Canadian TTO Valuations of the EQ-5D-5L: East versus West Differences Jeffrey A. Johnson (on behalf of the Canadian EQ-5D-5L Valuation Study Team)

Acknowledgements Canadian EQ-5D-5L Valuation Study Team Principal Investigators: Feng Xie (McMaster University) and Jeffrey Johnson (U of Alberta) Co-Investigators: Nick Bansback, Stirling Bryan (UBC), Arto Ohinmaa (University of Alberta), Lise Poissant (University of Montreal), Eleanor Pullenayegum (McMaster/University of Toronto) Research Coordinator: Gaebel K (McMaster University) Research Assistants: Samantha Pollard & Lidia Engel (UBC); Serena Humphries & Fatima Al Sayah (U of Alberta), Touria Addou (University of Montreal). Funding support from CIHR and the EuroQol Research Foundation

EQ-5D Preference-based HRQL (“utility”) instrument 5-dimension classification system and VAS Can produce variety of health status/HRQL scores (5D profile, EQ-VAS, EQ-index) Preference-based scoring system provides index score suitable for QALYs Country-specific preference-based value sets recommended for local resource allocation decisions

EQ-5D Descriptive System EQ-5D-5L I have no problems in walking about I have slight problems in walking about I have moderate problems in walking about I have severe problems in walking about I am unable to walk about I have no problems washing or dressing myself I have slight problems washing or dressing myself I have moderate problems washing or dressing myself I have severe problems washing or dressing myself I am unable to wash or dress myself I have no problems doing my usual activities I have slight problems doing my usual activities I have moderate problems doing my usual activities I have severe problems doing my usual activities I am unable to do my usual activities I have no pain or discomfort I have slight pain or discomfort I have moderate pain or discomfort I have severe pain or discomfort I have extreme pain or discomfort I am not anxious or depressed I am slightly anxious or depressed I am moderately anxious or depressed I am severely anxious or depressed I am extremely anxious or depressed ☐ 3125 health states EQ-5D-3L Mobility I have no problems in walking about I have some problems in walking about I am confined to bed ☐ Self-Care I have no problems washing or dressing myself I have some problems washing or dressing myself I am unable to wash or dress myself ☐ Usual Activities I have no problems doing my usual activities I have some problems doing my usual activities I am unable to do my usual activities ☐ Pain/ Discomfort I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort ☐ Anxiety Depression I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed ☐ 243 health states

Canadian EQ-5D-5L Valuation Study Objective was to derive a value set for Canada for the new EQ-5D-5L, based on preferences from the general population in Canada. Med Care 2016; 54:98-105

EQ Valuation Technology (EQ-VT) Standardized, computer-based interview protocol Composite time trade-off (cTTO) 86 health states into 10 blocks (10 states/block) one of 5 very mild states (21111, 12111, 11211, 11121, 11112) is included in each block 55555 is included in each block Discrete choice experiment (DCE) 28 blocks (7 pairs per block) Demographics and feedback Recommended sample size: ~1000/country

cTTO-better than dead

CAN EQ-5D-5L Valuation Study Computer-assisted face-to- face interviews EQ-VT and supplemental component N= 300 in Vancouver Edmonton, Hamilton, and Montreal Various recruitment strategies: random digit-dialing, community posters Quota sampling in terms of age, sex, education

“Inconsistent” TTO Valuations Considered respondents with inconsistent valuations Based on Dominance: e.g. 21111 vs 31111 Number of health states dominated by the very mild state varied from 5 to 8 The exclusion criteria: a participant gave the same or lower score to the very mild health state than to 55555; and if a participant gave the same or lower score to the very mild health state than to the majority of the health states that are dominated by the very mild health state within the same block

Data Analysis Dependent variable TTO values (n=10/respondent) tTTO and positive cTTO values WTD values transformed for 0 to -1 scale TTOij = {MO + SC + UA + PD + AD} + age + sex + SES* + marital status + comorbidities + urban/rural + ethnicity + birth country + health literacy + EQ-VAS + {Vancouver/Edmonton/Hamilton/Montreal (ref)} +/- inconsistent valuations (Y/N) * education, employment, household income

TTO Valuations West versus East 0.02 -0.124 Adjusted regression results comparing cities to Montreal as reference – our a priori consideration that Montreal respondents may have been the most different (by language/culture) -0.156 * adjusted age, sex, SES*, marital status, comorbidities, urban/rural, ethnicity, birth country, health literacy, EQ-VAS & inconsistent valuations

TTO Valuations West versus East EQ-5D-5L Health State Vancouver (N=299) Edmonton (N=310) Hamilton (N=300) Montreal p-value 11112 (N=241) 0.72 0.88 0.93 0.90 0.001 12344 (N=109) 0.19 0.25 0.45 0.48 0.042 53243 (N=123) 0.10 0.17 0.53 55555 (N=1209) -0.13 -0.07 0.06 <0.001 To show some unadjusted differences in mean TTO valuations for 4 selected specific health states (mild, mild-mod, mod-severe, and worst). Note that the worst health stated ‘55555’ had mean values below 0 (worse than dead) for Vancouver and Edmonton, but positive average values for Hamilton and Montreal.

Sample Characteristics West versus East Vancouver (N=299) Edmonton (N=310) Hamilton (N=300) Montreal p-value Age (yr) 49.7 (18.8) 48.3 (17.5) 46.3 (16.8) 46.2 (16.0) <0.001 Sex (Female) 49% 44% 51% 37% Married/Common Law 42% 60% 58% 53% Household Income (<$75K) 75% Education (HS+) 89% 96% 88% Ethnicity White Aboriginal 50% 9% 63% 7% 71% 67% 5% Born in Canada 80% 83% 70% Urban Dwelling 81% 77% EQ-VAS 80.5 (14.7) 81.6 (13.9) 81.8 (14.9) 85.2 (12.9) Comorbidities (2+) 35% 36% 28% 24% Inconsistent Valuations 11% 6.5% 13% 14% To show that there were differences between samples within each city, but not in any particular pattern that would explain the West vs East differences we observed. Note that all of these factors were controlled for in the multivariate regression models – with and without inconsistent valuations included.

Discussion Socio-demographic characteristics (age, sex, urban dwelling) are important determinants of TTO valuations; Respondents from western Canadian cities provided substantially lower TTO valuations than form eastern cities Should one Canadian preference/value set be used for EQ-5D-5L ?

Discussion Same valuation methodology (EQ-VT) Differences in recruitment/samples by city…? Interviewer effect within study site…? N=1 for QC and ON; N=2 or 4 for BC or AB Differences in health care policy/delivery…? Differences in health preferences…? Again, should one Canadian EQ-5D-5L preference set be used for the whole country…??

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