Table 4
| Treatment |
£s Cost/
QALY
|
| Cholesterol testing and diet therapy |
280 |
| Advice from GP to stop smoking |
350 |
| Heart pacemaker implantation |
1,420 |
| Hip replacement |
1,520 |
| Coronary artery bypass graft |
2,700 |
| Kidney transplant |
6,080 |
| Breast cancer treatment |
7,460 |
| Heart transplant |
10,110 |
| Continuous ambulatory peritoneal dialysis |
25,630 |
| Neurosurgery for brain tumour |
139,040 |
Source: Mason, Drummond and Torrance, British Medical Journal, 27 February 1993. |
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QALYs offer the possibility of carrying out effective cost benefit analysis and thus providing the information we need to make efficient decisions (Table 4). The National Institute for Clinical Excellence (NICE) collects evidence on the cost per QALY produced by the treatments it appraises (see Unit 4iv). Some "life-saving" treatments are unpleasant, do not extend life much and the time remaining is full of pain and discomfort, while other treatments may not save lives but are not expensive and considerably improve the quality of life of the patient. An efficient allocation might shift resources from the first type of treatment to the second.
Problems with QALYs
QALYs provide the best attempt so far to solve the problem of measuring health care outcomes but they still suffer from a number of serious problems. A key question is who is to make the subjective choices which determine the QALY? Is it health professionals, the general public or patients who have experience of the particular medical condition and treatment? Experiments have shown that the value of a QALY can change radically according to who is making the choices. Other problems include the fact that the responses given are to hypothetical situations and so may not accurately reflect people's real decisions, and the fact that valuations are influenced by the length of the illness and the way in which the questions are asked. Finally, QALYs are likely to undervalue health care because they do not capture the wider benefits (externalities) which may be gained, for example, by a patient's family and friends.
Developing QALYs and extending RCTs promises to provide the information we need to judge whether health care is being produced efficiently or not. A more fundamental question is whether health care is really that vital for health? |
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