A Value Set for the EQ-5D-Y-3L in the Netherlands

The Evolving Landscape of Discrete Choice Experiments in Health Economics: A Systematic Review

INTRODUCTION

Stakeholder preference evaluations are increasingly emphasized in healthcare policy and health technology assessment. Discrete choice experiments (DCEs) are the most common method for quantifying preferences among patients, the public, and healthcare professionals. While prior reviews (1990-2017) have examined DCE trends, no comprehensive synthesis exists for studies published since 2018. This updated review (2018-2023) provides critical insights into evolving methodologies and global trends in health-related DCEs.

METHODS

A systematic search (2018-2023) of Medline, Embase, and Web of Science identified relevant studies. Studies were screened for inclusion and data were extracted, including details on DCE design and analysis. To enable trend comparisons, the search strategy and extraction items aligned with previous reviews.

RESULTS

Of 2663 identified papers, 1279 met the inclusion criteria, reflecting a significant rise in published DCEs over time. DCEs were conducted globally, with a remarkable increase in publications from Asia and Africa compared with previous reviews. Experimental designs and econometric models have advanced, continuing prior trends. Notably, most recent DCEs were administered online.

DISCUSSION

The rapid growth of DCE applications underscores their importance in health research. While the methodology is advancing rapidly, it is crucial that researchers provide full transparency in reporting their methods, particularly in detailing experimental designs and validity tests, which are too often overlooked. Key recommendations include improving reporting of experimental designs, applying validity tests, following good practices for presenting benefit-risk attributes, and adopting open science practices. Ensuring methodological rigor will maximize the impact and reproducibility of DCE research in health economics.

An Acquired Taste: Latent Class Analysis to Compare Adolescent and Adult Preferences for EQ-5D-Y-3L Health States

OBJECTIVES

US stakeholders advised including adolescents in the valuation study for the EQ-5D-Y-3L, a step toward greater acknowledgment of children in informing societal values. This study aimed to assess the relative contribution of adolescent and adult preferences to a model when combined.

METHODS

Discrete choice experiment data were collected from an online sample of 1529 adults and 714 adolescents (ages 11-17). Each respondent completed 15 discrete choice experiment tasks, which were analyzed using latent class models representing varying number of preference classes. Within the best-fitting model, the contribution of each class was determined by the scale-adjusted class share (SACS), combining the class's proportion of respondents (class share) and the magnitude of coefficients (within-class scale). We estimated the contribution of adolescent and adult respondents to SACS for each class, with lower SACS representing less contribution to the combined model.

RESULTS

The best-fitting model described 6 classes. Adults had higher contribution to all except 1 class, accounting for 78.7% of the total contribution. After adjusting for the unequal sample size of adolescent and adult respondents, adults contributed approximately 65.0%, and adolescents contributed 35.0% of the weights toward a combined model.

CONCLUSIONS

Adolescents showed diminished, disproportionate representation in a combined model, due in part to more indifferent, less informative preferences for EQ-5D-Y-3L health states compared with adults. Latent class analysis showcases one approach to estimate and weight contributions from intentionally sampled subgroups in a combined model.

Omission of dexamethasone in paclitaxel premedication regimens: protocol of the multicentre, randomised, non-inferiority DEXASTOP trial

INTRODUCTION

Standard premedication for paclitaxel-based chemotherapy includes dexamethasone and an histamine 1-antagonist to prevent hypersensitivity reactions (HSRs). However, the pharmacological rationale for dexamethasone is limited, and its use is associated with adverse effects such as hyperglycaemia, insomnia and immunodeficiency, negatively impacting health-related quality of life (HRQoL). No clear link has been established between dexamethasone dose, administration route and HSR incidence. Previous studies suggest that discontinuing dexamethasone beyond the second administration does not increase HSR risk. Despite this, dexamethasone remains standard practice. This trial evaluates whether complete omission of dexamethasone as paclitaxel premedication is non-inferior to the standard regimen in preventing clinically relevant HSRs (Common Terminology Criteria for Adverse Events (CTCAE) grade≥3).

METHODS

The DEXASTOP trial is a prospective, multicentre, randomised, non-inferiority study conducted in four hospitals in the Netherlands. 500 adult patients receiving paclitaxel-based chemotherapy for any solid tumour indication will be randomised 1:1 to receive either standard premedication with dexamethasone or an experimental regimen without dexamethasone for up to five paclitaxel administrations. The primary endpoint is the incidence of clinically relevant HSRs (CTCAE grade≥3). Secondary endpoints include the incidence and severity of all-grade HSRs, the number of paclitaxel administrations before the first HSR, dexamethasone-related adverse events, HRQoL and cost-effectiveness from a healthcare and societal perspective.

ETHICS AND DISSEMINATION

This study has been approved by the Erasmus Medical Centre Ethics Committee (reference MEC-2024-0030, protocol version 3, May 2024). Study findings will be published open access in peer-reviewed journals and presented at national and international meetings. Results will be shared with patients, healthcare professionals and the public. Positive outcomes will be implemented in clinical practice, and trial data will be submitted to the EU Clinical Trials Information System for public access.

TRIAL REGISTRATION NUMBER

NCT06118710.

Measurement Properties of the EQ-5D Instruments in Children and Adolescents: A Systematic Review

BACKGROUND

The EQ-5D instruments have been widely used to measure health-related quality of life (HRQoL) in child and adolescent populations, especially the EQ-5D-Y-3L and EQ-5D-Y-5L (beta version). Although not specifically designed for younger users, the adult versions (EQ-5D-3L and EQ-5D-5L) are also used in these populations. While the measurement properties of these instruments have been evaluated in children and adolescents, no systematic review to date has employed a rigorous method to assess risk of bias. Additionally, quality criteria for good measurement properties and certainty of evidence have not been thoroughly evaluated. The aim of this study was to summarize and critically appraise the evidence on the measurement properties of all EQ-5D instruments in children and adolescents.

METHODS

We conducted electronic searches on MEDLINE, EMBASE, CINAHL, EconLit, National Health Service Economic Evaluation Database (NHS-EED), and Health Technology Assessment (HTA) databases up to May 2024. We included studies measuring HRQoL using either the self-reported or proxy-reported version of the EQ-5D instruments-EQ-5D-3L, EQ-5D-5L, EQ-5D-Y-3L, and EQ-5D-Y-5L-using the descriptive system, visual analogue scale, and/or utility score in children and adolescents up to 19 years of age, and that tested at least one measurement property (e.g., reliability). The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology was followed to assess risk of bias, to score results for measurement properties, and to perform an evidence synthesis using a modified Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach.

RESULTS

From 3586 records identified through the search, 65 studies were included in this systematic review. We found moderate certainty of evidence of sufficient comprehensibility and comprehensiveness of the EQ-5D-Y-3L and EQ-5D-Y-5L. Furthermore, we found very low certainty of evidence of inconsistent relevance for the EQ-5D-Y-3L, whereas the EQ-5D-Y-5L had sufficient relevance. Almost all the measurement properties (reliability, hypothesis testing for construct validity, and responsiveness) considering all the EQ-5D versions ranged from moderate certainty of evidence of insufficient results to very low certainty of evidence of insufficient results.

CONCLUSION

There is moderate certainty of evidence that the EQ-5D-Y-3L and EQ-5D-Y-5L have sufficient content validity. Both instruments can be recommended to measure HRQoL in children and adolescents aged 8-15 years. However, most of the measurement properties across all EQ-5D versions showed insufficient results, with certainty of evidence ranging from moderate to very low due to inconsistency and doubtful to inadequate risk of bias. Therefore, further research is needed to improve the methodological quality of studies on EQ-5D instruments for children and adolescents.

SYSTEMATIC REVIEW REGISTRATION

International prospective register of systematic reviews (PROSPERO): CRD42020218382 and Open Science Framework: https://osf.io/r8kt9/ .

Exploring the feasibility of using discrete choice experiment (DCE) to elicit preferences among children and adolescents: protocol for a convergent parallel mixed methods study

INTRODUCTION

Discrete choice experiments (DCEs) are increasingly used to elicit value sets for paediatric health-related quality of life instruments, including the EQ-5D-Y. In a multinational pilot study that compared EQ-5D-Y-5L health state preferences among children, adolescents and adults, more inconsistencies in DCE responses were observed among children and adolescents than adults. Possible explanations for inconsistencies could be youths' limited understanding of health state preferences or lack of engagement with the online survey. This protocol describes the methods of a study that explores the feasibility of eliciting health state preferences for the EQ-5D-Y-5L from Canadian children and adolescents using DCE.

METHODS AND ANALYSIS

A convergent parallel mixed methods study will be conducted with a purposive, stratified sample of 36 Canadian children and adolescents (13-18 years). In the quantitative study component, participants will complete an online questionnaire with EQ-5D-Y-5L and DCE exercises. The quantitative data on participants' sociodemographic characteristics, EQ-5D-Y-5L, and feasibility indicators of DCE (ie, incompletion, speeding, flatlining, violation of dominant choice task) will be analysed using descriptive statistics. The second component will be a qualitative focus group discussion to understand their experiences of completing the DCE tasks. Six focus groups (with six participants per group) will be conducted. The qualitative data will be analysed using content analysis. The findings from both components will then be integrated using narrative synthesis.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Hamilton Integrated Research Ethics Board (#17034). We will publish findings in peer-reviewed journals and present at key conferences. We will also disseminate results within the EuroQol community as the study findings are part of a methodological research programme aimed at informing the design of an EQ-5D-Y-5L valuation study in Canada.

Cost-effectiveness of support for health professionals to implement physical activity promotion: a protocol for within-trial and modelled economic evaluations of the PROMOTE-PA effectiveness-implementation hybrid trial

INTRODUCTION

Physical activity has important benefits for the prevention and management of chronic diseases and healthy ageing. Health professionals have valuable opportunities to promote physical activity to a large group of people across the lifespan. Promotion of Physical Activity by Health Professionals is a hybrid type 1 effectiveness-implementation cluster randomised trial designed to evaluate the impact of physical activity promotion by health professionals (n=30 clusters) on physical activity participation in their patients (n=720). To inform the future implementation of this programme, we will be conducting a within-trial and modelled economic evaluation.

METHODS AND ANALYSIS

We will conduct a cost-effectiveness and cost-utility analysis from the perspective of the healthcare, aged care and disability funder. The time horizon will be 6 months for the within-trial analysis and 2 years for the modelled analysis. Data on intervention costs will be collected using trial records. Data on healthcare utilisation will be collected using data linkage. Incremental cost-effectiveness ratios (ICERs) will be reported for physical activity and quality-adjusted life years outcomes. Bootstrapping will be used to explore uncertainty around the ICERs and estimate 95% CIs. Results will be presented on a cost-effectiveness plane. The probability that the intervention would be cost-effective at varying willingness-to-pay thresholds will be presented using a cost-effectiveness acceptability curve.

ETHICS AND DISSEMINATION

Ethics approval was obtained through Sydney Local Health District (RPAH zone) Ethics Review Committee (X23-0197). The findings of this study will be disseminated through peer-reviewed journal articles and conference presentations.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry: ACTRN12623000920695.

Care Coordination for Children with Neurodevelopmental Disorders and Medical Complexity: Is Child Behavioral Health a Key Mediator of Caregiver Stress?

INTRODUCTION

Children with neurodevelopmental disorders and medical complexity experience care that is fragmented, costly, and ineffective, causing health disparities and harm. The Neurodevelopmental Disorders Care Coordination (NDD-CC) program addresses these issues by connecting families with support across medical and social services. While NDD-CC has improved outcomes in several areas, many families continue to experience challenges.

OBJECTIVE

Using data from a longitudinal study, we investigated patterns of change across child health and behavior and caregiver stress during care coordination (CC).

METHODS

We performed an exploratory analysis of prospectively collected data from 67 caregivers of children with a neurodevelopmental disorder aged 2 to 17 years referred for CC. We examined changes in child health states (EQ-5D-Y), care-related quality of life (CarerQoL), and parenting stress (Parental Stress Index-Short Form) to assess impacts of CC over time and within subgroups.

RESULTS

Most caregivers who reported CarerQoL scores in the bottom half of the distribution at baseline saw improvements at 3 (89%) and 12 months (71%). Gains were strongly associated with improvements in mental health at both time points. Similarly, child health states in the bottom half of the distribution improved the most. The difficult child domain of the parenting stress index was the key contributor to clinically significant stress scores, and changes in the difficult child score were negatively associated with changes in CarerQoL, explaining 36% of the variance.

CONCLUSION

Findings show that CC has the most impact on those with the greatest need; yet clinically significant child behavior may prevent sustained improvements if left unaddressed.

Comparison of EQ-5D-Y-3L Utility Scores Using Nine Country-Specific Value Sets in Chinese Adolescents

OBJECTIVE

This study aimed to assess and compare the measurement properties of EQ-5D-Y-3L utilities derived from available countries' value sets (Chinese, Japanese, Slovenian, German, Spanish, Hungarian, Netherlandish, Belgian, and Indonesian), among Chinese adolescents.

METHODS

From July to September 2021, a large-scale cross-sectional survey was administered across 16 cities in Shandong, China, with the objective of assessing the health status of junior high school students aged 10-18 years. Supported by the educational authorities, quick response (QR) codes and questionnaire links were disseminated to schools. A total of 97,413 junior high school students completed the questionnaire. Agreement, convergent validity, and known-group validity were determined in the nine country-specific value sets.

RESULTS

The Indonesian value set demonstrated the highest mean health utility score (0.970), followed by the Japanese (0.961), Chinese (0.960), Netherlandish (0.948), Hungarian (0.942), German (0.938), Belgian (0.932), Slovenian (0.926), and Spanish (0.926) value sets, respectively. The utility scores derived from Asian value sets were higher than those from Europe. Good or excellent agreements (intraclass correlation coefficients > 0.7) were found between each paired value set. In Bland-Altman plots, the 95% limits of agreement for any two value sets were 0.046-0.348. A strong relationship (Spearman's correlation coefficients > 0.99) between any two value sets was found. The EQ-5D-Y-3L utility scores discriminated equally well for the nine value sets across three known groups. The effect size and the relative efficiency statistics showed the Chinese value sets were more sensitive in general. Referring to the Chinese value set, all the relative efficiency values in each value set were similar across three known groups, ranging from 0.9 to 1.0.

CONCLUSIONS

A total of nine country-specific EQ-5D-Y-3L value sets showed an overall high level of agreement, strong correlation, and good known-group validity. However, the utility scores derived from nine EQ-5D-Y-3L value sets were different and the country-specific value sets were not interchangeable.

A head-to-head comparison of the adult EQ-5D-5L and youth EQ-5D-Y-5L in adolescents with idiopathic scoliosis

BACKGROUND

Multiple diseases, such as Adolescent Idiopathic Scoliosis (AIS), present at adolescent age and the impact on quality of life (QoL) prolongs into adulthood. For the EQ-5D, a commonly used instrument to measure QoL, the current guideline is ambiguous whether the youth or adult version is to be preferred at adolescent age. To assess which is most suitable, this study tested for equivalence along predefined criteria of the youth (EQ-5D-5L) and adult (EQ-5D-Y-5L) version in an adolescent population receiving bracing therapy for AIS.

METHODOLOGY

107 adolescents were recruited from 4 scoliosis centers in the Netherlands between March 2022 and January 2023; they completed both EQ-5D's and the SRS-22r (scoliosis-specific questionnaire). The following criteria were evaluated using the individual and sum of domains (level-sum-score (LSS)). Our primary criterion for non-equivalence of the EQ-5D's was less than excellent (≤ 0.9) intra-individual agreement using Intraclass Correlation Coefficient (ICC) analysis for LSS and weighted (quadratic) kappa for domains. Secondary criteria were differences in ceiling using McNemar test; a different number of quantified hypotheses for construct validity achieved using the SRS-22r as comparator; differences in test-retest reliability by comparing ICC/kappa values using a Z-test.

RESULTS

Adolescents had a mean age of 14 years (range 12-18), and 78% were female. Ceiling was mostly comparable between EQ-5D's, ranging from 78 to 81% for mobility and self-care, 52-54% for usual activities, and 31-36% for pain/discomfort. The EQ-5D-5L showed more ceiling (57%) compared to the EQ-5D-Y-5L (41%) on anxiety/depression (p = 0.006). Agreement between the EQ-5D's did not meet our criterion for the LSS (ICC 0.79 (95% confidence interval 0.70-0.85)), and decreased further at the domain-level. Both EQ-5D's achieved 5/7 validity hypotheses. Test-retest reliability was slightly better for EQ-5D-5L LSS (ICC 0.76 (0.64-0.84)) compared to EQ-5D-Y-5L LSS (ICC 0.69 (0.55-0.79)), although this was statistically insignificant (p = 0.284). This pattern was similar for most domains.

CONCLUSIONS

The EQ-5D versions showed insufficient agreement, and cannot be considered fully equivalent. While they were similar in terms of validity and test-retest reliability, differences in score distribution were present. Taken together, we advise using the EQ-5D-5L to monitor the QoL in adolescent patients with AIS, as it avoids switching instruments and thus data discontinuities. Future studies should verify these findings in different patient groups and the general population.

The societal burden associated with adolescent idiopathic scoliosis: a cross-sectional burden-of-disease study

BACKGROUND

In the general population the prevalence of adolescent idiopathic scoliosis (AIS) is 2-3%. There is growing awareness of how AIS affects the quality of life of patients. However, the extent of the societal burden AIS poses remains poorly understood. Therefore, this study aimed to determine the societal burden of AIS.

METHODS

A cross-sectional burden of disease study was conducted using a bottom-up, prevalence-based approach. Patients with AIS or guardians of a child diagnosed with AIS residing in the Netherlands were eligible for inclusion. The survey was distributed between June - December 2022 and was completed once by each participant. Costs were assessed using the institute for Medical Technology Assessment - Medical Consumption and Productivity Cost Questionnaires. The health-related quality of life (HRQoL) was assessed using the EuroQol 5D-5L/EuroQol 5D Youth and the Scoliosis Research Society-22 revised questionnaires. Costs and HRQoL were identified, measured, and valued.

RESULTS

Participants (n = 229) were predominantly female (92%), on average 35 years old, and were employed (65%). The societal cost for a patient with AIS in the Netherlands was €12,275 per year. The largest costs were estimated for the healthcare and productivity losses. The mean utility score for adults was 0.7 (SD 0.20). Severe pain was experienced by 10% of the adult participants and 44% reported to experience moderate pain/discomfort. Statistically significant differences between different age groups were present for the sector costs and HRQoL.

CONCLUSIONS

AIS negatively impacts societal costs and the HRQoL. Reducing the burden that is posed on the productivity sector by AIS and further improving the HRQoL for AIS patients is needed.

A Direct Comparison Between Discrete Choice With Duration and Composite Time Trade-Off Methods: Do They Produce Similar Results?

OBJECTIVES

Discrete choice experiments including a duration attribute (DCEd) represent a promising candidate method for valuing health-related quality-of-life instruments. However, it has not been established that DCEd can produce similar results as composite time trade-off (cTTO) or EuroQol Valuation Technology (EQ-VT) valuations of the EQ-5D-5L instrument. This study provides a direct comparison between cTTO and EQ-VT, and DCEd valuation methods.

METHODS

An EQ-VT study was conducted in Trinidad and Tobago to value the EQ-5D-5L. 1079 respondents each completed 10 cTTO tasks and 12 discrete choice experiments tasks without a duration attribute. A separate sample of 970 respondents each completed 18 split-triplet DCEd tasks. Several regression models were applied to the EQ-VT data, and the DCEd data were analyzed using mixed logit models with an exponential discount rate. The estimated values were compared using scatterplots and Bland-Altman plots.

RESULTS

The ordering of dimensions was identical in level 5 for cTTO/EQ-VT and DCEd models, with pain/discomfort being the most important dimension and usual activities being least important. cTTO/EQ-VT models produced a value for state 55555 ranging between -0.52 and -0.69, whereas this was -0.543 for the nonlinear mixed logit model for the DCEd data. Scatterplots and Bland-Altman plots suggested excellent agreement between cTTO/EQ-VT and DCEd-based estimates.

CONCLUSIONS

CTTO/EQ-VT and DCEd valuations produce similar results when correcting DCEd for nonlinear time preferences. The ordering of importance of the dimensions and scale are identical, suggesting that the 2 methods measure the same construct and produce similar results.

Estimating an EQ-5D-Y-3L Value Set for Brazil

INTRODUCTION

The EQ-5D-Y-3L is a generic measure of health-related quality of life in children and adolescents. Although the Brazilian-Portuguese EQ-5D-Y-3L version is available, there is no value set for it, hampering its use in economic evaluations. This study aimed to elicit a Brazilian EQ-5D-Y-3L value set based on preferences of the general adult population.

METHODS

Two independent samples of adults participated in an online discrete choice experiment (DCE) survey and a composite time trade-off (cTTO) face-to-face interview. The framing was "considering your views for a 10-year-old child". DCE data were analyzed using a mixed-logit model. The 243 DCE predicted values were mapped into the observed 28 cTTO values using linear and non-linear mapping approaches with and without intercept. Mapping approaches' performance was assessed to estimate the most valid method to rescale DCE predicted values using the model fit (R2), Akaike Information Criteria (AIC), root mean squared error (RMSE), and mean absolute error (MAE).

RESULTS

A representative sample of 1376 Brazilian adults participated (DCE, 1152; cTTO, 211). The linear mapping without intercept (R2 = 96%; AIC, - 44; RMSE, 0.0803; MAE, - 0.0479) outperformed the non-linear without intercept (R2 = 98%; AIC, - 63; RMSE, 0.1385; MAE, - 0.1320). Utilities ranged from 1 (full health) to - 0.0059 (the worst health state). Highest weights were assigned to having pain or discomfort (pain/discomfort), followed by walking about (mobility), looking after myself (self-care), doing usual activities (usual activities), and feeling worried, sad, or unhappy (anxiety/depression).

CONCLUSION

This study elicited the Brazilian EQ-5D-Y-3L value set using a mixed-logit DCE model with a power parameter based on a linear mapping without intercept, which can be used to estimate the quality-adjusted life-years for economic evaluations of health technologies targeting the Brazilian youth population.

Who should value children's health and how? An international Delphi study

Valuing child health necessitates normative methodological decisions on whose preferences should be elicited and who should be imagined as experiencing impaired health. Formal guidance is limited and expert consensus unclear. This study sought to establish the degree of consensus among expert stakeholders on normative issues of who to ask and who should be imagined when valuing child health (7-17 years) to inform UK health technology assessment. Sixty-two experts (n = 47 in Round 2) from 18 countries participated in a modified, two-round online Delphi survey (Round 1: May-June 2023; Round 2: September-October 2023). Participants were expert stakeholders in child health valuation, including academics (n = 38); industry/consultancy representatives (including the charity/not-for-profit sector; n = 13); and UK policy/government representatives (n = 11). The Delphi survey was modified between rounds and consisted of 9-point Likert, categorical, multiple-choice, and free-text questions on normative issues in valuing child health. Responses were analysed descriptively and thematically. An a priori criterion of ≥75% agreement was established for formal consensus, while areas approaching consensus (≥70% agreement) and without consensus were identified as a future research primer. Consensus was observed that older adolescents (aged 16-17 years) and adults (18+ years) should be asked to value child health states. There was consensus that the former should think about themselves when valuing the health states and the latter should imagine a child of some form (e.g., imagining themselves as a child or another hypothetical child). However, no consensus was evident on what form this should take. Several other methodological issues also reached consensus. These findings are largely consistent with recent views elicited qualitatively from members of the public and other stakeholders on normative issues in valuing child health. The results mean that, contrary to what has been done in previous child health valuation studies, efforts should be made to involve both older adolescents (16+ years) and adults in child health valuation.

Cost-utility analysis of Social Stories™ for children with autism spectrum disorder in mainstream primary schools: results from a randomised controlled trial

BACKGROUND

One in 57 children are diagnosed with autism in the UK, and the estimated cost for supporting these children in education is substantial. Social Stories™ is a promising and widely used intervention for supporting children with autism in schools and families. It is believed that Social Stories™ can provide meaningful social information to children that can improve social understanding and may reduce anxiety. However, no economic evaluation of Social Stories has been conducted.

AIMS

To assess the cost-effectiveness of Social Stories through Autism Spectrum Social Stories in Schools Trial 2, a multi-site, pragmatic, cluster-randomised controlled trial.

METHOD

Children with autism who were aged 4-11 years were recruited and randomised (N = 249). Costs measured from the societal perspective and quality-adjusted life-years (QALYs) measured by the EQ-5D-Y-3L proxy were collected at baseline and at 6-month follow-up for primary analysis. The incremental cost-effectiveness ratio was calculated, and the uncertainty around incremental cost-effectiveness ratios was captured by non-parametric bootstrapping. Sensitivity analyses were performed to evaluate the robustness of the primary findings.

RESULTS

Social Stories is likely to result in a small cost savings (-£191 per child, 95% CI -767.7 to 337.7) and maintain similar QALY improvements compared with usual care. The probability of Social Stories being a preferred option is 75% if society is willing to pay £20 000 per QALY gained. The sensitivity analysis results aligned with the main study outcomes.

CONCLUSIONS

Compared with usual care, Social Stories did not lead to an increase in costs and maintained similar QALY improvements for primary-aged children with autism.

Psychometric Performance Comparison of the Adapted versus Original Versions of the EQ-5D-Y-3L and -Y-5L in Proxy Respondents for 2- to 4-Year-Olds

INTRODUCTION

Few preference-weighted instruments are available to measure health-related quality of life in young children (2-4 years of age). The EQ-5D-Y-3L and EQ-5D-Y-5L were recently modified for this purpose.

OBJECTIVE

The aim of this study was to test the psychometric properties of these adapted versions for use with parent proxies of children aged 2-4 years and to compare their performance with the original versions. It was hypothesised that the adapted instrument wording would result in improved psychometric performance.

METHODS

Survey data of children aged 2-4 years were obtained from the Australian Paediatric Multi-Instrument Comparison study. Distributional and psychometric properties tested included feasibility, convergence, distribution of level scores, ceiling effects, known-group validity (Cohen's D effect sizes for prespecified groups defined by the presence/absence of special healthcare needs [SHCNs]), test-retest reliability (intraclass correlation coefficients [ICCs]), and responsiveness (standardised response mean [SRM] effect sizes for changes in health). Level sum scores were used to provide summary outcomes. Supplementary analysis using utility scores (from the Swedish EQ-5D-Y-3L value set) were conducted for the adapted and original EQ-5D-Y-3L, and no value sets were available for the EQ-5D-Y-5L.

RESULTS

A total of 842 parents of children aged 2-4 years completed the survey. All instruments were easy to complete. There was strong convergence between the adapted and original EQ-5D-Y-3L and EQ-5D-Y-5L. The adapted EQ-5D-Y-3L and adapted EQ-5D-Y-5L showed more responses in the severe levels of the five EQ-5D-Y dimensions, particularly in the usual activity and mobility dimensions (EQ-5D-Y-5L: mobility level 1: adapted n = 478 [83%], original n = 253 [94%]; mobility level 4/5: adapted n = 17 [2.9%], original n = 4 [1.5%)]). The difference in the distribution of responses was more evident in children with SHCNs. Assessment of known-group validity showed a greater effect size for the adapted EQ-5D-Y-3L and adapted EQ-5D-Y-5L compared with the original instruments (EQ-5D-Y-5L: adapted Cohen's D = 1.01, original Cohen's D = 0.83) between children with and without SHCNs. The adapted EQ-5D-Y-3L and adapted EQ-5D-Y-5L showed improved reliability at 4-week follow-up, with improved ICCs (EQ-5D-Y-5L: adapted ICC = 0.83, original ICC = 0.44). The responsiveness of all instruments moved in the hypothesised direction for better or worse health at follow-up. Probability of superiority analysis showed little/no differences between the adapted and original EQ-5D-Y-3L and EQ-5D-Y-5L. Supplementary psychometric analysis of the adapted and original EQ-5D-Y-3L using utilities showed comparable findings with analyses using level sum scores.

CONCLUSIONS

The findings suggest improved psychometric performance of the adapted version of the EQ-5D-Y-3L and EQ-5D-Y-5L in children aged 2-4 years compared with the original versions.

Multilevel Characteristics of Cumulative Symptom Burden in Young Survivors of Childhood Cancer

Importance

Symptom burden and its characteristics among survivors of pediatric cancers aged 8 to 18 years remain understudied.

Objective

To examine the prevalence of symptom burden among young childhood cancer survivors and identify associations with sociodemographic, clinical, and psychological resilience skills, and health-related quality of life (HRQOL).

Design, Setting, and Participants

A cross-sectional analysis using data collected from November 1, 2017, to January 31, 2019, in a survivorship clinic at a US-based comprehensive cancer center was conducted. Participants included 302 dyads of children aged 8 to 18 years who survived at least 5 years beyond diagnosis and their primary caregivers. Data analysis was performed from March 13, 2023, to February 29, 2024.

Exposures

Diagnosis, caregiver-reported family conflict, self-reported caregiver anxiety, neighborhood-level social vulnerability, and survivor-reported meaning and purpose.

Main Outcomes and Measures

Novel symptom-level burden, integrating the attributes of severity and daily activity interference using the pediatric version of the Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events, global cumulative symptom burden, and HRQOL using the EuroQol-5D. Multinomial logistic regression identified characteristics associated with symptom burden; linear regression assessed symptom burden and HRQOL associations.

Results

Among 302 survivors (mean [SD] age, 14.2 [2.9] years, mean [SD] time since diagnosis, 10.9 [2.9] years; 153 [50.7%] male), 186 (62.0%) had low, 77 (25.7%) moderate, and 37 (12.3%) high global cumulative symptom burden. Greater caregiver anxiety was associated with moderate (risk ratio [RR], 1.56; 95% CI, 1.09-2.24) global symptom burden. Greater neighborhood deprivation was associated with moderate global symptom burden (RR, 4.86; 95% CI, 1.29-18.26). Survivors with greater meaning/purpose were less likely to have moderate (RR, 0.42; 95% CI, 0.29-0.61) and high (RR, 0.27; 95% CI, 0.16-0.46) global symptom burden. The burden of individual symptoms displayed similar patterns. Low (Cohen d, -0.60; 95% CI, -0.87 to -0.32) and moderate/high (d, -0.98; 95% CI, -1.53 to -0.43) general pain, moderate/high numbness (d, -0.99; 95% CI, -1.69 to -0.29), and moderate/high worry (d, -0.55; 95% CI, -0.99 to -0.11) were associated with lower HRQOL.

Conclusions and Relevance

In this cross-sectional study of young childhood cancer survivors, symptom burden was prevalent. Caregiver anxiety and disparity-related neighborhood factors were associated with greater symptom burden, whereas meaning and purpose was a protective factor. Greater specific symptom burden contributed to poorer HRQOL. The findings suggest that interventions targeting resilience and neighborhood adversity may alleviate symptom burden and improve HRQOL.

Understanding Canadian stakeholders' views on measuring and valuing health for children and adolescents: a qualitative study

OBJECTIVE

Valuing child health is critical to assessing the value of healthcare interventions for children. However, there remain important methodological and normative issues. This qualitative study aimed to understand the views of Canadian stakeholders on these issues.

METHODS

Stakeholders from health technology assessment (HTA) agencies, pharmaceutical industry representatives, healthcare providers, and academic researchers/scholars were invited to attend an online interview. Semi-structured interviews were designed to focus on: (1) comparing the 3-level and 5-level versions of the EQ-5D-Y; (2) source of preferences for valuation (adults vs. children); (3) perspective of valuation tasks; and (4) methods for valuation (discrete choice experiment [DCE] and its variants versus time trade-off [TTO]). Participants were probed to consider HTA guidelines, cognitive capacity, and potential ethical concerns. All interviews were recorded and transcribed verbatim. Framework analysis with the incidence density method was used to analyze the data.

RESULTS

Fifteen interviews were conducted between May and September 2022. 66.7% (N = 10) of participants had experience with economic evaluations, and 86.7% (N = 13) were parents. Eleven participants preferred the EQ-5D-Y-5L. 12 participants suggested that adolescents should be directly involved in child health valuation from their own perspective. The participants were split on the ethical concerns. Eight participants did not think that there was ethical concern. 11 participants preferred DCE to TTO. Among the DCE variants, 6 participants preferred the DCE with duration to the DCE with death.

CONCLUSIONS

Most Canadian stakeholders supported eliciting the preferences of adolescents directly from their own perspective for child health valuation. DCE was preferred if adolescents are directly involved.

The RETRIEVE Checklist for Studies Reporting the Elicitation of Stated Preferences for Child Health-Related Quality of Life

BACKGROUND

Recent systematic reviews show varying methods for eliciting, modelling, and reporting preference-based values for child health-related quality-of-life (HRQoL) outcomes, thus producing value sets with different characteristics. Reporting in many of the reviewed studies was found to be incomplete and inconsistent, making them difficult to assess. Checklists can help to improve standards of reporting; however, existing checklists do not address methodological issues for valuing child HRQoL. Existing checklists also focus on reporting methods and processes used in developing HRQoL values, with less focus on reporting of the values' key characteristics and properties. We aimed to develop a checklist for studies generating values for child HRQoL, including for disease-specific states and value sets for generic child HRQoL instruments.

DEVELOPMENT

A conceptual model provided a structure for grouping items into five modules. Potential items were sourced from an adult HRQoL checklist review, with additional items specific to children developed using recent reviews. Checklist items were reduced by eliminating duplication and overlap, then refined for relevance and clarity via an iterative process. Long and short checklist versions were produced for different user needs. The resulting long RETRIEVE contains 83 items, with modules for reporting methods (A-D) and characteristics of values (E), for researchers planning and reporting child health valuation studies. The short RETRIEVE contains 14 items for decision makers or researchers choosing value sets.

CONCLUSION

Applying the RETRIEVE checklists to relevant studies suggests feasibility. RETRIEVE has the potential to improve completeness in the reporting of preference-based values for child HRQOL outcomes and to improve assessment of preference-based value sets.

Using Age-Specific Values for Pediatric HRQoL in Cost-Effectiveness Analysis: Is There a Problem to Be Solved? If So, How?

Value sets for the EQ-5D-Y-3L published to date appear to have distinctive characteristics compared with value sets for corresponding adult instruments: in many cases, the value for the worst health state is higher and there are fewer values < 0. The aim of this paper is to consider how and why values for child and adult health differ; and what the implications of that are for the use of EQ-5D-Y-3L values in economic evaluations to inform healthcare resource allocation decisions. We posit four potential explanations for the differences in values: (a) The wording of severity labels may mean the worst problems on the EQ-5D-Y-3L are descriptively less severe than those on the EQ-5D-5L; (b) Adults may genuinely consider that children are less badly affected than adults by descriptively similar health issues. That is, for any given health problem, adult respondents in valuation studies consider children's overall health-related quality of life (HRQoL) on average to be higher than that for adults; (c) Values are being sought by eliciting adults' stated preferences for HRQoL in another person, rather than in themselves (regardless of whether the 'other person' concerned is a child); and (d) The need to elicit preferences for child HRQoL that are anchored at dead = 0 invokes special considerations regarding children's survival. Existing evidence does not rule out the possibility that (c) and (d) exert an upward bias in values. We consider the implications of that for the interpretation and use of values for pediatric HRQoL. Alternative methods for valuing children's HRQoL in a manner that is not 'age specific' are possible and may help to avoid issues of non-comparability. Use of these methods would place the onus on health technology assessment bodies to reflect any special considerations regarding child quality-adjusted life-year gains.

Discrete Choice Experiments in Health State Valuation: A Systematic Review of Progress and New Trends

BACKGROUND

Discrete choice experiments (DCEs) are increasingly used in health state valuation studies.

OBJECTIVE

This systematic review updates the progress and new findings of DCE studies in the health state valuation, covering the period since the review of June 2018 to November 2022. The review reports the methods that are currently being used in DCE studies to value health and study design characteristics, and, for the first time, reviews DCE health state valuation studies published in the Chinese language.

METHODS

English language databases PubMed and Cochrane, and Chinese language databases Wanfang and CNKI were searched using the self-developed search terms. Health state valuation or methodology study papers were included if the study used DCE data to generate a value set for a preference-based measure. Key information extracted included DCE study design strategies applied, methods for anchoring the latent coefficient on to a 0-1 QALY scale and data analysis methods.

RESULTS

Sixty-five studies were included; one Chinese language publication and 64 English language publications. The number of health state valuation studies using DCE has rapidly increased in recent years and these have been conducted in more countries than prior to 2018. Wide usage of DCE with duration attributes, D-efficient design and models accounting for heterogeneity has continued in recent years. Although more methodological consensus has been found than in studies conducted prior to 2018, this consensus may be driven by valuation studies for common measures with an international protocol (the 'model' valuation research). Valuing long measures with well-being attributes attracted attention and more realistic design strategies (e.g., inconstant time preference, efficient design and implausible states design) were identified. However, more qualitative and quantitative methodology study is still necessary to evaluate the effect of those new methods.

CONCLUSIONS

The use of DCEs in health state valuation continues to grow dramatically and the methodology progress makes the method more reliable and pragmatic. However, study design is driven by international protocols and method selection is not always justified. There is no gold standard for DCE design, presentation format or anchoring method. More qualitative and quantitative methodology study is recommended to evaluate the effect of new methods before researchers make methodology decisions.

Efficient Designs for Valuation Studies That Use Time Tradeoff (TTO) Tasks to Map Latent Utilities from Discrete Choice Experiments to the Interval Scale: Selection of Health States for TTO Tasks

BACKGROUND

In eliciting utilities to value multiattribute utility instruments, discrete choice experiments (DCEs) administered online are less costly than interviewer-facilitated time tradeoff (TTO) tasks. DCEs capture utilities on a latent scale and are often coupled with a small number of TTO tasks to anchor utilities to the interval scale. Given the costly nature of TTO data, design strategies that maximize value set precision per TTO response are critical.

METHODS

Under simplifying assumptions, we expressed the mean square prediction error (MSE) of the final value set as a function of the number J of TTO-valued health states and the variance VJ of the states' latent utilities. We hypothesized that even when these assumptions do not hold, the MSE 1) decreases as VJ increases while holding J fixed and 2) decreases as J increases while holding VJ fixed. We used simulation to examine whether there was empirical support for our hypotheses a) assuming an underlying linear relationship between TTO and DCE utilities and b) using published results from the Dutch, US, and Indonesian EQ-5D-5L valuation studies.

RESULTS

Simulation set (a) supported the hypotheses, as did simulations parameterized using valuation data from Indonesia, which showed a linear relationship between TTO and DCE utilities. The US and Dutch valuation data showed nonlinear relationships between TTO and DCE utilities and did not support the hypotheses. Specifically, for fixed J, smaller values of VJ reduced rather than increased the MSE.

CONCLUSIONS

Given that, in practice, the underlying relationship between TTO and DCE utilities may be nonlinear, health states for TTO valuation should be placed evenly across the latent utility scale to avoid systematic bias in some regions of the scale.

HIGHLIGHTS

Valuation studies may feature a large number of respondents completing discrete choice tasks online, with a smaller number of respondents completing time tradeoff (TTO) tasks to anchor the discrete choice utilities to an interval scale.We show that having each TTO respondent complete multiple tasks rather than a single task improves value set precision.Keeping the total number of TTO respondents and the number of tasks per respondent fixed, having 20 health states directly valued through TTO leads to better predictive precision than valuing 10 health states directly.If DCE latent utilities and TTO utilities follow a perfect linear relationship, choosing the TTO states to be valued by weighting on the 2 ends of the latent utility scale leads to better predictive precision than choosing states evenly across the latent utility scale.Conversely, if DCE latent utilities and TTO utilities do not follow a linear relationship, choosing the states to be valued using TTO evenly across the latent utility scale leads to better predictive precision than weighted selection does.In the context of valuation of the EQ-5D-Y-3L, we recommend valuing 20 or more health states using TTO and placing them evenly across the latent utility scale.

An EQ-5D-Y-3L Value Set for Belgium

BACKGROUND

In Belgium, a value set for children and adolescents for a generic health-related quality-of-life measure is not available. To inform drug pricing and make resource allocation decisions for children and adolescents, national tax-payers' preferences for youth health states should be known.

OBJECTIVE

We aimed to obtain a value set for EQ-5D-Y-3L in Belgium, following the international youth valuation protocol for data collection.

METHODS

Composite Time Trade-Off interviews were conducted in a sample of 200 adults, either face to face or via video conferencing. Another sample of 1000 adults completed an online discrete choice experiment survey. All adults were asked to take the perspective of a 10-year-old child for both methods. Both samples were representative for Belgium in terms of age, sex and region. A latent class analysis was selected to obtain the relative importance of the five dimensions and their levels based on the discrete choice experiment data, which were anchored with the composite Time Trade-Off censored value for the worst health state (33333).

RESULTS

Preferences from Belgian adults revealed a mean censored value for 33333 for children and adolescents of - 0.475. All the estimated coefficients of the model with 4 latent classes were statistically significant and showed higher disutility as severity levels increase. The most important health dimension was pain/discomfort, followed by feeling sad/worried/unhappy.

CONCLUSIONS

This study presents the Belgian EQ-5D-Y-3L value set, which will be included in the Belgian pharmacoeconomic guidelines. The value set enables the calculation of quality-adjusted life-years in children and adolescents, allowing a cost-effectiveness evaluation of health technologies and their youth-specific price setting.

In a Child's Shoes: Composite Time Trade-Off Valuations for EQ-5D-Y-3L with Different Proxy Perspectives

BACKGROUND AND OBJECTIVES

EQ-5D-Y-3L health states are commonly valued by asking adults to complete stated preference tasks, 'given their views about a 10-year-old child' (hereafter referred to as proxy 1). The use of this perspective has been a source of debate. In this paper, we investigated an alternative proxy perspective: i.e. adults considered what they think a 10-year old-child would decide for itself (hereafter, proxy 2 (substitute)]. Our main objective was to explore how the outcomes, dispersion and response patterns of a composite time trade-off valuation differ between proxy 1 and proxy 2.

METHODS

A team of four trained interviewers completed 402 composite time trade-off interviews following the EQ-5D-Y-3L protocol. Respondents were randomly allocated to value health states in either the proxy 1 or proxy 2 (substitute) perspective. Each respondent valued ten health states with the perspective they were assigned to, as well as one health state with the alternative perspective (33333).

RESULTS

The use of different proxy perspectives yielded differences in EQ-5D-Y-3L valuation. For states in which children had considerable pain and were very worried, sad or unhappy, respondents' valuations were lower in proxy 1 than in proxy 2 (substitute) perspectives, by about 0.2. Within-subject variation across health states was lower for proxy 2 (substitute) than proxy 1 perspectives. Analyses of response patterns suggest that data for proxy 2 (substitute) perspectives were less clustered.

CONCLUSIONS

There are systematic differences between composite time trade-off responses given by adults deciding for children and adults considering what children would want for themselves. In addition to warranting further qualitative exploration, such differences contribute to the ongoing normative discussion surrounding the source and perspective used for valuation of child and adolescent health.

Analytical Considerations When Anchoring Discrete Choice Experiment Values Using Composite Time Trade-Off Data: The Case of EQ-5D-Y-3L

Discrete choice experiments (DCEs) are becoming increasingly used to elicit preferences for children's health states. However, DCE data need to be anchored to produce value sets, and composite time trade-off (cTTO) data are typically used in the context of EQ-5D-Y-3L valuation. The objective of this paper is to compare different anchoring methods, summarise the characteristics of the value sets they produce, and outline key considerations for analysts. Three anchoring methods were compared using data from published studies: (1) rescaling using the mean value for the worst health state; (2) linear mapping; and (3) hybrid modelling. The worst state rescaling value set had the largest range. The worst state rescaling and linear mapping value sets preserved the relative importance of the dimensions from the DCE, whereas the hybrid model value set did not. Overall, the predicted values from the hybrid model value set were more closely aligned with the cTTO values. These findings are relatively generalisable. Deciding upon which anchoring approach to use is challenging, as there are numerous considerations. Where cTTO data are collected for more than one health state, anchoring on the worst health state will arguably be suboptimal. However, the final choice of approach may require value judgements to be made. Researchers should seek input from relevant stakeholders when commencing valuation studies to help guide decisions and should clearly set out their rationale for their preferred anchoring approach in study outputs.

Findings from a Roundtable Discussion with US Stakeholders on Valuation of the EQ-5D-Y-3L

OBJECTIVES

The International Valuation Protocol for the valuation of the EQ-5D-Y-3L provides baseline guidance, but country-specific context is also important. This study aimed to obtain US stakeholders' input on key considerations for youth valuation in the US.

METHODS

A total of 14 stakeholders representing various backgrounds were identified via the investigators' networks. A 2-h online meeting was held to discuss (1) the need for a US value set for the EQ-5D-Y-3L; (2) willingness to pay more for quality-adjusted life-year (QALY) gains for children versus adults; (3) sampling strategies; (4) framing perspectives; and (5) other challenges. The session was recorded, transcribed, and summarized.

RESULTS

Several stakeholders supported paying more for QALY gains for children in recognition of their potential future contributions to society, as well as to avoid potential undervaluation and promote access to innovative treatments. Concerns regarding possible double counting, lack of data to showcase long-term benefits, and dangers of paying more for certain subgroups were also expressed. Most of the stakeholders felt that adolescents could relate to a 10-year-old's perspective better than adults and were capable of self-completing valuation tasks, and thus should be directly included in the valuation study. There were concerns that adults would be inconsistent in their views about a 10-year-old, partly depending on their status as a parent.

CONCLUSIONS

US stakeholders provided insights relevant to youth valuation in a US context and were open to continued dialogue with investigators. This study could be useful to investigators who are conducting youth valuation studies in different countries and seeking stakeholder input.

Estimating an EQ-5D-Y-3L Value Set for China

INTRODUCTION

The standard EQ-5D-Y-3L valuation protocol applies DCE data as the primary preference source to model the relative importance of dimensions while cTTO data served to anchor the DCE coefficients onto the QALY scale. This study aims to estimate an EQ-5D-Y-3L value set for China following this protocol, but with a larger cTTO design to better understand the role of cTTO data in estimating EQ-5D-Y-3L value sets.

METHODS

In total, 150 choice sets and 28 EQ-5D-Y-3L health states were valued using DCE and cTTO methods with two independent samples, respectively. General public from 14 different regions were recruited using quota sampling method to achieve representativeness. We compared two modelling strategies: (1) fit the DCE data with mixed logit model with correlated coefficients and a subsequent mapping procedure for anchoring; (2) fit the DCE and TTO data jointly in a hybrid model. Two evaluation criteria (1) coefficient significance and monotonicity; (2) prediction accuracy of the observed cTTO values were used to select the value set.

RESULTS

In total, 1476 individuals participated in the study, with 1058 participated the DCE interview and 418 participated the cTTO interview. The highest mean TTO value was 0.924 for state 11112 and the lowest mean TTO value was - 0.088 for state 33333. The hybrid model with an A3 term performed the best and was selected as the value set.

DISCUSSION

Following the international protocol and using a larger cTTO design, this study established the EQ-5D-Y-3L value set using a hybrid model for China. Future EQ-5D-Y-3L valuation study could consider using a larger cTTO design for estimating the value set.