1. 1 EuroQol EQ-5D Jan J. V. Busschbach, Ph.D Psychotherapeutic Centrum ‘De Viersprong’, Halsteren –Jan.Busschbach@deviersprong.net Department of Medical Psychology and Psychotherapy, Erasmus MC –Busschbach@mpp.fgg.eur.nl

2. 2 EQ-5D 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

3. 3 The clinical perspective It is not the doctor who reports Quality of life is subjective….. –“Given its inherently subjective nature, consensus was quickly reached that quality of life ratings should, whenever possible, be elicited directly from patients themselves. “ (Aaronson, in B Spilker (Ed): Quality of life and Pharmacoeconomics in Clinical Trails, 1996, page 180) –As a CONSUMER of care, the patient is the best judged about the quality of care The patient values count in clinical quality of life research

4. 4 The economic perspective In a normal market: the consumer values count The patient seems to be the consumer –Thus the values of the patients…. If indeed health care is a normal market… But is it….?

5. 5 Health care is not a normal market Supply induced demands Subsidies (egalitarian structure) Government control Health care is an insurance market –A compulsory insurance market The patient does not pay –Patient  Consumer –Potential patients are paying –Consumer = General public

6. 6 Who determines the payments of unemployment insurance? Civil servant –Knowledge: professional –But strategy »more money, less problems »identify with unemployed persons The unemployed persons themselves –Knowledge: specific –But strategy General public (politicians) –Knowledge: experience –Payers

7. 7 Who’s values (of quality of life) should count in the health insurance? Doctors –Knowledge: professional –But strategy –But see only selection of patient (the complainers) Patients –Knowledge: disease specific –But strategy –But coping General public –Knowledge: experience –Payers

8. 8 Patient values seem high Stensman –Scan J Rehab Med 1985;17:87-99. Scores on a visual analogue scale –36 subjects in a wheelchair –36 normal matched controls Mean score –Wheelchair: 8.0 –Controls: 8.3

9. 9 Is there a problem? There is no problem... –if effect is linear –In the past, the general perspective was seen as a proxy for patient perspective There is a problem... –If there is no linear transformation –Patient and general public perspective reveal different results –Loss of power in patient perspective

10. 10 Patient Perspective

11. 11 The 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

12. 12 Validated Questionnaires Describe health states Have values from the general public –Rosser –QWB –15D –HUI Mark 2 –HUI Mark 3 –EuroQol EQ-5D

13. 13 EQ-5D 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

14. 14 EuroQol EuroQol Group Latest version: EQ-5D –5 dimensions »Mobility, self-care, usual activities, pain / discomfort, anxiety / depression –3 levels per dimension –243 health states Validation –Finland, Netherlands, Norway, Sweden, UK, Spain, Germany, Greece, US, Japan, New Zealand, Zimbabwe, Denmark –N = 200 - 3000

15. 15 How to get these societal values? Patient fills in questionnaire Choose the value function from the literature Calculate societal value COMPUTE MVH_A1 = 1. VARIABLE LABELS MVH_A1 'York A1 tariff'. DO IF (NVALID(mo, sc, ua, pd, ad) < 5 ). RECODE MVH_A1 (1 = SYSMIS). END IF. IF (MAX(mo, sc, ua, pd, ad) > 1) MVH_A1 = MVH_A1 -.081. IF (mo = 2) MVH_A1 = MVH_A1 -.069. IF (mo = 3) MVH_A1 = MVH_A1 -.314. IF (sc = 2) MVH_A1 = MVH_A1 -.104. IF (sc = 3) MVH_A1 = MVH_A1 -.214. IF (ua = 2) MVH_A1 = MVH_A1 -.036. IF (ua = 3) MVH_A1 = MVH_A1 -.094. IF (pd = 2) MVH_A1 = MVH_A1 -.123. IF (pd = 3) MVH_A1 = MVH_A1 -.386. IF (ad = 2) MVH_A1 = MVH_A1 -.071. IF (ad = 3) MVH_A1 = MVH_A1 -.236. IF (MAX(mo, sc, ua, pd, ad) > 2) MVH_A1 = MVH_A1 -.269.

16. 16 An example of a value function * SPSS syntax Dolan 1997, Medical Care, 1997;35:1095-108. * mo = mobility, sc= self care, ua = usual activities, pd = pain & discomfort, ad = anxiety and depression. COMPUTE MVH_A1 = 1. VARIABLE LABELS MVH_A1 'York A1 tariff'. DO IF (NVALID(mo, sc, ua, pd, ad) < 5 ). RECODE MVH_A1 (1 = SYSMIS). END IF. IF (MAX(mo, sc, ua, pd, ad) > 1) MVH_A1 = MVH_A1 -.081. IF (mo = 2) MVH_A1 = MVH_A1 -.069. IF (mo = 3) MVH_A1 = MVH_A1 -.314. IF (sc = 2) MVH_A1 = MVH_A1 -.104. IF (sc = 3) MVH_A1 = MVH_A1 -.214. IF (ua = 2) MVH_A1 = MVH_A1 -.036. IF (ua = 3) MVH_A1 = MVH_A1 -.094. IF (pd = 2) MVH_A1 = MVH_A1 -.123. IF (pd = 3) MVH_A1 = MVH_A1 -.386. IF (ad = 2) MVH_A1 = MVH_A1 -.071. IF (ad = 3) MVH_A1 = MVH_A1 -.236. IF (MAX(mo, sc, ua, pd, ad) > 2) MVH_A1 = MVH_A1 -.269.

17. 17 Some values Broken arm 12211 –no problems in walking about –some problems washing or dressing –some problems with performing usual activities –no pain or discomfort –not anxious or depressed Societal value = 0.779

18. 18 Some values Broken hip 22222 –some problems in walking about –some problems washing or dressing –some problems with performing usual activities –moderate pain or discomfort –moderately anxious or depressed Societal value = 0.516

19. 19 Impact on quality of life

20. 20 Effect psychotherapy

21. 21 Reimbursement arguments Dunning’s Funnel –1990 –Government declaration 2002 –Necessary care »Need »Equity elements –Efficacy –Cost effectiveness –Own account and responsibility

22. 22 Reimbursement arguments Impact on QoL Effect on QoL Cost effectiveness ? QALYs

23. 23 Quality Adjusted Life Years (QALY) Multiply life years with quality index Quality of life index –1.0 = normal health –0.0 = extremely bad health (death) Example –Losing sense of sight –Quality of life index is 0.5 –Life = 80 years –0.5 x 80 = 40 QALYs Accepted measure of health –Used by the WHO (DALY)

24. 24 QALY league table

25. 25 EQ-5D and cost effectiveness EQ-5D specially designed –Social perspective –Generic –0 to 1 scale Use EQ-5D for QALY analysis