Thursday, April 2, 2015

Quality of Life and Quality Adjusted Life Years (QALY)

What is Quality of Life and how is it related to Standard of Living? How should Health-Related Quality of Life play into decisions by individuals, health insurance plans, and government subsidized health care decisions? In particular, how are Quality Adjusted Life Years (QALY) calculated and used to approve or disapprove a given medical procedure by a government or private insurance system?

These are important questions that can have no definitive answers. However, they are well worth discussing in a collegial, rational, and fact-based way.

I presented this Topic to The Villages Philosophy Club in 2012 and updated it for a presentation on 3 April 2015 to the same group. Our meetings draw around 50 people, mostly retirees in their 60's, 70's and 80's.

Participants evaluate which beneficial factors in the "PERSONAL", "PEOPLE", and "THINGS" categories they judge to be the most important factors leading to high Quality of Life. They also use a questionaire called "EQ-5D" to estimate their individual Health-Related Quality of Life levels.

We then discuss the results and the implications for making individual Health Care decisions.The results of our selections and evaluations in 2012 are posted below.

You may view and download the updated, 2015 PowerPoint slides here.

Also see:
END OF LIFE Honest Brokers, not "Death Panels".

"Runaway Trolley" applied to END OF LIFE issues.


After researching this question on the Internet, and thinking about my own country, community, family, and life, I came to the conclusion that Standard of Living is only one contributor to a high Quality of Life. It is definitely possible to live at a moderate Standard of Living so long as you have other beneficial factors in your life. I came up with a list of some 21 beneficial factors, seven having to do with PERSONAL aspects of our lives, seven with PEOPLE in our lives, and seven with THINGS in our lives, as follows:
⃝ Higher Education and Knowledge
⃝ Honest, Hard-Working Reputation
⃝ Satisfying, Rewarding Career
⃝ Travel, Hobbies, Recreation and Leisure Time
⃝ Robust Health and Long Life
⃝ Emotional Well-Being
⃝ Strong Religious Faith

⃝ Loving Parents, Grandparents
⃝ Loving Spouse, Children, Grandchildren
⃝ Loving Siblings and Extended Family
⃝ Great Teachers, Clergy, Bosses, …
⃝ Loyal Friends and Good Neighbors
⃝ Cooperative, Competent Co-Workers
⃝ Competent and Friendly Service People
⃝ Freedom and Human Rights
⃝ Stable and Secure Finances
⃝ Comfortable, Safe Home and Community
⃝ High-Tech Electronics and Entertainment
⃝ Fine Food, Fancy Furnishings, High Lifestyle
⃝ Excellent Healthcare
⃝ Golf, Swimming and other Sports Facilities


During my presentation to The Villages Philosophy Club in 2012, nearly 50 people participated in the survey. Each member was asked to vote for his or her top ten items and the scores were tallied and are graphed below to determine the most important in each category and the most important ten in the whole list.

The top "THINGS" items were:
-Freedom and Human Rights, and (tied for second place)
-Stable and Secure Finances, and
-Excellent Healthcare

The top "PERSONAL" items were:
-Robust Health and Long Life, and
-Emptional Well-Being

The top "PEOPLE" items were:
-Loving Spouse, Children, Grands, and
-Loyal Friends, Good Neighbors

The overall top ten items were the ones with their numbers highlighted in pink:

They are:
1-Robust Health and Long Life
2-Freedom and Human Rights
3-Stable and Secure Finances
4-Excellent Healthcare
5-Loving Spouse, CHildren, Grands
6-Comfortable/Safe Home/Community
7-Emotional Well-Being
8-Loyal Friends, Good Neighbors
9-Travel, Hobbies, Recreation, leisure
10-Loving Parents, Grandparents


The Human Development Index (see
2014_UN_Human_Development_Report)is a 2014 UN publication that considers life expectancy, literacy, education, standards of living, and other aspects of Quality of Life to come up with a score for each country. Not surprisingly, the highest levels are found in the US, Canada, Western Europe, Japan, Australia, Chile, and Argentina. The lowest in Central Africa and parts of Asia.

The 2013 Where to be born index (formerly Quality of Life Index in 2005) 
(see for 2013 update) by the respected British magazine The Economist . They consider: 
Healthiness: Life expectancy at birth
Family life: Divorce rate
Community life: High rate of church attendance or trade-union membership
Material well being: GDP per person
Political stability and security: Political stability and security
Climate and geography: Latitude (warmer and colder climates)
Job security: Unemployment rate
Political freedom: Political and civil liberties
Gender equality: Average male and female earnings

Again, the US, Canada, Western Europe, Japan, and Australia get high scores, but, surprisingly, the top country is Switzerland (was Ireland in 2005 version). The US comes in 16th, between Germany and the United Arab Emirates (was 13th, just after Finland and ahead of Canada in 2005 version).

The Happy Planet Index (see is a 2015 update of the 2012 effort that "is not a measure of which are the happiest countries in the world: [but rather a] Measure of the environmental efficiency of supporting well-being in a given country, and of the Subjective life satisfaction, life expectancy at birth, and ecological footprint per capita."

The US comes in at a dismal  #105 in the 2015 rankings, and is in the worst category along with much of Central Africa and Russia. The best three countries in the 2015 ranking is Costa Rica, with a "Happy Planet Index" that is twice that of the US.


How should Quality of Life impact health care decisions? Government agencies, including the US Centers for Desease Control and Prevention (CDC) and the UK National Institute for Health and Clinical Excellence (NICE) have considered this question for decades, and their decisions are currrently affecting your health care availability, and will do so more and more in the future.

The US CDC website (see has links to many Health-Related Quality of Life pages, as does the UK NICE website (see

Health-Related Quality of Life is measured by several different questionaires, inluding the SF-36 and EQ-5D. The SF-36 (see consists of 36 multiple-choice questions. The EQ-5D (see has five multiple-choice quesitions. The result is a personal score that ranges from 1 (for perfect health) to 0 (for death). It is possible to score as low as -0.5 (worse than death).

In 2012 the members of The Villages Philosophy Club took the EQ-5D survey and the average personal score was 0.88, indicating a pretty healthy group. Around 40% of us reported PERFECT HEALTH with a score of 1.0. About 30% reported NEAR-PERFECT HEALTH with a score of 0.88. About 22% (including me) reported the next level down with a score of 0.76. About 4% reported a score of 0.62, and about 2% each reported 0.47 and 0.33.

When a health care decision is to be made between alternative treatments, consideration is given to an estimate of the level of Health-Related Quality of Life that will most likely result from each treatment alternative, as well as an estimate of how long the patient is likely to live if given that treatment. The result of multiplying Health-Related Quality of Life by Years of Life is called the Quality Adjusted Life Years (QALY).

In the UK, if a given treatment alternative costs less than about 30,000 pounds per QALY, and if the doctor and patient want that alternative, it is approved and paid for by the National Health Service. If the desired alternative is more expensive than about 30,000 pounds per QALY, it is denied, and a lower cost (and more cost-effective) alternative is approved. 30,000 pounds is equivalent to about $40,000 - $50,000.

Please feel free to comment. I would love to have an interactive discussion. Click on "Comments" just below my name, type your comment, then choose "Name/URL" and enter your name or nickname (URL not required), and then "Publish". If you are not an "Authorized Author" it may take a day or so for me to moderate your comment and then it will appear.)

Ira Glickstein