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Effect of framing of death on health state values obtained from DCEs

This study aims to investigate the impact of different framing techniques on health state values obtained from discrete choice experiments (DCEs). The hypothesis is that differences between health state values based on time trade-off (TTO) and DCE can be reconciled by harmonizing their framings. The study includes alternative framing of duration and death in the DCE questions.

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Effect of framing of death on health state values obtained from DCEs

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  1. Effect of framing of death on health state values obtained from DCEs Dr. Esther W. de Bekker-Grob e.debekker@erasmusmc.nl www.eur.nl/ecmc Marcel Jonker, de Bekker-Grob, Donkers, Stolk

  2. Introduction • Discrete choice experiments (DCE) is considered a promising technique for health state valuation • Nevertheless, the method is still in development and obtained results warrant further investigation • Notably, compared to TTO, DCE classifies more states as worse than death www.eur.nl/ecmc

  3. Hypothesis Differences between health state values based on TTO and DCE may at least in part be reconciled by harmonizing their framings • TTO includes an endowment, whereas DCE involves a neutral choice between option A and option B www.eur.nl/ecmc

  4. Aim • To determine how alternative framing of the DCE questions affects • EQ-5D-5L health state values www.eur.nl/ecmc

  5. DCE health-state valuations latent utility scale QALY scale 1-1-1-1-1 1-1-1-1-1 = 1 death = 0 5-5-5-5-5 5-5-5-5-5

  6. 2 ways to obtain QALY values • Including “death” as an alternative-specific health state in the DCE • Including “duration” as an additional attribute in the DCE • (zero duration of life = death) 1-1-1-1-1 = 1 death = 0 5-5-5-5-5

  7. Methods www.eur.nl/ecmc 9 different study arms: • 5 different DCE duration framings • 4 different DCE death framings

  8. Methods www.eur.nl/ecmc 9 different study arms: • 5 different DCE duration framings • 4 different DCE death framings

  9. Base case (A vs B) Which health state do you prefer, A or B? A B C 10 yearsin this health 10 yearsin this health state, followed by death state, followed by death no problems in walking about no problems in walking about Mobility noproblems washing or dressing noproblems washing or dressing Self-care moderateproblems doing usual activities moderateproblems doing usual activities Usual activities extreme pain or discomfort severe pain or discomfort Pain slightlyanxious or depressed extremelyanxious or depressed Anxiety

  10. Base case (B vs C) Which health state do you prefer, B or C? B C 10 yearsin this health 10 yearsin this health state, followed by death state, followed by death no problems in walking about no problems in walking about Mobility noproblems washing or dressing noproblems washing or dressing Self-care moderateproblems doing usual activities moderateproblems doing usual activities Usual activities extreme pain or discomfort severe pain or discomfort Pain slightlyanxious or depressed extremelyanxious or depressed Anxiety

  11. Base case (DCE death) Which health state do you prefer, B or C? B C 10 yearsin this health 10 yearsin this health You die immediately state, followed by death state, followed by death no problems in walking about no problems in walking about Mobility noproblems washing or dressing noproblems washing or dressing Self-care moderateproblems doing usual activities moderateproblems doing usual activities Usual activities extreme pain or discomfort severe pain or discomfort Pain slightlyanxious or depressed extremelyanxious or depressed Anxiety

  12. Base case (DCE duration) Which health state do you prefer, B or C? B C 10 yearsin this health 10 yearsin this health 7 yearsin this health state, followed by death state, followed by death state, followed by death no problems in walking about no problems in walking about no problems in walking about Mobility noproblems washing or dressing noproblems washing or dressing no problems in walking about Self-care no problems in walking about moderateproblems doing usual activities moderateproblems doing usual activities Usual activities no problems in walking about extreme pain or discomfort severe pain or discomfort Pain slightlyanxious or depressed extremelyanxious or depressed no problems in walking about Anxiety

  13. Framing 1: lead time Which health state do you prefer, A or B? C You will live 20 years, of which 10 in full health and 10 yearsin this health below You will live 10 yearsin perfect health, followed by death You will live 20 years, of which 10in full health and 10 yearsin this health below no problems in walking about no problems in walking about no problems in walking about Mobility noproblems washing or dressing noproblems washing or dressing no problems in walking about Self-care no problems in walking about moderateproblems doing usual activities moderateproblems doing usual activities Usual activities no problems in walking about extreme pain or discomfort severe pain or discomfort Pain slightlyanxious or depressed extremelyanxious or depressed no problems in walking about Anxiety

  14. Framing 2: endowment health state Assume you live 10 years in health state A. Which health state do you prefer, health state A or do you want to substitute for health state B? C A B 10 yearsin this health 10 yearsin this health state, followed by death state, followed by death no problems in walking about no problems in walking about Mobility noproblems washing or dressing noproblems washing or dressing Self-care moderateproblems doing usual activities moderateproblems doing usual activities Usual activities extreme pain or discomfort severe pain or discomfort Pain slightlyanxious or depressed extremelyanxious or depressed Anxiety

  15. Framing 3: reversed endowment Assume you would die immediately. Which health state do you prefer, health state A or do you want to substitute for health state B? C A B 10 yearsin this health 10 yearsin this health You die immediately state, followed by death state, followed by death no problems in walking about no problems in walking about Mobility noproblems washing or dressing noproblems washing or dressing Self-care moderateproblems doing usual activities moderateproblems doing usual activities Usual activities extreme pain or discomfort extreme pain or discomfort Pain slightlyanxious or depressed slightlyanxious or depressed Anxiety

  16. Framing 4: years of life lost Which health state do you prefer, B or C? B C 10 yearsin this health 10 yearsin this health You loose 3 out of the remaining 10 years state, followed by death state, followed by death no problems in walking about no problems in walking about no problems in walking about Mobility noproblems washing or dressing noproblems washing or dressing no problems in walking about Self-care no problems in walking about moderateproblems doing usual activities moderateproblems doing usual activities Usual activities no problems in walking about extreme pain or discomfort severe pain or discomfort Pain slightlyanxious or depressed extremelyanxious or depressed no problems in walking about Anxiety

  17. Methods www.eur.nl/ecmc Sample: Online panel (Dutch general population) 2,700 respondents (300 per arm) Respondents were randomly assigned to one of the 9 study arms

  18. Methods www.eur.nl/ecmc Sample: Online panel (Dutch general population) 2,700 respondents (300 per arm) Respondents were randomly assigned to one of the 9 study arms Experimental DCE design: Bayesian D-efficient design with 2*15 choices for each respondent jointly optimized for DCE duration and death Keeping all aspects of the DCE design constant except for the framing (!)

  19. Methods www.eur.nl/ecmc Estimations: • Bayesian mixed logit models • Comparisons between 9 study arms in terms of QALY tariffs (on a comparable scale)

  20. Results DCE duration www.eur.nl/ecmc

  21. Results DCE death www.eur.nl/ecmc

  22. Results – QALY scale www.eur.nl/ecmc

  23. Results – QALY scale www.eur.nl/ecmc

  24. Results – QALY scale www.eur.nl/ecmc

  25. Conclusion • Framing effects were substantial • Our harmonizing framings did not reconcile differences between health state values based on TTO and DCE • Interestingly, we found something else: our base case values were not that different anymore from TTO values

  26. Further research needed • 1) Our design was jointly optimized for ‘DCE duration’ and ‘DCE death’. •  QALY-balanced DCE designs (?) 2) The death parameter in DCE death might not be normally distributed.  Mixture of normals, dirichlet process prior (?) 3) Our results showed that the TTO values lay exactly between DCE duration and DCE death results  How desirable is it to “tweak” DCE to reach similar values as TTO?

  27. Previous & current DCE design www.eur.nl/ecmc

  28. Distribution of the death parameter www.eur.nl/ecmc

  29. Acknowledgement www.eur.nl/ecmc

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