1. Is healthcare any good for patients
Is healthcare any good for patients? Measuring health outcomes using EQ-5D
Professor Paul Kind
Principal Investigator
Outcomes Research Group
Centre for Health Economics
University of York England

2. Health care
Designed / delivered with the intention of altering the “natural” health status of patients over time
Relieving pain, suffering
Prolonging (enabling) life
Easing process of dying
Cure (sometimes)

3. Hippocratic Oath : First, do no harm
Fundamental question : how do you know if you are helping / harming the patient ?
You need to know
does treatment CHANGE anything ?
what is the DIRECTION of change ?
what is the MAGNITUDE of change ?

4. Health care intervention
Symptomatic relief,
cure, palliation ?
Yes
Problem

5. Measuring health outcomes the biomedical model
(a) [ FEV1 ]t0 - [ FEV1 ]t  FEV1
(b) [ health]t0 - [ health ]t  health status
there is a calibrated test procedure for (a)
what do we use for (b) ?

6. Outcome measures 'Classical' indicators
Survival rates
Readmission rates
Symptom counts
Employment status
Days lost through sickness
Clinical parameters

7. Grading angina severity New York Heart Association
Grade I
ordinary physical activity does not cause undue fatigue, palpitation or anginal pain
Grade II
comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnoea or anginal pain
Grade III
comfortable at rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnoea or anginal pain
Grade IV
inability to carry on physical activity without discomfort. Symptoms of cardiovascular insufficiency or the anginal syndrome may be present even at rest

8. Karnofsky Performance Scale

9. FACT-L

10. Health-related quality of life a specialised measure of outcome
What are the health outcomes ?
EQ-5D
Health-related
quality of life

11. The EuroQoL Group
Set up in 1987 by a multidisciplinary group of researchers concerned with EVALUATION in health and health care
Clinicians
Health economists
Others (sociology, psychology …)

12. The EuroQoL Group Extended network Founders Finland Netherlands
(Norway)
Sweden UK
Extended network
Argentina
Canada
China
Denmark
Germany
Greece
Hungary
Italy
Japan
Korea
New Zealand Portugal
Russia
Slovenia
Spain
Taiwan
USA
Poland ?

13. So .. what is EQ-5D ?
A generic measure of health status (health-related quality of life) capable of being represented as a single index
Health is defined in terms of 5 dimensions
mobility
self care
usual activity
pain / discomfort
anxiety / depression
Each dimension is divided into 3 levels
none
some
extreme

14. What is EQ-5D ? Health state A generic, single index
measure of health status
Based on 5 dimensions
Mobility
Self-Care
Usual Activity
Pain / Discomfort
Anxiety / Depression
Defines a total of 35
= 243 health states
Mobility
Self-Care
Usual Activity
Pain / Discomfort
Anxiety / Depression
Health
state

15. State 12212 Self-care Pain / discomfort Mobility Health state Usual
Anxiety / depression
Health state
Usual
activities
For example :
no problems in walking about (1)
some problems washing self (2)
some problems with usual activity (2)
no pain or discomfort (1)
moderately anxiety or depression (2)
State 12212

16. There is a logical ordinal relationship between some states
In general we know NOTHING about the order or values of EQ-5D health states
There is a logical ordinal relationship between some states
For example is logically better than 33333
But what is the distance between these states ?

17. Does moving from state A to state B constitute a patient benefit
Does moving from state A to state B constitute a patient benefit ? If so, then by how much?
Profile A :
Profile B :

18. Shared objective : Valuing health
Needed a simple method
Self-administered
Capable of being used in population surveys
Relatively quick
Able to produce cardinal values

19. Valuation method(s) EuroQoL Group standard Individual experimentation
Visual analogue scale rating using a vertical 20cm scale
Range 0 – 100 corresponding to “worst imaginable” and “best imaginable” health
Individual experimentation
Time Trade-Off (York MVH Project)
Ranking
Paired comparisons
Standard Gamble

20. VAS rating of EQ-5D health states
Health state E
Health state F
Health state H
VAS rating of EQ-5D health states
Health state A
Health state C
Health state D

21. Profile A : 1 1 2 2 3 Profile B : 1 1 3 2 2 Population preference
weights
Profile B :

22.      MOBILITY I have no problems in walking about 
MOBILITY
  I have no problems in walking about 
I have some problems in walking about 
I am confined to bed  
·       For each group of statements please indicate the one that best describes your health today
·   Please tick one box for each group of statements.
SELF-CARE
  I have no problems with self-care 
I have some problems washing or dressing myself 
I am unable to wash or dress myself  
USUAL ACTIVITIES
  I have no problems with performing my usual activities 
(e.g. work, study, housework, family or leisure activities)
I have some problems with performing my usual activities 
I am unable to perform 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  

24. TThink about how good or bad your own health is today
TThink about how good or bad your own health is today
 This scale may help. The best health you can imagine is marked 100 and the worst health you can imagine is marked 0
  Please write in the box below, the number between 0 and 100 that you feel best shows how good your health is today
100
Worst imaginable health
Best imaginable health 10 60 50 40 30 20 90 80 70
Your own health today

26. Page 3 : Patient Perspective

27. Page 2 : Societal Perspective
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 with self-care
I have some problems washing or dressing myself
I am unable to wash or dress myself
USUAL ACTIVITIES (e.g. work, study, housework family or leisure activities)
I have no problems with performing my usual activities
I have some problems with performing my usual activities
I am unable to perform 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 ?
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 with self-care
I have some problems washing or dressing myself
I am unable to wash or dress myself
USUAL ACTIVITIES (e.g. work, study, housework family or leisure activities)
I have no problems with performing my usual activities
I have some problems with performing my usual activities
I am unable to perform 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

28. How are EQ-5D data presented ?
As a profile
based on reported level of problem on each dimension
As a health state
As a weighted index
based on values of the general public
As self-rated health status
EQ-5D
profile
health state
weighted
index
self-rated
health status
Part I
Part II

29. Some examples

30. Frequency of reported problems by age group in UK population
Older age groupsshow more problems
Mobiltiy and oain and discomfort are sources of problems 40

31. Population “norms” mean EQ-5Dindex
Source : Health Survey for England, 1996

32. EQ-5Dindex by age / smoking behaviour45

33. EQ-5D for GP clinic attenders

34. Primary care clinic attendees EQ-5D profile by diagnostic group59

36. Rheumatoid arthritis Functional Class
I .. complete functional capacity
ability to carry out all normal activities
II .. adequate for normal activities
despite discomfort or limited motion at 1 or more joints
III .. limited functional capacity
only little or none of duties of normal occupation or selfcare
IV .. incapacitated
largely or wholly bed-ridden or confined to wheelchair; little or no selfcare

37. EQ-5Dindex by Functional Class
rheumatoid arthritis patients

38. EQ-5D in treatment of HIV/AIDS

39. Where are we now ? Science
Likely to increase number of response levels from 3 to 5
Investigating a “child-friendly” version of EQ-5D
Computer-based valuation and self-assessment methods
Electronic data capture – web based technologies

40. 5-level or 3-level ?
One suggested modification to existing 3-level descriptive system
Place unmarked level between existing levels

41. Where are we now ? Application
Nearly 100 language versions available
Worldwide take-up with many normative population studies
Widespread incorporation in clinical studies that involve economic evaluation
Major head:head study in US of the leading generic HrQoL measures

42. ends
Paul Kind :
EuroQoL Group :