COST UTILITY ANALYSIS (CUA) Prof.

Mahmoud Alhaddad
INTRODUCTION
CUA is sometimes considered as a subset of CEA because the
outcomes are measured in using a special type of clinical outcome
measure, usually the quality adjusted life years (QALY).
A CUA takes patient preferences, also referred to as utilities, into
account when measuring health consequences.
The most outcome unit used in CUA is QALY which incorporates both
morbidity (quality) and mortality (quantity) of life.
The advantage of CUA is that different types of health outcomes and
diseases with multiple outcomes of interest can be compared (unlike
CEA) using one common unit such as QALY.
Sometimes treatments that extend life are more toxic, so the
incorporation of length and quality of life is very important in these
cases.
Many other conditions may not affect on the length of life but affect
on the quality of life, in this case CUA is also a good choice of
analysis.
Examples are hearing loss, seasonal allergies, erectile dysfunction.
CUA also can be used when comparing treatments and outcomes that
are very different because outcomes for both treatments can be
summarized into one outcome unit such as QALY.
The disadvantage of this method is that it is difficult to determine an
accurate utility or QALY value.
This is relatively new outcome measure which is difficult to be
understood by many decision makers and healthcare providers.
When calculating QALYs, 1 year of life in perfect health has a score
of 1.0 QALY and death equal 0.0 QALY.
If a person’s health diminished by a disease or treatment, 1 year of
life is then valued at less than 1QALY.
STEPS IN CALCULATING QALYS
To calculate QALYs, various steps apply:
1. Develop a description of each disease state or condition of
interest.
2. Choose a method for determining utilities.
3. Choose subject who will determine utilities
4. Multiply utilities by the length of life for each option to obtain
QALYs.
STEP1: DEVELOP DESCRIPTION OF EACH
DISEASE STATE OR CONDITION OF INTEREST
The description should concisely depict the usual health effects
expected from the disease state or condition.
It should include the amount of pain or discomfort, any restrictions on
activities, the time it may take for treatment, possible changes in
health perceptions (worry or concern) and any mental changes.
Example describing hospital-based kidney dialysis:
You often feel tired and sluggish. A piece of tubing has been inserted into your arm or
leg, which may restrict your movement. There is no severe pain but rather chronic
discomfort. You must go to the hospital twice a week for 8 hour per visit. You must
follow a strict diet (low fat, little meat, no alcohol). Many people become depressed
because of the nuisances and restrictions, and some feel they being kept alive by a
machine.
STEP 2: CHOOSE METHOD FOR
DETERMINING UTILITIES
Three most common methods for determining preferences, or utility,
scores are:
Rating scale RS
Standard gamble SG
Time tradeoff TTO
RATING SCALE
RS consists of a line on a page with scaled markings somewhat like a
thermometer with perfect health at the top (100) and death at the
bottom (0).
Different disease states or conditions are described to subjects, who
are asked to place their estimated preferences for the different
disease states or conditions somewhere on the RS.
If they place disease state at 70 on the scale, the disease state is
given a utility score of 0.7.
STANDARD GAMBLE
This is the second method for estimating utility scores.
For this method, each subject is offered two alternatives.
Alternative one is treatment with two possible outcomes: either to
return to normal health or immediate death.
Alternative two is a certain outcome of a chronic disease state for life
based on person’s life expectancy.
The probability of normal health and immediate death is varied until
the subject is indifferent between alternative 1 and 2 (living with
disease state or condition).
An example, a person considers two options: a kidney transplant with
a 20% probability of dying (80% chance of returning to normal life)
during the operation (alternative 1) or certain dialysis for the rest of
his or her life (alternative 2).
Percentage of success and going back to normal life is changed
based on subject responses until the subject is indifferent between the
two alternatives.
Then the percent of success and going back to normal life is
considered the utility.
TIME TRADEOFF
This is the third technique for measuring health utilities.
Again the subject is offered two alternatives
Alternative 1 is a certain disease state for a specific length of time (t)
the life expectancy for a person with a disease, and then death.
Alternative 2 is being healthy for time x, which is less than t.
Time x is varied until the respondent is indifferent between the two
alternatives.
The utility score is calculated as x divided by t.
Example: a person with life expectancy of 50 years is given two
options: alternative 1 is being blind for 50 years, and alternative 2 is
being healthy (including being able to see) for 25 years followed by
death.
Years of being healthy and able to see are changed up or down
according to the subject responses until the subject is indifferent in
both alternatives.
In this example lets say that for a person who expects to live 50 more
years, the person’s point of indifference is 40 years of sight versus 50
years of being blind.
The utility score would be x/t – 40/50 = 0.8
STEP 3: CHOOSE SUBJECTS WHO WILL
DETERMINE UTILITIES
In the previous three methods we used the term “subjects” to represent
the respondents.
Respondents could be patients with the disease, the healthcare
professional, the caregiver, or people from the general population.
Patients may understand the effect of the disease than others. Others
view that patients represent biased view of their disease than other
diseases.
Some contend that healthcare professionals could provide good
estimate because they understand various diseases.
Others argue that general public should be the respondents, but
general public may not be familiar with each disease state or
outcome.
Many studies in the literature use healthcare professionals as subjects
for providing health utilities.
STEP 4: MULTIPLY UTILITIES BY THE LENGTH
OF LIFE FOR EACH OPTION TO OBTAIN QALYS
When comparing the options, the difference in the length of life
permitted by each option is multiplied by the utility score obtained
earlier.