Rx Communications has just returned triumphant from the 11th annual European Congress of ISPOR. ISPOR is a great place to meet old friends, find new ones, and discuss current issues with competitors, clients and collaborators. This year’s venue (Athens) provided an interesting reminder of how far we have moved in some respects from the beginnings of the civilised world, and yet how there is “nothing new under the sun”. Indeed, the ISPOR chairmen Uwe Siebert and John Yfantopolous quoted Pericles in 450 BC saying “We Athenians, as individuals, take our own decisions on policy and submit them to proper discussions; for we do not think that there is an incompatibility between words and deeds; the worse thing is to rush into action before the consequences have been properly debated”.
And debate there was. A recurring theme was the harmonisation or standardisation of HTA evaluations from agency to agency. One plenary session provoked a lively discussion of international guidelines for the evaluation of healthcare interventions, with the lead protagonists advocating the QALY (Mike Drummond) or the efficiency frontier (Jaime Caro), and with Milton Weinstein and Uwe Seibert inserting provocative questions regarding the applicability of standard approaches and the flaws in methodology.
Mike Drummond paraphrased Winston Churchill’s famous quote “democracy is a lousy form of government but it’s the best we have” by saying “QALY’s are a lousy form of measure but they are the best we have”. He added, somewhat cynically, that incremental cost per QALY is at least flexible enough to cope with the needs of politicians.
There are both methodological and political issues arising from the use of QALYs as the fundamental decision-making approach. For example, different measurement approaches for estimating the health state preference values for QALYs can give different answers, and if the concern is about the provision of social value, then equal weighting of QALYs won’t necessarily give it to us. As always, the “devil is in the detail” and in the eyes of decision-makers some QALYs are more equal than others.
On the other hand, using an efficiency frontier approach, where the value of the benefit is plotted against the total net cost, is a useful way of determining what role price plays in the estimation of value. A frontier is set depending on points specified by existing healthcare interventions, which enables one to plot what the current market sets as a reasonable return (benefit) for a given cost. However, this too has issues – it doesn’t provide a decision rule, or address societal preferences regarding the priority of various diseases.
It was an interesting debate, with no clear outcome. In some ways, it reminded me of the contentions regarding the peer-review process in publications – if you think of the QALY as a means of measuring value in healthcare, the peer review process in publications is the means of measuring value in a publication. And again, there are methodological issues and political issues in the peer review process. For example, reviewers’ opinions about the value of a manuscript can be strongly influenced by their own perceptions/positions in the therapeutic area, and in many cases the decision of the journal editor whether or not to accept the article is influenced by political considerations (the prestige of the lead author for example, or the likelihood of reprints) as much as they are influenced by the value of the research in the article.
So in my view both the QALY and peer review methods are deeply flawed – but they are the only ones we have for decision making. The question then becomes: do we “throw the baby out with the bathwater” as it were, and redesign the whole process of measuring value, or do we use these flawed measures as a guideline of value and apply commonsense and a little humanity in our decision-making?
The value of congresses such as ISPOR is that these issues are raised and debated, and with an open exchange of views and perceptions we gradually move forward in our thinking, and eventually find better ways of making decisions.