Introducing “Health Years in Total:” A Novel Framework for Valuing Health Outcomes in Cost-Effectiveness Analyses

Published Jan 21, 2020

New Metric Provides a Robust and Feasible Approach That Overcomes Specific Limitations of the QALY

Lawrenceville, NJ, USA—January 21, 2020—Value in Health, the official journal of ISPOR—the professional society for health economics and outcomes research, announced today the publication of an article introducing a new framework for valuing health outcomes in cost-effectiveness analyses. This new metric, “health years in total” (HYT), is a robust approach that overcomes specific limitations of quality-adjusted life-year (QALY) and equal value of life (EVL) measures. The report, “Health Years in Total: A New Health Objective Function for Cost-Effectiveness Analysis,” appears in the January 2020 issue of Value in Health.

Researchers from the University of Washington developed HYT as an alternative to other frameworks for valuing health outcomes in cost-effectiveness analyses. In short, HYT equals the sum of life expectancy plus modified QALYs. The modified QALYs are calculated over a time frame corresponding to the maximum survival of any given alternative. The Value in Health article establishes a theoretical framework, provides illustrations of the use of the HYT framework, and assesses decision-making thresholds for using HYT.

Despite the importance of QALY in cost-effectiveness analyses, its potential to be discriminatory toward patients with lower quality of life presents a critical challenge that has resulted in the exclusion of the use of cost-effectiveness analyses in some public healthcare decision making in the United States. The use of the QALY in cost-effectiveness analyses has been publicly criticized, as highlighted in the Oregon Health Insurance Experiment, specific language in the Affordable Care Act barring the use of QALYs, resistance to the Institute of Clinical and Economic Review’s activities, and the recent letter from the National Council on Disability to the President of the United States.

The main premise for these criticisms centers on the fact that QALYs, by definition, would value life extension for patients with lower baseline quality of life less than a similar life extension for patients with better baseline quality of life. The National Council on Disability specifically calls for alternatives to QALY. However, alternatives to QALY, such as EVL, have not gained traction because EVL fails to recognize the quality of life gains during added years of life. And disability-adjusted life years (DALYs), recommended by the World Health Organization, have the same limitations as QALYs.

“We propose a solution that can address this specific distributional issue of QALYs without failing to account for the quality of life impacts during the added years of life,” said author Anirban Basu, PhD, of The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA, USA. “In this article, we introduce the framework of health years in total, which separates life expectancy effects from quality of life impacts through the use of an additive, rather than multiplicative, approach. By disentangling life expectancy impacts from quality of life effects, the HYT framework enables patients with lower quality of life to fully benefit from interventions that extend life expectancy.”

The HYT framework proves a robust alternative to QALY in the use of cost-effectiveness analyses. Continued development, application, and testing of the HYT framework are needed to assess its potential for moving the field beyond the limitations of QALYs, DALYs, and EVL.


ISPOR, the professional society for health economics and outcomes research (HEOR), is an international, multistakeholder, nonprofit dedicated to advancing HEOR excellence to improve decision making for health globally. The Society is the leading source for scientific conferences, peer-reviewed and MEDLINE®-indexed publications, good practices guidance, education, collaboration, and tools/resources in the field.
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Value in Health (ISSN 1098-3015) is an international, indexed journal that publishes original research and health policy articles that advance the field of health economics and outcomes research to help healthcare leaders make evidence-based decisions. The journal’s 2018 impact factor score is 5.037. Value in Health is ranked 5th of 98 journals in healthcare sciences and services, 4th of 81 journals in health policy and services, and 11th of 363 journals in economics. Value in Health is a monthly publication that circulates to more than 10,000 readers around the world.
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