one healthy year of life costs more than other diseases, but not two million – News Checkers

Does each additional healthy year of life for the average COVID-19 patient really cost about two million euros? Professor Ira Helsloot’s claim cannot be substantiated and probably exaggerated. He is right, however, that those costs are probably higher than what we normally spend on treatments for diseases.

Allegation

Dutch society pays approximately two million euros for an extra healthy year of life for the average COVID19 patient.

Judgment

Probably false

Source of the claim

‘How much is 1 extra healthy year of life worth to us?’ Asks Ira Helsloot in an interview on 2 November de Volkskrant. From Nijmegen professor Management of Safety calculates the answer for a moment: Dutch society pays approximately 2 million euros for 1 extra healthy life year of the average COVID-19 patient, if we assume 50 thousand healthy life years saved and 100 billion euros in social damage. He thinks it is ‘madness’, because for the same extra year of living in health we would usually spend at most 40,000 euros for other diseases. So it is time for reflection.

Why is this statement probably incorrect?

Helsloot actually says three things here. His first claim is that 50,000 healthy life years would be lost if we stopped the corona measures. Secondly, he claims that the social costs of the measures amount to 100 billion euros and finally he says that we normally spend at most 40,000 euros per healthy year of life on the treatment of, for example, cancer.

Let’s start with this last claim about the usual cost of treatment per healthy year of life. The addition of ‘healthy’ is important here: it is not just about the number of years of life that a medical treatment ‘saves’, but also about its quality. Health economists speak in this context of QALYs: Quality Adjusted Life Years. Someone who, after a medical intervention, lives happily with health problems for ten years, does not gain 10 QALYs in this calculation, but only, for example, half.

According to a report of the Council for Public Health and Society, the amount we spend on interventions varies considerably per QALY. For example, a liver transplant as a result of alcohol consumption in 2006 cost nearly one and a half tons per healthy year of life saved. If we look at the average costs per QALY of all procedures, then 40,000 euros is a realistic estimate, says Johan Mackenbach, who retired last month as professor of social health care at ErasmusMC.

Helsloot then claims that the corona measures provide 50,000 healthy life years. Helsloot explains his statement in an email exchange. To understand how many QALYs the measures yield, he estimates how many deaths would occur without those measures, if we let the virus circulate freely. According to him, that is a maximum of 50 thousand deaths. He emails:

‘50,000 is the 30,000 prevented IC admissions of Mark Rutte and the max 20,000 extra deaths that we would get if corona with a small factor 3 higher IFR than severe flu (with 10,000 deaths) were circulated in a bleak scenario.’ (IFR means Infection Fatality Rate: the percentage of people who die among the infected people.)

About the prevented IC admissions: on June 24, Rutte said that without all measures 35,000 corona patients in intensive care ended up during the first wave. Helsloot apparently assumes that those people would not be treated in his scenario and would therefore die. This ties in with what he says in the Volkskrant article about triage and ‘our choice of how we deal with this disease.’ He e-mails about this: “In my reasoning, ICs will not overflow in such a way that treatment is no longer possible, but possibly more suboptimal and with earlier triage of people who would already die.”

How he gets to 20,000 when he multiplies the deaths from a severe flu (10,000) by 3 is a mystery to us.

We now know how Helsloot arrives at 50,000 lives saved, but its claim concerns healthy extra years of life, or QALYs. According to him, the vast majority of people who die would have very few healthy life years ahead of them: ‘Almost all corona victims of a younger age also have serious and serious underlying suffering (such as cancer), which made their life expectancy very limited, too. without corona. ‘

Hence, he assumes 1 QALY for every human life saved by the corona measures.

Uncertainties

Is it true that about 50,000 people would die if we allowed the virus to circulate freely? To calculate that, we need to know the mortality probability of people who get COVID-19 among the members. In the Netherlands, this mortality probability is not fixed, and the RIVM does not give a percentage either. Chance differs in any case per country and depends on, among other things, the health care system, the age structure and the health of the population. If we want to know what the chances are in the Netherlands, we need to know how many people have been infected so far and how many of them have died. The number of infections so far is unknown, because not all infected people have themselves tested. The exact number of deaths is also unknown, as not all deaths from COVID-19 are recorded. In every report that the RIVM presents weekly regarding the corona situation in the Netherlands, it is stated that the actual infection and mortality figures will be higher than stated.

If, as in Helsloots scenario, we were to deny a large number of people access to intensive care to prevent this, then the mortality probability estimates for Western countries would no longer be valid. To give you an idea: ended up in the Netherlands since February this year 4,939 people with COVID-19 in the ICU, of whom about a quarter died.

During his Johan Mackenbach presented his farewell speech his own ‘beer coasters calculation’. Had the virus gone unimpeded during the first wave, he said it would have caused between 40,000 and 80,000 deaths. “Virologists assume that if the virus is spread unimpeded, until herd immunity is achieved, it would infect about half of the Dutch population,” he explains by telephone. Under normal circumstances in high-income countries, the Infection Fatality Rate is approximately 0.5 percent, which is approximately 40,000 deaths in the Netherlands. If the spread is unimpeded, healthcare institutions will probably become overburdened, possibly resulting in a doubling of the Infection Fatality Rate to 1 percent; that would then be about 80,000 dead. ‘ We are subtracting the 10,000 corona deaths that occurred during the first wave have fallen despite all measures from this number, we come to 70,000 dead. So these are the deaths that would still fall if we lifted the corona measures. Or, conversely, the deaths we prevent by sticking to the measures.

Wet finger

It may be clear that this is all guesswork. It is a wild guess that the overburdening of care would double mortality. On the other hand, according to WHO, it varies mortality worldwide of 0.3 to 1 percent. In the United Kingdom, it was estimated at 0.9 percent in August and in Spain at 0.8 percent. That 0.5 percent could therefore just be too low. It is also about the mentioned group immunity last word not yet said.

Healthy years of life

We are not there yet with the number of deaths prevented, because we want to know how many healthy extra years of life (QALYs) have not been lost thanks to the measures. As mentioned, Helsloot assumes 1 QALY for every human life saved by the corona measures. It is true that most of the people who died so far were very old and / or had underlying conditions. Of all recorded COVID-19 deaths since February were about 10 percent younger than 70. Of these, only 9.4 percent had no underlying condition. If you include the unregistered COVID19 deaths, mostly deaths in nursing homes, the percentage of people over 70 will be even higher.

Yet 1 lost QALY per death is very little. Remarkably, Helsloot is going to be own report in August, it is still expected to be just under ten years old – with the caveat that this number is probably too high.

Mackenbach also thinks that 1 QALY per prevented death is a far too low estimate. He assumes about four years old. If you multiply 70 thousand by four, you arrive at 280,000 healthy life years gained. For a substantiation of his assumption, he refers to (unpublished) calculations by health economist Xander Koolman of the VU.

According to Koolman, Helsloot’s central assumption is wrong: Helsloot assumes that the people who die if the virus is circulating freely will have the same characteristics as those who have died so far. ‘We don’t believe that assumption,’ says Koolman. Just look at other areas, such as New York or Northern Italy, where the virus was circulating. There you saw that the virus reached more people, including people with a higher life expectancy. Health economist Andrew Briggs once has one ‘middle of the road-berekening’ and came to six to eight QALYs. ‘

Koolman thinks this will also apply to the Netherlands, although he is still slightly lowering the expected healthy extra years of life. ‘Eight QALYs is high if you look at what we see around us now. We therefore assume that many baby boomers in the Netherlands will continue to protect themselves more than average – especially those who have a high degree of independence. ‘ If the baby boomers keep quiet until a vaccine or medication is available, the number of QALYs lost will be less. ‘Then we arrive at three to five. That seems to me to be a realistic lower limit if the virus moves freely through society. ‘

Of course, these numbers cannot be substantiated at the moment either. Koolman acknowledges this. “We stack one assumption on top of another.”

By calculating only with mortality figures, we do not take into account Covid-19 patients who are not in danger of life, but nevertheless remain ill for a long time after infection (‘Long Covid’). There is now evidence that some people heart and lung disease to an infection. It is unknown how many people are affected, how long they remain ill on average and what the possible permanent impact on their health is.

Economic cost

For the sake of convenience, we take for granted the 100 billion euros in costs that Helsloot charges – a sum of 80 billion euros in corona policy and 20 billion in losses of large Dutch companies. It should be clear that these are also difficult to estimate. If we assume that 100 billion and Mackenbach’s QALY estimate, then each healthy extra year of life costs a few tons rather than two million.

This does not alter the fact that those costs are much higher than we usually spend for the treatment of serious illnesses. Moreover, the corona crisis is not over yet – costs will continue to rise, while deaths continue to occur despite all measures. ‘Never before in history has the entire society been shut down to contain a pandemic,’ says Mackenbach, ‘and the sacrifices that have to be made for this are unheard of, Helsloot has a point. He also has a point when he says there should be more debate about it. But the amounts he posits with great aplomb are highly uncertain. From that one hundred billion that he mentions, you also have to deduct the economic damage that would result if no measures were taken. He does not do that.’

Conclusion

It is not possible to say with certainty how many healthy life years the corona measures will provide. Ira Helsloot’s estimate is probably too low and the amount per healthy extra year of life is more likely to be a few tons than two million. However, the uncertainties in such calculations are very great. It is likely that the costs per healthy life year saved are considerably higher than what we usually spend for other conditions.

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