Effect of framing of death on health state values obtained from DCEs Marcel Jonker, de Bekker-Grob, Donkers, Stolk Dr. Esther W. de Bekker-Grob e.debekker@erasmusmc.nl www.eur.nl/ecmc

Introduction Discrete choice experiments (DCE) is considered a promising technique for health state valuation Nevertheless, the method is still in development and obtained results warrant further investigation Notably, compared to TTO, DCE classifies more states as worse than death www.eur.nl/ecmc

Hypothesis Differences between health state values based on TTO and DCE may at least in part be reconciled by harmonizing their framings TTO includes an endowment, whereas DCE involves a neutral choice between option A and option B www.eur.nl/ecmc

Aim To determine how alternative framing of the DCE questions affects EQ-5D-5L health state values www.eur.nl/ecmc

DCE health-state valuations latent utility scale QALY scale 1-1-1-1-1 1-1-1-1-1 = 1 death = 0 5-5-5-5-5 5-5-5-5-5

2 ways to obtain QALY values Including “death” as an alternative-specific health state in the DCE Including “duration” as an additional attribute in the DCE (zero duration of life = death) 1-1-1-1-1 = 1 death = 0 5-5-5-5-5

Methods 9 different study arms: 5 different DCE duration framings 4 different DCE death framings www.eur.nl/ecmc

Methods 9 different study arms: 5 different DCE duration framings 4 different DCE death framings www.eur.nl/ecmc

Base case (A vs B) Which health state do you prefer, A or B? 10 years in this health 10 years in this health state, followed by death state, followed by death no problems in walking about no problems in walking about Mobility no problems washing or dressing no problems washing or dressing Self-care Usual activities moderate problems doing usual activities moderate problems doing usual activities severe pain or discomfort extreme pain or discomfort Pain extremely anxious or depressed slightly anxious or depressed Anxiety

Base case (B vs C) Which health state do you prefer, B or C? 10 years in this health 10 years in this health state, followed by death state, followed by death no problems in walking about no problems in walking about Mobility no problems washing or dressing no problems washing or dressing Self-care Usual activities moderate problems doing usual activities moderate problems doing usual activities severe pain or discomfort extreme pain or discomfort Pain extremely anxious or depressed slightly anxious or depressed Anxiety

Base case (DCE death) Which health state do you prefer, B or C? 10 years in this health 10 years in this health You die immediately state, followed by death state, followed by death no problems in walking about no problems in walking about Mobility no problems washing or dressing no problems washing or dressing Self-care Usual activities moderate problems doing usual activities moderate problems doing usual activities severe pain or discomfort extreme pain or discomfort Pain extremely anxious or depressed slightly anxious or depressed Anxiety

Base case (DCE duration) Which health state do you prefer, B or C? B C 10 years in this health 10 years in this health 7 years in this health state, followed by death state, followed by death state, followed by death no problems in walking about no problems in walking about no problems in walking about Mobility no problems washing or dressing no problems washing or dressing no problems in walking about Self-care Usual activities moderate problems doing usual activities moderate problems doing usual activities no problems in walking about extreme pain or discomfort no problems in walking about Pain severe pain or discomfort extremely anxious or depressed slightly anxious or depressed no problems in walking about Anxiety

Framing 1: lead time Which health state do you prefer, A or B? You will live 20 years, of which 10 in full health and 10 years in this health below You will live 20 years, of which 10 in full health and 10 years in this health below You will live 10 years in perfect health, followed by death no problems in walking about no problems in walking about no problems in walking about Mobility no problems washing or dressing no problems washing or dressing no problems in walking about Self-care no problems in walking about Usual activities moderate problems doing usual activities moderate problems doing usual activities severe pain or discomfort extreme pain or discomfort no problems in walking about Pain extremely anxious or depressed slightly anxious or depressed no problems in walking about Anxiety

Framing 2: endowment health state Assume you live 10 years in health state A. Which health state do you prefer, health state A or do you want to substitute for health state B? A B C 10 years in this health 10 years in this health state, followed by death state, followed by death no problems in walking about no problems in walking about Mobility no problems washing or dressing no problems washing or dressing Self-care Usual activities moderate problems doing usual activities moderate problems doing usual activities severe pain or discomfort extreme pain or discomfort Pain extremely anxious or depressed slightly anxious or depressed Anxiety

Framing 3: reversed endowment Assume you would die immediately. Which health state do you prefer, health state A or do you want to substitute for health state B? A B C 10 years in this health 10 years in this health You die immediately state, followed by death state, followed by death no problems in walking about no problems in walking about Mobility no problems washing or dressing no problems washing or dressing Self-care Usual activities moderate problems doing usual activities moderate problems doing usual activities extreme pain or discomfort extreme pain or discomfort Pain slightly anxious or depressed slightly anxious or depressed Anxiety

Framing 4: years of life lost Which health state do you prefer, B or C? B C 10 years in this health 10 years in this health You loose 3 out of the remaining 10 years state, followed by death state, followed by death no problems in walking about no problems in walking about no problems in walking about Mobility no problems washing or dressing no problems washing or dressing no problems in walking about Self-care Usual activities moderate problems doing usual activities moderate problems doing usual activities no problems in walking about extreme pain or discomfort no problems in walking about Pain severe pain or discomfort extremely anxious or depressed slightly anxious or depressed no problems in walking about Anxiety

Methods Sample: Online panel (Dutch general population) 2,700 respondents (300 per arm) Respondents were randomly assigned to one of the 9 study arms www.eur.nl/ecmc

Methods Sample: Online panel (Dutch general population) 2,700 respondents (300 per arm) Respondents were randomly assigned to one of the 9 study arms Experimental DCE design: Bayesian D-efficient design with 2*15 choices for each respondent jointly optimized for DCE duration and death Keeping all aspects of the DCE design constant except for the framing (!) www.eur.nl/ecmc

Methods Estimations: Bayesian mixed logit models Comparisons between 9 study arms in terms of QALY tariffs (on a comparable scale) www.eur.nl/ecmc

Results DCE duration www.eur.nl/ecmc

Results DCE death www.eur.nl/ecmc

Results – QALY scale www.eur.nl/ecmc

Results – QALY scale www.eur.nl/ecmc

Results – QALY scale www.eur.nl/ecmc

Conclusion Framing effects were substantial Our harmonizing framings did not reconcile differences between health state values based on TTO and DCE Interestingly, we found something else: our base case values were not that different anymore from TTO values

Further research needed 1) Our design was jointly optimized for ‘DCE duration’ and ‘DCE death’.  QALY-balanced DCE designs (?) 2) The death parameter in DCE death might not be normally distributed.  Mixture of normals, dirichlet process prior (?) 3) Our results showed that the TTO values lay exactly between DCE duration and DCE death results  How desirable is it to “tweak” DCE to reach similar values as TTO?

Previous & current DCE design www.eur.nl/ecmc

Distribution of the death parameter www.eur.nl/ecmc

Acknowledgement www.eur.nl/ecmc