Quality Adjusted Life years: an equal deal for renal patients?

Contents.
Introduction.
QALY'S: a definition.
The economic/political implications.
The ethical and social implications.
Implications for dialysis dependent patients.
  Conclusion.
References.

Back to Nursing Progress contents.
Back to Issue 4 contents list.

Recent changes in the delivery and management of health care services have focused attention on the need for efficiency and cost-effectiveness. There has always been rationing in the NHS, but the introduction of the internal market has led to explicit attempts to define the processes involved. It is argued that the use of QALY's is an ethical method of allocating finite resources in times of increasing pressures on health care budgets. As yet there is little evidence of any systematic use and review of QALY techniques. However, the technique is the subject of increasing discussion. For example, the Department of Health has suggested in the past that regional health authorities use QALY's to determine a list of treatments that will not be available to the general public. (1) Dialysis therapy is an excellent example of an area where QALY's could be justifiably applied to enable treatment decisions to be made. Yet the methodology and applications of the technique are untested and the central question remains - who benefits from QALY's? This paper examines the QALY debate and the implications for health care resources.

Back to contents

QALY'S: a definition

QALY's were pioneered in Oregon in the USA, where they have been used to prioritise medical conditions and allocate resources accordingly. Professor Alan Williams has been the person most associated with the use of QALY's in the UK. Williams' definition of the QALY's technique is that a QALY takes a year of healthy life expectancy to be worth one, and a year of unhealthy life expectancy to be worth less than one. The worse the quality of life, the lower the value obtained. The general idea is that a beneficial health care treatment will generate a positive number of QALY's and that an efficient treatment will be one where the cost per QALY is as low as possible. Therefore a high priority treatment is one where the cost per QALY is low, whilst low priority treatments are those where the cost per QALY is high.(2) This method of allocating resources could  have disturbing  implications for expensive treatments such as dialysis. Treatment with dialysis generates high cost QALY's, which would be seen as a low priority area for investment. Inevitably, a policy would be introduced to determine which patients should have dialysis. This would affect not only patients and their relatives, but also the staff working in these areas. However, the QALY continues to be promoted as a means for providing health care managers with objective information for the allocation of resources, as well as a means for medical/nursing staff to make "rational" treatment decisions. If this system is introduced then QUALY's will end up benefiting not the patients, but rather the balance sheets of hospital managers.

Back to contents

The economic/political implications

QALY advocates are in the main health economists and managers, and their argument is based on the fact that there are simply not enough resources to allow all the treatment required. The QALY, it is argued, is a fair means of allocating these scarce resources in a beneficial way. (3) Critics of this view do not accept this and whilst accepting that resources are finite, question why health care expenditure in the UK is the lowest in Europe.(4)

Back to contents

Maynard also argues that it is the ethical role of health care managers and economists to determine what the "best buy" treatment is. He feels that evaluative research, not doctors or nurses should decide how patients are treated stating that "QALY's should be maximised in our hospitals even if patients with treatable renal failure are not cared for in our hospitals". The main thrust of the argument that is often repeated in the literature, is that clinicians will try to obtain as many resources for their speciality with scant regard for the costs and benefits to others. Williams states that procedures where QALY outcomes are high in relation to costs e.g. heart valve replacements should take precedence over procedures such as dialysis where the costs per QALY are higher. This argument pays little attention to the staff and patients in these areas and the pioneering work that is being undertaken, which may in time reduce the cost and maximize the outcomes of dialysis.

Priority setting should remain with the doctors and nurses responsible for dealing with patients, as they have always considered the social and economic consequences of their actions. The best is always done for each patient. The responsibility for clinical decision making has not been handed to health care economists.(5) Further resources would be required to fund the introduction of a system of QALY's. It would take a very foolhardy political party to advocate their use, particularly as QALY's undermine the ethical ethos of the NHS and would be a very unpopular move with the public.

Back to contents

The ethical and social implications

Supporters of QALY's feel that inefficient overspending is unethical and that overspending on one group of patients denies others who may benefit more. (3) (6) Critics of QALY's argue that the methodology employed to make decisions regarding treatment is unethical. It has not been validated, but despite this the QALY has been used for cost effective clinical trials.(7) lf QALY's were to be used to benefit patients ie decide the best treatment option, then there would be no criticism. The critics are adamant that the QALY would be used not to decide how to treat but rather which groups of patients to treat. (8) QALY's discriminate against the elderly as they value life years rather than lives. The dialysis population is increasingly elderly, so will these people who have every right to enjoy their later years be denied a chance of treatment because it is not cost effective?

Applying QALY's to individuals is not appropriate as their impersonal calculations would not be morally defensible. Cubbon argues that the most applicable use is in planning services.(9) Certain groups will always be deprived in some way and if QALY's are utilised then those affected will not be known as individuals. This moral judgement is defended on the grounds that discrimination is less clear when the members of the group are not easily defined. Denying people their basic right to health care is not a ethically sound argument. Several public surveys have revealed that if resources for health care needed rationing, then priority should go to the young and those with families. No comment was made regarding an individuals perceived worth to society ie intelligence, status, etc.(6)

Back to contents

The above arguments call the ethics of QALY's into question. They would appear to benefit neither the individual patient or wider society. Do we really want to live in a society where access to health care depends on your age and perceived worth to society? Everyone should have the opportunity to have access to the best medical resources. It is morally indefensible to use the QALY's system to allocate resources.

Back to contents

Conclusion

Back to contents

References

1. Dean M. ls your treatment economic, effective, efficient? Lancet 1991: 337; 480-1.

Back to Nursing Progress contents.

Back to Issue 4 contents list.

Back to Top

Page last revised 22/4/02

[RLH League]

[League Notices]

[Membership]

[League history]

[Education]

[Hospital History]