Optimisation des dépenses de santé pour la prise de décision : une approche par le QALY

This thesis focuses on the economic evaluation of health interventions and the monetary valuation of a Quality-Adjusted Life Year (QALY). In the first chapter, we reviewed the literature and performed a meta-analysis on the monetary value of a QALY. The use of a threshold for cost-utility studies is of major importance to health authorities for making the best allocation decisions in a setting of limited resources. Regarding the increasing number of studies worldwide that seek to establish a value for a qualityadjusted life year (QALY), it is necessary to review these studies to provide a global insight into the literature. A systematic review on willingness to pay (WTP) studies focusing on QALY was conducted in 8 databases up to June 26, 2020. From a total of 9,991 entries, 39 studies were selected and 511 observations were extracted for the meta-analysis using the ordinary least squares method. The results showed a predicted mean empirical value of US$ 52,619.39 (CI : 49,952.59 ; 55,286.19) per QALY in US dollars of 2018. A 1 % increase in income led to an increase of 0.6 % in the WTP value, while a one-year increase in respondent age led to a decrease of 3.3 % in the WTP value. Sex, education level and employment status had significant effects on WTP. Compared to face-to-face interviews, surveys conducted via internet or telephone were more likely to have a significantly higher value of WTP per QALY, while out-of-pocket payment tended to lower the value. The prediction made for the province of Quebec, Canada, provided a QALY value of approximately US$ 98,450 (CA$ 127,985), which is about 2.3 times its gross domestic product (GDP) per capita in 2018. This study is consistent with the existing literature and will be useful for countries that do not have yet a preference-based survey for the value of a QALY. In the second chapter, we surveyed the Quebec population to determine its willingness to pay for a QALY. Making decisions on financing new drugs, health interventions or technologies requires answering the central question of the monetary value the population places on the health gain, especially the quality-adjusted life year (QALY). No willingness-to-pay per QALY exists yet for the province of Quebec, Canada. In this paper we empirically investigated the monetary value of a QALY for the population of Quebec. Based on the Short-Form 6-Dimension version 2 (SF-6Dv2), we conducted an on-line survey with a representative adult sample living in Quebec. We used time trade-off (TTO) combined with contingent valuation (CV), and a discrete choice experiment (DCE) to assess both the population’s willingness to pay (WTP) for one QALY and the marginal WTP for health attributes. Preference-based value sets for health states utility was developed using the hybrid regression. Main analysis was conducted for an adult population of 993 for the CV and 2,143 for the DCE. The willingness-to-pay per QALY varied from CA$ 47,048.84 (CI : 21,554.38 ; 72,543.30) for CV to CA$ 73,936.87 (CI : 63,105.40 ; 84,768.35) for DCE. Among the 6 dimensions of the SF-6Dv2, marginal WTP varied from CA$ 4,499.15 (CI : 2,975.06 ; 6,023.25) for more role accomplishment in daily activities to CA$ 15,867.12 (CI : 13,825.75 ; 17,908.49) for less pain. Robustness check with multiple alternative samples, as well as alternative health utility algorithms, showed that the mains results were robust and both methods (CV and DCE) provided comparable results. This paper provides useful information for decision-makers to monetary value a QALY in Quebec. Finally, in the third chapter, we conducted a cost-effectiveness and cost-utility analysis of an obesity management program. Obesity has become over the years a major public health problem affecting millions of people around the world. In Canada, the proportion of people with overweight and obesity has increased dramatically in recent decades. To address this issue, the CHUS obesity clinic has developed an obesity preceptorship and an online learning community for the benefit of family physicians and nurses. This study aims to assess the cost-effectiveness of the educational intervention combining a clinical preceptorship with electronic networking tools versus a control group on a sample of patients from Family Medicine Groups (FMG). A total of 346 patients were enrolled in 10 FMG after applying the inclusion criteria. Cost and outcome data were collected during an 18-month follow-up. The analysis was made according to the perspective of the patients and the health network. Incremental cost-effectiveness ratios (ICER) were calculated by performing seemingly unrelated regression (SUR) bootstrap resampling with 5,000 replications. We used parametric (bivariate and multivariate) and non-parametric bootstrap techniques and carried out sensitivity analyses of our results with three weight classes. The main outcome variable was the change in body mass index (BMI). There was an improvement of results in the treatment group, especially for weight, waist circumference, and body mass index. The calculated cost-effectiveness ratio gave us a value of CA$ 2,269.43 (CI : 621.70 ; 3,917.15) per point of BMI lost. For the waistline, the ICER was CA$ 366.55 (CI : 247.17 ; 485.92) per centimeter lost. As for weight, this ratio was CA$ 1,257.09 (CI : -663.41 ; 3,177.59) per kilogram lost. The ICERs for the QALY are inconclusive considering the divergent results provided by the two measures used (i.e. SF-6D and TTO). The cost-effectiveness ratios calculated from different perspectives (patients, healthcare network) seem to confirm that the program has been efficient in the fight against obesity. The calculation of monetary benefits showed that overall they were not statistically significant for the QALY. However, in the absence of socially accepted willingness to pay (WTP) for the different clinical indicators used, these results can be questioned.

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