D. Cost-Utility Analysis Using Cost per QALY 基于QALY成本的成本效用分析

As noted above, QALYs are often used in cost-utility analysis for the purposes of optimizing allocation of health care spending to maximize QALYs gained, and thereby maximize social welfare. 如之前介绍，QALYs通常用于成本效用分析，以用于优化医疗支出配置，最大化QALYs，从而使社会福利最大化。Cost per QALY gained, i.e., the marginal (additional or incremental) cost required to gain 1.0 QALY by using a technology, is one means to quantify the value to society of using that technology instead of the alternative(s). 每增加一年QALY的成本是一种量化该项技术而不是其他选择对社会的效用，比如：采用一项技术而增加的1.0 QALY 所需要的边际成本（额外的或增加的）。Because the QALY incorporates length of life and quality of life but is not specific to any particular disease state or condition, it enables cost-utility comparisons across virtually the entire spectrum of health care interventions.因为QALY综合了寿命和生活质量，并非局限于特定的疾病或病情，所以QALY能几乎对医疗干预的方方面面进行成本效用比较。

As shown in Box V-8, a cost per QALY analysis can account for large differences in technology costs, survival, and quality of life. Here, cost utilities are compared for three alternative therapies for a particular disease, end-stage heart disease. 在这里，成本效用可以比较针对特定疾病，终末期心脏病的三种替代疗法。

An early, controversial example of using cost-utility analysis to assess the relative societal benefits of a diverse range of technologies is shown in Box V-9. In this type of list (sometimes known as a “league table”), allocating health care spending for the technologies higher on the list is more efficient (i.e., purchases the next QALY at lower cost and therefore enables maximizing the QALYs purchased) than allocating those resources to technologies further down the list. 在这种类型的列表（有时被称为“联盟表”）中，为列表中更高的技术分配医疗支出更有效（即以更低的成本购买下一个QALY，从而实现最大化所购买的QALY），而不是分配给列表中更低的技术。That is, the technologies on that list are arranged in order of greatest to least cost utility. 也就是说，该列表中的技术按照最高到最低成本效用的顺序排列。

Box V-8. Cost-Utilities for Alternative Therapies for End-Stage Heart Disease 用于终末期心脏病的替代疗法的成本效用

Outcomes and Costs by Therapy* 治疗结果和费用*

*Costs and outcomes were discounted at 3% per year; 20-year horizon.*成本和成果每年3％的折扣； 20年期。Mean utilities derived using time-tradeoff method on scale for which 1.0 was well, 0.0 was death, and states worse than death were valued between 0.0 and -1.0. 使用时间权衡法的平均效用数值范围,健康为1.0，死亡为0.0，状态差于死为0.0和-1.0之间。

Cost-Utility Ratios for Therapy Comparisons 治疗的成本效用比较

This cost-utility comparison indicates that, for patients with end-stage heart disease, both heart transplantation and the total artificial heart yield more quality-adjusted life years at higher costs compared to conventional medical therapy. 这种成本效用比较表明，对于终末期心脏病患者，与常规治疗相比，心脏移植和整体人造心脏以更高的成本产生更多质量调整寿命年。However, the cost-utility ratio of heart transplantation vs. conventional medical treatment is preferred to (i.e., lower than) the cost-utility ratio of total artificial heart vs. conventional medical therapy. 然而，心脏移植与常规治疗的成本效用比优于（即，低于）整体人造心脏与常规治疗的成本效用比。Also, compared to heart transplantation, the total artificial heart costs more and results in fewer quality-adjusted life years, and therefore the total artificial heart is “dominated” by heart transplantation. 此外，与心脏移植相比，整体人造心脏总成本更高，导致质量调整寿命年减少，因此心脏移植优于整体人造心脏。

Adapted from estimates provided in: Hogness JR, Van Antwerp M. The Artificial Heart: Prototypes, Policies, and Patients. Washington, DC: National Academy Press; 1991.

Box V-9. Cost per QALY for Selected Health Care Technologies 精选卫生技术的QALY成本

This table ranks selected procedures for a variety of health problems according to their cost utility, (i.e., the amount of money that must be spent on each procedure to gain one more QALY). 就各种健康问题选定的处理方式，该表对其成本效用（即，为获得多1年的QALY,每个过程须花费的钱）进行排序。There were some methodological differences in determining costs and QALYs among the studies from which these results were derived. 在确定这些结果的研究中，确定成本和QALYs有一些方法上的差异。Nonetheless, giving considerable latitude to these figures, the range in the magnitude of investment required to yield the next QALY for these treatments is great. 尽管如此，对这些数字给予了相当大的自由度，为产生下一个QALY所需治疗的投资幅度很大。This type of "bucks for the bang" (here, British pounds for the QALY) analysis helps to illustrate implicit choices made in allocating scarce health care resources, and suggests how decision makers might move toward reallocating those resources if the allocation rule is intended to optimize societal gain in net health benefits (e.g., as measured using QALYs). 这种类型的“砰砰声”（这里是英国的QALY）分析有助于说明在分配稀缺的医疗资源方面所作的隐含选择，并提出如果分配规则旨在最优化健康净福利的社会收益（例如，使用QALY计算）,决策者如何优化资源配置。

Source: Maynard A. Developing the health care market. Econ J. 1991;101(408):1277-86. Copyright © 1991. Blackwell Publishing Ltd. Reprinted with permission of Blackwell Publishing Ltd.

In some instances, the impact of a technology on survival may be sufficiently great as to diminish its relative impact on HRQL, such that there is little need to adjust survival for HRQL. 在某些情况下，技术对生存的影响可能足够大，以减少其对HRQL的相对影响，因此几乎不需要调整HRQL的生存期。In other instances, the impact of an intervention on HRQL is great, and adjusting survival for it to determine the QALYs gained will affect the relative cost-utility of alternative interventions (Chapman 2004; Greenberg 2011).

An example of a league table of costs per DALY gained for several interventions in low-to-middle-income countries is shown in Box V-10.

Box V-10. Cost per DALY Gained for Selected Interventions inLow- and Middle-Income Countries 低收入和中等收入国家每项精选干预措施获得DALY成本

¹Cost per DALY represents an average for low- and middle-income countries, except where noted.

²Directly observed treatment short course (DOTS) for epidemic infectious tuberculosis

³Refers to South Asia only; includes measures to address life-threatening complications

Source: Disease Control Priorities Project, Using Cost-Effectiveness Analysis for Setting Health Priorities. March 2008. Calculations based on Chapters 2, 16, 26, and 33 of: Jamison DT, Breman G, Measham AR, et al., eds., Disease Control Priorities in Developing Countries. 2^nd ed. New York: Oxford University Press; 2006.

Certain methodological aspects and the proposed use of QALYs or similar units in setting health care priorities remain controversial (Arnesen 2000; Gerard 1993; Nord 1994; Ubel 2000). Research on public perceptions of the value of health care programs indicates that health gain is not necessarily the only determinant of value, and that an approach of maximizing QALYs (or other HALY or similar measure) per health expenditure to set priorities may be too restrictive, not reflecting public expectations regarding fairness or equity. 关于公众对医疗保健计划价值观念的研究表明，健康收益不一定是唯一的价值决定因素，而每份卫生支出产出的最大化QALY（或其他HALY或类似衡量标准）来确定优先事项的方法可能过于限制，不反映公众对公平或公正的期望。For example, because people who are elderly or disabled may have a lower “ceiling” or potential for gain in QALYs (or other measure of HRQL) than other people would have for the same health care expenditure, making resource allocation decisions based on cost-utility is viewed by some as being biased against the elderly and disabled. 例如，因为老年人或残疾人士的QALY（或HRQL的其他衡量标准）的“上限”或“潜在的收益”可能比其他支出同样医疗费用人的QALY有所降低，有些人认为根据成本效用的方法来分配资源对老年人和残疾人有偏见。A review of such concerns in the context of analyses of cancer care by the UK NICE cited three potential limitations: 1) insufficient sensitivity of the EQ-5D HRQL instrument to changes in health status of cancer patients, 2) diminished validity of certain assumptions of the time-tradeoff method for estimating the values of various health states for patients at the end of life, and 3) relying on using members of the general population rather than actual cancer patients to estimate the values of various health states (Garau 2011).

Certain cost-per-QALY-gained levels have been cited as informal decision thresholds for acceptance of new interventions (e.g., the equivalent of $50,000 or $100,000 per QALY in the wealthy nations); however, analyses of societal preferences suggest much higher levels of acceptance (Braithwaite 2008). Further, without recognition of any limits to providing all potentially beneficial health technologies to all people, such a threshold for the acceptable cost of a QALY has little relevance (Weinstein 2008). Comparisons of the cost per QALY gained from various health care interventions in widespread use can be revealing about how efficient health care systems are in allocating their resources. 从广泛使用的各种医疗干预措施中获得每个QALY的成本比较可以揭示医疗系统在分配资源方面的效率。A continuously updated, detailed set of standardized cost-utility analyses, including tables of cost-utility ratios for many types of health care interventions, can be found at the Cost-Effectiveness Analysis Registry, maintained by the Tufts Medical Center.

QALYs and other HALYs can enable comparisons among health technologies that have different types of health effects and help to inform resource allocation. QALY和其他HALY可以比较不同卫生技术对健康的影响，并有助于资源分配。Given their relative strengths and weaknesses, these measures are preferable to other measures of health improvement when it is important to make comparisons across diverse interventions. 当比较不同干预措施时，鉴于他们的相对优势和劣势，这些措施优于其他健康改善措施。Aside from methodological considerations, their use has been limited by various political and social concerns (Neumann 2010). The relevance of cost-utility analysis for resource allocation depends, at least in part, on how health care is organized and financed. 成本效用分析与资源分配的相关性至少部分取决于如何组织和资助医疗保健。