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Why use the EQ-5D?

Why use the EQ-5D? . What are the alternatives?. What are the alternatives for Direct valuation? . Other VAS Time Trade-Off Standard Gamble Willingness to pay Difficult… Paired comparisons DCE etc. Normal health. X. Dead. Visual Analogue Scale. VAS Also called “category scaling”

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Why use the EQ-5D?

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  1. Why use the EQ-5D? What are the alternatives?

  2. What are the alternatives for Direct valuation? • Other VAS • Time Trade-Off • Standard Gamble • Willingness to pay • Difficult… • Paired comparisons • DCE etc

  3. Normal health X Dead Visual Analogue Scale • VAS • Also called “category scaling” • From psychological research • “How is your quality of life?” • “X” marks the spot • Rescale to [0..1] • Different anchor point possible: • Normal health (1.0) versus dead (0.0) • Best imaginable health versusworse imaginable health

  4. Time Trade-Off • TTO • Wheelchair • With a life expectancy: 50 years • How many years would you trade-off for a cure? • Max. trade-off is 10 years • QALY(wheel) = QALY(healthy) • Y * V(wheel) = Y * V(healthy) • 50 V(wheel) = 40 * 1 • V(wheel) = .8

  5. Standard Gamble • SG • Wheelchair • Life expectancy is not important here • How much are risk on death are you prepared to take for a cure? • Max. risk is 20% • wheels = (100%-20%) life on feet • V(Wheels) = 80% or .80

  6. Willingness to pay • Cost benefit analyis • Revealed preferences • Look in market how much subject are willing to pay • Different situations give different results • Weighted by in income • Conclusion: • the validity of cost benefit analysis is not sufficient

  7. Alternatives for indirect measurements MOBILITY • I have no problems in walking about • I have some problems in walking about • I am confined to bed SELF-CARE • I have no problems with self-care • I have some problems washing or dressing myself • I am unable to wash or dress myself USUAL ACTIVITIES (e.g. work, study, housework family or leisure activities) • I have no problems with performing my usual activities • I have some problems with performing my usual activities • I am unable to perform my usual activities PAIN/DISCOMFORT • I have no pain or discomfort • I have moderate pain or discomfort • I have extreme pain or discomfort ANXIETY/DEPRESSION • I am not anxious or depressed • I am moderately anxious or depressed • I am extremely anxious or depressed

  8. Validated questionnaires

  9. The Rosser & Kind Index

  10. The Rosser & Kind index • Criticism on the Rosser & Kind index • Sensitivity (only 30 health states) • New initiatives • Higher sensitivity (more then 30 states) • EuroQol Group • EQ-5D-3L and the EQ-5D-5L • McMaster University • Health Utility Index 2 & 3 • SF-36 • SF-6D

  11. Health Utility Index • Developed from pediatric care • Strong proxy versions • Symptom driven: • “Outside the skin” instead of “inside the skin” • EQ-5D: “problems with daily activity” • HUI: “Unable to read ordinary newsprint…” • Commercial • All user have to pay • 35 Translations

  12. HUI 2

  13. HUI 3

  14. Increasing number of health states

  15. No longer value all states • Impossible to value all health states • If one uses more than 30 health states • Estimated the value of the other health states with statistical techniques • Statistically inferred strategies • Regression techniques • EuroQol, Quality of Well-Being Scale (QWB) • Explicitly decomposed methods • Multi Attribute Utility Theory (MAUT) • Health Utility Index (HUI)

  16. Statistically inferred strategies • Value a sample of states empirically • Extrapolation • Statistical methods, like linear regression • 11111 = 1.00 • 11113 = .70 • 11112 = ?

  17. Statistically inferred strategies • EuroQol • EQ-5D: 5 dimensions of health • 245 health states • Quality of Well-Being scale (QWB) • 4 dimensions of health • 2200 health states plus 22 additional symptoms • SF-36 • SF-6D: 6 dimensions of health • 18.000 health states

  18. Explicitly Decomposed Methods • Value dimensions separately • Between the dimensions • What is the relative value of: • Mobility…... 20% • Mood……….. 15% • Self care.… .24% • Value the levels • Within the dimensions • What is the relative value of • Some problems with walking…..80% • Much problems with walking……50% • Unable to walk………..……………….10% • 21111 = 1 - (0.20 x (1.00 - 0.80)) = 0.96

  19. Explicitly Decomposed Methods • Combine values of dimensions and levels with specific assumptions • Multi Attribute Utility Theory (MAUT) • Mutual utility independence • Structural independence

  20. Explicitly Decomposed Methods • Health Utilities Index (Mark 2 & 3) • Torrance at McMaster • 8 dimensions • Mark 2: 24.000 health states • Mark 3: 972.000 health states • The 15-D • Sintonen H. • 15 dimensions • 3,052,000,000 health states (3 billion)

  21. More health states, higher sensitivity ? (1) • EuroQol criticised for low sensitivity • Low number of dimensions • Development of EQ-5D plus cognitive dimension • Low number of levels (3) • Gab between best and in-between level

  22. More health states, higher sensitivity ? (2) • Little published evidence • Sensitivity EQ-5D < SF-36 • Compared as profile, not as utility measure • Sensitivity EQ-5D  HUI • Sensitivity  the number of health states • How well maps the classification system the illness? • How valid is the modelling? • How valid is the valuation?

  23. More health states, more assumptions • General public values at the most 50 states • The ratios empirical (50) versus extrapolated • Rosser & Kind 1:1 • EuroQol 1:5 • QWB 1:44 • SF-36 1:180 • HUI (Mark III) 1:19,400 • 15D 1:610,000,000 • What is the critical ratio for a valid validation?

  24. Conflicting evidence sensitivity SF-36 Liver transplantation, Longworth et al., 2001

  25. SF-36 as utility instrument • Transformed into SF6D • SG • N = 610 • Inconsistencies in model • 18.000 health states • regression technique stressed to the edge • Floor effect in SF6D

  26. Collapsing levels SF-6D • Many levels are taken together • If PF=2 decrement: - 0.056 • If PF=3 decrement: - 0.056 • If RL=2 decrement: - 0.073 • If RL=3 decrement: - 0.073 • If RL=4 decrement: - 0.073

  27. SF-6D loses a lot of levels • Levels clas.systemand actual levels • PF 6 5 • RL 4 2 • SF 5 5 • PN 6 5 • MH 5 4 • VI 5 3 • Levels in clas. system: 18.000 • 6x4x5x6x5x5 • Actual levels: 480 • 5x2x5x5x4x3

  28. Somelevels in the SF-6D do notwork…

  29. EQ-5D • Strong punts • Very sensitive in the low • Measures subjective burden (inside the skin) • Low administrative burden • Many translations • Cheap • Most used QALY questionnaire • Most international validations • Weak points • Only there levels per dimensions • Insensitive in the high regions

  30. HUI • Strong punts • Sensitive • Measures objective burden (outside the skin) • Well developed proxy versions • Well developed child versions • Weak points • Expensive • Only a few valuation studies

  31. SF-6D • Strong punts • Probably sensitive in the high regions • Often already include in trials (SF-36) • Many translations • Weak points • Insensitive in the low regions • Only a few validation study • Might be expensive

  32. Conclusions More states  better sensitivity The three leading questionnaires have different strong and weak points

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