Lead author of the BMJ article, Dr Ross Camidge, Clinical Lecturer in Cancer Therapeutics at The University of Edinburgh, explains: "If someone had a disease that they would eventually die from and a new treatment could prolong their life by a few months, should the value of that treatment be considered the same regardless of whether the individual had six months or six years left to live without it?
The National Institute for Clinical Excellence (NICE) in England and Wales, and the Scottish Medicines Consortium (SMC), make recommendations about which new treatments should be made available to patients on the NHS. Similar bodies also exist in other countries to try to make the best use of available healthcare resources. Recommendations all focus on how effective any new treatment is compared to the existing standard of care and on its value-for-money. Currently, none of these organisations adjust their value-for-money assessments by how long patients with a particular condition would live on average without the treatment under consideration.
Dr Camidge says: "Many medical conditions shorten life to a greater or lesser extent. If an expensive new treatment makes terminal cancer patients live three months longer then it seems intuitively unfair that this should be ascribed the same low value-for-money rating - and potentially not be funded – as a treatment that gives three months to those with, for example, diabetes or high cholesterol, when these patients may live for decades with standard care."
A pilot study at Edinburgh's Western General Hospital showed that when resources were limited and hypothetical patients all gained the same amount of time from treatment, 93% of doctors, nurses and medical secretaries used information on 'prognosis without treatment' to decide who to treat. Dr Camidge reports that a larger, more detailed study of doctors' and cancer patients' attitudes on this matter is already underway, supported by the Chief Scientist Office.
He says: "We aim to determine whether information on patients' prognosis without the new treatment could be used routinely in the kind of decisions made by NICE and the SMC. Many value-for-money assessments already include information on the incremental cost associated with improving not just the quantity of patients' lives but also their quality, usually through units called quality-adjusted life years (QALYs). Additional measures, such as the incremental cost for a given percentage change in lifespan or percentage change in QALYs may improve the fairness of these assessments even further."
Professor David J. Webb of the University of Edinburgh, Chairman of SMC and senior author of the article comments: "SMC and NICE recognise the need to use QALYs to inform judgements on the benefits associated with new medicines. Work that raises awareness among the public and health professionals about gaining good value for money from advances in health care is very useful, and research that may help refine the way QALYs are used to make them more representative of society's values should be encouraged."
Prognosis without treatment as a modifier in health economic assessments, British Medical Journal, 10 June, 2005:Ross Camidge, Andrew Walker, James J. Oliver, Fiona Nussey, Simon Maxwell, Duncan Jodrell, David J. Webb.