Controversies surrounding quality adjusted life years in healthcare resource allocation

QALY

Quality Adjusted Life Years (QALYs)

The purpose of this paper is to examine the controversial issues using the rational examination of ideas based on logic and current research instead of emotions. This paper focuses on proponent's arguments and oppositional argument's of using Quality Adjusted Life Years or QALYs when deciding how healthcare resources should be allocated. Both sides of the issue are presented. Quality Adjusted Life Years is first defined by the World Health Organization. The researcher then presents both sides of the issue, offering a synopsis of the proponent's side and opponent's side of the QALY issue. Following this a summary of opinions and declarations is offered for review and discussion.

Definition

To understand QALYs one must first define them so a position may be taken. There is no universal definition of QALY that all healthcare providers or institutions use. In fact, some people deviate from the norm when describing QALY. For example, some refer to quality adjusted life years as simply "quality of life" issues or life years (Drotar, 1998). The terminology is not the primary source of conflict, however, it will prove useful in deciding how beneficial QALY is or whether QALY is something healthcare entities should do away with.

Quality adjusted life years refers to quality of life research, which WHO (World Health Organization) defines as "a state of complete physical, mental, and social well being not simply the absence of disease or infirmity" (Drotar, 1998:3, WHO, 1948). This suggests quality adjusted life years is something that one can quantify or measure using the elements named above. Doctors often use physical, mental and social status to decide how to care for patients, whether they need medical intervention or other tools to promote health. A similar philosophy is adopted when one considers the definition of QALY measures.

Others comment the definition of QALY fits with the World Health Organization's definition if expands to include other essential factors including one's disease state or how much the disease has progressed, the physical symptoms a person is having and whether they are debilitation, their independent functional status, their psychological ability and function as well as their ability to function and operate socially (Drotar, 1998; Fitzpatrick, 1994). Doctors want to measure the quantity of life a person may have and the quality of life a person has when undergoing measurements using this approach (Wilson & Clearly, 1994).

The purpose of QALY is primarily to decide how healthcare resources should be allocated. The use of QALY for example, may help determine which patients are eligible for participation in quality clinical trials. From a health insurance perspective, quality adjusted life years may impact the calculation of cost for a person or their family. In fact, health insurance companies have long relied on similar calculations to decide what premium participants may pay. They base their analysis on factors much like QALY including the individual's projected lifespan, current health and medical history. These elements are all used to decide how much insurance an individual will qualify for (based on their life expectancy and health). While even this process is controversial for some, by and large it is widely accepted as a tool for measuring how much insurance can or cannot be offered an individual.

In the next sections the researcher will provide an overview of proponents arguments for the use of QALY to allocate health resources, and opponent's views on such calculations, so that an unbiased decision may be made as to whether companies should continue the use of QALY measures.

Proponents

Proponents of QALYs argue allocation of healthcare resources based on the individual's expected lifespan using QALY analysis is a logical and efficient way to ensure the people that are most likely to live quality years are cared for in an appropriate manner (Kerr, Asch, Hamilton, et al., 2000). They do not suggest that people with shorter projected life terms or serious healthcare problems not receive the vital care they need, which is a common argument among opposition. Rather, the proponents' argument is that healthcare resources should provide for individuals that have the greatest probability of living quality life years first, and then provide for individuals that have less probability of living or of living quality of life years (Kerr et al., 2000). The ideology is something like this; if an emergency medical response team is sent to a call where a car accident has occurred, and there is ample evidence that one passenger will die but two others may have a greater probability of surviving, then EMTs or paramedics would give the patients with the greatest chance of life first access to health resources available to help sustain them. This does not mean they will ignore the dying patient; rather they will work to provide comfort for this patient in his or her time of need. Such actions seem logical in this setting.

QALYs are established using empirical data and quantitative scores to describe the "quality of life" one can expect for a patient, whether the patient is an adult, child or elder (Drotar, 1998:2). Physicians will value patients based on their previous medical health history, and their eligibility for using modern technology to assist with quality of life (Wilson & Cleary, 1994). Other assessment tools can be used to monitor health status including the following: (1) well-being scale as described by Kaplan, Bush, & Berry (1976); (2) the chronic condition index as used for long-term patients including autoimmune or cancer patients, or those with progressive diseases likely to continue to contribute to a poor quality of life later in life (Drotar, 1998); and (3) the "sickness impact profile" which assesses how well or unwell a patient may be as related to their wellness or lack thereof (Bergner, Bobbit, Carter, & Gilson, 1981).

There is much debate regarding the usefulness of quality adjusted life years depending on what measures research facilities, doctors or advocates care to explore in depth. Many people supporting QALY measures suggest there are patients that suffer from conditions including chronic degenerative disease or cancer that prove so debilitating, many patients would prefer to die or have the option to do so rather than try to extend the quantity of their life (Puma & Lawlor, 1990). Puma & Lawlor (1990) assert that QALY measures do consider the ethics of measuring quality and quantity of life, using several assumptions that prove ethical. These include the idea that (1) it is possible to measure the quality of life and use this calculation efficiently to project probably outcomes and (2) the community is able to provide information as to its preferences and an individual may do the same, and (3) the "old have less capacity to benefit than the young" thus physicians do not use QALY "maxims" in cases as these (Puma & Lawlor, 1990). Using these protocols, one may assume QALY measures are not carried out primarily for economic benefit although they can prove beneficial when attempting to budget and measure health outcomes for patients. However, even proponents of QALY suggest by using quality adjusted life years the clinical encounter control is changed, reflecting the preferences of communities, patient autonomy and clinical judgment. Decision making does not occur by the physician alone, but rather involves discussion with the patient and community. The goal is to ascertain the "societal usefulness" of QALY measures for groups of patients in need of scarce resources (Puma & Lawlor, 1990).

Proponents also claim the use of technology has enhanced their ability to project life outcomes and quantity using data clustering and other new statistical methods available thanks to modern technology (Stein, Sugar, Velikova, & Stark, 2003).

Conclusions

Kerr, Asch, Hamilton & Mcglynn (2000) suggest that healthcare professionals must decide how to distribute resources using several approaches outlined in "general medical literature" (p.22). These indicators may include the nature of the disease, the age of the patient, the family medical history, the patient's prognosis and other facets that help doctors and the healthcare team assesses the likelihood that a patient will survive or not following quality care treatment (Kerr, Asch, Hamilton, et al. 2000). The subject of quality adjusted life years is one that will remain controversial for some time. What is positive is the controversy surrounding QALY continues, and as it does more so now than ever before healthcare professionals are looking to establish ethical guidelines for the use of healthcare recommendations. It seems logical that healthcare providers would need to allocate resources sensibly in times when resources are not readily available. This does not suggest however, that people will suffer or not receive proper care as a result of QALY measures when used to allocate resources.

Opponents want to establish a formal tool that is not subjective that would ensure individual autonomy and the rights of patients are not taken away. To achieve this goal all opponents will have to provide evidence that QALY outcomes result in less benefit than good. Thus far based on the research gathered, there is little evidence suggesting QALY is wholly good or bad.

There is enough evidence to suggest healthcare administrators are working to establish ethical guidelines that would ensure all patients have an opportunity to elect whether they receive care or not. Ethical and moral guidelines are not to be taken lightly. The use of QALY is not something that officials or agents can decide overnight. Further research is necessary to help decide how QALY can be best utilized so all patients benefit and all resources are intelligently allocated. Ultimately for QALY to work the final decision must be one that is made through the collaborative efforts of patients, community members, family, doctors, nurses and healthcare administrators.