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.

WHAT IS QUALITY OF LIFE?

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:

PERSONAL

⃝ 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

PEOPLE

⃝ 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

THINGS

⃝ 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

RESULTS OF THE SURVEY

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


OTHER MEASURES OF QUALITY OF LIFE

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 http://en.wikipedia.org/wiki/Quality-of-life_index 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 http://en.wikipedia.org/wiki/File:Happy_Planet.PNG) 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.

WHAT IS HEALTH-RELATED QUALITY OF LIFE?

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 http://www.cdc.gov/hrqol/concept.htm) has links to many Health-Related Quality of Life pages, as does the UK NICE website (see http://www.nice.org.uk/).

Health-Related Quality of Life is measured by several different questionaires, inluding the SF-36 and EQ-5D. The SF-36 (see http://www.anapsid.org/cnd/files/sf36.pdf) consists of 36 multiple-choice questions. The EQ-5D (see

http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/QALY.pdf) 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

Uncle Sam's Illness

"Dr. Mitt", Uncle Sam, and "Dr. Barry"
A Responsible Approach vs Hopey Changey Happy Pills

[from billlifka[ I have a deceased uncle (let’s call him Sam) who was a heavy smoker. He was feeling poorly and a doctor diagnosed his condition as an advanced case of lung cancer. Sam didn’t want to hear that so he went to several other doctors who delivered the same verdict, along with the prognosis of an early, painful death.

 

One of these, Doctor Mitt, was quite experienced in the field and had cured many cancer patients before. He promised Sam that he could be cured if he were willing to undergo treatment that would be very uncomfortable for a time but would return him to robust health as he had enjoyed before he became addicted to smoking. The treatment would require that Sam cease smoking immediately and submit to chemotherapy and radiation. His hair would fall out, temporarily, he’d be extremely nauseous most of the time and he’d lose much weight. On the other hand, Dr. Mitt would prescribe modest doses of pain killers and a special diet of food and food supplements that would build up Sam’s total body to offset much of the damage to the localized cancer area.

 

Sam considered this advice but sought an easier solution. 

In all professions, there are practitioners who tell their clients what they want to hear. Usually, they are successful in their practices since most humans want to hear what they want to hear. And so it was that Sam was able to find other doctors who told him just the opposite of what Dr. Mitt and others of his persuasion had told him.

 

Principal among these was Dr. Barry who was a glib, handsome devil who was very popular with his patients, especially the ladies. Dr. Barry said all that discomfiture was unnecessary and, most likely, was bad; even a little bit of suffering caused patients to lose hope and hope was known to be the best medicine for any kind of ailment. Giving up smoking, according to Dr. Barry, was also bad; resultant unhappiness was another cause of the loss of hope. He prescribed stronger pain killers that produced a euphoric feeling in Sam for several months. 

After a few months, the stronger pain killers and the continued smoking didn’t make Sam any better. In fact, his condition steadily worsened and he spent an extremely painful eight months until his early death. To the end he recommended Dr. Barry to friends and associates as a doctor who cared deeply for his patients. 

This is a true story but I’ve changed the names of my uncle and the doctors to protect the guilty and the innocent. You might have noticed the similarity between my real uncle’s story and the on-going story of our Uncle Sam. My uncle’s immediate family members were enablers to him in his choice of a comfortable short term over a successful long term cure. Currently, Americans have the opportunity to enable their Uncle Sam to continue in his rotten habits that feel good in the very short term but will lead to his painful death in the slightly longer term. They have an alternate opportunity to restore him to full health and a long life. Which will it be? 

This analogy may offend some but it’s dead on. Just because one is a lemming doesn’t mean that one must follow one’s leader over a cliff. Many lemmings are credits to their species and have the intelligence to know a cliff is ahead and it’s time to ease themselves to the sides of their pack and not get swept over in the crowd. It will allow their species to survive, which should be high on their list of instincts. Their next step should be to select a leader with more common sense.

 

billlifka                                  

Affordable Food Care Act

Now that the Affordable Healthcare Act (aka "Obamacare") has been declared constitutional by the US Supreme Court, and has gone into effect, it is high time we move into the even more important realm of FOOD CARE.

After all, most of us EAT three times a day (some five times or more) while most of us only require health care a few times a year. If we are deprived of health care, most of us will live on for years, but, if we are deprived of food, even the strongest of us we will survive for only days (or three weeks max).

Having established that FOOD CARE is more critical than Healthcare, let us come up with a solution that will reduce costs and improve quality. Let us take the unfair profits away from the blood-sucking supermarkets by establishing a single-payer food program that will assure the healthiest foods at the lowest possible cost to us and our fellow citizens (and legal and illegal aliens as well, of course).

For example, there are dozens of supermarkets in my Zip Code, all of them profit-based and all making fat profits selling food that is often unhealthy and that has made many of my neighbors sickly and obese. Each of these supermarkets is earning exorbitant profits by jacking up their prices to the highest levels possible. Why should there be more than one food supplier in any given Zip Code? Why should we, the consumers, have to pay the bloated overhead of all these duplicated stores?

THE FOOD CARE SOLUTION

The advent of email, and unfair competition from profit-making UPS and FedEx, has nearly destroyed the United States Post Office. Most of their buildings are underutilized and they require large subsidies to continue operation and pay their employees.

The FOOD CARE solution is OBVIOUS. Turn FOOD distribution over to the real delivery experts at the US Post Office and FOOD acquisition over to the real nutrition experts at the US Agriculture Department. Make fresh, healthy food available for free, delivered seven days a week directly to every home in America. Letter Carriers will once again have full mailbags. Since they already deliver mail six days a week, adding a seventh day will not raise costs by more than 15%.  By eliminating profits, costs will go down, and by eliminating unhealthy foods, there will be large savings in the public health care system.

Everyone will be required to purchase Food Care Insurance and those who refuse to do so will be charged a $500 tax per year (but only if they can afford it). In that way:

- Everyone in our great country will be assured three square meals a day!

- Fresh food will be delivered daily, eliminating the cost of weekly trips to the supermarket and the expense of household refrigerators and freezers as well as the Global Warming imposed by the energy demands imposed by unnecessary travel and household appliances.

- And disabilities due to unhealthy, fattening and sugar-filled foods will be a thing of the past!

- And health-care costs will go down as life-expectancy goes way up!

- And, the US Post Office, a cherished memory of government services at their best, will survive and prosper!

What could possibly be wrong with this plan?

Ira Glickstein

UPDATE 27 Sep 2012 

 

Howard Pattee posted a comment on 26 Sep regarding US Health Care costs, and why they are so much higher than other countries. I did some research on why US health care costs have risen so fast and concluded that about half the increase is due to medical technology advances that were not available in the past and that are both increasing lifetimes and are very expensive.

However, it appears (see chart below) that the other half of the rapid increase in costs is driven by government programs where a third-party (US Taxpayer) is paying and the consumer gets the care for "free" so they have no reason to shop around or limit their consumption and, as a result, suppliers have no incentive to contain costs. This almost completely eliminates normal market forces that balance supply and demand according to cost and affordability.

My (sarcastic) example of "free" food supplied by the government was meant to show how ridiculous it would be to remove market forces that improve quality and convenience and keep costs affordable.  Milton Freedman said that if the government was put in charge of the Sahara Desert, within six years there would be a shortage of sand! And the cost of sand would skyrocket as the quality declined.

In other countries, notably the UK, medical costs are contained by rationing care based on a limit of about $40,000 per additional Quality-Adjusted Life Year (QALY). If a given procedure would increase the lifetime and quality of life of the recipient, but exceeds the cost limit per QALY, an alternate, less expensive procedure, such as palliative care, will be provided.

For the record, I wrote about the QALY concept way back in 2009 see http://tvpclub.blogspot.com/2009/09/end-of-life-honest-brokers-not-death.html and I support it for public medical expenditures in the US.

(More recently, see http://tvpclub.blogspot.com/2011/02/runaway-trolley-applied-to-end-of-life.html, and http://tvpclub.blogspot.com/2012/08/quality-of-life-and-health-related.html for my views. Unless we thoughtfully address End of Life and rationing of health care for people with chronic and terminal conditions, we will never be able to control overspending on health care. A false sense of "compassion" and "fairness" and "caring" will continue to bankrupt the USA.)