A global view on effectiveness research

We badly need effectiveness research — which medical treatments work and which ones don’t. After all, some reasonable estimates are that a third or so what we spend on medical treatments is for things that aren’t known to work, or worse, don’t work. Effectiveness research means comparing two competing therapies to see which works better; if both work the same, our preference should be for the less expensive one. We have very little of that now.

There is another way to think of effectiveness research, a more global one. This approach looks at the bottom line — does a treatment make people’s lives better and/or make them live longer? A key metric for this kind of research is the quality-adjusted life year, or QALY. The idea is simple: to what extent does the treatment add meaningful years of life to people? This notion has been around for decades. It’s particularly useful because it crosses all disease categories, simply comparing life outcomes.

The idea of the QALY, however, can create fears that it will somehow be used to judge lives, one against the other, regarding which has a higher “qualtiy.” Could QALY measurement be a stalking horse for rationing, of allocating heathcare resources to those some committee deems more deserving. The political traction that Sarah Palin’s nonexistent “death panels” received shows the depth of this distrust.

This fear is, in fact, embedded in the recent healthcare reform bill, the Affordable Care Act. The Act established an outcomes research center, called the Patient-Centered Outcomes Research Institute. But, as a recent editorial in the New Journal England of Medicine notes, the Act specifically forbids the use of QALY measurement “as a threshold.” It is not clear at all what that means, but, like the authors of the editorial, I think it reflects a fear that some lives will be judged more worthy than others, leading to unfair (or unethical) rationing of care.

But here’s the problem: QALY analysis is one of the most powerful tools of effectiveness research, and it’s absurd to pretend is should not or will not be used. From the article:

The antagonism toward cost-per-QALY comparisons also suggests a bit of magical thinking — the notion that the country can avoid the difficult trade-offs that cost-utility analysis helps to illuminate. It pretends that we can avert our eyes from such choices, and it kicks the can of cost-consciousness further down the road. It represents another example of our country’s avoidance of unpleasant truths about our resource constraints.

I suppose the fear-of-QALY clause made into the bill because the legislative sausage-making machine contains many pet items of the various legislators. But this particular one is absurd.

Christopher Johnson is a pediatric intensive care physician and author of Your Critically Ill Child: Life and Death Choices Parents Must Face, How to Talk to Your Child’s Doctor: A Handbook for Parents, and How Your Child Heals: An Inside Look At Common Childhood Ailments.  He blogs at his self-titled site, Christopher Johnson, MD.

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  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    “A key metric for this kind of research is the quality-adjusted life year, or QALY. The idea is simple: to what extent does the treatment add meaningful years of life to people? ”

    The problem I see here is that the word “meaningful” is subjective. Perhaps less so at the extremes, but very muddied in the middle. I just don’t see how you apply subjective metrics to scientific research and obtain objective conclusions. Isn’t there a more exact way to analyze and quantify results in this field?

  • Doc99

    The slippery slope is rapidly becoming a frictionless plane.

    • http://www.chrisjohnsonmd.com Chris Johnson

      So we’re not supposed to care if our treatments cause more harm than good? Or if we are getting any value for our money? What would you measure?