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 prioritised over patients with less severe illness if both would get the same absolute increase in utility. as early as 1989, loomes and mckenzie recommended that research be conducted concerning the validity of qalys. in 2010, with funding from the european commission, the european consortium in healthcare outcomes and cost-benefit research (echoutcome) began a major study on qalys as used in health technology assessment. ariel beresniak, 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". 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. 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). they concluded that "preferences expressed by the respondents were not consistent with the qaly theoretical assumptions" that quality of life can be measured in consistent intervals, that life-years and quality of life are independent of each other, that people are neutral about risk, and that willingness to gain or lose life-years is constant over time. echoutcome also released "european guidelines for cost-effectiveness assessments of health technologies", which recommended not using qalys in healthcare decision making. instead, the guidelines recommended that cost-effectiveness analyses focus on "costs per relevant clinical outcome". in response to the echoutcome study, representatives of the national institute for health and care excellence, the scottish medicines consortium, and the organisation for economic co-operation and development made the following points. first, qalys are better than alternative measures. second, the study was "limited". third, problems with qalys were already widely acknowledged. fourth, the researchers did not take budgetary constraints into consideration. 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. finally, people who call for the elimination of qalys may have "vested interests".