A new QALY for the UK?

[Ivor the Engineer]

http://www.independent.co.uk/life-s...0-now-nhs-drugs-body-recalculates-958708.html

What price a life? The controversial National Institute for Clinical Excellence (Nice) is about to decide. Under bitter attack for denying life-extending drugs for conditions such as cancer and dementia, the body is to revolutionise how it chooses which vital life- saving drugs are funded by the NHS.


For the past nine years, Nice has come under attack repeatedly over the medications it approves or denies for NHS patients. Only yesterday, Carol Rummels won the right to a cancer drug called Tarceva denied by Nice and which she has been paying for herself. Now, South Gloucestershire Primary Care Trust has agreed to pay £1,500 a month for the drug which is available for free in Scotland, where Nice doesn't rule.

On Tuesday, the world will have its first glimpse into how the system might change: new research by leading UK health economists will raise serious questions about the way Nice makes its decisions and suggest how it might change.

...

The research from Newcastle University, commissioned by Nice and to be published in the journal Health Economics, will criticise the system for failing to take into account public opinion. The new maths calculates the figure by asking people their willingness to pay for health and what they would sacrifice to have it.

Another new study by Imperial College found that the current system fails to capture the real impact of devastating health problems on patients and their families. It says that the public wants Nice to consider age, type of illness and, most controversially, the extent to which patients themselves, or the NHS, must bear some of the blame. This array of new research means that Nice will have to abandon a "one size fits all" system of valuing patients' lives and adopt a more radical approach.

Nice has revealed that it plans to move quickly to implement some of the findings. Experts will meet in February to discuss the benchmark figure Nice currently uses to approve drugs. Meanwhile, the drug appraisal committees at Nice have been instructed to take into account the new evidence about the public's priorities. Work will begin to improve the way the QALY is calculated. The body's citizens' council will begin the process next month.

...

I can't wait to see the algorithm used to determine how much blame to attatch to patients and how it will affect the choice of treatments they are offered.

 

[Cuddles]

I can't wait to see the algorithm used to determine how much blame to attatch to patients and how it will affect the choice of treatments they are offered.

Attaching blame to patients sounds nasty, but it isn't such a bad thing to consider. In an ideal world, we would treat everything, but with limited resources that's just not possible. If you have a choice of treating two patients, one of which is ill purely due to their own actions, surely that's a valid way to decide how to allocate resources?

For example, my father is (or was until recently at least) a head and neck cancer specialist, which means that many of his patients were ill because they smoked. Not only that, most of them carried on chain smoking afterwards, often ending up back in hospital with cancer again a few years later. Is it really fair to waste public resources on people who not only cause their own problems, but refuse to change their behaviour even after nearly dying from it? OK, smoking isn't the best example here given that the taxes from smoking are actually more than the cost of treating the associated problems, but I'm sure you get the point.

 

[drkitten]

For example, my father is (or was until recently at least) a head and neck cancer specialist, which means that many of his patients were ill because they smoked. Not only that, most of them carried on chain smoking afterwards, often ending up back in hospital with cancer again a few years later. Is it really fair to waste public resources on people who not only cause their own problems, but refuse to change their behaviour even after nearly dying from it?

Another good example.... transplantation surgery and smoking. One of the effects that smoking has on your system is vasoconstriction -- it narrows the blood vessels that supplies blood to various parts of your body. If you've just had some sort of transplantation surgery, ensuring a supply of blood to the new parts of your body can be crucial.

Basically -- if you've just had finger-attachment surgery, don't smoke. If you smoke, your new fingers will get gangrenous and drop off.

... and with fingers available for transplantation in short supply, it makes sense to not give them to people who can't not-smoke.

Similarly, obesity can lead to kidney failures; if you can't lose enough weight to keep your own kidneys from shutting down, the chances of your being able to keep other people's from shutting down are pretty low.

And if you've ruined your liver through alcoholism, that's a good sign that you should stop drinking. If you can't do that, maybe you shouldn't be at the front of the line for a liver transplant.



I think the new NHS policy makes a lot of sense, unfortunately.

 

[Ivor the Engineer]

The problem with blame is we see others' negative behaviour as being caused by a flaw in their character, while we explain our own negative behaviour as being caused by external factors.

A more humane way (IMO) to satisfy the publics’ desire for "just" medicine would be to use statistics on the proportion of people with negative health behaviours, significant to the outcome of the particular intervention, who continue to engage in them after treatment. Using the examples already mentioned this could include such information as the risk of a smoker continuing to smoke after having treatment for a smoking-related illness, or an alcoholic continuing to drink after having a liver transplant being used to set treatment priorities.

However, I think it would be exceedingly difficult to apply such statistics to an individual, and since everyone (except me of course) has some negative health behaviours which are under their control, where would the line be drawn?

 

[paximperium]

I don't know how the UK handles the cases you've mentioned but in the US, transplant priorities and criteria are stringent. Before receiving a liver, someone must be off alcohol AND be in a rehab program for at least 6months before being placed on a transplant list. Smokers aren't even considered for lung transplants.

PS: The cost of one human life is old news. Insurance companies have been using that data for decades.