Quality of Life and Health-Related Quality of Life

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?

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 today and had the nearly 50 people who attended, mostly retirees in their 60's, 70's and 80's, select what they judged to be the most important factors leading to high Quality of Life. They also used a questionaire called "EQ-5D" to estimate their individual Health-Related Quality of Life levels. We then discussed the results and the implications for making individual Health Care decisions.The results of our selections and evaluations are posted below.

You may view and download the PowerPoint slides here: https://sites.google.com/site/iraclass/my-forms/QualityOfLife3Aug2012.pptx?attredirects=0&d=1


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 today, nearly 50 people participated in the survey. Each member was asked to vote for his or her top ten items and the scores are tallied and graphed below to determine the most important two 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

http://en.wikipedia.org/wiki/File:2011_UN_Human_Development_Report_Quartiles.svg) is a 2011 UN publication that considers life expectance, 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 Quality of Life Index (see http://en.wikipedia.org/wiki/Quality-of-life_index) was put out in 2005 by the respected British magazine The Economist and 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 Ireland. The US comes in 13th, just after Finland and ahead of Canada.

The Happy Planet Index (see http://en.wikipedia.org/wiki/File:Happy_Planet.PNG) is a 2006-2012 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  #114 in the 2009 rankings, and is in the worst category along with much of Central Africa and Russia. The best three countries in the 2012 ranking are Costa RIca, Vietnam, and Columbia which each have 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).

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 $47,000.

Ira Glickstein

Voting and Notions of Fairness

In our continuing discussion of L/C (Liberal/Conservative) mindset differences, let us consider the relative importance attributed to fairness versus effectiveness. It is my belief that conservatives tend to rate effectiveness more highly than do liberals, and the reverse applies to fairness.

The current controversy over seating the Florida and Michigan delegations to the Presidential party conventions is what got me thinking about this issue. (I do not intend to stray into partisan politics that favors Sen. Clinton or Sen. Obama or the Republicans or the Democrats. Please try to keep any comments clearly on the issue of fairness and effectiveness and L/C differences.)

Both political parties made an attempt this year to discourage states from "jumping the gun" and holding their primaries prior to February 5th. Exceptions were made for the traditionally-first New Hampshire primary and caucuses in Iowa and a few other states. As a result, some 26 states complied and scheduled their primaries or caucuses for February 5th, named "Super Tuesday," and most other states scheduled for after Super Tuesday.

1) Fairness of Penalty for "Jumping the Gun"

To discourage states from going before Super Tuesday, both parties imposed penalties. This provides us with the first example of notions of fairness.

The Republican C-minded penalty was loss of half the delegates. The Democratic L-minded penalty was far more strict. Any offending state would lose all their convention delegates. Any candidate campaigning in those states would lose all party funding.

At first glance, The Democratic Party penalties seem more fair. We would be appalled if a rule-breaking racer was given half credit for winning the race! Imagine if the "halfies" rule was applied to criminals - the robber who was caught would be allowed to keep half the haul!

On the other hand, Florida and Michigan are important states when it comes to winning the general election in November. Any political party that upsets the voters in those states risks losing them. In that light, the "fair" penalty seems harsh. Indeed, the Democratic Party is scrambling to give Florida and Michigan some kind of representation at their convention. Schemes for a re-vote seem to have failed (see next item).

On second thought, the less fair C-minded "halfies" penalty seems more effective and less divisive than the more fair L-minded strict penalty.

2) Fairness of a "Do-Over"

Clinton, who won both Florida and Michigan, would like the Democratic Party to recind the penalty, or, failing that, allow a "do-over" primary in June.

A revote would cost tens of millions of dollars that would have to come from the state or national Democratic Party coffers since the taxpayers of Florida and Michigan have already paid for one primary. A less-costly mail-in primary was considered in Florida but had to be dropped because five counties are under legal restrictions against changing voting rules due to previous racial discrimination. Here is another case where fairness (preventing future racial discrimination) runs into effectiveness (re-doing the primary at reasonable cost). The Michigan legislature seems to have failed in their attempts to schedule a "do-over".

So, why not simply recind the penalties and give Clinton and Obama the delegates they won in the original primary? Clinton would love that because she won Florida. Obama removed his name from the ballot in Michigan and Clinton also won there. Quite understandably, Obama, who leads in elected delegates, opposes that plan. Why not just split the delegates evenly between Clinton and Obama? Quite understandably, Clinton objects.

Once again, it appears that L-minded fairness (representation of the Democratic primary voters in Florida and Michigan) will take a back seat to the C-minded idea of not changing the rules in the middle of the game.

3) Fairness Schemes for Scheduling Primaries

Fairness advocates favor some national rule for scheduling primaries. One idea is to schedule a primary in a different geographic region each month. To make that fair, the order of regions would be random each election so no one region would go first each time.

The traditional early-primary states object to that idea. It would also be hard to get the various interest groups to agree on how the regions would be designated.

On second thought it seems this L-minded fairness idea is dead on arrival.

4) Proportional vs Winner-Take-All

In winner-take-all primaries, the candidate who gets, say, 51% of the popular vote gets 100% of the convention delegates. That seems unfair to the candidate who got 49%. L-minded fairness advocates are rightly concerned about this and favor a proportional system where convention delegates are awarded by county or proportionately by state.

Nearly all Democratic primaries and caucuses are run on a proportional system, confirming their generally L-minded attitudes. The reverse is true of most Republican primaries.

As a result, the Republicans settled on a presumptive candidate in February. This is quite effective but it seems unfair to deprive the late-primary states of any voice in the selection process.

It appears the Democrats will be going at it until June or perhaps even at their convention. The candidates will continue spending heavily and attacking each other. This seems less effective, but it does give a voice to Democratic voters in late-primary states.

On second thought, it appears L-minded fairness may lead the Democrats to "snatch defeat from the jaws of victory." (Advocates of eliminating the Electoral College process or requiring all states to award Electoral College votes proportionately might want to rethink their positions based on this example.)

6) "Superdelegates"

This is an ironic example of where the Democratic Party has taken what I consider a more C-minded approach than the Republicans! The voice of the people as expresssed in primaries and caususes counts for 80% of the delegates to the Democratic convention, while the remaining 20% are seated automatically on the basis of the offices they hold. This system was put in place in 1982 after some convention disasters to assure that people with demonstrated knowledge and experience would help select the party's Presidential nominee. (The Republicans have a similar system, but with far less power.)

It appears the superdelegates are Sen. Clinton's only hope to reverse her deficit in elected delegates. She is trying to convince them she is the more experienced and safest candidate with the best chance to win. Most superdelegates will probably follow the will of their constituencies, but it will only take a hundred or so to flip the Presidential candidate selection to Clinton.

I generally favor a system where the raw vote "voice of the people" is tempered by something like the old "smoke-filled room" expertise of political pros.

7) "Open" vs "Closed" Primaries

Many states and counties are so "Blue" or "Red' that whoever wins the primary of the dominant party is virtually assured of election. For example, most inner-city counties are Blue and many suburban counties are Red.

L-minded fairness advocates are rightly concerned that members of the minority party, and independents, have no say in the election of their representatives. Therefore, many primaries are "open" - allowing independents and members of the opposite party to change their party affiliation at the last moment or vote in whichever party primary they choose.

Most Republican-dominated states have closed primaries. Of course, anyone can register in either party and some members of the minority party do register in the majority party to get a voice in the primaries. However, the decision to switch party affilliation must be done well before the primary date.

L-minded independents and Democrats generally favor open primaries. Ironically, some conservative talk show hosts have exploited the open primary system and asked their listeners to switch parties and vote for Sen. Clinton to increase the chaos and extend the Democratic primary contest.

I generally favor closed primaries. I don't like the idea of people flipping parties at the last minute. However, if I lived in a jurisdiction where the other party was dominant, I would change my party affilliation to that party to get a voice in their primary.

I'd be interested in your opinions on these issues. Please don't be partisan. Try to stick to the philosophical issues of fairness vs effectiveness.

Ira Glickstein