1. 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

2. 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

3. 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

4. Aim To determine how alternative framing of the DCE questions affects
EQ-5D-5L health state values

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

6. 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
death = 0

7. Methods 9 different study arms: 5 different DCE duration framings
4 different DCE death framings

8. Methods 9 different study arms: 5 different DCE duration framings
4 different DCE death framings

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

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

18. 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 (!)

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

20. Results DCE duration

21. Results DCE death

22. Results – QALY scale

23. Results – QALY scale

24. Results – QALY scale

25. 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

26. 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?

27. Previous & current DCE design

28. Distribution of the death parameter

29. Acknowledgement