1 eq-5d, hui and sf-36 of the shelf instruments…
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…or use validated questionnaires
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
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Validated questionnaires
Rosser
EuroQol EQ-5D www.euroqol.org
QWB
SF-36 (SF-6D) www.sf-36.org
HUI Mark 2
HUI Mark 3
15D www.15d-instrument.net
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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” 1985: High impact article
Williams A. For Debate... Economics of Coronary Artery Bypass Grafting. British Medical Journal 291: 326-28, 1985.
Survey at the celebration of 25 years of health economics: chosen most influential article on health economics
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More health states
Criticism on the Rosser & Kind index Sensitivity (only 30 health states)
The unclear meaning of “distress”
The compression of states in the high values
The involvement of medical personnel
New initiatives Higher sensitivity (more then 30 states)
More and better defined dimensions
Other valuation techniques
• Standard Gamble, Time Trade-Off
Values of the general public
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Validated questionnaires
Questionnaire Number of health state
Rosser 30
EuroQol EQ-5D 243
QWB 2,200
SF-36 (SF-6D) 9,000
HUI Mark 2 24,000
HUI Mark 3 972,000
15D 3,052,000,000
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No longer value all states
Impossible to value all health states If one uses more than 30 health states
Estimated the value of the other health states with statistical techniques Statistically inferred strategies
• Regression techniques
• EuroQol, Quality of Well-Being Scale (QWB)
Explicitly decomposed methods
• Multi Attribute Utility Theory (MAUT)
• Health Utility Index (HUI)
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Statistically inferred strategies
Value a sample of states empirically Extrapolation
Statistical methods, like linear regression
11111 = 1.00
11113 = .70
11112 = ?
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Statistically inferred strategies
EuroQol EQ-5D: 5 dimensions of health
245 health states
Quality of Well-Being scale (QWB) 4 dimensions of health
2200 health states plus 22 additional symptoms
SF-36 SF-6D: 6 dimensions of health
18.000 health states
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Explicitly Decomposed Methods
Value dimensions separately Between the dimensions What is the relative value of:
• Mobility…... 20%• Mood…….. 15%• Self care.… 24%.
Value the levels Within the dimensions What is the relative value of
• Some problems with walking…… 80%• Much problems with walking…... 50%• Unable to walk…………………….10%
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Explicitly Decomposed Methods
Combine values of dimensions and levels with specific assumptions Multi Attribute Utility Theory (MAUT)
• Mutual utility independence
• Structural independence
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Explicitly Decomposed Methods
Health Utilities Index (Mark 2 & 3) Torrance at McMaster
8 dimensions
Mark 2: 24.000 health states
Mark 3: 972.000 health states
The 15-D Sintonen H.
15 dimensions
3,052,000,000 health states (3 billion)
Exercise EQ-5D: 12311
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The EQ-5D
For each of the following question, please mark the circle that best describes your answer, still imagining of course that you require a wheelchair to get around. By placing a tick (thus ) in one box in each group below, please indicate which statements best describe your own health state today, imagining that you require a wheelchair to get around independently. 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
X
X
X
X
X
Scoring EQ-5D state 123111. COMPUTE MVH_A1 = 1.00. 2. IF (MAX(eq_mobility,eq_selfcare,eq_usual activities,eq_pain, eq_anxiety/depression)
> 1) MVH_A1 = MVH_A1 - .081 . 3. IF (eq_mobility = 2) MVH_A1 = MVH_A1 - .069. 4. IF (eq_mobility = 3) MVH_A1 = MVH_A1 - .314. 5. IF (eq_selfcare = 2) MVH_A1 = MVH_A1 - .104. 6. IF (eq_selfcare = 3) MVH_A1 = MVH_A1 - .214. 7. IF (eq_usual activities = 2) MVH_A1 = MVH_A1 - .036. 8. IF (eq_usual activities = 3) MVH_A1 = MVH_A1 - .094. 9. IF (eq_pain = 2) MVH_A1 = MVH_A1 - .123. 10. IF (eq_pain = 3) MVH_A1 = MVH_A1 - .386. 11. IF (eq_anxiety/depression = 2) MVH_A1 = MVH_A1 - .071. 12. IF (eq_anxiety/depression = 3) MVH_A1 = MVH_A1 - .236. 13. IF (MAX(eq_mobility,eq_selfcare,eq_usual activities,eq_pain, eq_anxiety/depression)
> 2) MVH_A1 = MVH_A1 - .269 .
For instance state 12311:
Line 1: You start with 1.00 Line 2: at least one of the dimensions is above 1: subtract 0.081; 1,00 – 0.081 = 0.919 Line 3: does not apply: mobility is 1 and not 2 Line 4: does not apply: mobility is 1 and not 3 Line 5: self care is 2: subtract 0.104; 0.919 – 0.104 = 0.815 Line 6: does not apply Line 7: does not apply: usual activities is 3 and not 2 Line 8: subtract 0.094; 0.815 – 0.094 = 0.721 Line 9: does not apply Line 10: does not apply Line 11: does not apply Line 12: does not apply Line 13: at least one of the dimensions is above 3: subtract 0.269; 0.721 – 0,269 = 0,452 16
Converting SF-36 into SF-6D
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Does your health limit you in these activities? If so, how much
SF # Question Yes,
limited a lot
Yes, limited a
little
No, not
limited at all
SF 3 Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports
1 2 3
SF 4 Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
1 2 3
SF 12 Bathing and dressing yourself 1 2 3 Take the highest score possible from the scoring rules: If SF3 = 3 Physical Functioning =1 does not apply If SF3 = 1 or 2 Physical Functioning =2 does apply If SF4 = 2 Physical Functioning =3 does not apply If SF4 = 1 Physical Functioning =4 does not apply If SF12 = 2 Physical Functioning =5 does not apply If SF12 = 1 Physical Functioning =6 does apply and is the highest score
X
X
X
X
Scoring the SF-6D
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Dimension: Physical Functioning (PF) If PF=1 decrement: 0 If PF=2 decrement: - 0.056 If PF=3 decrement: - 0.056 If PF=4 * decrement: - 0.072 If PF=5 * decrement: - 0.080 If PF=6 * decrement: - 0.134 Dimension: Role Limitations (RL) If RL=1 decrement: 0 If RL=2 decrement: - 0.073 If RL=3 * decrement: - 0.073 If RL=4 * decrement: - 0.073
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More health states, higher sensitivity ? (1)
EuroQol criticised for low sensitivity Low number of dimensions
• Development of EQ-5D plus cognitive dimension
Low number of levels (3)
• Gab between best and in-between level
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More health states, higher sensitivity ? (2)
Little published evidence Sensitivity EQ-5D < SF-36
• Compared as profile, not as utility measure
Sensitivity EQ-5D HUI
Sensitivity the number of health states How well maps the classification system the illness?
How valid is the modelling?
How valid is the valuation?
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More health states, more assumptions
General public values at the most 50 states The ratios empirical (50) versus extrapolated
Rosser & Kind 1:1
EuroQol 1:5
QWB 1:44
SF-36 1:180
HUI (Mark III) 1:19,400
15D 1:610,000,000
What is the critical ratio for a valid validation?
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SF-36 as utility instrument
Transformed into SF6D SG N = 610 Inconsistencies in model
18.000 health states
regression technique stressed to the edge
Floor effect in SF6D
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EQ-5D
Strong punts Very sensitive in the low
Measures subjective burden (inside the skin)
Low administrative burden
Many translations
Cheap
Most used QALY questionnaire
Most international validations
Weak points Only there levels per dimensions
Insensitive in the high regions
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HUI
Strong punts Sensitive
Measures objective burden (outside the skin)
Well developed proxy versions
Well developed child versions
Weak points Expensive
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SF-6D
Strong punts Probably sensitive in the high regions
Often already include in trials (SF-36)
Cheap
Many translations
Weak points Insensitive in the low regions
Only one validation study
Changed Standard Gamble
• Upwards shift of values