to a QALY. An ethical human will say there is no limit to the value of a (positive) QALY. But the insurance company or the state-run health service will put a value on it based on the cost of treatment and the resources available. And decides whether the cost of your QALY is good value for money.

It (the insurance company or the state-run health service) plays god.

... being arbitrary, this threshold value is likely to vary in different societies and cultures, depending on how they themselves value healthcare.

Hang on ... or how large their healthcare budget is.

The cost of treatment per three year-old with malaria is clearly less than the cost per three year-old with AIDS. But can we compare? I feel this is beyond comparison. Both will kill.

Value healthcare or value QALY ?

There are other objections to QALY, or rather, cost per QALY ... Central to Eisai's arguments (that we posted about here) was the “lack of sensitivity when comparing two treatments in the same therapy area or treatments for mild as opposed to severe forms of a disease. In other words, differences that may be important clinically or to the patient may not be shown by cost per QALY estimates.

NICE would not reveal how it took this lack of sensitivity into account.

And I wonder whether the cost per QALY of an entire treatment is taken into the equation. The cost of an individual dose of IT Methotrexate versus Daunorubicin/MTX/Dexamethasone/Vincristine etc etc for 2.5 years.

It has been argued that a paediatric QALY should be evaluated differently from an adult QALY – clearly paediatric is different from geriatic. Am I to play God?

NICE has arbitrarily put a threshold of £20,000-£30,000 per QALY.

Links - What is a QALY?, Implementing QALYs

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