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Lugnér AK, Krabbe PFM. An overview of the time trade-off method: concept, foundation, and the evaluation of distorting factors in putting a value on health. Expert Rev Pharmacoecon Outcomes Res 2020; 20:331-342. [PMID: 32552002 DOI: 10.1080/14737167.2020.1779062] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Preference-based instruments measuring health status express the value of specific health states in a single number. One method used is time trade-off (TTO). Health-status values are key elements in calculating quality-adjusted life years (QALYs) and are pertinent for resource allocation. Since they are used in economic evaluations of healthcare, searching for a theoretical foundation of TTO in economics is justified. AREA COVERED This paper provides an overview of TTO, including its relation to economic theory, and discusses biases and distortions, compiled from recent and older research. Inconsistencies between TTO and random utility theory were detected; The TTO is confounded by time preferences and by respondents' life expectancies. TTO is cognitively challenging, therefore guidance during the interviews is needed, producing interview effects. TTO does not measure one thing at a time, nor are the values independent of other states that are being valued in the same task. That is, TTO does not exhibit theoretical measurement properties such as unidimensionality and the invariance principle. EXPERT OPINION We conclude that the TTO may be a pragmatic method of eliciting health state values, but the limitations in regard to measurement theory and practical elicitation problems makes it prone to inconsistencies and arbitrariness.
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Affiliation(s)
| | - Paul F M Krabbe
- Department of Epidemiology, University of Groningen, University Medical Center Groningen , Groningen, The Netherlands
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McTaggart-Cowan H, King MT, Norman R, Costa DSJ, Pickard AS, Regier DA, Viney R, Peacock SJ. The EORTC QLU-C10D: The Canadian Valuation Study and Algorithm to Derive Cancer-Specific Utilities From the EORTC QLQ-C30. MDM Policy Pract 2019; 4:2381468319842532. [PMID: 31245606 PMCID: PMC6580722 DOI: 10.1177/2381468319842532] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 02/18/2019] [Indexed: 01/22/2023] Open
Abstract
Objective. The EORTC QLQ-C30 is widely used for assessing quality of life in cancer. However, QLQ-C30 responses cannot be incorporated in cost-utility analysis because they are not based on general population's preferences, or utilities. To overcome this limitation, the QLU-C10D, a cancer-specific utility algorithm, was derived from the QLQ-C30. The aim of this study was to obtain Canadian population utility weights for the QLU-C10D. Methods. Respondents from a Canadian research panel expressed their preferences for 16 choice sets in an online discrete choice experiment. Each choice set consisted of two health states described by the 10 QLU-C10D domains plus an attribute representing duration of survival. Using a conditional logit model, responses were converted into utility decrements by evaluating the marginal rate of substitution between each QLU-C10D domain level with respect to duration. Results. A total of 3,363 individuals were recruited. A total of 2,345 completed at least one choice set and 2,271 completed all choice sets. The largest utility decrements were associated with the worse levels of Physical Functioning (-0.24), Pain (-0.18), Role Functioning (-0.15), Emotional Functioning (-0.12), and Nausea (-0.12). The remaining domains and levels had decrements of -0.05 to -0.09. The utility of the worst possible health state was -0.15. Conclusion. Respondents from the general population were most concerned with generic health domains, but Nausea and Bowel Problems also had an impact on the individual's utility. It is unclear as to whether cancer-specific domains will affect cost-utility analysis when evaluating cancer treatments; this will be tested in the next phase of the study.
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Affiliation(s)
- Helen McTaggart-Cowan
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Madeleine T King
- Faculties of Science and Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Richard Norman
- School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Daniel S J Costa
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - A Simon Pickard
- Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago, Illinois, USA
| | - Dean A Regier
- Canadian Centre for Applied Research in Cancer Control, Vancouver, British Columbia, Canada
| | - Rosalie Viney
- Centre for Health Economics Research and Evaluation, University of Technology, Sydney, New South Wales, Australia
| | - Stuart J Peacock
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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Gandhi M, Rand K, Luo N. Valuation of Health States Considered to Be Worse Than Death-An Analysis of Composite Time Trade-Off Data From 5 EQ-5D-5L Valuation Studies. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:370-376. [PMID: 30832976 DOI: 10.1016/j.jval.2018.10.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 09/26/2018] [Accepted: 10/02/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To evaluate the discriminative ability of negative values measured in 5-level EuroQol 5-dimensional questionnaire (EQ-5D-5L) value set studies. METHODS This is a secondary analysis of EQ-5D-5L value set studies from Singapore, the Netherlands, China, Thailand, and Canada in which health state values were elicited from a general population sample using a composite time trade-off (TTO) method. Mean values were calculated for health states with same severity. The association between the mean values and severity was evaluated using Pearson correlation (r). A linear mixed model using severity as the fixed effect was fitted for values. The analyses were performed separately for positive values (from a conventional TTO for health states considered "better than death") and negative values (from a lead time TTO for health states considered "worse than death"). RESULTS In Singapore (N = 1000; negative values 32.6%), the mean decreased with severity from 0.89 to 0.21 for positive values and increased with severity from -0.98 to -0.89 for negative values. The correlation between values and severity was much lower for negative values (r = -0.016) than for positive values (r = -0.614). The coefficient of severity in the linear mixed model for negative values was much smaller (coefficient = -0.009; pseudo-R2 < 0.001) compared with the model for positive values (coefficient = -0.041; pseudo-R2 = 0.337). Results using data sets from the other countries were similar. CONCLUSIONS Negative values are not associated with severity of health states in EQ-5D-5L valuation studies, suggesting poor discriminative ability of the lead time TTO method in valuing health states considered worse than death.
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Affiliation(s)
- Mihir Gandhi
- Department of Biostatistics, Singapore Clinical Research Institute, Singapore; Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore; Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland.
| | - Kim Rand
- Health Services Research Centre, Akershus University Hospital, Lørenskog, Norway; Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Nan Luo
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
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Korman M, Wisløff T. Modelling the cost-effectiveness of PCSK9 inhibitors vs. ezetimibe through LDL-C reductions in a Norwegian setting. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2019; 4:15-22. [PMID: 28444187 PMCID: PMC5843101 DOI: 10.1093/ehjcvp/pvx010] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 03/31/2017] [Indexed: 01/03/2023]
Abstract
Aims Despite the success of statins, there remains unmet clinical need in cardiovascular disease (CVD) prevention. New proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors reduce low-density lipoprotein cholesterol (LDL-C) by 55-65%. Two PCSK9 inhibitors, evolocumab, and alirocumab, were approved for use in Norway but not yet for reimbursement through public national insurance. We aim to explore the cost-effectiveness of these compared with available treatments in a Norwegian setting. Methods and results A state transition Markov model was developed to model the cost-effectiveness of PCSK9 inhibitors for prevention of coronary heart disease, ischaemic strokes, and death among high-risk patient subpopulations in Norway, in both primary and secondary settings. Evolocumab and alirocumab are compared against ezetimibe and standard treatment. Risk of CVD is based on population incidence rates and adjusted according to baseline risk factors. Preventative effect of treatment was modelled according to absolute reduction in LDL-C. PCSK9 inhibitors were never found to be cost-effective in primary prevention. In secondary prevention they were cost-effective only for older, high-risk patients. The lowest cost-effectiveness ratios were for heterozygous familial hypercholesterolaemia patients and high-risk diabetics, with €63 200 and €68 400 per quality-adjusted life-year, respectively. Conclusion High lifetime costs of PCSK9 inhibitors may not be offset by estimated health gains for most eligible patients. PCSK9 inhibitors are found in the model only to be cost-effective in secondary prevention for older patients with high absolute risk of CVD. This picture is likely to change as price decreases. Future research is needed to determine the long-term preventative effects of PCSK9 inhibitors.
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Affiliation(s)
- Max Korman
- Department of Health Management and Health Economics, The Faculty of Medicine, University of Oslo, Postboks 1089, Blindern, 0317 Oslo, Norway
| | - Torbjørn Wisløff
- Department of Health Management and Health Economics, The Faculty of Medicine, University of Oslo, Postboks 1089, Blindern, 0317 Oslo, Norway.,Norwegian Institute of Public Health, Infectious Diseases Epidemiology and Modelling, Postboks 4404, Nydalen, 0403 Oslo, Norway
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Heijink R, Reitmeir P, Leidl R. International comparison of experience-based health state values at the population level. Health Qual Life Outcomes 2017; 15:138. [PMID: 28683747 PMCID: PMC5501450 DOI: 10.1186/s12955-017-0694-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 05/24/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Decision makers need to know whether health state values, an important component of summary measures of health, are valid for their target population. A key outcome is the individuals' valuation of their current health. This experience-based perspective is increasingly used to derive health state values. This study is the first to compare such experience-based valuations at the population level across countries. METHODS We examined the relationship between respondents' self-rated health as measured by the EQ-VAS, and the different dimensions and levels of the EQ-5D-3 L. The dataset included almost 32,000 survey respondents from 15 countries. We estimated generalized linear models with logit link function, including country-specific models and pooled-data models with country effects. RESULTS The results showed significant and meaningful differences in the valuation of health states and individual health dimensions between countries, even though similarities were present too. Between countries, coefficients correlated positively for the values of mobility, self-care and usual activities, but not for the values of pain and anxiety, thus underlining structural differences. CONCLUSIONS The findings indicate that, ideally, population-specific experience-based value sets are developed and used for the calculation of health outcomes. Otherwise, sensitivity analyses are needed. Furthermore, transferring the results of foreign studies into the national context should be performed with caution. We recommend future studies to investigate the causes of differences in experience-based health state values through a single international study possibly complemented with qualitative research on the determinants of valuation.
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Affiliation(s)
- Richard Heijink
- National Institute for Public Health and the Environment, P.O. Box 1, 3720, BA, Bilthoven, the Netherlands. .,Dutch Healthcare Authority, Utrecht, the Netherlands.
| | - Peter Reitmeir
- Institute for Health Economic and Healthcare Management, Helmholtz Zentrum München, Neuherberg, Germany
| | - Reiner Leidl
- Institute for Health Economic and Healthcare Management, Helmholtz Zentrum München, Neuherberg, Germany.,Munich Center of Health Sciences, Ludwig-Maximilians-University, Munich, Germany
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Oppe M, Rand-Hendriksen K, Shah K, Ramos‐Goñi JM, Luo N. EuroQol Protocols for Time Trade-Off Valuation of Health Outcomes. PHARMACOECONOMICS 2016; 34:993-1004. [PMID: 27084198 PMCID: PMC5023738 DOI: 10.1007/s40273-016-0404-1] [Citation(s) in RCA: 166] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
The time trade-off (TTO) valuation technique is widely used to determine utility values of health outcomes to inform quality-adjusted life-year (QALY) calculations for use in economic evaluation. Protocols for implementing TTO vary in aspects such as the trade-off framework, iteration procedure and its administration model and method, training of respondents and interviewers, and quality control of data collection. The most widely studied and utilized TTO valuation protocols are the Measurement and Valuation of Health (MVH) protocol, the Paris protocol and the EuroQol Valuation Technology (EQ-VT) protocol, all developed by members of the EuroQol Group. The MVH protocol and its successor, the Paris protocol, were developed for valuation of EQ-5D-3L health states. Both protocols were designed for a trained interviewer to elicit preferences from a respondent using the conventional TTO framework with a fixed time horizon of 10 years and an iteration procedure combining bisection and titration. Developed for valuation of EQ-5D-5L health states, the EQ-VT protocol adopted a composite TTO framework and made use of computer technology to facilitate data collection. Training and monitoring of interviewers and respondents is a pivotal component of the EQ-VT protocol. Research is underway aiming to further improve the EuroQol protocols, which form an important basis for the current practice of health technology assessment in many countries.
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Affiliation(s)
- Mark Oppe
- EuroQol Research Foundation, Rotterdam, The Netherlands
| | - Kim Rand-Hendriksen
- Health Services Research Centre, Akershus University Hospital, Lørenskog, Norway
- Dept. of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | | | | | - Nan Luo
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, Block MD1, #11-01D, Singapore, 117549 Singapore
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Oddershede L, Petersen KD. Adjustment of foreign EQ-5D-3L utilities can increase their transferability. CLINICOECONOMICS AND OUTCOMES RESEARCH 2015; 7:629-36. [PMID: 26719715 PMCID: PMC4687628 DOI: 10.2147/ceor.s93280] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Foreign utilities of the EQ-5D-3L (3-level version of the EuroQol-5 Dimension of health questionnaire) are not readily transferrable to economic evaluations conducted from a national perspective. It has been advised to avoid transferring mean utilities from one country to another without adjusting them; yet no such method exists. Purpose The present study aimed to develop a method for adjusting mean utilities to increase their transferability from one country to another. Methods Seven datasets containing EQ-5D-3L answers were valued using value sets from four countries: the UK, the Netherlands, Germany, and Spain. Hereby, seven mean utility values were obtained for each country. This allowed for three pairwise comparisons: 1) UK mean values vs Dutch mean values; 2) UK mean values vs German mean values; and 3) UK mean values vs Spanish mean values. For each of these three comparisons, a regression model was fitted using the mean UK utilities as the dependent variable and the other country’s mean utilities as the independent variable. The coefficients from the three regression models were validated using results from a published article containing mean utilities obtained by valuing the EQ-5D-3L data using all four value sets. Results The findings suggested that adjustment of foreign utilities may increase transferability between countries where value sets are not comparable. It was possible to adjust the mean utilities valued by the Dutch and German value sets to make them reflect mean UK utilities as there were substantial differences between these value sets. Transferability of the Spanish mean utility values was not improved as the Spanish and UK value sets are sufficiently similar. Conclusion It is feasible to adjust foreign mean utilities of the EQ-5D-3L to make them reflect national preferences for health.
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Affiliation(s)
- Lars Oddershede
- Danish Center for Healthcare Improvements, Faculty of Social Sciences, Faculty of Health Sciences, Aalborg University, Aalborg East, Denmark ; HEOR Consult ApS, Copenhagen, Denmark
| | - Karin Dam Petersen
- Danish Center for Healthcare Improvements, Faculty of Social Sciences, Faculty of Health Sciences, Aalborg University, Aalborg East, Denmark
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Scalone L, Cortesi PA, Ciampichini R, Belisari A, D'Angiolella LS, Cesana G, Mantovani LG. Italian population-based values of EQ-5D health states. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2013; 16:814-22. [PMID: 23947975 DOI: 10.1016/j.jval.2013.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Revised: 02/25/2013] [Accepted: 04/10/2013] [Indexed: 05/06/2023]
Abstract
OBJECTIVE To estimate a value set for the calculation of Italian-specific quality-adjusted life years (QALYs), based on preferences elicited on EuroQol five-dimensional (EQ-5D) questionnaire health states using the time trade-off technique. METHODS The revised standard Measurement and Valuation of Health protocol was followed. Twenty-five health states, divided into three groups and given to 450 subjects, were selected to obtain 300 observations per state. Subjects aged 18 to 75 years were recruited to be representative of the Italian general adult population for age, sex, and geographical distribution. To improve efficiency, face-to-face interviews were conducted by using the Computer Assisted Personal Interviewing approach. Several random effects regression models were tested to predict the full set of EQ-5D questionnaire health states. Model selection was based on logical consistency of the estimates, sign and magnitude of the regression coefficients, goodness of fit, and parsimony. RESULTS The model that satisfied the criteria of logical consistency and was more efficient includes 10 main effect dummy variables for the EQ-5D questionnaire domain levels and the D1 interaction term, which accounts for the number of dimensions at levels 2 or 3 beyond the first. This model has an R(2) of 0.389 and a mean absolute error of 0.03, which are comparable to or better than those of models used in other countries. The utility estimates after state 11111 range from 0.92 (21111) to -0.38 (33333). Italian utility estimates are higher than those estimated in the United Kingdom and Spain and used so far to assess QALYs and conduct cost-utility evaluations in Italy. CONCLUSIONS A specific value set is now available to calculate QALYs for the conduction of health economic studies targeted at the Italian health care system.
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Augestad LA, Rand-Hendriksen K, Stavem K, Kristiansen IS. Time trade-off and attitudes toward euthanasia: implications of using 'death' as an anchor in health state valuation. Qual Life Res 2012; 22:705-14. [PMID: 22678351 DOI: 10.1007/s11136-012-0192-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2012] [Indexed: 11/25/2022]
Abstract
PURPOSE Health state values are by convention anchored to 'perfect health' and 'death.' Attitudes toward death may consequently influence the valuations. We used attitudes toward euthanasia (ATE) as a sub-construct for attitudes toward death. We compared the influence on values elicited with time trade-off (TTO), lead-time TTO (LT-TTO) and visual analogue scale (VAS).Since the 'death' anchor is most explicit in TTO, we hypothesized that TTO values would be most influenced by ATE. METHODS Respondents valued eight EQ-5D health states with VAS, then TTO (n = 328) or LT-TTO (n = 484). We measured ATE on a scale from -2 (fully disagree) to 2 (fully agree) and used multiple linear regressions to predict VAS, TTO, and LT-TTO values by ATE, sex, age, and education. RESULTS A one-point increase on the ATE scale predicted a mean TTO value change of -.113 and LT-TTO change of -.072. Demographic variables, but not ATE, predicted VAS values. CONCLUSIONS TTO appears to measure ATE in addition to preferences for health states. Different ways of incorporating death in the valuation may impact substantially on the resulting values. 'Death' is a metaphysically unknown concept, and implications of attitudes toward death should be investigated further to evaluate the appropriateness of using 'death' as an anchor.
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Affiliation(s)
- Liv A Augestad
- Health Services Research Centre, Akershus University Hospital, 1478, Lørenskog, Norway.
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