Palliative Care and the QALY Problem

Abstract

Practitioners of palliative care often argue for more resources to be provided by the state in order to lessen its reliance on charitable funding and to enable the services currently provided to some of those with terminal illnesses to be provided to all who would benefit from it. However, this is hard to justify on grounds of cost-effectiveness, since it is in the nature of palliative care that the benefits it brings to its patients are of short duration. In particular, palliative care fares badly under a policy of QALY-maximisation, since procedures which prevent premature death (provided the life is of reasonable quality) or improve quality of life for those with longer life expectancy will produce more QALYs. This paper examines various responses to this problem and argues that in order to justify increased resources for palliative care its advocates must reject the 'atomistic' view of the value of life implicit in the QALY approach in favour of a 'holistic' or 'narrative' account. This, however, has implications which advocates of palliative care may be reluctant to embrace.

The economic evidence for advance care planning: Systematic review of evidence

“…Finally, the primary purpose of ACP is to improve people's quality of life and reduce avoidable distress. In economic evaluations, it is increasingly common to use a health-related quality of life measure to generate estimates of quality-adjusted life years (QALY) (Petrou and Gray, 2011;NICE, 2013), with the Palliative Care Yardstick (or PalY) promoted by some as a potential alternative measure (Normand, 2009;Round, 2012;Hughes, 2005;Gomes, 2009). …”

Is a QALY still a QALY at the end of life?

“…Coast and Lavender (2009), presented a review of many of the arguments against the QALY. In particular, it has been argued the QALY, as currently conceptualised, is unable to satisfy a number of conditions for use and is therefore rendered unsuitable (Carr-Hill, 1991) for allocating resources, particularly in end of life care (Coast and Lavender, 2009;Normand, 2009;Hughes, 2005). Within end of life care, there are several arguments that have developed to challenge welfarist and extra-welfarist notions of how outcomes should be measured and valued.…”

“…Key criticisms of the use of the QALY in evaluating end of life care (Coast and Lavender, 2009;Normand, 2009;Hughes, 2005;Arnesen and Norheim, 2003;Dolan and Stalmeier, 2003;Coast et al, 2008b) have not raised issues of equity. One potential such criticism might be that the use of cost-effectiveness analysis incorporating QALYs is ageist; most people die in old age, and so the bulk of end of life care is provided to this group.…”

“…Briefly stated, it has been proposed that there may be some interventions that are deemed desirable by the public and decision makers but that would not be accepted as costeffective using the standard analytical approaches used in other areas of healthcare (Normand, 2009;Hughes, 2005). Despite the protestations of the progenitors of the claim (Normand, 2009), this is largely a case of special pleading and is not a phenomenon unique to end of life care.…”

“…The first is that patients nearing the end of life are sufficiently distinct from other population groups that the standard evaluation methodologies should not apply (Coast and Lavender, 2009). The second is based on the supposed 'QALY problem' -that there exists some subset of interventions which are considered desirable by both the public and decision makers but would not generate sufficient QALYs to be considered cost-effective (Hughes, 2005;Normand, 2009). In this paper, I discuss the arguments made in favour of supplanting the QALY with an alternative outcomes framework.…”