Health Outcomes for

Economics
Evaluations
11th December 2017

Fatiha Shabaruddin (PhD, RPh, B.Pharm)

Faculty of Medicine, University of Malaya
fatiha.shabaruddin@um.edu.my
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 Outcomes (Benefits)
of Health Care
 Benefits, outcomes and consequences refer to the effect of
health care interventions on the patient, not the effect on the
people providing the service
 Some examples of outcome measures (benefits) of health
care interventions:
•Reduction in severity of symptoms
•Improvements in organ function
•Number of cases diagnosed
•Number of deaths avoided
•Years of life gained
•Improvements in quality of life
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 Health Outcomes used in
economic evaluations
 Main types of outcome measures (benefits) considered in
economic evaluations are:

•Clinical effectiveness
•Quality-adjusted life-years

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 Effectiveness
•Effectiveness is the outcome of a health care
intervention measured in natural units
•Can use clinical indicators to measure effectiveness
•Specific outcome measures:
o Reduction in severity of flu symptoms
o Number of Hepatitis C cases diagnosed
o Number of diabetes patients treated
o Number of cervical cancer cases avoided
o Improvements in lung function
•General outcome measures:
o Life-years gained
o Number of deaths avoided 4
Effectiveness as an
outcome measure
•How can we measure the
effectiveness of a primary care
clinic health programme: for
example a hypertension
screening programme?
o General outcome measures
o Specific outcome measures

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 Effectiveness
Effectiveness: outcome of health care intervention measured in natural
units

Source:http://images.slideplayer.com/18/5690892/slides/slide_9.jpg
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 Challenges of using
effectiveness as an
outcome measure
o Different patient populations
o Different disease characteristics
o Use of different outcome measures
 Variations in the data used to compete for
the same healthcare resources & budget

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Effectiveness

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 Quality of Life
•Many new interventions or medicines improves quality of life
(QoL) rather than quantity of life (length of life)
•QoL is a generic concept reflecting concern with the
modification and enhancement of life attributes (for example
physical, political, moral and social environment relating to the
overall condition of a human life)
•Many factors impact on QoL:
o Functional
o Social
o Psychological
o Cognitive
o Subjective
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 Quality of Life
•Measuring QoL is methodologically complex

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Source: http://open.jorum.ac.uk/xmlui/bitstream/handle/123456789/801/Items/K203_5_section13.html
Quality of Life

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 Quality-adjusted life-years

•Quality-adjusted life years (QALY) is an outcome measure for

life expectancy adjusted for quality of life

•QALY combines morbidity and mortality by including the

change in the quantity and quality of life

•The quality of life component included in

QALY is in term of utility

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 Utility

•Utility is the value attached by an individual for:

– a specific health status or a specific health outcome
•Utility reflects the preferences individuals or society may have for
any particular set of health outcomes
•Utilities for health states are based on preferences for the
different health states (the more preferred health states receive
greater weight)
•Utility is very subjective
– Different individuals may attach different values (utility) to
the same health state
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 Utility
For example, imagine a health state of being unable to walk
further than 1 kilometre a day.
– A 30 year old person may attach a lower utility value for
this than an 80 year old person

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 Utility
• Utility is anchored at 0 to 1
– with 0 indicating death and 1 being perfect health
• Utility can be used:
– with patients with different illnesses
– to compare health outcomes of different patient groups and
for different health care interventions
• How to measure utility
– Direct methods
• Visual analogue scale
• Standard gamble
• Time-trade off
– Indirect methods
• generic preference-based questionnaires such as EQ-5D 15
 Measuring Utility:
Visual Analogue Scale

How do you feel today?

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Source: http://ebn.bmj.com/content/12/4/102.extract
 Measuring Utility:
Visual Analogue Scale

How do you think you

would feel with
congestive heart failure?

The difference is the utility lost due to congestive heart failure 17

Measuring Utility:
Standard Gamble

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Source: http://pn.bmj.com/content/8/3/175.abstract
 Measuring Utility:
Standard Gamble
Would you choose state A or B?

State A (sure thing) State B (gamble)

Lifetime in perfect
Lifetime with congestive
health (10 years)
heart failure p = 0.80

(10 year lifetime)

p = 0.20
Immediate death from
the intervention
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Measuring Utility:
Standard Gamble

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Source: http://pn.bmj.com/content/8/3/175.abstract
 Measuring Utility:
Time Trade-Off
Would you choose state A or B?
State A State B
•You have congestive •You will have 5 years in
heart failure perfect health
•You are on medication,
have limited mobility and
various lifestyle restrictions
•You will live 15 years in this
health state
Time t is varied in State B for the trade-off
At the point of indifference  t = value for state i 21
 Measuring Utility:
Standard gamble & Time Trade-Off
For SG: Probability p is varied
At the point of indifference  p = value for state i
For TTO: Time t is varied
At the point of indifference  t = value for state i

Source: http://www.ispor.org/news/articles/aug05/qaly.asp
The value for p or t obtained is then used in a mathematical
equation to calculate utility 22
 Measuring Utility:
Indirect method (questionnaire)
•There are several questionnaires that use the indirect method
(a.k.a generic preference-based measure) to measure utility
•Examples of these questionnaires include:
o EQ-5D
o SF-6D
o HUI

•Once completed, a utility score is generated using an algorithm

(adjusted for the values [preference] for different domains)
- For EQ-5D, the algorithm (mathematical equation) is based
on values that have been obtained from a sample of the
general public for the 5 domains 23
Measuring
Utility:
EQ-5D

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Source: http://bmb.oxfordjournals.org/content/96/1/5.full
 Measuring Utility: SF-6D

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Source: http://www.jclinepi.com/article/S0895-4356%2898%2900103-6/abstract
 Quality-adjusted life-years

• QALYs are calculated by:

– multiplying the utility value (which reflects the ‘quality’ of
being in the resulting health state from the intervention)
with
– the years of life produced by the intervention (life-years
gained)

• Using the QALY as the measure of outcome allows decision-

makers to compare across different types of interventions for
different clinical conditions

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 Quality-adjusted life-years
• QALYs are calculated by multiplying the utility value with the
life-years gained from a health care intervention

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Source: https://www.google.com/imgres?imgurl=https://upload.wikimedia.org/wikipedia/commons/4/49/QALY_graph.png&imgrefurl=https://en.wikipedia.org/wiki/Quality-adjusted_life_year
Quality-adjusted
Life Years

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Quality-adjusted life-years
• QALYs are calculated by multiplying the utility value with the
life-years gained from a health care intervention

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Source:http://holisticpracticedevelopment.com/health-economics-101-quality-adjusted-life-years/
Quality-adjusted life-years
• QALYs are calculated by multiplying the utility value with the
life-years gained from a health care intervention

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Source: http://www.qalibra.eu/guide/images/image007.jpg /
 Quality-adjusted life-years
Example of QALY calculations
• Patient Thomas received a coronary artery bypass graft
surgery (CABG) and was hospitalised for 1 month, after which
he spends 3 months attending physiotherapy.
• Patient Katie received a pharmacological intervention
(medicine) and was on the drug for 6 months, after which she
spends 4 months attending physiotherapy.
• What are the QALYs for these patients for a year if the utilities
for the health states are as below:
– Utility while hospitalised: 0.4
– Utility while on medication: 0.7
– Utility while attending physiotherapy: 0.8
– Utility after physiotherapy: 0.9
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Useful references

•Whitehead & Ali (2010) Health outcomes in economic evaluation: the QALY
and utilities. British Medical Bulletin 96: 5–21 (DOI:10.1093/bmb/ldq033)
•Gray, Clarke, Wolstenholme & Wordsworth (2010) Applied Methods of Cost-
effectiveness Analysis in Healthcare. Oxford University Press