Questioning the differences between general public vs. patient based preferences towards EQ-5D-5L defined hypothetical health states

Developing a utility value set for the Gambling Quality of Life Scale-Brief (GQoLS-Brief) using a discrete choice experiment

OBJECTIVES

The Gambling Quality of Life Scale -brief (GQoLS-Brief) assesses the impact of gambling disorder (GD) on quality of life (QoL). Preference-based measures are essential for obtaining the quality adjustment weight (i.e. utility score) needed to calculate quality-adjusted life years (QALYs) in economic evaluations. We aimed to derive a value set for the GQoLS-Brief.

METHODS

We employed a discrete choice experiment for preference elicitation. An online survey was administered (n = 928). Respondents completed 10 choice tasks, each presenting two GQoLS-Brief health states alongside life expectancy. Conditional logit regression, parameterized to fit the QALY framework, was used for data analysis. QALY weights for each health state defined by the GQoLS-Brief were calculated.

RESULTS

The estimated coefficients from the conditional logit models aligned with expectations: utility increased with survival time and decreased with QoL impairment. Utility values for health states ranged from - 1.48 (worse than death) to 1.0. "Financial difficulties" exhibited the highest utility decrement, followed by "Sleep disturbance related to financial difficulties."

CONCLUSIONS

This reference set facilitates the calculation of QALYs for economic evaluations of GD interventions. The weight of subjective financial difficulties underscores the need for therapeutic interventions to target this aspect.

Differences in health utilities between cancer patients and the general population: The case of Quebec using the SF-6Dv2

A considerable debate persists in the literature about whose preferences should be considered in the calculation of quality-adjusted life-years. Some suggest considering only the preferences of the general population, while others advocate for the consideration of those of patients or a combination of both. This study aims to inform and measure the differences in health preferences between cancer patients and the general population in Quebec. A total of 60,976 observations representing the preferences of the general population for various health states were collected and used to develop a new value set using the SF-6Dv2. This value set was generated by combining 34,299 observations with time trade-off (TTO) and 26,677 observations with discrete choice experiment (DCE). Utility scores derived from this value set were compared to those of patients' preferences from a new value set in breast and colorectal patients for the SF-6Dv2. For both patients and the general population, the 'Pain' dimension was the highest contributor to the utility score. However, noticeable differences were observed in the estimates. Estimates of levels 2 and 3 were generally lower for cancer patients, while they were more likely to have greater estimates in severe levels. Significant differences in utility scores were also noticed with the general population showing higher mean utility scores for the same health states. These differences increased as the health states worsened. This study sheds light on the existing differences in preferences between cancer patients and the general population of Quebec for a better consideration in healthcare decision-making.

Multiple sclerosis health-related quality of life utility values from the UK MS register

Background

New interventions for multiple sclerosis (MS) commonly require a demonstration of cost-effectiveness using health-related quality of life (HRQoL) utility values. The EQ-5D is the utility measure approved for use in the UK NHS funding decision-making. There are also MS-specific utility measures - e.g., MS Impact Scale Eight Dimensions (MSIS-8D) and MSIS-8D-Patient (MSIS-8D-P).

Objectives

Provide EQ-5D, MSIS-8D and MSIS-8D-P utility values from a large UK MS cohort and investigate their association with demographic/clinical characteristics.

Methods

UK MS Register data from 14,385 respondents (2011 to 2019) were analysed descriptively and using multivariable linear regression, with self-report Expanded Disability Status Scale (EDSS) scores.

Results

The EQ-5D and MSIS-8D were both sensitive to differences in demographic/clinical characteristics. An inconsistency found in previous studies whereby mean EQ-5D values were higher for an EDSS score of 4 rather than 3 was not observed. Similar utility values were observed between MS types at each EDSS score. Regression showed EDSS score and age were associated with utility values from all three measures.

Conclusions

This study provides generic and MS-specific utility values for a large UK MS sample, with the potential for use in cost-effectiveness analyses of treatments for MS.

Hypothetical versus experienced health state valuation: a qualitative study of adult general public views and preferences

OBJECTIVES

Responses from hypothetical and experienced valuation tasks of health-related quality of life differ, yet there is limited understanding of why these differences exist, what members of the public think about them, and acceptable resolutions. This study explores public understanding of, opinions on, and potential solutions to differences between hypothetical versus experienced responses, in the context of allocating health resources.

METHODS

Six focus groups with 30 members of the UK adult public were conducted, transcribed verbatim, and analysed using framework analysis. Participants self-completed the EQ-5D-5L, before reporting the expected consequences of being in two hypothetical EQ-5D-5L health states for ten years. Second, participants were presented with prior results on the same task from a public (hypothetical) and patient (experienced) sample. Third, a semi-structured discussion explored participants': (1) understanding, (2) opinions, and (3) potential resolutions.

RESULTS

Twenty themes emerged, clustered by the three discussion points. Most participants found imagining the health states difficult without experience, with those aligned to mental health harder to understand. Participants were surprised that health resource allocation was based on hypothetical responses. They viewed experienced responses as more accurate, but noted potential biases. Participants were in favour of better informing, but not influencing the public. Other solutions included incorporating other perspectives (e.g., carers) or combining/weighting responses.

CONCLUSION

Members of the UK public appear intuitively not to support using potentially uninformed public values to hypothetical health states in the context of health resource allocation. Acceptable solutions involve recruiting people with greater experience, including other/combinations of views, or better informing respondents.

Do they just know more, or do they also have different preferences? An exploratory analysis of the effects of self-reporting serious health problems on health state valuation

BACKGROUND

Health state valuation is often conducted by people valuing either only their own health state (experience-based valuation) or several stylised states (hypothetical valuation). The approach used can affect the elicited values, but it is not clear whether this is caused by different understandings of the states (an "information mechanism") and/or by different opinions of the states (a "preference mechanism"). Justifying privileging the valuations of those with the relevant health state experience solely because they are better informed is insufficient when their opinions differ. This study proposes a new framework to examine the effect of having health problems on health state valuation by distinguishing "within-dimensional" effects (which can be due to better information or due to differences in opinion) and "cross-dimensional" effects (which must be due to differences in opinion).

METHODS

Secondary data from the UK that valued EQ-5D-5L using Discrete Choice Experiments with duration (DCE_TTO) are remodelled controlling for whether a respondent self-reports serious (viz., severe or extreme) problems in "pain or discomfort" (PD) or "anxiety or depression" (AD). The main analysis uses respondents who have serious PD or serious AD alongside matched respondents who do not, and assumes constant proportional time trade-off.

RESULTS

Self-reporting serious PD or serious AD problems has no within-dimensional effect on health state preferences. However, self-reporting serious AD problems has negative cross-dimensional effects on the utility of having any problem in PD, which suggests that the preference mechanism is present. A similar pattern holds when all available (unmatched) data are used and when constant proportional time trade-off is relaxed.

CONCLUSIONS

Findings consistent with the preference mechanism indicate that those with serious health problems may have different opinions on the value of health states compared to the rest of the population, which has normative implications for the debate on which values to use.

Public versus patient health preferences: protocol for a study to elicit EQ-5D-5L health state valuations for patients who have survived a stay in intensive care

INTRODUCTION

The value set used when calculating quality-adjusted life-years (QALYs) is most often based on stated preference data elicited from a representative sample of the general population. However, having a severe disease may alter a person's health preferences, which may imply that, for some patient groups, experienced QALYs may differ from those that are estimated via standard methods. This study aims to model 5-level EuroQol 5-dimensional questionnaire (EQ-5D-5L) valuations based on preferences elicited from a sample of patients who have survived a stay in a Danish intensive care unit (ICU) and to compare these with the preferences of the general population. Further, the heterogeneity in the ICU patients' preferences will be investigated.

METHODS AND ANALYSIS

This valuation study will elicit EQ-5D-5L health state preferences from a sample of 300 respondents enrolled in two randomised controlled trials at Danish ICUs. Patients' preferences will be elicited using composite time trade-off based on the EuroQol Valuation Technology, the same as that used to generate the EQ-5D-5L value set for the Danish general population. The patient-based and the public-based EQ-5D-5L valuations will be compared. Potential underlying determinants of the ICU preferences will be investigated through analyses of demographic characteristics, time since the ICU stay, self-reported health, willingness to trade-off length of life for quality of life, health state reference dependency and EQ-5D dimensions that patients have experienced themselves during their illness.

ETHICS AND DISSEMINATION

Under Danish regulations, ethical approval is not required for studies of this type. Written informed consent will be obtained from all patients. The study results will be published in peer-reviewed scientific journals and presented at national and international conferences. The modelling algorithms will be publicly available for statistical software, such as Stata and R.

The EORTC QLU-C10D discrete choice experiment for cancer patients: a first step towards patient utility weights

Background

The European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Utility-Core 10 Dimensions (QLU-C10D) is a novel cancer-specific preference-based measure (PBM) for which value sets are being developed for an increasing number of countries. This is done by obtaining health preferences from the respective general population. There is an ongoing discussion if instead patients suffering from the disease in question should be asked for their preferences. We used the QLU-C10D valuation survey, originally designed for use in the general population, in a sample of cancer patients in Austria to assess the methodology’s acceptability and applicability in this target group before obtaining QLU-C10D patient preferences.

Methods

The core of the QLU-C10D valuation survey is a discrete choice experiment in which respondents are asked to give preferences for certain health states (described by a relatively large number of 10 quality of life domains) and an associated survival time. They therewith are asked to trade off quality of life against life time. As this might be a very burdensome task for cancer patients undergoing treatment, a cognitive interview was conducted in a pilot sample to assess burden and potential additional needs for explanation in order to be able to use the DCE for the development of QLU-C10D patient preferences. In addition, responses to general feedback questions on the survey were compared against responses from a matched control group from the already completed Austrian general population valuation survey.

Results

We included 48 patients (mean age 59.9 years; 46% female). In the cognitive interview, the majority indicated that their experience with the survey was positive (85%) and overall clarity as good (90%). In response to the general feedback questions, patients rated the presentation of the health states less clear than matched controls (p = 0.008). There was no difference between patients and the general population concerning the difficulty in choosing between the health states (p = 0.344).

Conclusion

Despite the relatively large number of DCE domains the survey was manageable for patients and allows going on with the QLU-C10D patient valuation study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00430-5.

Modifying the quality-adjusted life year calculation to account for meaningful change in health-related quality of life: insights from a pragmatic clinical trial

BACKGROUND

We propose a modified quality-adjusted life year (QALY) calculation that aims to be consistent with guidance for interpreting change in patient-reported outcomes. This calculation incorporates the minimally important difference (MID) in generic preference-based health-related quality of life (HRQL) change scores to reflect what might be considered meaningful HRQL improvement/deterioration. In doing so, we review common issues in QALY calculations such as adjustment for baseline scores and standardizing for between-group differences.

METHODS

Using EQ-5D-5L outcome data from the Alberta TEAMCare-Primary Care Network trial in the management of depression for patients with type 2 diabetes (n = 98), this study compared results from different QALY calculation methods to investigate the impact of (i) adjusting for baseline HRQL score, (ii) standardizing between-group differences at baseline, and (iii) adjusting for 'meaningful' HRQL changes. The following QALY calculation methods are examined: area under curve (QALY-AUC), change from baseline (QALY-CFB), regression modelling (QALY-R), and incorporating an MID for HRQL changes from baseline (QALY-MID).

RESULTS

The incremental QALY-AUC estimate favoured the Collaborative Care group (0.031) while the incremental QALY-CFB (-0.028) estimate favoured Enhanced Care. Adjusting for meaningful HRQL changes resulted in a crude incremental QALY-MID of -0.023; however, after adjusting for between-group differences at baseline, QALY-R and adjusted incremental QALY-MID estimates were -0.007 and -0.001, respectively. In addition, recursive regression analyses showed that very low baseline HRQL scores impact incremental QALY estimates.

CONCLUSIONS

Uncertainty in incremental QALY estimates reflects uncertainty in the value of small within-individual change as well as the impact of small differences between groups at baseline. Applying a responder-definition approach yielded crude and adjusted QALY-MID estimates that were more in favour of Collaborative Care than QALY-CFB and QALY-R estimates, respectively, suggesting that ambiguous small changes in HRQL scores have the potential to influence QALY outcomes used in economic or non-economic applications.

Monetary Valuation of a Quality-Adjusted Life Year (QALY) for Depressive Disorders Among Patients and Non-Patient Respondents: A Matched Willingness to Pay Study

Background

As estimated by the World Health Organization, depressive disorders will be the leading contributor to the Global Burden of Disease by 2030. In light of this fact, we designed a study whose aim was to investigate whether the value placed on health-related quality of life (HRQoL) for a depressive disorder is higher in patients diagnosed with a major depressive disorder (MDD) compared to non-patients in a matched sample.

Method

We collected data on willingness to pay (WTP) for a total of four health-gain scenarios, which were presented to 18 outpatients diagnosed with a MDD versus 18 matched non-patient respondents with no symptoms of depression. Matching characteristics included age, income, level of education, and type of health insurance. Respondents were presented with different HRQoL scenarios in which they could choose to pay money to regain their initial health state through various treatment options (e.g., inpatient treatment, electroconvulsive therapy). To test whether the probability of stating a positive WTP differed significantly between the two samples, Fisher's exact test was used. Differences regarding stated WTP between the samples were investigated using the Mann-Whitney U-test.

Results

For most of the health scenarios, the probability of stating a positive WTP did not differ between the two samples. However, patient respondents declared WTP values up to 7.4 times higher than those stated by matched non-patient respondents.

Conclusion

Although the perceived necessity to pay for mental-HRQoL gains did not differ between respondents with MDD and respondents with no symptoms of depression, patient respondents stated higher values.

Small differences in EQ-5D-5L health utility scores were interpreted differently between and within respondents

OBJECTIVE

This study aims to determine how population-based health-utility score (HUS) differences reflect individuals' health preferences using responses from the Canadian EQ-5D-5L Valuation Study, including time trade-off (TTO) and discrete-choice experiment (DCE) tasks (n=1073).

STUDY DESIGN AND SETTING

Cardinal TTO responses were transformed into pairwise comparisons to yield ordinal TTO responses. We investigated how EQ-5D-5L HUS differences differ from participants' stated cardinal preferences, and determined the smallest HUS difference that may be expected to represent participants' ordinal preferences.

RESULTS

HUS differences near 0 have 30.6% (95% confidence interval: 29.1 to 31.9%) probability of representing a tie in individuals' TTO values. Differences in EQ-5D-5L HUS of -0.054 (-0.071 to -0.029) and 0.047 (0.026 to 0.076) maximized the sensitivity and specificity of discriminating transitions to worse/better health states. For small HUS differences of +/-0.03 to +/-0.07, the magnitude of respondents' average TTO difference on the cardinal scale was 0.17 and 0.35 whether ties were included or excluded, respectively. Absolute HUS differences between 0.043 and 0.064 had a 50% probability of representing respondents' ordinal preferences.

CONCLUSION

A HUS needs to be large enough to reflect individuals' stated health preferences, which may lend support to the application of a minimally important difference for decision-making.

Crosswalk EQ-5D-5L Value Set for Slovenia

INTRODUCTION

Due to the availability of the EQ-5D-5L instrument official translation into Slovenian its use is widespread in Slovenia. However, the health profiles obtained in many studies cannot be ascribed their appropriate values as the EQ-5D-5L value set does not yet exist in Slovenia. Our aim was to estimate an interim EQ-5D-5L value set for Slovenia using the crosswalk methodology developed by the EuroQol Group on the basis of the EQ-5D-3L Slovenian TTO value set. Our secondary aim was to compare the interim values obtained with the EQ-5D-3L Slovenian values.

METHODS

To obtain a Slovenian interim EQ-5D-5L value set, we applied the crosswalk methodology developed by the EuroQol Group to the Slovenian EQ-5D-3L TTO value set. We examined the differences between values by comparing the mean 3L and 5L value scores and the distribution of values across all respondents.

RESULTS

By definition, 3-level and 5-level versions have the same range (from 1 to -0.495) and a health state coded 22222 in the 3-level version corresponds to 33333 in the 5-level version. While the addition of a "slight" severity level (22222) in the 5-level version has a low informational value, the addition of a "severe" health state (44444) covers larger range of the scale. The 5-level version results in fewer health states being valued below 0 and above 0.8.

CONCLUSION

The EQ-5D-5L value set, based on the crosswalk methodology, should be used until a value set for the EQ-5D-5L is derived from preferences elicited directly from a representative sample of the Slovenian general population.

Experience-Based Swedish TTO and VAS Value Sets for EQ-5D-5L Health States

BACKGROUND AND OBJECTIVE

Although value sets for the five-level version of the generic health-related quality-of-life instrument EQ-5D are emerging, there is still no value set available in the literature based on time trade-off valuations made by individuals experiencing the valued health states. The aim of this study was to estimate experience-based value sets for the EQ-5D-5L for Sweden using time trade-off and visual analogue scale valuation methods.

METHODS

In a large, cross-sectional, population-based, self-administered postal health survey, the EQ-5D-5L descriptive system, EQ visual analogue scale and a time trade-off question were included. Time trade-off and visual analogue scale valuations of the respondent's current health status were used in statistical modelling to estimate a single-index value of health for each of the 3125 health states. Ordinary least-squares and generalised linear models were estimated with the main effect within each of the five dimensions represented by 20 dummy variables reflecting the additional decrement in value for levels 2-5 when the severity increases by one level sequentially beginning from having no problem. Interaction variables representing the occurrence of severity levels in at least one of the dimensions were tested: severity level 2 or worse (N2); severity level 3 or worse (N3); severity level 4 or worse (N4); severity level 5 (N5).

RESULTS

A total of 896 health states (28.7% of the 3125 possible EQ-5D-5L health states) were reported by the 25,867 respondents. Visual analogue scale (n = 23,899) and time trade-off (n = 13,381) responders reported valuations of their currently experienced health state. The preferred regression models used ordinary least-squares estimation for both time trade-off and visual analogue scale values and showed consistency in all coefficients after combining certain levels. Levels 4 and 5 for the dimensions of mobility, self-care and usual activities were combined in the time trade-off model. Including the interaction variable N5, indicating severity level 5 in at least one of the five dimensions, made it possible to distinguish between the two worst severity levels where no other dimension is at level 5 as this coefficient is applied only once. In the visual analogue scale regression model, levels 4 and 5 of the mobility dimension were combined. The interaction variables N2-N4 were included, indicating that each of these terms reflect a statistically significant decrement in visual analogue scale value if any of the dimensions is at severity level 2, 3 or 4, respectively.

CONCLUSIONS

Time trade-off and visual analogue scale value sets for the EQ-5D-5L are now available for Sweden. The time trade-off value set is the first such value set based on experience-based time trade-off valuation. For decision makers with a preference for experience-based valuations of health states from a representative population-based sample, the reported value sets may be considered fit for purpose to support resource allocation decision as well as evaluating population health and healthcare performance.

Whom should we ask? A systematic literature review of the arguments regarding the most accurate source of information for valuation of health states

To determine and critically evaluate the arguments in the published literature regarding the most accurate source of information for valuation of health states: values based on experienced health states (patient values) or values based on described health states (general public values).

Are guidelines for measurement of quality of life contrary to patient-centred care?

AIMS

A discussion of how quality-adjusted life years are used to inform resource allocation decisions and highlight how assumptions underpinning the measurement of quality of life are contrary to the principles of patient-centred care.

BACKGROUND

Cost-effectiveness analyses (CEAs) can provide influential guidance for health resource allocation, particularly in the context of a budget-constrained public health insurance plan. Most national economic guideline bodies recommend that quality-adjusted life year weights for CEA be elicited indirectly (public preferences). This has potentially important implications for healthcare provision and research, as it discounts the ability of a person experiencing an illness to describe how it affects their quality of life.

DESIGN

Discussion paper.

DATA SOURCES

Guidelines for the conduct of health economic evaluations, influential methodological and theoretical texts, and a review of PubMed conducted in April 2017.

IMPLICATIONS FOR NURSING

Nurses are increasingly interested in leveraging methods from health economics to aid in decision-making and advocacy. In this analysis, we highlight how taken-for-granted approaches to the measurement of quality of life may discount the experience of patients and lead to decisions that are contrary to the principles of patient-centred care. Nurses conducting or reading research using these methods should consider whether the approach used to measure the quality of life are appropriate for the population under consideration.

CONCLUSION

Since patient and public health preferences can differ in both magnitude and direction, guideline bodies should re-evaluate their partiality for public preferences in the reference case.

Is the DLQI appropriate for medical decision-making in psoriasis patients?

Dermatology Life Quality Index (DLQI) is the most commonly applied measure of health-related quality of life (HRQoL) in psoriasis patients. It is among defining criteria of moderate-to-severe psoriasis and present in treatment guidelines. Our objective was to estimate preference-based HRQoL values (i.e., utilities) for hypothetical health states described by the 10 items of the DLQI in psoriasis patients. Moreover, we compare results to findings of a similar study previously conducted among the general public. A cross-sectional survey was carried out among 238 psoriasis patients. Seven hypothetical DLQI-defined health states with total scores of 6, 11, and 16 (3-3 and 1 states, respectively) were evaluated by time trade-off method. The difference in DLQI scores between hypothetical health states was set at 5 points, as it exceeds the minimal clinically important difference (MCID). Utility scores were found to be homogenous across the seven hypothetical health states (range of means for the 6-point states 0.85-0.91, range of means for the 11-point states 0.83-0.85, and mean of 0.84 for the 16-point state). Overall, mean utilities assessed by psoriasis patients were higher for all seven states compared with the general public (mean difference 0.16-0.28; p < 0.001). In 11 out of the 15 comparisons between health states with DLQI scores differing larger than the MCID, there was no statistically significant difference in utility. Thus, in clinical settings, patients with DLQI scores differing more than the MCID may have identical HRQoL. Improving the definition of moderate-to-severe disease and reconsideration of the DLQI in clinical assessment of psoriasis patients are suggested.