MCQ Quiz: Cost-Utility Analysis

Welcome, PharmD students, to this in-depth MCQ quiz on Cost-Utility Analysis (CUA)! As a specialized form of pharmacoeconomic evaluation, CUA goes beyond just clinical effectiveness by incorporating patient preferences and quality of life into the assessment of health interventions. This is most commonly achieved using Quality-Adjusted Life Years (QALYs). This quiz will test your understanding of the principles of CUA, how utilities and QALYs are measured and interpreted, the calculation and significance of the Incremental Cost-Utility Ratio (ICUR), and the application of CUA in healthcare decision-making. Let’s explore this vital tool for evaluating the true value of medical treatments!

1. Cost-Utility Analysis (CUA) is a type of pharmacoeconomic analysis where outcomes are primarily measured in terms of:

• a) Monetary benefits.
• b) Natural clinical units like blood pressure reduction.
• c) Patient preference-based units that reflect both quantity and quality of life, such as Quality-Adjusted Life Years (QALYs).
• d) Number of cases cured.

Answer: c) Patient preference-based units that reflect both quantity and quality of life, such as Quality-Adjusted Life Years (QALYs).

2. A Quality-Adjusted Life Year (QALY) is calculated by multiplying:

• a) The cost of an intervention by its effectiveness.
• b) The number of years of life gained by a utility score representing the quality of life in those years.
• c) The direct medical costs by the indirect costs.
• d) The sensitivity of a diagnostic test by its specificity.

Answer: b) The number of years of life gained by a utility score representing the quality of life in those years.

3. The utility score used in QALY calculations typically ranges from:

• a) 0 (perfect health) to 1 (death).
• b) 0 (death) to 1 (perfect health), though some scales allow for negative values for states worse than death.
• c) 1 (worst health) to 100 (best health).
• d) It is always measured in dollars.

Answer: b) 0 (death) to 1 (perfect health), though some scales allow for negative values for states worse than death.

4. Which of the following methods is used to directly elicit utility values from individuals for specific health states?

• a) Cost-of-illness method
• b) Human capital approach
• c) Standard Gamble or Time Trade-Off techniques
• d) Discounted cash flow

Answer: c) Standard Gamble or Time Trade-Off techniques

5. The primary advantage of using QALYs as an outcome measure in CUA is that they:

• a) Are easy and inexpensive to measure in all patient populations.
• b) Allow for the comparison of interventions across different disease areas and with diverse types of health outcomes on a common scale.
• c) Eliminate all ethical considerations in resource allocation.
• d) Are based solely on physician assessments.

Answer: b) Allow for the comparison of interventions across different disease areas and with diverse types of health outcomes on a common scale.

6. An Incremental Cost-Utility Ratio (ICUR) is typically expressed as:

• a) Cost per life-year gained.
• b) Cost per QALY gained.
• c) Benefit-to-cost ratio.
• d) Net monetary benefit.

Answer: b) Cost per QALY gained.

7. CUA is considered a specific type of which other pharmacoeconomic analysis?

• a) Cost-Minimization Analysis (CMA)
• b) Cost-Benefit Analysis (CBA)
• c) Cost-Effectiveness Analysis (CEA)
• d) Cost-of-Illness (COI) study

Answer: c) Cost-Effectiveness Analysis (CEA) (where effectiveness is measured in utility-based units like QALYs).

8. When is Cost-Utility Analysis particularly useful or recommended?

• a) When interventions being compared have identical health outcomes.
• b) When quality of life is an important outcome of the intervention, or when comparing interventions that affect both morbidity and mortality.
• c) When all costs and benefits can be easily valued in monetary terms.
• d) Only for preventive interventions.

Answer: b) When quality of life is an important outcome of the intervention, or when comparing interventions that affect both morbidity and mortality.

9. If a treatment extends life by 2 years in perfect health (utility=1), it provides 2 QALYs. If it extends life by 2 years but in a health state valued at a utility of 0.5, it provides:

• a) 0.5 QALYs
• b) 1.0 QALY
• c) 1.5 QALYs
• d) 2.0 QALYs

Answer: b) 1.0 QALY (2 years * 0.5 utility/year = 1 QALY)

10. The EQ-5D and SF-6D are examples of:

• a) Disease-specific HRQoL instruments.
• b) Generic, preference-based Health-Related Quality of Life (HRQoL) instruments that can be used to derive utility values for CUA.
• c) Methods for calculating direct medical costs.
• d) Statistical software for pharmacoeconomic modeling.

Answer: b) Generic, preference-based Health-Related Quality of Life (HRQoL) instruments that can be used to derive utility values for CUA.

11. A major challenge or limitation associated with Cost-Utility Analysis is:

• a) The inability to compare different types of health programs.
• b) The difficulty, subjectivity, and potential biases in accurately measuring utility values for different health states.
• c) That it does not consider costs.
• d) Its results are always easy for the general public to understand.

Answer: b) The difficulty, subjectivity, and potential biases in accurately measuring utility values for different health states.

12. The “societal perspective” in a CUA would ideally include consideration of:

• a) Only costs to the healthcare payer.
• b) All relevant costs (direct medical, direct non-medical, indirect) and all relevant health utility gains for all affected members of society.
• c) Only the patient’s out-of-pocket expenses.
• d) Only changes in QALYs, not costs.

Answer: b) All relevant costs (direct medical, direct non-medical, indirect) and all relevant health utility gains for all affected members of society.

13. If a new drug costs an additional $60,000 compared to standard care and provides an additional 2 QALYs, the ICUR is:

• a) $30,000 per QALY gained.
• b) $60,000 per QALY gained.
• c) $120,000 per QALY gained.
• d) $2 per QALY gained.

Answer: a) $30,000 per QALY gained. ($60,000 / 2 QALYs)

14. The “Standard Gamble” technique for eliciting utility values involves asking an individual to choose between:

• a) Living in a specific health state for a certain time versus living for a shorter time in perfect health.
• b) Two different drug treatments with varying side effect profiles.
• c) A certain health state versus a gamble with a chance of perfect health and a chance of immediate death.
• d) Paying a certain amount of money for a health improvement.

Answer: c) A certain health state versus a gamble with a chance of perfect health and a chance of immediate death.

15. The “Time Trade-Off” (TTO) method for utility assessment asks individuals to state how many years in a particular health state they would trade for:

• a) A monetary payment.
• b) A shorter period in perfect health.
• c) A guaranteed cure.
• d) A different, less severe health state.

Answer: b) A shorter period in perfect health. (e.g., X years in state Y is equivalent to Z years in perfect health, where Z < X).

16. Health-Related Quality of Life (HRQoL) is a sub-component of overall quality of life that specifically focuses on:

• a) Financial well-being.
• b) The aspects of quality of life that are affected by health, illness, and treatment.
• c) Environmental quality.
• d) Job satisfaction.

Answer: b) The aspects of quality of life that are affected by health, illness, and treatment.

17. A QALY value of 0 typically represents:

• a) Perfect health.
• b) Death.
• c) A health state slightly better than death.
• d) A health state much worse than death.

Answer: b) Death.

18. Discounting future QALYs in a CUA is done because:

• a) QALYs gained in the future are generally valued more highly than QALYs gained today.
• b) QALYs gained in the future are generally valued less highly than QALYs gained today (time preference).
• c) It simplifies the calculations.
• d) It is only required if costs are also discounted.

Answer: b) QALYs gained in the future are generally valued less highly than QALYs gained today (time preference). (Both costs and QALYs are usually discounted at the same rate).

19. CUA allows for comparisons of interventions that might have very different clinical effects (e.g., a life-saving cancer drug vs. a drug that improves mobility in arthritis) by:

• a) Ignoring the differences in clinical effects.
• b) Converting these diverse effects into a common unit of health utility (QALYs).
• c) Only comparing their costs.
• d) Focusing solely on mortality.

Answer: b) Converting these diverse effects into a common unit of health utility (QALYs).

20. The interpretation of an ICUR (e.g., $X per QALY gained) often involves comparing it to a “willingness-to-pay” (WTP) threshold. This threshold represents:

• a) The maximum amount a drug company is willing to charge.
• b) The amount an individual patient is actually paying for the intervention.
• c) A societal value judgment on how much it is willing to spend for a unit of health gain (e.g., one QALY).
• d) The cost of the comparator treatment.

Answer: c) A societal value judgment on how much it is willing to spend for a unit of health gain (e.g., one QALY).

21. If a CUA finds that a new treatment is “dominant,” it means the new treatment is:

• a) More costly and provides fewer QALYs than the comparator.
• b) Less costly and provides more QALYs than the comparator.
• c) More costly but provides more QALYs.
• d) Less costly but provides fewer QALYs.

Answer: b) Less costly and provides more QALYs than the comparator.

22. What is a potential ethical concern when using QALYs in resource allocation decisions?

• a) They always favor treatments for younger people over older people if life expectancy is a major factor.
• b) They may undervalue treatments for conditions that primarily affect quality of life without major life extension, or for certain patient groups.
• c) They can lead to ageism or discrimination against people with disabilities if not carefully applied.
• d) All of the above.

Answer: d) All of the above.

23. A Visual Analog Scale (VAS) used for utility assessment typically asks individuals to:

• a) Choose between two health states.
• b) Rate a health state on a line anchored by “best imaginable health” and “worst imaginable health” (or death).
• c) Trade years of life for better health.
• d) Answer a series of multiple-choice questions about their health.

Answer: b) Rate a health state on a line anchored by “best imaginable health” and “worst imaginable health” (or death).

24. When critiquing a CUA, it is important to assess how utility values were derived. Using utilities from _______ is generally preferred over using utilities estimated by _______.

• a) physicians; patients
• b) the general population or patients with the condition; healthcare providers or researchers making assumptions
• c) pharmaceutical company employees; independent researchers
• d) healthy individuals only; patients with the disease

Answer: b) the general population or patients with the condition; healthcare providers or researchers making assumptions

25. The main output that distinguishes a CUA from a standard CEA (where outcomes are in natural units like life-years) is the use of:

• a) Incremental Cost Ratio (ICR).
• b) Quality-Adjusted Life Years (QALYs) as the measure of health benefit.
• c) Direct medical costs only.
• d) A societal perspective exclusively.

Answer: b) Quality-Adjusted Life Years (QALYs) as the measure of health benefit.

26. Sensitivity analysis in a CUA is important to determine:

• a) How sensitive patients are to the drug’s side effects.
• b) How robust the cost per QALY estimate is to changes in key assumptions or parameters (e.g., utility values, costs, discount rate).
• c) The diagnostic sensitivity of a related test.
• d) The minimum effective dose.

Answer: b) How robust the cost per QALY estimate is to changes in key assumptions or parameters (e.g., utility values, costs, discount rate).

27. If a treatment results in a gain of 0.2 QALYs at an additional cost of $5,000, the ICUR is:

• a) $1,000 per QALY
• b) $5,000 per QALY
• c) $10,000 per QALY
• d) $25,000 per QALY

Answer: d) $25,000 per QALY ($5,000 / 0.2 QALYs)

28. Which scenario makes CUA a particularly strong choice over CEA using only life-years gained?

• a) Comparing two drugs that extend life by the same amount but have vastly different impacts on daily functioning and side effect profiles.
• b) Comparing two generic drugs with identical clinical effects.
• c) When only mortality data is available.
• d) When costs are the only concern.

Answer: a) Comparing two drugs that extend life by the same amount but have vastly different impacts on daily functioning and side effect profiles.

29. The results of CUAs are often used by health technology assessment (HTA) bodies to:

• a) Set the retail price for all consumer goods.
• b) Make recommendations about the value and reimbursement of new health technologies, including drugs.
• c) Directly regulate pharmaceutical manufacturing.
• d) Diagnose diseases.

Answer: b) Make recommendations about the value and reimbursement of new health technologies, including drugs.

30. A common challenge in applying CUA results from one country to another is differences in:

• a) The chemical structure of drugs.
• b) Social preferences for health states (utility values), healthcare costs, and willingness-to-pay thresholds.
• c) The laws of physics.
• d) The definition of a year.

Answer: b) Social preferences for health states (utility values), healthcare costs, and willingness-to-pay thresholds.

31. A “utility weight” of 0.8 for a particular health state implies that individuals, on average, value a year in that health state as equivalent to:

• a) 0.8 years in perfect health.
• b) 0.2 years in perfect health.
• c) 0.8 years of death.
• d) Perfect health plus an additional 0.8 years.

Answer: a) 0.8 years in perfect health.

32. Disease-specific HRQoL instruments are often more _______ to changes in a particular condition than generic HRQoL instruments, but their scores may not be easily convertible to _______.

• a) resistant; costs
• b) sensitive; utility values needed for QALYs
• c) applicable; natural units
• d) robust; monetary values

Answer: b) sensitive; utility values needed for QALYs (Unless they have a utility-based scoring algorithm).

33. If an intervention is found to be less costly and provide more QALYs than its comparator, it is said to be:

• a) Dominated
• b) Dominant (and therefore cost-effective)
• c) A trade-off requiring WTP consideration
• d) Only cost-saving but not utility-gaining

Answer: b) Dominant (and therefore cost-effective)

34. One key assumption when calculating QALYs is that the utility of a health state is ________ over the duration spent in that state.

• a) always increasing
• b) constant
• c) always decreasing
• d) irrelevant

Answer: b) constant (This is a simplifying assumption for basic QALY calculation).

35. The perspective taken in a CUA (e.g., healthcare system vs. societal) will most significantly affect the types of _______ included in the analysis.

• a) QALYs measured
• b) costs considered
• c) clinical trial designs preferred
• d) utility elicitation methods used

Answer: b) costs considered

36. When critiquing a CUA, it’s essential to verify that the source and method of utility assessment are:

• a) Biased towards the new drug.
• b) Clearly described, appropriate for the health states being valued, and from a relevant population.
• c) Based on physician estimates only.
• d) Not disclosed in the publication.

Answer: b) Clearly described, appropriate for the health states being valued, and from a relevant population.

37. A CUA comparing a new expensive drug that slightly improves quality of life for a chronic condition with an older, cheaper drug that provides less quality of life improvement would likely focus on the:

• a) Cost per life year saved.
• b) Incremental cost per QALY gained to see if the additional QoL is “worth” the extra cost.
• c) Total cost of the new drug only.
• d) Number of patients who prefer the new drug’s color.

Answer: b) Incremental cost per QALY gained to see if the additional QoL is “worth” the extra cost.

38. Which of these is NOT a direct input into a basic QALY calculation?

• a) Duration of time spent in a health state.
• b) Utility value of that health state.
• c) The cost of the medication used to achieve that health state.
• d) Years of life.

Answer: c) The cost of the medication used to achieve that health state. (Cost is used with QALYs to get ICUR, but not in QALY calc itself).

39. The primary advantage CUA holds over CEA (using non-utility natural units) is its ability to:

• a) Incorporate only mortality, not morbidity.
• b) Provide a common outcome unit (QALY) that allows for comparisons across interventions with very different types of health benefits.
• c) Be less expensive to conduct.
• d) Avoid all ethical dilemmas.

Answer: b) Provide a common outcome unit (QALY) that allows for comparisons across interventions with very different types of health benefits.

40. If a CUA uses utilities derived from a small group of healthy volunteers for health states experienced by elderly patients with multiple comorbidities, this could be a limitation affecting the results’:

• a) Cost accuracy.
• b) Validity and generalizability, as preferences may differ.
• c) Discount rate.
• d) Time horizon.

Answer: b) Validity and generalizability, as preferences may differ.

41. When costs and QALYs are discounted in a CUA, a higher discount rate will give _______ weight to future QALYs and costs.

• a) more
• b) less
• c) equal
• d) unpredictable

Answer: b) less

42. The main reason quality of life is explicitly incorporated into CUA through utility measurement is because:

• a) It makes the analysis more complicated.
• b) Healthcare interventions aim not only to prolong life but also to improve the quality of the life lived.
• c) All patients value health states identically.
• d) It is required by all drug manufacturers.

Answer: b) Healthcare interventions aim not only to prolong life but also to improve the quality of the life lived.

43. A well-conducted CUA should clearly state the source of its effectiveness data (e.g., clinical trial) and how this was used to estimate:

• a) Only the costs of the interventions.
• b) The expected changes in both length and quality of life (utilities) for each alternative.
• c) Only the patient satisfaction scores.
• d) Only the direct non-medical costs.

Answer: b) The expected changes in both length and quality of life (utilities) for each alternative.

44. An ICUR of “$X per QALY gained” means that for every additional QALY gained by choosing the new intervention over the comparator, society or the payer must spend an additional $X. This helps in assessing:

• a) Clinical efficacy only.
• b) Value for money.
• c) Absolute affordability for an individual patient.
• d) The drug’s mechanism of action.

Answer: b) Value for money.

45. The “Quality of Life Assessment” video lecture (from PHA5244) likely covers different types of HRQoL instruments, including:

• a) Only laboratory-based assays.
• b) Generic (e.g., EQ-5D, SF-36) and disease-specific questionnaires.
• c) Only physician-reported outcomes.
• d) Financial assessment tools.

Answer: b) Generic (e.g., EQ-5D, SF-36) and disease-specific questionnaires.

46. If two interventions have the same cost, but Intervention A yields 5 QALYs and Intervention B yields 4 QALYs, then:

• a) Intervention B is more cost-effective.
• b) Intervention A is more cost-effective (or dominant if it were also cheaper).
• c) A CUA is not needed.
• d) Both are equally cost-effective.

Answer: b) Intervention A is more cost-effective (or dominant if it were also cheaper). (Provides more QALYs for same cost).

47. One reason that CUA is often preferred by national health technology assessment bodies for broad resource allocation decisions is its ability to:

• a) Guarantee funding for all new technologies.
• b) Provide a standardized metric (QALY) allowing comparisons across diverse health programs (e.g., cancer care vs. heart disease vs. mental health).
• c) Simplify complex ethical choices completely.
• d) Eliminate the need for clinical trials.

Answer: b) Provide a standardized metric (QALY) allowing comparisons across diverse health programs (e.g., cancer care vs. heart disease vs. mental health).

48. When critiquing a CUA, if a very wide range is found for the ICUR in the sensitivity analysis, it suggests:

• a) The base-case result is highly certain and robust.
• b) The cost-effectiveness conclusion is highly dependent on the specific values of uncertain parameters.
• c) The discounting was done incorrectly.
• d) The utility measures were perfect.

Answer: b) The cost-effectiveness conclusion is highly dependent on the specific values of uncertain parameters.

49. The primary role of pharmacists in relation to CUA studies is often to:

• a) Conduct the utility elicitation interviews for all studies.
• b) Critically appraise published CUAs to inform formulary decisions, guideline development, and patient care recommendations.
• c) Design and manufacture the drugs being analyzed.
• d) Set national willingness-to-pay thresholds.

Answer: b) Critically appraise published CUAs to inform formulary decisions, guideline development, and patient care recommendations.

50. Understanding Cost-Utility Analysis helps pharmacists appreciate that the “value” of a drug therapy considers not just its clinical effect (e.g., extending life) but also its impact on the ________ of that life.

• a) cost
• b) quality
• c) color
• d) marketing potential

Answer: b) quality