QALYs and Value Assessment


QALYs and Value Assessment

Mayvis Rebeira PhD, Canadian Health Policy Institute


This literature review highlights the limitations of using Quality-Adjusted Life-Years or QALYs, in assessing the value of therapies through its use in cost-effectiveness analysis. Objective: To highlight key issues and limitations with the use of QALYs and present alternative methods to assess value-for-money for evaluating innovative therapies: Methods and Results: Key considerations highlighted include ethical considerations, use of QALYs for resource allocation, underestimating impact of therapy, ageist bias and double jeopardy with respect to people with disabilities or permanent ill-health. Methodological and other limitations covered include lack of established threshold in cost-effectiveness analysis and QALY derivation. Recommendations: Several recommendations are proposed that can either be used in conjunction with QALYs or replace the current QALY metric in value assessment. Conclusion: QALYs are deeply embedded in health technology assessments. For a long period, it represented the only measure that attempts to quantify the impact of a therapy on an individual’s health and wellbeing. Given the limitations highlighted here, use of QALYs in value assessments can lead to sub-optimal decisions and impact health outcomes of patients. The gradual inclusion of alternate measures can lead to better evaluation of value-for money of new interventions whilst enabling a more just and fair system for all patients.


CITATION: Rebeira, Mayvis (2022). QALYs and Value Assessment. Canadian Health Policy, NOV 2022. Toronto: Canadian Health Policy Institute. ISSN 2562-9492,,


DISCLOSURE: No conflicts were declared.

OPEN ACCESS: N/A Not sponsored.

REVIEW: This article was subject to peer review.



  1. Neumann, P. J., Cohen, J. T., & Weinstein, M. C. (2014). Updating cost-effectiveness—the curious resilience of the $50,000-per-QALY threshold. N Engl J Med, 371(9), 796-797.
  2. Rebeira, Mayvis (2016). Limitations of Economic Evaluations for Health Technology Assessments in Canada. Canadian Health Policy, October 17, 2016. Toronto: Canadian Health Policy Institute. URL:
  3. NICE UK (National Institute for Health and Care Excellence) (; GRADE website (
  4. Drummond, M. F., Sculpher, M. J., Claxton, K., Stoddart, G. L., & Torrance, G. W. (2015). Methods for the economic evaluation of health care programmes. Oxford university press.
  5. McCabe, C., Claxton, K., & Culyer, A. J. (2008). The NICE cost-effectiveness threshold. Pharmacoeconomics, 26(9), 733-744.
  6. Braithwaite, R. S., Meltzer, D. O., King Jr, J. T., Leslie, D., & Roberts, M. S. (2008). What does the value of modern medicine say about the $50,000 per quality-adjusted life-year decision rule? Medical care, 349-356.
  7. Kaura, S., Nanavaty, M., Seetasith, A., Nyandege, A., & Khan, Z. M. (2015). Literature review of the use of ICER thresholds in Healthcare decision-making. Value in Health, 18(3), A90.
  8. Pettitt, D. A., Raza, S., Naughton, B., Roscoe, A., Ramakrishnan, A., Ali, A., … & Brindley, D. A. (2016). The limitations of QALY: a literature review. Journal of Stem Cell Research and Therapy, 6(4).
  9. Rawles, J. (1989). Castigating QALYs. Journal of medical ethics, 15(3), 143-147.
  10. Kappel, K., & Sandøe, P. (1992). QALYs, age and fairness. Bioethics, 6(4), 297-316.
  11. Singer, P., McKie, J., Kuhse, H., & Richardson, J. (1995). Double jeopardy and the use of QALYs in health care allocation. Journal of medical ethics, 21(3), 144.
  12. Broome, J. (1994). Fairness versus doing the most good. The Hastings Center Report, 24(4), 36-39.
  13. Neumann, P. J., & Cohen, J. T. (2018). QALYs in 2018—advantages and concerns. Jama, 319(24), 2473-2474.
  14. Payne, K., McAllister, M., & Davies, L. M. (2013). Valuing the economic benefits of complex interventions: when maximising health is not sufficient. Health economics, 22(3), 258-271.
  15. Torrance, G. W. (1986). Measurement of health state utilities for economic appraisal: a review.Journal of health economics,5(1), 1-30.
  16. Torrance, G. W. (1970). A generalized cost-effectiveness model for the evaluation of health programs.
  17. Harris, J. (1987). QALYfying the value of life. Journal of medical ethics, 13(3), 117-123.
  18. Whitehead, S. J., & Ali, S. (2010). Health outcomes in economic evaluation: the QALY and utilities. British medical bulletin, 96(1), 5-21.
  19. Lakdawalla, D. N., Doshi, J. A., Garrison Jr, L. P., Phelps, C. E., Basu, A., & Danzon, P. M. (2018). Defining elements of value in health care—a health economics approach: an ISPOR Special Task Force report [3]. Value in Health, 21(2), 131-139.
  20. Chapman, R. H., Berger, M., Weinstein, M. C., Weeks, J. C., Goldie, S., & Neumann, P. J. (2004). When does quality‐adjusting life‐years matter in cost-effectiveness analysis?. Health economics, 13(5), 429-436.
  21. Mehrez, A., & Gafni, A. (1991). The healthy-years equivalents: how to measure them using the standard gamble approach. Medical Decision Making, 11(2), 140-146.
  22. Keeney, R. L., Raiffa, H., & Meyer, R. F. (1993). Decisions with multiple objectives: preferences and value trade-offs. Cambridge university press.