Intro QALY & need assessment
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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
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
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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
• 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%
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
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
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
Dagelijkse activiteiten (bijv. werk, studie, huishouden,
Ik heb geen problemen met mijn dagelijkse activiteiten
Dagelijkse activiteiten (bijv. werk, studie, huishouden,
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
Ik ben niet in staat mijn dagelijkse activiteiten uit te voeren
Stemming
Pijn/klachten
Ik heb geen pijn of andere klachten
Ik heb matige pijn of andere klachten
Ik heb zeer ernstige pijn of andere klachten
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
Ik ben niet angstig of somber
Ik ben matig angstig of somber
Ik ben erg angstig of somber
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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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
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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
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
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
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
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
Conclusions
states better sensitivity
The three leading questionnaires
More
have different strong and weak points
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