The Mystical Viral QALY


Richard Dawkins in his best seller A Devils Chaplain describes a meme as a mind virus. In common with a computer virus a meme can transmit or propagate from one individual to another with high fidelity if two conditions are met: a readiness to replicate information accurately (ISPOR practice guidelines; textbooks as primers for building imaginary models) and a readiness to obey instructions encoded in the information (education programs, graduate studies, sitting at the feet of the leaders in technology assessment). A perfect storm of basic ignorance of the standards of normal science in discovery plus an environment where truth is consensus and one that abhors apostasy; particularly when your career and the support of colleagues is at stake. Importantly we must not overlook the enduring support by journal editors for the publication of imaginary claims. CHEERS 22 was endorsed by 15 leading journals (but only peer reviewed by the BMJ on their behalf) so we can look forward, presumably, to an endless series of publications of imaginary claims, many (if not most) disguised marketing exercises to support a client’s products as they have in the past.

The ISPOR meme fits these conditions; it is now a global mind virus with thousands of believers who support the invention of imaginary value claims as the key input to formulary decisions. From countries as diverse in their health care systems as the UK, the Netherlands, Australia, New Zealand, Singapore and Indonesia, health technology assessment is dominated by the invented evidence virus. From the launching of the virus, initially by Australia in the early 1990s, the creation of ISPOR, and the adoption of the invented evidence reference case by NICE in the late 1990s, the virus has, without obvious mutations, spread globally. Certainly, there have been holdouts with refusals by a handful of single payer systems rejecting the ubiquitous QALY, but for reasons that have typically nothing to do with the fact that modeling defies the standards of normal science with preference scores that are ordinal scales. The simplest objection, that the QALY is an impossible mathematical construct, seems not to have occurred to them as a reason for rejection.

With the meme so well entrenched, it will require a high level of missionary fervor to dislodge imaginary claims. One interpretation is that the believers have painted themselves into a corner with CHEERS 22 in its focus entirely on submitting modeled assumption driven imaginary claims to journals. There is no mention of the evidence needs of formulary committees.  Whether this is intentional or not is a matter for conjecture; what is clear is that formulary committees should endorse submission guidelines that meet the standards of normal science. A further obstacle is the presence of health economists (or those claiming those skills) in the various manufacturers who are believers in the approximate information meme. In the US there is often an apparent rapport with ICER when an evidence model is being developed, with an exchange of information and active participation in model building and choice of assumed parameters for their own product. It is also noteworthy that when offered the chance to comment on a draft ICER evidence report, the focus is not on the imaginary nature of the claims and the espousal on non-science standards, but on the model assumptions with recommendations for modification to support a final model and the impossible recommendations for pricing and access. It is very much shooting themselves in the foot. Again, we face a basic lack of knowledge of the standards of normal science and fundamental measurement; the fact that the QALY is an impossible measure is a totally foreign concept.


Langley P. Nothing to cheer about: Endorsing imaginary economic evaluations and value claims with CHEERS 22.

Langley P. Peter Rabbit is a Badger in Disguise: Deconstructing the Belief System of the Institute for Clinical and Economic Review in Health Technology Assessment. InovPharm. 2021; 12(2): No.20

Langley P. Supping with the Devil: Belief and the Imaginary World of Multiple Myeloma Therapies Invented by the Institute for Clinical and Economic Review. InovPharm. 2021; 12(3): No. 6

Langley PC.  Imaginary worlds: Modeled claims for cost-effectiveness published in PharmacoEconomics January 2015 to December 2015. InovPharm . 2016;7(2): No. 9

Langley PC, Rhee TG.  Imaginary worlds: A systematic review of the status of modeled cost-effectiveness claims published in the Journal of Medical Economics from January 2015 to December 2015.  InovPharm . 2016;7(2): No. 16.

Langley PC, Rhee TG.Imaginary worlds: The status of modeled economic evaluation claims published in Value in Health January 2015 to December 2015. InovPharm . 2016;7(2): No. 18.