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Both the method and the conclusions do not appear sound in this
article. QALY is calculated from the mean of responses from a large number
of patients, including life expectancy. This article seems to suggest that
those patients who do not wish to have an intervention are those who have
least to benefit from this intervention, but this appears to be just an
assumption and might not necessarily be the case. What if those people
choosing not to take up the intervention were those who might benefit
more, not just in quality terms but also in years of life saved? Just such
evidence exists with the inverse care law. One example from 2000 showed
that socioeconomically deprived patients were more likely to develop
coronary heart disease but were less likely to be investigated and offered
surgery once it has developed (1).
If we apply these facts to the authors hypothesis that QALYs should be
recalculated with the characteristics of the patients declining the
intervention omitted, then surely this would lead to reducing the QALY
gain in the original estimate, as it is likely those patients not
receiving the treatment might actually be at higher risk of the disease
than those accepting?
Surely the more accurate methodology might be to reanalyze the data using
patient characteristics of those who actually take up the intervention,
giving a more accurate measure of the potential QALY in practice.
(1) Pell J, Pell A, Norrie J, Ford I,Cobbe S Effect of socioeconomic
deprivation on waiting time for cardiac surgery: retrospective cohort
study BMJ 2000;320:15–9
No competing interests
07 March 2006
honorary senior lecturer in primary care
UEA School of Medicine, Health Policy and Practice