Thread by @ContainmentNow

Notice a pattern? Only in Sweden, the UK and the Netherlands is explicit cost-utility analysis (CUA) the basis of decision making on medical interventions. Our key thread👇

english.zorginstituutnederland.nl/binaries/zinl-…

Allow us to explain.

Healthcare is very expensive. In most countries the government needs to make difficult choices which come down to rationing of care.

Rationing is most visible with reimbursement of medicines. Inevitably, expensive drugs with few benefits are kept out.

So far, so good.

But the threesome (S, GB, NL) also apply CUA to actual medical interventions. Do we treat this patient or not?

The basic framework is a threshold cost per QALY (quality adjusted life year).

QALY is a year of life saved, but adjusted to quality of life. If a life year lived has less value according to a bureaucratic committee, less will be done to save it.

In Holland, the threshold is 80,000 euros per QALY.

So if you are 20 years old and healthy, an intervention that will return you to full health can cost op to 5m euros.

If you are 84, wheelchair bound, deaf and can't go outside, and the intervention will afford you a year of additional life, the max spend is 40,000 euros.

Other health care systems, of course, also spend less money on saving old sick people than on healthy ones.

But this is is usually left to the patient ("don't intubate me please") or to the veil of hypocrisy ("shouldn't we just give your father some peace?").

There are many issues associated with explicit cost benefit analysis. How to mark down a life year is arbitrary, of course. Many other assumptions are controversial.

But the main issue is that it puts a monetary value on "priceless" life.

This points to the conclusion that CUA is not the cause of utilitarian thinking in healthcare, but an effect.

This has dramatic consequences for pandemic thinking.

The average government thinks: 100,000 dead. Not on my watch! Let's act!

The utilitarian government thinks: "we lose 95,000 who had months to live, and 5,000 who had a few years to live. If interventions cost over 8bn euros, forget it. We'll take it on the chin".

But pandemics are not choices on saving one life. They affect societies.

In the case of the Netherlands, persistence of the virus for years may costs hundreds of billions, especially if the country is quarantined by its neighbors and yoyo-lockdowns (to avoid empty AND full hospitals) become a fact of life.

The British media did not accept mass death (forcing the government to change course and contain the virus), but Swedish and Dutch media still do.

This is helped by the fact that care homes do not have much access to hospitals (CUA!). The Covid deaths are largely off-camera.

This is why the world cannot grasp the Dutch/Swedish approach.

It is patently irrational when a pandemic threatens the entire economy and millions of healthy lives.

And becoming more irrational by the day as containment of the outbreak is proven to be sort of easy everywhere.

And ironically, it is the very quality of health care and societal organization that
- enable CUA in a country
- create/maintain a lot of trust from the public when CUA fails so catastrophically.

Even outsiders think: "shining-city-on-a-hill countries, maybe they have a point".

It is wishful thinking to hope for a change of course by a bureaucracy whose glue is the thinking that is harming society.

And so rescue must come from outside. When the world contains the virus, maintaining it in your population is imposing sanctions on yourself.

We advocate an immediate change of strategy to maximum-quality test-trace-isolate and mandatory masks. Dozens of countries are proving that this will largely eliminate the virus within months.

This change is inevitable, we only hope it comes quickly before damage escalates.

👆important thread on CUA, QALY, Sweden and the Netherlands.
#BreekDeGolf #HerdImmunity @tomaspueyo @devisridhar @Ammer_B @XanderKoolman @bosmana @NaomiOhReally @profhelenward @TarekFatah @DFisman @yaneerbaryam

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