To find an alternative for quality-adjusted life-year (QALY) and equal value of life (EVL) measures. Despite the importance of QALY in cost-effectiveness analysis (CEA)—because it captures the effects of both life expectancy and health-related quality of life (QOL) and enables comparisons across interventions and disease areas—its potential to be discriminatory towards patients with lower QOL presents a critical challenge that has resulted in the exclusion of its use in some public decision making (eg, US Medicare) on healthcare in the United States. Alternatives to QALY, such as EVL, have not gained traction because EVL fails to recognize the QOL gains during added years of life.
We present a new metric for effectiveness for CEA, health years in total (HYT), which overcomes both the specific distributional issue raised by QALY and the efficiency challenges of EVL.
The HYT framework separates life expectancy changes and QOL changes on an additive scale. HYT have the same axiomatic foundations as QALY and perform better than both QALY, in terms of the discriminatory implications, and EVL, in terms of capturing QOL gains during added years of life. HYT are straightforward to calculate within a CEA model. We found that thresholds of $34 000/HYT and $89 000/HYT correspond to CEA thresholds of $50 000/QALY and $150 000/QALY, respectively.
The HYT framework may provide a viable alternative to both the QALY and the EVL; its application to diverse healthcare technologies and stakeholder assessments are important next steps in its development and evaluation.
Anirban Basu Josh Carlson David Veenstra