1. Overview of the EQ-5D Purpose and origins of the descriptive system

2. Health Economics Comparing different allocations –Should we spent our money on Wheel chairs Screening for cancer –Comparing costs –Comparing outcome Outcomes must be comparable –Make a generic outcome measure

3. Outcomes in health economics Specific outcome are incompatible –Allow only for comparisons within the specific field Clinical successes: successful operation, total cure Clinical failures: “events” –“Hart failure” versus “second psychosis” Generic outcome are compatible –Allow for comparisons between fields Life years Quality of life Most generic outcome –Quality adjusted life year (QALY)

4. Example –Blindness –Time trade-off value is 0.5 –Life span = 80 years –0.5 x 80 = 40 QALYs Quality Adjusted Life Years (QALY) 0.00 1.00 X Life years 40 80 0.5 x 80 = 40 QALYs

5. Area under the curve

6. Burden of disease (WHO): QALY lost = DALY Disability adjusted life year DALY QALY

7. QALY league table

8. 8 7000 Citations in PubMed

9. In search of a QoL value… Most controversy about QoL measure –In QALY analysis Uni-dimensional value –Like temperature –Like the IQ-test measures intelligence Ratio or interval scale –Difference 0.00 and 0.80… –… must be 8 time higher than 0.10

10. Unidimensional, ratio scales Two popular methods have these pretensions –Time trade-off –Standard gamble Two methods are less clear…. –Visual analog scale –Paired comparison Conjoint analysis; DCE, etc

11. The Rosser & Kind Index

12. The Rosser & Kind index One of the oldest valuation 1978: Magnitude estimation –Magnitude estimation  PTO –N = 70: Doctors, nurses, patients and general public 1982: Transformation to “utilities” –Other word for “value of QoL”

13. 1985: High impact article

15. –Survey at the celebration of 25 years of health economics in the UK (HESG): chosen most influential article on health economics

16. Criticism on the Matrix Sensitivity –only 30 health states The compression of states in the high values The unclear meaning of “distress” The involvement of medical personnel No clear way how to classify the patients –into the matrix Only British values

17. Value compression

18. New initiatives Higher sensitivity (more then 30 states) More and better defined dimensions Other valuation techniques –Standard Gamble, Time Trade-Off, Visual Analogue Scale Values of the general public A questionnaire… –to allow patients to ‘self classify’ themselves An international standard –to allow international comparisons –That is at that time “Europe”

19. EuroQoL Group First meeting 1987 Participants from –UK, Finland, Sweden, The Netherlands A common core instrument –To allow international comparisons –To allow linking of international results Instrument should be small Suitable for sever ill patients –The emerging of high tech medicine, especially transplantation

20. The first EuroQol Higher sensitivity (more then 30 states) –216 states More and better defined dimensions –6 dimensions –Mobility; –Daily activity and self care; –Work performance –Family and leisure performance –Pain/discomfort –Present mood Other valuation techniques –Visual Analogue Scale

21. The first EuroQol Values of the general public –Values from general public –But also values from patients (!) A questionnaire –to allow patients to ‘self classify’ themselves A international standard –to allow international comparisons –That is at that time “Europe”

22. Direct utility assessment

23. Indirect utility assessment

24. First indirect values Add the value of death

25. First international comparisons in 1988 with EQ-6D and VAS

26. EQ-5D-3L Value Sets TTO Value SetsVAS Value Sets Health State Value Health State

27. Why indirect utility measures? Original: To avoid ‘strategic responses’ –Patients pressure groups To avoid coping –Underestimating the value of health To allow complex utility assessments –Time Trade Off –Standard Gamble –Willingness to pay –Person Trade off –Paired comparisons (DCE) To allow for societal values of health states –Like costs: the societal perspective

28. Why indirect utility measures? Original: To avoid ‘strategic responses’ –Patients pressure groups To avoid coping –Underestimating the value of health To allow complex utility assessments –Time Trade Off –Standard Gamble –Willingness to pay –Person Trade off –Paired comparisons (DCE) To allow for societal values of health states –Like costs: the societal perspective

29. Coping: can be a problem in the patient perspective…. 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 –Health controls: 8.3 Need for indirect valuation Healthy Death

30. Why indirect utility measures? Original: To avoid ‘strategic responses’ –Patients pressure groups To avoid coping –Underestimating the value of health To allow complex utility assessments –Time Trade Off –Standard Gamble –Willingness to pay –Person Trade off –Paired comparisons (DCE) To allow for societal values of health states –Like costs: the societal perspective

31. Time Trade-Off TTO: alternative for VAS Wheelchair –With a life expectancy: 50 years How many years would you trade-off for a cure? –Max. trade-off is 10 years QALY(wheel) = QALY(healthy) –Y * V(wheel) = Y * V(healthy) –50 V(wheel) = 40 * 1 V(wheel) =.80

32. Health economics prefer TTO Visual analogue scale –No trade-off: no relation to QALY No interval proportions –Easy Time trade-Off –Trade-off: clear relation to QALY Interval proportions –Less easy Time consuming in patients Need for indirect valuation

33. Why indirect utility measures? Original: To avoid ‘strategic responses’ –Patients pressure groups To avoid coping –Underestimating the value of health To allow complex utility assessments –Time Trade Off –Standard Gamble –Willingness to pay –Person Trade off –Paired comparisons (DCE) To allow for societal values of health states –Like costs: the societal perspective

34. 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….?

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

36. Health care is an insurance market Values of benefit in health care have to be judged from a insurance perspective Who values should be used the insurance perspective?

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

38. Who’s values (of quality of life) should count in the health insurance? Doctors –Knowledge: professional –But suspected for strategical answers See only selection of patient Identification with own patient Patients –Knowledge: disease specific –But suspected for strategical answers –But coping General public –Knowledge: experience –Payers –Like costs: the societal perspective

39. The general public should be informed… Valuing without knowledge makes no sense –Thyroid Eye Disease Give description of the disease –For instance in terms of the EQ-5D A patient with bilateral thyroid eye disease with upper lid retraction and exophthalmos.

40. Why indirect utility measures? Original: To avoid ‘strategic responses’ –Patients pressure groups To avoid coping –Underestimating the value of health To allow complex utility assessments –Time Trade Off –Standard Gamble –Willingness to pay –Person Trade off –Paired comparisons (DCE) To allow for societal values of health states –Like costs: the societal perspective

41. Indirect utility measrue 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

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