EuroQol EQ-5D

1. EuroQol EQ-5D • Jan J. V. Busschbach, Ph.D • Psychotherapeutic Centrum ‘De Viersprong’, Halsteren • Jan.Busschbach@deviersprong.net • Department of Medical Psychology and Psychotherapy, Erasmus MC • Busschbach@mpp.fgg.eur.nl

2. EQ-5D • 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

3. The clinical perspective • It is not the doctor who reports • Quality of life is subjective….. • “Given its inherently subjective nature, consensus was quickly reached that quality of life ratings should, whenever possible, be elicited directly from patients themselves. “ (Aaronson, in B Spilker (Ed): Quality of life and Pharmacoeconomics in Clinical Trails, 1996, page 180) • As a CONSUMER of care, the patient is the best judged about the quality of care • The patient values count in clinical quality of life research

4. The economic perspective • In a normal market: the consumer values count • The patient seems to be the consumer • Thus the values of the patients…. • If indeed health care is a normal market… • But is it….?

5. Health care is not a normal market • Supply induced demands • Subsidies (egalitarian structure) • Government control • Health care is an insurance market • A compulsory insurance market • The patient does not pay • Patient  Consumer • Potential patients are paying • Consumer = General public

6. Who determines the payments of unemployment insurance? • Civil servant • Knowledge: professional • But strategy • more money, less problems • identify with unemployed persons • The unemployed persons themselves • Knowledge: specific • But strategy • General public (politicians) • Knowledge: experience • Payers

7. Who’s values (of quality of life) should count in the health insurance? • Doctors • Knowledge: professional • But strategy • But see only selection of patient (the complainers) • Patients • Knowledge: disease specific • But strategy • But coping • General public • Knowledge: experience • Payers

8. Patient values seem high • Stensman • Scan J Rehab Med 1985;17:87-99. • Scores on a visual analogue scale • 36 subjects in a wheelchair • 36 normal matched controls • Mean score • Wheelchair: 8.0 • Controls: 8.3

9. Is there a problem? • There is no problem... • if effect is linear • In the past, the general perspective was seen as a proxy for patient perspective • There is a problem... • If there is no linear transformation • Patient and general public perspective reveal different results • Loss of power in patient perspective

10. Patient Perspective

11. The Societal Perspective • 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

12. Describe health states Have values from the general public Rosser QWB 15D HUI Mark 2 HUI Mark 3 EuroQol EQ-5D Validated Questionnaires

13. EQ-5D • 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

14. EuroQol • EuroQol Group • Latest version: EQ-5D • 5 dimensions • Mobility, self-care, usual activities, pain / discomfort, anxiety / depression • 3 levels per dimension • 243 health states • Validation • Finland, Netherlands, Norway, Sweden, UK, Spain, Germany, Greece, US, Japan, New Zealand, Zimbabwe, Denmark • N = 200 - 3000

15. How to get these societal values? • Patient fills in questionnaire • Choose the value function from the literature • Calculate societal value COMPUTE MVH_A1 = 1. VARIABLE LABELS MVH_A1 'York A1 tariff'. DO IF (NVALID(mo, sc, ua, pd, ad) < 5 ). RECODE MVH_A1 (1 = SYSMIS). END IF. IF (MAX(mo, sc, ua, pd, ad) > 1) MVH_A1 = MVH_A1 -.081. IF (mo = 2) MVH_A1 = MVH_A1 - .069. IF (mo = 3) MVH_A1 = MVH_A1 - .314. IF (sc = 2) MVH_A1 = MVH_A1 - .104. IF (sc = 3) MVH_A1 = MVH_A1 - .214. IF (ua = 2) MVH_A1 = MVH_A1 - .036. IF (ua = 3) MVH_A1 = MVH_A1 - .094. IF (pd = 2) MVH_A1 = MVH_A1 - .123. IF (pd = 3) MVH_A1 = MVH_A1 - .386. IF (ad = 2) MVH_A1 = MVH_A1 - .071. IF (ad = 3) MVH_A1 = MVH_A1 - .236. IF (MAX(mo, sc, ua, pd, ad) > 2) MVH_A1 = MVH_A1 - .269.

16. An example of a value function * SPSS syntax Dolan 1997, Medical Care, 1997;35:1095-108. * mo = mobility, sc= self care, ua = usual activities, pd = pain & discomfort , ad = anxiety and depression. COMPUTE MVH_A1 = 1. VARIABLE LABELS MVH_A1 'York A1 tariff'. DO IF (NVALID(mo, sc, ua, pd, ad) < 5 ). RECODE MVH_A1 (1 = SYSMIS). END IF. IF (MAX(mo, sc, ua, pd, ad) > 1) MVH_A1 = MVH_A1 -.081. IF (mo = 2) MVH_A1 = MVH_A1 - .069. IF (mo = 3) MVH_A1 = MVH_A1 - .314. IF (sc = 2) MVH_A1 = MVH_A1 - .104. IF (sc = 3) MVH_A1 = MVH_A1 - .214. IF (ua = 2) MVH_A1 = MVH_A1 - .036. IF (ua = 3) MVH_A1 = MVH_A1 - .094. IF (pd = 2) MVH_A1 = MVH_A1 - .123. IF (pd = 3) MVH_A1 = MVH_A1 - .386. IF (ad = 2) MVH_A1 = MVH_A1 - .071. IF (ad = 3) MVH_A1 = MVH_A1 - .236. IF (MAX(mo, sc, ua, pd, ad) > 2) MVH_A1 = MVH_A1 - .269.

17. Some values • Broken arm • 12211 • no problems in walking about • some problems washing or dressing • some problems with performing usual activities • no pain or discomfort • not anxious or depressed • Societal value = 0.779

18. Some values • Broken hip • 22222 • some problems in walking about • some problems washing or dressing • some problems with performing usual activities • moderate pain or discomfort • moderately anxious or depressed • Societal value = 0.516

19. Impact on quality of life

20. Effect psychotherapy

21. Reimbursement arguments • Dunning’s Funnel • 1990 • Government declaration 2002 • Necessary care • Need • Equity elements • Efficacy • Cost effectiveness • Own account and responsibility

22. Reimbursement arguments Impact on QoL Effect on QoL Cost effectiveness ? QALYs

23. Quality Adjusted Life Years (QALY) • Multiply life years with quality index • Quality of life index • 1.0 = normal health • 0.0 = extremely bad health (death) • Example • Losing sense of sight • Quality of life index is 0.5 • Life = 80 years • 0.5 x 80 = 40 QALYs • Accepted measure of health • Used by the WHO (DALY)

24. QALY league table

25. EQ-5D and cost effectiveness • EQ-5D specially designed • Social perspective • Generic • 0 to 1 scale • Use EQ-5D for QALY analysis