Do QALY-based CEAs discriminate against disabled patients? A theoretical and empirical analysis

OBJECTIVES: Quality-adjusted life years (QALYs) have been widely used in cost-effectiveness analyses (CEAs). Nonetheless, critics argue that this measure may inherently discriminate against people with disabilities. This study aims to investigate whether the use of QALYs disadvantages disabled populations through combining theoretical analysis with examination of empirical evidence. METHODS: For the theoretical analysis, we constructed 5 scenarios to compare incremental QALYs between disabled and nondisabled patients reflecting different treatment effects on health-related quality of life or survival. We then searched the Tufts CEA Registry to identify published CEAs for selected chronic diseases including rheumatoid arthritis, type 2 diabetes, and chronic kidney disease to match published evidence with these scenarios. RESULTS: Across 5 scenarios, the differences in incremental QALYs between disabled and nondisabled groups were driven by relative changes in utility and life-years, rather than indicating a systematic bias. In 9 of 11 published CEAs, the disabled subgroup achieved greater incremental QALY, lower (more favorable) incremental cost-effectiveness ratios, or dominant results. CONCLUSIONS: These findings suggest that, within the theoretical scenarios and empirical contexts examined, QALY-based CEAs do not appear to inherently disadvantage patients with disabilities.