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Available in 17 languages" > <label id="p-lang-btn-label" for="p-lang-btn-checkbox" class="vector-dropdown-label cdx-button cdx-button--fake-button cdx-button--fake-button--enabled cdx-button--weight-quiet cdx-button--action-progressive mw-portlet-lang-heading-17" aria-hidden="true" ><span class="vector-icon mw-ui-icon-language-progressive mw-ui-icon-wikimedia-language-progressive"></span> <span class="vector-dropdown-label-text">17 languages</span> </label> <div class="vector-dropdown-content"> <div class="vector-menu-content"> <ul class="vector-menu-content-list"> <li class="interlanguage-link interwiki-ar mw-list-item"><a href="https://ar.wikipedia.org/wiki/%D8%B9%D8%AF%D8%AF_%D8%A7%D9%84%D8%B3%D9%86%D9%88%D8%A7%D8%AA_%D8%A7%D9%84%D9%85%D8%B5%D8%AD%D8%AD%D8%A9_%D8%A8%D8%AC%D9%88%D8%AF%D8%A9_%D8%A7%D9%84%D8%AD%D9%8A%D8%A7%D8%A9" title="عدد السنوات المصححة بجودة الحياة – Arabic" lang="ar" hreflang="ar" data-title="عدد السنوات المصححة بجودة الحياة" data-language-autonym="العربية" data-language-local-name="Arabic" class="interlanguage-link-target"><span>العربية</span></a></li><li class="interlanguage-link interwiki-ca mw-list-item"><a href="https://ca.wikipedia.org/wiki/Anys_de_vida_ajustats_per_qualitat" title="Anys de vida ajustats per qualitat – Catalan" lang="ca" hreflang="ca" data-title="Anys de vida ajustats per qualitat" data-language-autonym="Català" data-language-local-name="Catalan" class="interlanguage-link-target"><span>Català</span></a></li><li class="interlanguage-link interwiki-de mw-list-item"><a href="https://de.wikipedia.org/wiki/Qualit%C3%A4tskorrigiertes_Lebensjahr" title="Qualitätskorrigiertes Lebensjahr – German" lang="de" hreflang="de" data-title="Qualitätskorrigiertes Lebensjahr" data-language-autonym="Deutsch" data-language-local-name="German" class="interlanguage-link-target"><span>Deutsch</span></a></li><li class="interlanguage-link interwiki-es mw-list-item"><a href="https://es.wikipedia.org/wiki/QALY" title="QALY – Spanish" lang="es" hreflang="es" data-title="QALY" data-language-autonym="Español" data-language-local-name="Spanish" class="interlanguage-link-target"><span>Español</span></a></li><li class="interlanguage-link interwiki-fr mw-list-item"><a href="https://fr.wikipedia.org/wiki/QALY" title="QALY – French" lang="fr" hreflang="fr" data-title="QALY" data-language-autonym="Français" data-language-local-name="French" class="interlanguage-link-target"><span>Français</span></a></li><li class="interlanguage-link interwiki-it mw-list-item"><a href="https://it.wikipedia.org/wiki/QALY" title="QALY – Italian" lang="it" hreflang="it" data-title="QALY" data-language-autonym="Italiano" data-language-local-name="Italian" class="interlanguage-link-target"><span>Italiano</span></a></li><li class="interlanguage-link interwiki-he mw-list-item"><a href="https://he.wikipedia.org/wiki/%D7%A9%D7%A0%D7%AA_%D7%97%D7%99%D7%99%D7%9D_%D7%9E%D7%AA%D7%95%D7%A7%D7%A0%D7%A0%D7%AA_%D7%9C%D7%90%D7%99%D7%9B%D7%95%D7%AA" title="שנת חיים מתוקננת לאיכות – Hebrew" lang="he" hreflang="he" data-title="שנת חיים מתוקננת לאיכות" data-language-autonym="עברית" data-language-local-name="Hebrew" class="interlanguage-link-target"><span>עברית</span></a></li><li class="interlanguage-link interwiki-mk mw-list-item"><a href="https://mk.wikipedia.org/wiki/%D0%93%D0%BE%D0%B4%D0%B8%D0%BD%D0%B8_%D0%BD%D0%B0_%D0%B6%D0%B8%D0%B2%D0%BE%D1%82_%D0%BA%D0%BE%D1%80%D0%B5%D0%B3%D0%B8%D1%80%D0%B0%D0%BD%D0%B8_%D0%B2%D0%BE_%D0%BE%D0%B4%D0%BD%D0%BE%D1%81_%D0%BD%D0%B0_%D0%BA%D0%B2%D0%B0%D0%BB%D0%B8%D1%82%D0%B5%D1%82%D0%BE%D1%82" title="Години на живот корегирани во однос на квалитетот – Macedonian" lang="mk" hreflang="mk" data-title="Години на живот корегирани во однос на квалитетот" data-language-autonym="Македонски" data-language-local-name="Macedonian" class="interlanguage-link-target"><span>Македонски</span></a></li><li class="interlanguage-link interwiki-ms mw-list-item"><a href="https://ms.wikipedia.org/wiki/Jangka_hayat_berlaras_kualiti" title="Jangka hayat berlaras kualiti – Malay" lang="ms" hreflang="ms" data-title="Jangka hayat berlaras kualiti" data-language-autonym="Bahasa Melayu" data-language-local-name="Malay" class="interlanguage-link-target"><span>Bahasa Melayu</span></a></li><li class="interlanguage-link interwiki-nl mw-list-item"><a href="https://nl.wikipedia.org/wiki/Quality-adjusted_life_year" title="Quality-adjusted life year – Dutch" lang="nl" hreflang="nl" data-title="Quality-adjusted life year" data-language-autonym="Nederlands" data-language-local-name="Dutch" class="interlanguage-link-target"><span>Nederlands</span></a></li><li class="interlanguage-link interwiki-ja mw-list-item"><a href="https://ja.wikipedia.org/wiki/%E8%B3%AA%E8%AA%BF%E6%95%B4%E7%94%9F%E5%AD%98%E5%B9%B4" title="質調整生存年 – Japanese" lang="ja" hreflang="ja" data-title="質調整生存年" data-language-autonym="日本語" data-language-local-name="Japanese" class="interlanguage-link-target"><span>日本語</span></a></li><li class="interlanguage-link interwiki-no mw-list-item"><a href="https://no.wikipedia.org/wiki/Kvalitetsjusterte_leve%C3%A5r" title="Kvalitetsjusterte leveår – Norwegian Bokmål" lang="nb" hreflang="nb" data-title="Kvalitetsjusterte leveår" data-language-autonym="Norsk bokmål" data-language-local-name="Norwegian Bokmål" class="interlanguage-link-target"><span>Norsk bokmål</span></a></li><li class="interlanguage-link interwiki-pl mw-list-item"><a href="https://pl.wikipedia.org/wiki/QALY" title="QALY – Polish" lang="pl" hreflang="pl" data-title="QALY" data-language-autonym="Polski" data-language-local-name="Polish" class="interlanguage-link-target"><span>Polski</span></a></li><li class="interlanguage-link interwiki-sl mw-list-item"><a href="https://sl.wikipedia.org/wiki/Leto_zdravstveno_kakovostnega_%C5%BEivljenja" title="Leto zdravstveno kakovostnega življenja – Slovenian" lang="sl" hreflang="sl" data-title="Leto zdravstveno kakovostnega življenja" data-language-autonym="Slovenščina" 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<nav class="vector-appearance-landmark" aria-label="Appearance"> <div id="vector-appearance-pinned-container" class="vector-pinned-container"> <div id="vector-appearance" class="vector-appearance vector-pinnable-element"> <div class="vector-pinnable-header vector-appearance-pinnable-header vector-pinnable-header-pinned" data-feature-name="appearance-pinned" data-pinnable-element-id="vector-appearance" data-pinned-container-id="vector-appearance-pinned-container" data-unpinned-container-id="vector-appearance-unpinned-container" > <div class="vector-pinnable-header-label">Appearance</div> <button class="vector-pinnable-header-toggle-button vector-pinnable-header-pin-button" data-event-name="pinnable-header.vector-appearance.pin">move to sidebar</button> <button class="vector-pinnable-header-toggle-button vector-pinnable-header-unpin-button" data-event-name="pinnable-header.vector-appearance.unpin">hide</button> </div> </div> </div> </nav> </div> </div> <div id="bodyContent" class="vector-body" aria-labelledby="firstHeading" data-mw-ve-target-container> <div class="vector-body-before-content"> <div class="mw-indicators"> </div> <div id="siteSub" class="noprint">From Wikipedia, the free encyclopedia</div> </div> <div id="contentSub"><div id="mw-content-subtitle"></div></div> <div id="mw-content-text" class="mw-body-content"><div class="mw-content-ltr mw-parser-output" lang="en" dir="ltr"><div class="shortdescription nomobile noexcerpt noprint searchaux" style="display:none">Measure of disease burden</div> <figure typeof="mw:File/Thumb"><a href="/wiki/File:QALY_graph-en.svg" class="mw-file-description"><img src="//upload.wikimedia.org/wikipedia/commons/thumb/5/59/QALY_graph-en.svg/320px-QALY_graph-en.svg.png" decoding="async" width="320" height="227" class="mw-file-element" srcset="//upload.wikimedia.org/wikipedia/commons/thumb/5/59/QALY_graph-en.svg/480px-QALY_graph-en.svg.png 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/5/59/QALY_graph-en.svg/640px-QALY_graph-en.svg.png 2x" data-file-width="750" data-file-height="531" /></a><figcaption>Demonstration of quality-adjusted life years (QALYs) for two individuals. Individual A (who did not receive an intervention) has fewer QALYs than individual B (who received an intervention). The letters A and B designate the boundary lines, with the QALY for A being only the blue area, the QALY for B being the blue area plus the additional tan area. NB It is possible to experience an <i>improvement</i> in health-related quality of life with age, for example through healthier life choices.</figcaption></figure> <p>The <b>quality-adjusted life year</b> (<b>QALY</b>) is a generic measure of <a href="/wiki/Disease_burden" title="Disease burden">disease burden</a>, including both the quality and the quantity of life lived.<sup id="cite_ref-NICE2013_1-0" class="reference"><a href="#cite_note-NICE2013-1"><span class="cite-bracket">[</span>1<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-NICEglossary_2-0" class="reference"><a href="#cite_note-NICEglossary-2"><span class="cite-bracket">[</span>2<span class="cite-bracket">]</span></a></sup> It is used in <a href="/wiki/Economic_evaluation" title="Economic evaluation">economic evaluation</a> to assess the value of <a href="/wiki/Medical" class="mw-redirect" title="Medical">medical</a> interventions.<sup id="cite_ref-NICE2013_1-1" class="reference"><a href="#cite_note-NICE2013-1"><span class="cite-bracket">[</span>1<span class="cite-bracket">]</span></a></sup> One QALY equates to one year in perfect health.<sup id="cite_ref-NICEglossary_2-1" class="reference"><a href="#cite_note-NICEglossary-2"><span class="cite-bracket">[</span>2<span class="cite-bracket">]</span></a></sup> QALY scores range from 1 (perfect health) to 0 (dead).<sup id="cite_ref-Weinstein2009_3-0" class="reference"><a href="#cite_note-Weinstein2009-3"><span class="cite-bracket">[</span>3<span class="cite-bracket">]</span></a></sup> QALYs can be used to inform <a href="/wiki/Health_insurance" title="Health insurance">health insurance</a> coverage determinations, treatment decisions, to evaluate programs, and to set priorities for future programs.<sup id="cite_ref-Weinstein2009_3-1" class="reference"><a href="#cite_note-Weinstein2009-3"><span class="cite-bracket">[</span>3<span class="cite-bracket">]</span></a></sup> </p><p>Critics argue that the QALY oversimplifies how actual patients would assess risks and outcomes, and that its use may restrict patients with disabilities from accessing treatment.<sup id="cite_ref-:0_4-0" class="reference"><a href="#cite_note-:0-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup> Proponents of the measure acknowledge that the QALY has some shortcomings, but that its ability to quantify tradeoffs and <a href="/wiki/Opportunity_cost" title="Opportunity cost">opportunity costs</a> from the patient, and societal perspective make it a critical tool for equitably allocating resources.<sup id="cite_ref-:0_4-1" class="reference"><a href="#cite_note-:0-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup> </p> <meta property="mw:PageProp/toc" /> <div class="mw-heading mw-heading2"><h2 id="Calculation">Calculation</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Quality-adjusted_life_year&action=edit&section=1" title="Edit section: Calculation"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <style data-mw-deduplicate="TemplateStyles:r1251242444">.mw-parser-output .ambox{border:1px solid #a2a9b1;border-left:10px solid #36c;background-color:#fbfbfb;box-sizing:border-box}.mw-parser-output .ambox+link+.ambox,.mw-parser-output .ambox+link+style+.ambox,.mw-parser-output .ambox+link+link+.ambox,.mw-parser-output .ambox+.mw-empty-elt+link+.ambox,.mw-parser-output .ambox+.mw-empty-elt+link+style+.ambox,.mw-parser-output .ambox+.mw-empty-elt+link+link+.ambox{margin-top:-1px}html body.mediawiki .mw-parser-output .ambox.mbox-small-left{margin:4px 1em 4px 0;overflow:hidden;width:238px;border-collapse:collapse;font-size:88%;line-height:1.25em}.mw-parser-output .ambox-speedy{border-left:10px solid #b32424;background-color:#fee7e6}.mw-parser-output .ambox-delete{border-left:10px solid #b32424}.mw-parser-output .ambox-content{border-left:10px solid #f28500}.mw-parser-output .ambox-style{border-left:10px solid #fc3}.mw-parser-output .ambox-move{border-left:10px solid #9932cc}.mw-parser-output .ambox-protection{border-left:10px solid #a2a9b1}.mw-parser-output .ambox .mbox-text{border:none;padding:0.25em 0.5em;width:100%}.mw-parser-output .ambox .mbox-image{border:none;padding:2px 0 2px 0.5em;text-align:center}.mw-parser-output .ambox .mbox-imageright{border:none;padding:2px 0.5em 2px 0;text-align:center}.mw-parser-output .ambox .mbox-empty-cell{border:none;padding:0;width:1px}.mw-parser-output .ambox .mbox-image-div{width:52px}@media(min-width:720px){.mw-parser-output .ambox{margin:0 10%}}@media print{body.ns-0 .mw-parser-output .ambox{display:none!important}}</style><table class="box-Unreferenced_section plainlinks metadata ambox ambox-content ambox-Unreferenced" role="presentation"><tbody><tr><td class="mbox-image"><div class="mbox-image-div"><span typeof="mw:File"><a href="/wiki/File:Question_book-new.svg" class="mw-file-description"><img alt="" src="//upload.wikimedia.org/wikipedia/en/thumb/9/99/Question_book-new.svg/50px-Question_book-new.svg.png" decoding="async" width="50" height="39" class="mw-file-element" srcset="//upload.wikimedia.org/wikipedia/en/thumb/9/99/Question_book-new.svg/75px-Question_book-new.svg.png 1.5x, //upload.wikimedia.org/wikipedia/en/thumb/9/99/Question_book-new.svg/100px-Question_book-new.svg.png 2x" data-file-width="512" data-file-height="399" /></a></span></div></td><td class="mbox-text"><div class="mbox-text-span">This section <b>does not <a href="/wiki/Wikipedia:Citing_sources" title="Wikipedia:Citing sources">cite</a> any <a href="/wiki/Wikipedia:Verifiability" title="Wikipedia:Verifiability">sources</a></b>.<span class="hide-when-compact"> Please help <a href="/wiki/Special:EditPage/Quality-adjusted_life_year" title="Special:EditPage/Quality-adjusted life year">improve this section</a> by <a href="/wiki/Help:Referencing_for_beginners" title="Help:Referencing for beginners">adding citations to reliable sources</a>. Unsourced material may be challenged and <a href="/wiki/Wikipedia:Verifiability#Burden_of_evidence" title="Wikipedia:Verifiability">removed</a>.</span> <span class="date-container"><i>(<span class="date">March 2024</span>)</i></span><span class="hide-when-compact"><i> (<small><a href="/wiki/Help:Maintenance_template_removal" title="Help:Maintenance template removal">Learn how and when to remove this message</a></small>)</i></span></div></td></tr></tbody></table> <p>A measure of the state of health of a person or group in which the benefits, in terms of length of life, are adjusted to reflect the quality of life. One quality-adjusted life year (QALY) is equal to 1 year of life in perfect health.<sup id="cite_ref-5" class="reference"><a href="#cite_note-5"><span class="cite-bracket">[</span>5<span class="cite-bracket">]</span></a></sup> It combines two different benefits of treatment—length of life and quality of life—into a single number that can be compared across different types of treatments. For example, one year lived in perfect health equates to 1 QALY. This can be interpreted as a person getting 100% of the value for that year. A year lived in a less than perfect state of health can also be expressed as the amount of value accrued to the person living it. For example, 1 year of life lived in a situation with utility 0.5 yields 0.5 QALYs—a person experiencing this state is getting only 50% of the possible value of that year. In other words, they value the experience of being in less than perfect health for a full year as much as they value living for half a year in perfect health (0.5 years × 1 Utility).<sup id="cite_ref-6" class="reference"><a href="#cite_note-6"><span class="cite-bracket">[</span>6<span class="cite-bracket">]</span></a></sup> </p><p>Therefore, calculating a QALY requires two inputs. One is the <a href="/wiki/Utility" title="Utility">utility</a> value (or utility weight) associated with a given state of health by the years lived in that state. The underlying measure of utility is derived from clinical trials, and studies that measure how people feel in these specific states of health. The way they feel in a state of perfect health equates to a value of 1 (or 100%). Death is assigned a utility of 0 (or 0%), and in some circumstances it is possible to accrue negative QALYs to reflect health states deemed "worse than dead."<sup id="cite_ref-Weinstein2009_3-2" class="reference"><a href="#cite_note-Weinstein2009-3"><span class="cite-bracket">[</span>3<span class="cite-bracket">]</span></a></sup> The value people perceive in less than perfect states of health are expressed as a fraction between 0 and 1. </p><p>The second input is the amount of time people live in various states of health. This information usually comes from clinical trials. </p><p>The QALY calculation is simple: the change in utility value induced by the treatment is multiplied by the duration of the treatment effect to provide the number of QALYs gained. QALYs can then be incorporated with medical costs to arrive at a final common denominator of cost/QALY. This parameter can be used to compare the cost-effectiveness of any treatment.<sup id="cite_ref-7" class="reference"><a href="#cite_note-7"><span class="cite-bracket">[</span>7<span class="cite-bracket">]</span></a></sup> </p> <div class="mw-heading mw-heading3"><h3 id="Weighting">Weighting</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Quality-adjusted_life_year&action=edit&section=2" title="Edit section: Weighting"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>The utility values used in QALY calculations are generally determined by methods that measure people's willingness to trade time in different health states, such as those proposed in the <i><a href="/wiki/Journal_of_Health_Economics" title="Journal of Health Economics">Journal of Health Economics</a></i>:<sup id="cite_ref-8" class="reference"><a href="#cite_note-8"><span class="cite-bracket">[</span>8<span class="cite-bracket">]</span></a></sup> </p> <ul><li><a href="/wiki/Time-trade-off" class="mw-redirect" title="Time-trade-off">Time-trade-off</a> (TTO): Respondents are asked to choose between remaining in a state of ill health for a period of time, or being restored to perfect health but having a shorter life expectancy.</li> <li>Standard gamble (SG): Respondents are asked to choose between remaining in a state of ill health for a period of time, or choosing a medical intervention which has a chance of either restoring them to perfect health or killing them.</li> <li><a href="/wiki/Visual_analogue_scale" title="Visual analogue scale">Visual analogue scale</a> (VAS): Respondents are asked to rate a state of ill health on a scale from 0 to 100, with 0 representing being dead, and 100 representing perfect health. This method has the advantage of being the easiest to ask, but is the most subjective.</li></ul> <p>Another way of determining the weight associated with a particular health state is to use standard descriptive systems such as the EuroQol Group's <a href="/wiki/EQ-5D" title="EQ-5D">EQ-5D</a> questionnaire, which categorizes health states according to five dimensions: mobility, self-care, usual activities (e.g. work, study, homework or leisure activities), pain/discomfort and anxiety/depression.<sup id="cite_ref-9" class="reference"><a href="#cite_note-9"><span class="cite-bracket">[</span>9<span class="cite-bracket">]</span></a></sup> </p> <div class="mw-heading mw-heading2"><h2 id="Use">Use</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Quality-adjusted_life_year&action=edit&section=3" title="Edit section: Use"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>Data on medical costs are often combined with QALYs in <a href="/wiki/Cost-utility_analysis" class="mw-redirect" title="Cost-utility analysis">cost-utility analysis</a> to estimate the cost-per-QALY associated with a health care intervention. This parameter can be used to develop a <a href="/wiki/Cost-effectiveness_analysis" title="Cost-effectiveness analysis">cost-effectiveness analysis</a> of any treatment. This <a href="/wiki/Incremental_cost-effectiveness_ratio" title="Incremental cost-effectiveness ratio">incremental cost-effectiveness ratio</a> (ICER) can then be used to allocate <a href="/wiki/Health_care" title="Health care">healthcare</a> resources, often using a threshold approach.<sup id="cite_ref-10" class="reference"><a href="#cite_note-10"><span class="cite-bracket">[</span>10<span class="cite-bracket">]</span></a></sup> </p><p>In the <a href="/wiki/United_Kingdom" title="United Kingdom">United Kingdom</a>, the <a href="/wiki/National_Institute_for_Health_and_Care_Excellence" title="National Institute for Health and Care Excellence">National Institute for Health and Care Excellence</a> (NICE), which advises on the use of health technologies within the <a href="/wiki/National_Health_Service" title="National Health Service">National Health Service</a>, used "£ per QALY" to evaluate their utility since its founding in 1999.<sup id="cite_ref-11" class="reference"><a href="#cite_note-11"><span class="cite-bracket">[</span>11<span class="cite-bracket">]</span></a></sup> </p><p>In 1989, the state of <a href="/wiki/Oregon" title="Oregon">Oregon</a> attempted to reform its Medicaid system by incorporating the QALY metric. This was found to be discriminatory, and in violation of the <a href="/wiki/Americans_with_Disabilities_Act_of_1990" title="Americans with Disabilities Act of 1990">Americans with Disabilities Act</a> in 1992.<sup id="cite_ref-12" class="reference"><a href="#cite_note-12"><span class="cite-bracket">[</span>12<span class="cite-bracket">]</span></a></sup> <a href="/wiki/Louis_W._Sullivan" title="Louis W. Sullivan">Louis W. Sullivan</a>, the Secretary of Health and Human Services at the time, criticized the plan by stating that "Oregon's plan in substantial part values the life of a person with a disability less than the life of a person without a disability."<sup id="cite_ref-13" class="reference"><a href="#cite_note-13"><span class="cite-bracket">[</span>13<span class="cite-bracket">]</span></a></sup> </p> <div class="mw-heading mw-heading2"><h2 id="History">History</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Quality-adjusted_life_year&action=edit&section=4" title="Edit section: History"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>The first mention of Quality Adjusted Life Years appeared in a doctoral thesis at Harvard University by Joseph S. Pliskin (1974). The need to consider quality of life is credited to work by Klarman et al. (1968),<sup id="cite_ref-14" class="reference"><a href="#cite_note-14"><span class="cite-bracket">[</span>14<span class="cite-bracket">]</span></a></sup> Fanshel and Bush (1970) <sup id="cite_ref-15" class="reference"><a href="#cite_note-15"><span class="cite-bracket">[</span>15<span class="cite-bracket">]</span></a></sup> and Torrance et al. (1972) <sup id="cite_ref-16" class="reference"><a href="#cite_note-16"><span class="cite-bracket">[</span>16<span class="cite-bracket">]</span></a></sup> who suggested the idea of length of life adjusted by indices of functionality or health.<sup id="cite_ref-17" class="reference"><a href="#cite_note-17"><span class="cite-bracket">[</span>17<span class="cite-bracket">]</span></a></sup> A 1976 article by <a href="/wiki/Richard_Zeckhauser" title="Richard Zeckhauser">Zeckhauser</a> and Shepard<sup id="cite_ref-18" class="reference"><a href="#cite_note-18"><span class="cite-bracket">[</span>18<span class="cite-bracket">]</span></a></sup> was the first appearance in print of the term.<sup id="cite_ref-Sassi2006_19-0" class="reference"><a href="#cite_note-Sassi2006-19"><span class="cite-bracket">[</span>19<span class="cite-bracket">]</span></a></sup> QALYs were later promoted through medical <a href="/wiki/Technology_assessment" title="Technology assessment">technology assessments</a> conducted by the <a href="/wiki/US_Congress" class="mw-redirect" title="US Congress">US Congress</a> <a href="/wiki/Office_of_Technology_Assessment" title="Office of Technology Assessment">Office of Technology Assessment</a>. </p><p>In 1980, Pliskin et al. justified the QALY indicator using <a href="/wiki/Multi-attribute_utility" title="Multi-attribute utility">multiattribute utility</a> theory: if a set of conditions pertaining to agent preferences on life years and quality of life are verified, then it is possible to express the agent's preferences about couples (number of life years/health state), by an interval (Neumannian) utility function.<sup id="cite_ref-Pliskin1980_20-0" class="reference"><a href="#cite_note-Pliskin1980-20"><span class="cite-bracket">[</span>20<span class="cite-bracket">]</span></a></sup> This utility function would be equal to the product of an interval utility function on "life years", and an interval utility function on "health state". </p> <div class="mw-heading mw-heading2"><h2 id="Debate">Debate</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Quality-adjusted_life_year&action=edit&section=5" title="Edit section: Debate"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1251242444"><table class="box-Cleanup plainlinks metadata ambox ambox-style ambox-Cleanup" role="presentation"><tbody><tr><td class="mbox-image"><div class="mbox-image-div"><span typeof="mw:File"><span><img alt="" src="//upload.wikimedia.org/wikipedia/en/thumb/f/f2/Edit-clear.svg/40px-Edit-clear.svg.png" decoding="async" width="40" height="40" class="mw-file-element" srcset="//upload.wikimedia.org/wikipedia/en/thumb/f/f2/Edit-clear.svg/60px-Edit-clear.svg.png 1.5x, //upload.wikimedia.org/wikipedia/en/thumb/f/f2/Edit-clear.svg/80px-Edit-clear.svg.png 2x" data-file-width="48" data-file-height="48" /></span></span></div></td><td class="mbox-text"><div class="mbox-text-span">This section may <b>require <a href="/wiki/Wikipedia:Cleanup" title="Wikipedia:Cleanup">cleanup</a></b> to meet Wikipedia's <a href="/wiki/Wikipedia:Manual_of_Style" title="Wikipedia:Manual of Style">quality standards</a>. The specific problem is: <b>Need to fix citation format of new additions and notify author.</b><span class="hide-when-compact"> Please help <a href="/wiki/Special:EditPage/Quality-adjusted_life_year" title="Special:EditPage/Quality-adjusted life year">improve this section</a> if you can.</span> <span class="date-container"><i>(<span class="date">May 2022</span>)</i></span><span class="hide-when-compact"><i> (<small><a href="/wiki/Help:Maintenance_template_removal" title="Help:Maintenance template removal">Learn how and when to remove this message</a></small>)</i></span></div></td></tr></tbody></table> <p>According to Pliskin et al., the QALY model requires <a href="/wiki/Utility" title="Utility">utility</a> independent, <a href="/wiki/Risk_neutral" class="mw-redirect" title="Risk neutral">risk neutral</a>, and constant proportional tradeoff behavior.<sup id="cite_ref-Pliskin1980_20-1" class="reference"><a href="#cite_note-Pliskin1980-20"><span class="cite-bracket">[</span>20<span class="cite-bracket">]</span></a></sup> For the more general case of a life time health profile (i.e., experiencing more than one health state during the remaining years of life), the utility of a life time health profile must equal the sum of single-period utilities.<sup id="cite_ref-21" class="reference"><a href="#cite_note-21"><span class="cite-bracket">[</span>21<span class="cite-bracket">]</span></a></sup> Because of these theoretical assumptions, the meaning and usefulness of the QALY is debated.<sup id="cite_ref-autogenerated1_22-0" class="reference"><a href="#cite_note-autogenerated1-22"><span class="cite-bracket">[</span>22<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-23" class="reference"><a href="#cite_note-23"><span class="cite-bracket">[</span>23<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-24" class="reference"><a href="#cite_note-24"><span class="cite-bracket">[</span>24<span class="cite-bracket">]</span></a></sup> Perfect health is difficult, if not impossible, to define. Some argue that there are health states worse than being dead, and that therefore there should be negative values possible on the health spectrum (indeed, some health economists have incorporated negative values into calculations). Determining the level of health depends on measures that some argue place disproportionate importance on physical pain or disability over mental health.<sup id="cite_ref-25" class="reference"><a href="#cite_note-25"><span class="cite-bracket">[</span>25<span class="cite-bracket">]</span></a></sup> </p><p>The method of ranking interventions on grounds of their cost per QALY gained ratio (or <a href="/wiki/Incremental_cost-effectiveness_ratio" title="Incremental cost-effectiveness ratio">ICER</a>) is controversial because it implies a quasi-<a href="/wiki/Utilitarian" class="mw-redirect" title="Utilitarian">utilitarian</a> calculus to determine who will or will not receive treatment.<sup id="cite_ref-26" class="reference"><a href="#cite_note-26"><span class="cite-bracket">[</span>26<span class="cite-bracket">]</span></a></sup> However, its supporters argue that since health care resources are inevitably limited, this method enables them to be allocated in the way that is approximately optimal for society, including most patients. Another concern is that it does not take into account equity issues such as the overall distribution of health states—particularly since younger, healthier cohorts have many times more QALYs than older or sicker individuals. As a result, QALY analysis may undervalue treatments which benefit the elderly or others with a lower life expectancy. Also, many would argue that all else being equal, patients with more severe illness should be prioritized over patients with less severe illness if both would get the same absolute increase in utility.<sup id="cite_ref-27" class="reference"><a href="#cite_note-27"><span class="cite-bracket">[</span>27<span class="cite-bracket">]</span></a></sup> </p><p>As early as 1989, <a href="/wiki/Graham_Loomes" title="Graham Loomes">Loomes</a> and McKenzie recommended that research be conducted concerning the validity of QALYs.<sup id="cite_ref-Loomes1989_28-0" class="reference"><a href="#cite_note-Loomes1989-28"><span class="cite-bracket">[</span>28<span class="cite-bracket">]</span></a></sup> In 2010, with funding from the <a href="/wiki/European_Commission" title="European Commission">European Commission</a>, the European Consortium in Healthcare Outcomes and Cost-Benefit Research (ECHOUTCOME) began a major study on QALYs as used in <a href="/wiki/Health_technology_assessment" title="Health technology assessment">health technology assessment</a>.<sup id="cite_ref-ECHOUTCOMEhome_29-0" class="reference"><a href="#cite_note-ECHOUTCOMEhome-29"><span class="cite-bracket">[</span>29<span class="cite-bracket">]</span></a></sup> <a href="/wiki/Ariel_Beresniak" title="Ariel Beresniak">Ariel Beresniak</a>, the study's lead author, was quoted as saying that it was the "largest-ever study specifically dedicated to testing the assumptions of the QALY."<sup id="cite_ref-Holmes2013_30-0" class="reference"><a href="#cite_note-Holmes2013-30"><span class="cite-bracket">[</span>30<span class="cite-bracket">]</span></a></sup> In January 2013, at its final conference, ECHOUTCOME released preliminary results of its study which surveyed 1361 people "from academia" in Belgium, France, Italy and the UK.<sup id="cite_ref-Holmes2013_30-1" class="reference"><a href="#cite_note-Holmes2013-30"><span class="cite-bracket">[</span>30<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-BBC_31-0" class="reference"><a href="#cite_note-BBC-31"><span class="cite-bracket">[</span>31<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Beresniak2015_32-0" class="reference"><a href="#cite_note-Beresniak2015-32"><span class="cite-bracket">[</span>32<span class="cite-bracket">]</span></a></sup> The researchers asked the subjects to respond to 14 questions concerning their preferences for various health states and durations of those states (e.g., 15 years limping versus 5 years in a wheelchair).<sup id="cite_ref-Beresniak2015_32-1" class="reference"><a href="#cite_note-Beresniak2015-32"><span class="cite-bracket">[</span>32<span class="cite-bracket">]</span></a></sup> They concluded that: </p> <ul><li>"Preferences expressed by the respondents were not consistent with the QALY theoretical assumptions";</li> <li>Quality of life can be measured in consistent intervals;</li> <li>Life-years and quality of life are independent of each other;</li> <li>People are neutral about risk; and</li> <li>Willingness to gain or lose life-years is constant over time.<sup id="cite_ref-Beresniak2015_32-2" class="reference"><a href="#cite_note-Beresniak2015-32"><span class="cite-bracket">[</span>32<span class="cite-bracket">]</span></a></sup></li></ul> <p>ECHOUTCOME also released "European Guidelines for Cost-Effectiveness Assessments of Health Technologies", which recommended not using QALYs in healthcare decision making.<sup id="cite_ref-ECHOUTCOMEguidelines_33-0" class="reference"><a href="#cite_note-ECHOUTCOMEguidelines-33"><span class="cite-bracket">[</span>33<span class="cite-bracket">]</span></a></sup> Instead, the guidelines recommended that cost-effectiveness analyses focus on "costs per relevant clinical outcome."<sup id="cite_ref-Holmes2013_30-2" class="reference"><a href="#cite_note-Holmes2013-30"><span class="cite-bracket">[</span>30<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-ECHOUTCOMEguidelines_33-1" class="reference"><a href="#cite_note-ECHOUTCOMEguidelines-33"><span class="cite-bracket">[</span>33<span class="cite-bracket">]</span></a></sup> </p><p>In response to the ECHOUTCOME study, representatives of the National Institute for Health and Care Excellence, the <a href="/wiki/Scottish_Medicines_Consortium" class="mw-redirect" title="Scottish Medicines Consortium">Scottish Medicines Consortium</a>, and the <a href="/wiki/Organisation_for_Economic_Co-operation_and_Development" class="mw-redirect" title="Organisation for Economic Co-operation and Development">Organisation for Economic Co-operation and Development</a> made the following points. </p> <ul><li>First, QALYs are better than alternative measures.<sup id="cite_ref-Holmes2013_30-3" class="reference"><a href="#cite_note-Holmes2013-30"><span class="cite-bracket">[</span>30<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-BBC_31-1" class="reference"><a href="#cite_note-BBC-31"><span class="cite-bracket">[</span>31<span class="cite-bracket">]</span></a></sup></li> <li>Second, the study was "limited."<sup id="cite_ref-Holmes2013_30-4" class="reference"><a href="#cite_note-Holmes2013-30"><span class="cite-bracket">[</span>30<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-BBC_31-2" class="reference"><a href="#cite_note-BBC-31"><span class="cite-bracket">[</span>31<span class="cite-bracket">]</span></a></sup></li> <li>Third, problems with QALYs were already widely acknowledged.<sup id="cite_ref-BBC_31-3" class="reference"><a href="#cite_note-BBC-31"><span class="cite-bracket">[</span>31<span class="cite-bracket">]</span></a></sup></li> <li>Fourth, the researchers did not take budgetary constraints into consideration.<sup id="cite_ref-BBC_31-4" class="reference"><a href="#cite_note-BBC-31"><span class="cite-bracket">[</span>31<span class="cite-bracket">]</span></a></sup></li> <li>Fifth, the UK's National Institute for Health and Care Excellence uses QALYs that are based on 3395 interviews with residents of the UK, as opposed to residents of several European countries.<sup id="cite_ref-Holmes2013_30-5" class="reference"><a href="#cite_note-Holmes2013-30"><span class="cite-bracket">[</span>30<span class="cite-bracket">]</span></a></sup></li> <li>Finally, according to Franco Sassi, a senior health economist at the Organization for Economic Co-operation and Development, people who call for the elimination of QALYs may have "<a href="/wiki/Conflict_of_interest" title="Conflict of interest">vested interests</a>".<sup id="cite_ref-Holmes2013_30-6" class="reference"><a href="#cite_note-Holmes2013-30"><span class="cite-bracket">[</span>30<span class="cite-bracket">]</span></a></sup></li></ul> <p>While supporters laud QALY's efficiency, critics argue that use of QALY can cause medical inefficiencies because a less-effective, cheaper drug may be approved based on its QALY calculation.<sup id="cite_ref-auto_34-0" class="reference"><a href="#cite_note-auto-34"><span class="cite-bracket">[</span>34<span class="cite-bracket">]</span></a></sup> </p><p>The use of QALYs has been criticized by disability advocates because otherwise healthy individuals cannot return to full health or achieve a high QALY score. Treatments for quadriplegics, patients with multiple sclerosis, or other disabilities are valued less under a QALY-based system.<sup id="cite_ref-35" class="reference"><a href="#cite_note-35"><span class="cite-bracket">[</span>35<span class="cite-bracket">]</span></a></sup> </p><p>Critics also argue that a QALY-based system would limit research on treatments for rare disorders because the upfront costs of the treatments tend to be higher. Officials in the United Kingdom were forced to create the Cancer Drugs Fund to pay for new drugs regardless of their QALY rating because innovation had stalled since NICE was founded. At the time, one in seven drugs were turned down.<sup id="cite_ref-36" class="reference"><a href="#cite_note-36"><span class="cite-bracket">[</span>36<span class="cite-bracket">]</span></a></sup> Additionally there is a trend where QALY is getting position as a capital allocation tool although many sources and publications show that QALY has relatively significant gaps as formula and as organization management mechanism in healthcare<sup id="cite_ref-37" class="reference"><a href="#cite_note-37"><span class="cite-bracket">[</span>37<span class="cite-bracket">]</span></a></sup> </p><p>The Partnership to Improve Patient Care, a group opposed to the adoption of QALY-based metrics, argued that a QALY-based system could exacerbate racial disparities in medicine because there is no consideration of genetic background, demographics, or comorbidities that may be elevated in minority racial groups that do not have as much weight in the consideration of the average year of perfect health.<sup id="cite_ref-38" class="reference"><a href="#cite_note-38"><span class="cite-bracket">[</span>38<span class="cite-bracket">]</span></a></sup> </p><p>Critics have also noted that QALY only considers the quality of life when patients may choose to suffer negative side-effects to live long enough to attend a milestone event, such as a wedding or graduation.<sup id="cite_ref-auto_34-1" class="reference"><a href="#cite_note-auto-34"><span class="cite-bracket">[</span>34<span class="cite-bracket">]</span></a></sup> </p><p>The <a href="/wiki/Rule_of_rescue" class="mw-redirect" title="Rule of rescue">Rule of rescue</a> and immoral or "inhuman acting" are frequently used arguments to ignore cost-effectiveness analysis and the use of QALYs. Especially during the 2020/2021 Covid-19 pandemic, national responses represented a massive form of applying the 'rule of rescue' and disregard of cost-effectiveness analysis (see e.g. <a rel="nofollow" class="external text" href="https://onlinelibrary.wiley.com/doi/full/10.1111/bioe.12771">Utilitarianism and the pandemic</a>). </p><p>Both the Rule of rescue and immoral behavior are heavily attacked by Shepley Orr and Jonathan Wolff in their 2014 article "Reconciling cost-effectiveness with the rule of rescue: the institutional division of moral labor".<sup id="cite_ref-39" class="reference"><a href="#cite_note-39"><span class="cite-bracket">[</span>39<span class="cite-bracket">]</span></a></sup> They argued that the "Rule of rescue" is the result of wrong reasoning, and that cost-effectiveness reasoning with the aid of QALYs always leads to moral superior outcomes and optimal public health outcome, although not always perfect, given constraints of resources. </p> <div class="mw-heading mw-heading2"><h2 id="Future_development">Future development</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Quality-adjusted_life_year&action=edit&section=6" title="Edit section: Future development"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>The UK <a href="/wiki/Medical_Research_Council_(United_Kingdom)" title="Medical Research Council (United Kingdom)">Medical Research Council</a> and others are exploring improvements to or replacements for QALYs.<sup id="cite_ref-Brazier2015_40-0" class="reference"><a href="#cite_note-Brazier2015-40"><span class="cite-bracket">[</span>40<span class="cite-bracket">]</span></a></sup> Among other possibilities are extending the data used to calculate QALYs (e.g., by using different survey instruments); "using well-being to value outcomes" (e.g., by developing a "well-being-adjusted life-year"; and by value outcomes in monetary terms.<sup id="cite_ref-Brazier2015_40-1" class="reference"><a href="#cite_note-Brazier2015-40"><span class="cite-bracket">[</span>40<span class="cite-bracket">]</span></a></sup> In 2018 <a href="/wiki/HM_Treasury" title="HM Treasury">HM Treasury</a> set a <a href="/wiki/Social_discount_rate" title="Social discount rate">discount rate</a> of 1.5% for QALYs, which is lower than the discount rates for other costs and benefits, because the QALY is a direct utility measure.<sup id="cite_ref-41" class="reference"><a href="#cite_note-41"><span class="cite-bracket">[</span>41<span class="cite-bracket">]</span></a></sup> </p> <div class="mw-heading mw-heading2"><h2 id="See_also">See also</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Quality-adjusted_life_year&action=edit&section=7" title="Edit section: See also"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>Related units: </p> <ul><li><a href="/wiki/Disability-adjusted_life_year" title="Disability-adjusted life year">Disability-adjusted life year</a> (DALY)</li> <li>Wellbeing-adjusted Life Year <a href="/w/index.php?title=WALY_(unit)&action=edit&redlink=1" class="new" title="WALY (unit) (page does not exist)">WALY</a> and Wellbeing Year (<a href="/wiki/WELLBY" class="mw-redirect" title="WELLBY">WELLBY</a>)</li> <li><a href="/wiki/Life-years_lost" title="Life-years lost">Life-years lost</a></li> <li><a href="/wiki/Value_of_life" title="Value of life">Value of a Statistical Life (VSL)</a></li></ul> <p>Other: </p> <ul><li><a href="/wiki/Case_mix_index" title="Case mix index">Case mix index</a></li> <li><a href="/wiki/Cost-Effectiveness_Analysis_Registry" class="mw-redirect" title="Cost-Effectiveness Analysis Registry">Cost-Effectiveness Analysis Registry</a></li> <li><a href="/wiki/Cost-utility_analysis" class="mw-redirect" title="Cost-utility analysis">Cost-utility analysis</a></li> <li><a href="/wiki/Incremental_cost-effectiveness_ratio" title="Incremental cost-effectiveness ratio">Incremental cost-effectiveness ratio</a></li> <li><a href="/wiki/Quality_of_life" title="Quality of life">Quality of life</a> and measurements such as <a href="/wiki/MANSA" title="MANSA">MANSA</a> and <a href="/wiki/Life_Quality_Index" title="Life Quality Index">Life Quality Index</a></li></ul> <div class="mw-heading mw-heading2"><h2 id="References">References</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Quality-adjusted_life_year&action=edit&section=8" title="Edit section: References"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <style data-mw-deduplicate="TemplateStyles:r1239543626">.mw-parser-output .reflist{margin-bottom:0.5em;list-style-type:decimal}@media screen{.mw-parser-output .reflist{font-size:90%}}.mw-parser-output .reflist .references{font-size:100%;margin-bottom:0;list-style-type:inherit}.mw-parser-output .reflist-columns-2{column-width:30em}.mw-parser-output .reflist-columns-3{column-width:25em}.mw-parser-output .reflist-columns{margin-top:0.3em}.mw-parser-output .reflist-columns ol{margin-top:0}.mw-parser-output .reflist-columns li{page-break-inside:avoid;break-inside:avoid-column}.mw-parser-output .reflist-upper-alpha{list-style-type:upper-alpha}.mw-parser-output .reflist-upper-roman{list-style-type:upper-roman}.mw-parser-output .reflist-lower-alpha{list-style-type:lower-alpha}.mw-parser-output .reflist-lower-greek{list-style-type:lower-greek}.mw-parser-output .reflist-lower-roman{list-style-type:lower-roman}</style><div class="reflist reflist-columns references-column-width" style="column-width: 30em;"> <ol class="references"> <li id="cite_note-NICE2013-1"><span class="mw-cite-backlink">^ <a href="#cite_ref-NICE2013_1-0"><sup><i><b>a</b></i></sup></a> <a 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title="PMID (identifier)">PMID</a> <a rel="nofollow" class="external text" href="https://pubmed.ncbi.nlm.nih.gov/26324402">26324402</a>.</cite><span title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.jtitle=Applied+Health+Economics+and+Health+Policy&rft.atitle=Improving+Cross-Sector+Comparisons%3A+Going+Beyond+the+Health-Related+QALY&rft.volume=13&rft.issue=6&rft.pages=557-565&rft.date=2015&rft_id=https%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC4661222%23id-name%3DPMC&rft.issn=1175-5652&rft_id=info%3Apmid%2F26324402&rft_id=info%3Adoi%2F10.1007%2Fs40258-015-0194-1&rft.aulast=Brazier&rft.aufirst=John&rft.au=Tsuchiya%2C+Aki&rft_id=https%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC4661222&rfr_id=info%3Asid%2Fen.wikipedia.org%3AQuality-adjusted+life+year" class="Z3988"></span></span> </li> <li id="cite_note-41"><span class="mw-cite-backlink"><b><a href="#cite_ref-41">^</a></b></span> <span class="reference-text"><link 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assessment">Charity assessment</a></li> <li><a href="/wiki/Demandingness_objection" title="Demandingness objection">Demandingness objection</a></li> <li><a href="/wiki/Disability-adjusted_life_year" title="Disability-adjusted life year">Disability-adjusted life year</a></li> <li><a href="/wiki/Disease_burden" title="Disease burden">Disease burden</a></li> <li><a href="/wiki/Distributional_cost-effectiveness_analysis" title="Distributional cost-effectiveness analysis">Distributional cost-effectiveness analysis</a></li> <li><a href="/wiki/Earning_to_give" title="Earning to give">Earning to give</a></li> <li><a href="/wiki/Equal_consideration_of_interests" title="Equal consideration of interests">Equal consideration of interests</a></li> <li><a href="/wiki/Longtermism" title="Longtermism">Longtermism</a></li> <li><a href="/wiki/Marginal_utility" title="Marginal utility">Marginal utility</a></li> <li><a href="/wiki/Moral_circle_expansion" title="Moral circle expansion">Moral circle expansion</a></li> <li><a href="/wiki/Psychological_barriers_to_effective_altruism" title="Psychological barriers to effective altruism">Psychological barriers to effective altruism</a></li> <li><a class="mw-selflink selflink">Quality-adjusted life year</a></li> <li><a href="/wiki/Utilitarianism" title="Utilitarianism">Utilitarianism</a></li> <li><a href="/wiki/Venture_philanthropy" title="Venture philanthropy">Venture philanthropy</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Key figures</th><td class="navbox-list-with-group navbox-list navbox-even hlist" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Sam_Bankman-Fried" title="Sam Bankman-Fried">Sam Bankman-Fried</a></li> <li><a href="/wiki/Liv_Boeree" title="Liv Boeree">Liv Boeree</a></li> <li><a href="/wiki/Nick_Bostrom" title="Nick Bostrom">Nick Bostrom</a></li> <li><a href="/wiki/Hilary_Greaves" title="Hilary Greaves">Hilary Greaves</a></li> <li><a href="/wiki/Holden_Karnofsky" title="Holden Karnofsky">Holden Karnofsky</a></li> <li><a href="/wiki/William_MacAskill" title="William MacAskill">William MacAskill</a></li> <li><a href="/wiki/Dustin_Moskovitz" title="Dustin Moskovitz">Dustin Moskovitz</a></li> <li><a href="/wiki/Yew-Kwang_Ng" title="Yew-Kwang Ng">Yew-Kwang Ng</a></li> <li><a href="/wiki/Toby_Ord" title="Toby Ord">Toby Ord</a></li> <li><a href="/wiki/Derek_Parfit" title="Derek Parfit">Derek Parfit</a></li> <li><a href="/wiki/Peter_Singer" title="Peter Singer">Peter Singer</a></li> <li><a href="/wiki/Cari_Tuna" title="Cari Tuna">Cari Tuna</a></li> <li><a href="/wiki/Eliezer_Yudkowsky" title="Eliezer Yudkowsky">Eliezer Yudkowsky</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Organizations</th><td class="navbox-list-with-group navbox-list navbox-odd hlist" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/80,000_Hours" title="80,000 Hours">80,000 Hours</a></li> <li><a href="/wiki/Against_Malaria_Foundation" title="Against Malaria Foundation">Against Malaria Foundation</a></li> <li><a href="/wiki/Animal_Charity_Evaluators" title="Animal Charity Evaluators">Animal Charity Evaluators</a></li> <li><a href="/wiki/Animal_Ethics_(organization)" title="Animal Ethics (organization)">Animal Ethics</a></li> <li><a href="/wiki/Centre_for_Effective_Altruism" title="Centre for Effective Altruism">Centre for Effective Altruism</a></li> <li><a href="/wiki/Centre_for_Enabling_EA_Learning_%26_Research" title="Centre for Enabling EA Learning & Research">Centre for Enabling EA Learning & Research</a></li> <li><a href="/wiki/Center_for_High_Impact_Philanthropy" title="Center for High Impact Philanthropy">Center for High Impact Philanthropy</a></li> <li><a href="/wiki/Centre_for_the_Study_of_Existential_Risk" title="Centre for the Study of Existential Risk">Centre for the Study of Existential Risk</a></li> <li><a href="/wiki/Development_Media_International" title="Development Media International">Development Media International</a></li> <li><a href="/wiki/Evidence_Action" title="Evidence Action">Evidence Action</a></li> <li><a href="/wiki/Faunalytics" title="Faunalytics">Faunalytics</a></li> <li><a href="/wiki/Fistula_Foundation" title="Fistula Foundation">Fistula Foundation</a></li> <li><a href="/wiki/Future_of_Humanity_Institute" title="Future of Humanity Institute">Future of Humanity Institute</a></li> <li><a href="/wiki/Future_of_Life_Institute" title="Future of Life Institute">Future of Life Institute</a></li> <li><a href="/wiki/Founders_Pledge" title="Founders Pledge">Founders Pledge</a></li> <li><a href="/wiki/GiveDirectly" title="GiveDirectly">GiveDirectly</a></li> <li><a href="/wiki/GiveWell" title="GiveWell">GiveWell</a></li> <li><a href="/wiki/Giving_Multiplier" title="Giving Multiplier">Giving Multiplier</a></li> <li><a href="/wiki/Giving_What_We_Can" title="Giving What We Can">Giving What We Can</a></li> <li><a href="/wiki/Good_Food_Fund" title="Good Food Fund">Good Food Fund</a></li> <li><a href="/wiki/The_Good_Food_Institute" title="The Good Food Institute">The Good Food Institute</a></li> <li><a href="/wiki/Good_Ventures" title="Good Ventures">Good Ventures</a></li> <li><a href="/wiki/The_Humane_League" title="The Humane League">The Humane League</a></li> <li><a href="/wiki/Mercy_for_Animals" title="Mercy for Animals">Mercy for Animals</a></li> <li><a href="/wiki/Machine_Intelligence_Research_Institute" title="Machine Intelligence Research Institute">Machine Intelligence Research Institute</a></li> <li><a href="/wiki/Malaria_Consortium" title="Malaria Consortium">Malaria Consortium</a></li> <li><a href="/wiki/Nuclear_Threat_Initiative" title="Nuclear Threat Initiative">Nuclear Threat Initiative</a></li> <li><a href="/wiki/Open_Philanthropy_(organization)" class="mw-redirect" title="Open Philanthropy (organization)">Open Philanthropy</a></li> <li><a href="/wiki/Raising_for_Effective_Giving" title="Raising for Effective Giving">Raising for Effective Giving</a></li> <li><a href="/wiki/Sentience_Institute" title="Sentience Institute">Sentience Institute</a></li> <li><a href="/wiki/Unlimit_Health" title="Unlimit Health">Unlimit Health</a></li> <li><a href="/wiki/Wild_Animal_Initiative" title="Wild Animal Initiative">Wild Animal Initiative</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Focus areas</th><td class="navbox-list-with-group navbox-list navbox-even hlist" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Biotechnology_risk" title="Biotechnology risk">Biotechnology risk</a></li> <li><a href="/wiki/Climate_change" title="Climate change">Climate change</a></li> <li><a href="/wiki/Cultured_meat" title="Cultured meat">Cultured meat</a></li> <li><a href="/wiki/Economic_stability" title="Economic stability">Economic stability</a></li> <li><a href="/wiki/Existential_risk_from_artificial_general_intelligence" class="mw-redirect" title="Existential risk from artificial general intelligence">Existential risk from artificial general intelligence</a></li> <li><a href="/wiki/Global_catastrophic_risk" title="Global catastrophic risk">Global catastrophic risk</a></li> <li><a href="/wiki/Global_health" title="Global health">Global health</a></li> <li><a href="/wiki/Global_poverty" class="mw-redirect" title="Global poverty">Global poverty</a></li> <li><a href="/wiki/Intensive_animal_farming" title="Intensive animal farming">Intensive animal farming</a></li> <li><a href="/wiki/Land_use" title="Land use">Land use reform</a></li> <li><a href="/wiki/Life_extension" title="Life extension">Life extension</a></li> <li><a href="/wiki/Malaria_prevention" class="mw-redirect" title="Malaria prevention">Malaria prevention</a></li> <li><a href="/wiki/Mass_deworming" title="Mass deworming">Mass deworming</a></li> <li><a href="/wiki/Neglected_tropical_diseases" title="Neglected tropical diseases">Neglected tropical diseases</a></li> <li><a href="/wiki/Risk_of_astronomical_suffering" title="Risk of astronomical suffering">Risk of astronomical suffering</a></li> <li><a href="/wiki/Wild_animal_suffering" title="Wild animal suffering">Wild animal suffering</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Literature</th><td class="navbox-list-with-group navbox-list navbox-odd hlist" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><i><a href="/wiki/Doing_Good_Better" title="Doing Good Better">Doing Good Better</a></i></li> <li><i><a href="/wiki/The_End_of_Animal_Farming" title="The End of Animal Farming">The End of Animal Farming</a></i></li> <li><i><a href="/wiki/Famine,_Affluence,_and_Morality" title="Famine, Affluence, and Morality">Famine, Affluence, and Morality</a></i></li> <li><i><a href="/wiki/The_Life_You_Can_Save" title="The Life You Can Save">The Life You Can Save</a></i></li> <li><i><a href="/wiki/Living_High_and_Letting_Die" title="Living High and Letting Die">Living High and Letting Die</a></i></li> <li><i><a href="/wiki/The_Most_Good_You_Can_Do" title="The Most Good You Can Do">The Most Good You Can Do</a></i></li> <li><i><a href="/wiki/Practical_Ethics" title="Practical Ethics">Practical Ethics</a></i></li> <li><i><a href="/wiki/The_Precipice:_Existential_Risk_and_the_Future_of_Humanity" title="The Precipice: Existential Risk and the Future of Humanity">The Precipice</a></i></li> <li><i><a href="/wiki/Superintelligence:_Paths,_Dangers,_Strategies" title="Superintelligence: Paths, Dangers, Strategies">Superintelligence: Paths, Dangers, Strategies</a></i></li> <li><i><a href="/wiki/What_We_Owe_the_Future" title="What We Owe the Future">What We Owe the Future</a></i></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Events</th><td class="navbox-list-with-group navbox-list navbox-even hlist" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Effective_Altruism_Global" title="Effective Altruism Global">Effective Altruism Global</a></li></ul> </div></td></tr></tbody></table></div> <div class="navbox-styles"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1129693374"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1236075235"></div><div role="navigation" class="navbox" aria-labelledby="Health_care_quality" style="padding:3px"><table class="nowraplinks mw-collapsible autocollapse navbox-inner" style="border-spacing:0;background:transparent;color:inherit"><tbody><tr><th scope="col" class="navbox-title" colspan="2"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1129693374"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1239400231"><div class="navbar plainlinks hlist navbar-mini"><ul><li class="nv-view"><a 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research">Health services research</a></li> <li><a href="/wiki/Routine_health_outcomes_measurement" title="Routine health outcomes measurement">Routine health outcomes measurement</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Accreditation</th><td class="navbox-list-with-group navbox-list navbox-odd hlist" style="width:100%;padding:0"><div style="padding:0 0.25em"> <ul><li><a href="/wiki/Hospital_accreditation" title="Hospital accreditation">Hospital accreditation</a></li> <li><a href="/wiki/International_healthcare_accreditation" title="International healthcare accreditation">International healthcare accreditation</a></li> <li><a href="/wiki/List_of_international_healthcare_accreditation_organizations" title="List of international healthcare accreditation organizations">List of international healthcare accreditation organizations</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Costs and benefits</th><td 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