Transcript Intro QALY & need assessment

EQ-5D, HUI and SF-36
Of the shelf instruments….
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Direct valuation
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…or use validated questionnaires
MOBILITY
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I have no problems in walking about
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I have some problems in walking about
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I am confined to bed
SELF-CARE
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I have no problems with self-care
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I have some problems washing or dressing myself
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I am unable to wash or dress myself
USUAL ACTIVITIES (e.g. work, study, housework family or
leisure activities)
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I have no problems with performing my usual activities
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I have some problems with performing my usual activities
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I am unable to perform my usual activities
PAIN/DISCOMFORT
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I have no pain or discomfort
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I have moderate pain or discomfort
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I have extreme pain or discomfort
ANXIETY/DEPRESSION
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I am not anxious or depressed
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I am moderately anxious or depressed
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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
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The Rosser & Kind index
 One
of the oldest valuation
 1978: Magnitude estimation
 Magnitude estimation  PTO / VAS
 N = 70
• Doctors, nurses, patients and general public
 1982:
Transformation to “utilities”
 On a 0.00 to 1.00 scale
 Could be used for QALYs
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1985: High impact article
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1985: High impact article
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1985: High impact article
 Survey at the celebration of 25 years of health economics in
the UK (HESG): chosen most influential article on health
economics
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Criticism on the Matrix
 Sensitivity
 only 30 health states
 The
unclear meaning of “distress”
 The involvement of medical personnel
 No clear way how to classify the patients
 into the matrix
 Only
British values
 The compression of states in the high values
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Value compression
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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”
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Validated questionnaires
Questionnaire
Rosser
EuroQol EQ-5D
Number of health state
30
243
QWB
2,200
EQ-5D-5L
3125
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
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• 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%.
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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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21111 = 1 - (0.20 x (1.00 - 0.80)) = 0.96
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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)
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Exercise
 EuroQol
EQ-5D (3 level)
 SF-6D
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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
 Now
development of 5 Level
 EQ-5D-5L
 No consensus in EuroQoL that more levels is always better…
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EQ-5D-3L versus EQ-5D-5l
Zet bij iedere groep in de lijst hieronder een kruisje in het hokje achter de zin die het
best past bij uw eigen gezondheidstoestand vandaag.
Zet bij iedere groep in de lijst hieronder een kruisje in het hokje achter de zin die het
best past bij uw eigen gezondheidstoestand vandaag.
Mobiliteit
Mobiliteit
Ik heb geen problemen met lopen
Ik heb een beetje problemen met lopen
Ik heb matige problemen met lopen
Ik heb ernstige problemen met lopen
Ik ben niet in staat niet om te lopen
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Ik heb een beetje problemen met mijzelf wassen of aankleden
Ik heb matige problemen met mijzelf wassen of aankleden
Ik heb ernstige problemen met mijzelf wassen of aankleden
Ik ben niet in staat mijzelf te wassen of aan te kleden
Ik heb enige problemen met lopen
Ik ben bedlegerig
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Ik heb enige problemen om mijzelf te wassen of aan te kleden
Ik ben niet in staat mijzelf te wassen of aan te kleden
gezins- en vrijetijdsactiviteiten)
Ik heb enige problemen met mijn dagelijkse activiteiten
gezins- en vrijetijdsactiviteiten)
Ik heb geen problemen met mijn dagelijkse activiteiten
Ik heb een beetje problemen met mijn dagelijkse activiteiten
Ik heb matige problemen met mijn dagelijkse activiteiten
Ik heb ernstige problemen met mijn dagelijkse activiteiten
Ik ben niet in staat mijn dagelijkse activiteiten uit te voeren
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Dagelijkse activiteiten (bijv. werk, studie, huishouden,
Ik heb geen problemen met mijn dagelijkse activiteiten
Dagelijkse activiteiten (bijv. werk, studie, huishouden,
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Zelfzorg
Ik heb geen problemen om mijzelf te wassen of aan te kleden
Zelfzorg
Ik heb geen problemen met mijzelf wassen of aankleden
Ik heb geen problemen met lopen
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Ik ben niet in staat mijn dagelijkse activiteiten uit te voeren
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Stemming
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Pijn/klachten
Ik heb geen pijn of andere klachten
Ik heb matige pijn of andere klachten
Ik heb zeer ernstige pijn of andere klachten
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Pijn/ongemak
Ik heb geen pijn of ongemak
Ik heb een beetje pijn of ongemak
Ik heb matige pijn of ongemak
Ik heb ernstige pijn of ongemak
Ik heb extreme pijn of ongemak
Angst/somberheid
Ik ben niet angstig of somber
Ik ben een beetje angstig of somber
Ik ben matig angstig of somber
Ik ben erg angstig of somber
Ik ben extreem angstig of somber
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Ik ben niet angstig of somber
Ik ben matig angstig of somber
Ik ben erg angstig of somber
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More health states, higher
sensitivity ? (2)
 Little
published evidence
 Sensitivity EQ-5D < SF-36
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• 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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5Lmore sensitive than 3L
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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
 EuroQol EQ-5D-3L
 QWB
 EQ-5D-5L
 SF-36
 HUI (Mark III)
 15D
 What
1:1
1:5
1:44
1:63
1:180
1:19,400
1:610,000,000
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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Collapsing levels SF-6D
 Many
levels are taken together
 If PF=2
 If PF=3
decrement: - 0.056
decrement: - 0.056
 If RL=2
 If RL=3 *
 If RL=4 *
decrement: - 0.073
decrement: - 0.073
decrement: - 0.073
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SF-6D loses a lot of levels
 Levels
 PF
 RL
 SF
 PN
 MH
 VI
in system and actual levels
6
4
5
6
5
5
5
2
5
5
4
3
 Levels
in system: 18.000
 Actual
levels:
 6x4x5x6x5x5
 5x2x5x5x4x3
480
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Conflicting evidence sensitivity SF-36
Liver transplantation, Longworth et al., 2001
EQ-5D-3L
 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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EQ-5D-5L
 Strong
punts
 Very sensitive in the low
 Measures subjective burden (inside the skin)
 Low administrative burden
 Many translations
 Cheap
 Weak
points
 No scorings algorithm yet
 Might still not be as sensitive 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
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EQ-5D-Y
EQ-5D-Y
Describing the child’s health today
PLEASE ANSWER ON BEHALF OF THE CHILD: Under each heading, mark the ONE
box that you think the child would mark to describe his/her own health TODAY if he/she
were able to do so.
Mobility (walking about)
 No
scoring algorithm
He/she has no problems walking about
He/she has some problems walking about
He/she has a lot of problems walking about
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Looking after myself
He/she has no problems washing or dressing him/herself
He/she has some problems washing or dressing him/herself
He/she has a lot of problems washing or dressing him/herself
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Doing usual activities (for example. going to school, hobbies,
sports, playing, doing things with family or friends)
He/she has no problems doing his/her usual activities
He/she has some problems doing his/her usual activities
He/she has a lot of problems doing his/her usual activities
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Having pain or discomfort
He/she has no pain or discomfort
He/she has some pain or discomfort
He/she has a lot of pain or discomfort
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Feeling worried, sad or unhappy
He/she is not worried, sad or unhappy
He/she is a bit worried, sad or unhappy
He/she is very worried, sad or unhappy
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Conclusions
states  better sensitivity
 The three leading questionnaires
 More
 have different strong and weak points
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