Transcript Measuring health outcomes : the first 2000 years

Is healthcare any good for
patients?
Measuring health outcomes
using EQ-5D
Professor Paul Kind
Principal Investigator
Outcomes Research Group
Centre for Health Economics
University of York
England
Health care
• Designed / delivered with the
intention of altering the “natural”
health status of patients over time
• Relieving pain, suffering
• Prolonging (enabling) life
• Easing process of dying
• Cure (sometimes)
Hippocratic Oath : First, do no harm
• Fundamental question : how do you
know if you are helping / harming the
patient ?
• You need to know
– does treatment CHANGE anything ?
– what is the DIRECTION of change ?
– what is the MAGNITUDE of change ?
Health care intervention
Symptomatic relief,
cure, palliation ?
No
Yes
Problem
Measuring health outcomes
the biomedical model
(a) [ FEV1 ]t0 - [ FEV1 ]t1
 FEV1
(b) [ health]t0 - [ health ]t1
status
 health
there is a calibrated test procedure for (a)
what do we use for (b) ?
Outcome measures
'Classical' indicators
•
•
•
•
•
•
Survival rates
Readmission rates
Symptom counts
Employment status
Days lost through sickness
Clinical parameters
Grading angina severity
New York Heart Association
• Grade I
• ordinary physical activity does not cause undue fatigue,
palpitation or anginal pain
• Grade II
• comfortable at rest. Ordinary physical activity results in
fatigue, palpitation, dyspnoea or anginal pain
• Grade III
• comfortable at rest. Less than ordinary physical activity
causes fatigue, palpitation, dyspnoea or anginal pain
• Grade IV
• inability to carry on physical activity without discomfort.
Symptoms of cardiovascular insufficiency or the anginal
syndrome may be present even at rest
Karnofsky Performance Scale
Description
Normal
Normal activity ; minor signs / symptoms
Subnormal activity ; some signs / symptoms
Unable to work or to continue normal activities
Score
100
90
80
70
Requires occasional assistance
60
Requires considerable assistance and frequent
care
Disabled ; requires special care
50
Severely disabled ; hospitalised
30
Very sick ; hospitalised with active support
treatment
Moribund
20
Dead
0
40
40
10
FACT-L
PHYSICAL WELL-BEING
Not
at all
A little
bit
Somewhat
Quite
a bit
Very
much
GP1
I have a lack of energy .......................................................... 0
1
2
3
4
GP2
I have nausea......................................................................... 0
1
2
3
4
GP3
Because of my physical condition, I have trouble
meeting the needs of my family............................................ 0
1
2
3
4
GP4
I have pain............................................................................. 0
1
2
3
4
GP5
I am bothered by side effects of treatment ............................ 0
1
2
3
4
GP6
I feel ill .................................................................................. 0
1
2
3
4
GP7
I am forced to spend time in bed........................................... 0
1
2
3
4
Health-related quality of life
a specialised measure of outcome
What are
the health
outcomes ?
EQ-5D
Health-related
quality of life
The EuroQoL Group
• Set up in 1987 by a multidisciplinary
group of researchers concerned with
EVALUATION in health and health
care
– Clinicians
– Health economists
– Others (sociology, psychology …)
The EuroQoL Group
• Founders
Finland
Netherlands
(Norway)
Sweden
UK
• Extended
network
Argentina
Canada
China
Denmark
Germany
Greece
Hungary
Italy
Japan
Korea
New Zealand
Portugal
Russia
Slovenia
Spain
Taiwan
USA
....
Poland ?
So .. what is EQ-5D ?
• A generic measure of health status
(health-related quality of life) capable of
being represented as a single index
• Health is defined in
terms of 5 dimensions
- mobility
- self care
- usual activity
- pain / discomfort
- anxiety / depression
• Each dimension
is divided into 3
levels
- none
- some
- extreme
What is EQ-5D ?
• A generic, single index
measure of health status
• Based on 5 dimensions
Mobility
Self-Care
Usual Activity
Pain / Discomfort
Anxiety / Depression
Anxiety /
Depression
Pain /
Discomfort
Mobility
Health
state
Self-Care
Usual Activity
• Defines a total of 35
= 243 health states
Self-care
Pain / discomfort
Mobility
Health state
Usual
activities
Anxiety / depression
For example :
no problems in walking about (1)
some problems washing self (2)
some problems with usual activity (2)
no pain or discomfort (1)
moderately anxiety or depression (2)
State 12212
• In general we know NOTHING about
the order or values of EQ-5D health
states
• There is a logical ordinal relationship
between some states
– For example 11111 is logically better than
33333
– But what is the distance between these
states ?
Does moving from state A to state
B constitute a patient benefit ?
Profile A : 1 1 2 2 3
anxiety /
depression
pain /
discomfort
0
usual activity
0
self care
1
anxiety /
depression
1
pain /
discomfort
2
usual activity
2
self care
3
mobility
3
mobility
If so, then by how much?
Profile B : 1 1 3 2 2
Shared objective : Valuing health
• Needed a simple method
• Self-administered
• Capable of being used in
population surveys
• Relatively quick
• Able to produce cardinal values
Valuation method(s)
• EuroQoL Group standard
– Visual analogue scale rating using a
vertical 20cm scale
– Range 0 – 100 corresponding to “worst
imaginable” and “best imaginable” health
• Individual experimentation
– Time Trade-Off (York MVH Project)
– Ranking
– Paired comparisons
– Standard Gamble
VAS rating of EQ-5D health states
Health
state A
Health
state E
11111
Health
state F
Health
state C
33333
Health
state D
Health
state H
anxiety /
depression
pain /
discomfort
usual
activity
self care
mobility
anxiety /
depression
pain /
discomfort
usual
activity
self care
mobility
Profile A : 1 1 2 2 3
3
2
1
0
Population
preference
weights
Profile B : 1 1 3 2 2
3
2
1
0
0.4
0.3
0.36
0.25
0.2
0.11
0.1
0
State A
State B
Difference
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
I have no problems with performing my usual activities
(e.g. work, study, housework, family or leisure 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




 For each
group of
statements
please indicate
the one that best
describes your
health today
 Please tick one
box for each
group of
statements.
TThink about how good or bad your own
health is today
This scale may help. The best health you
can imagine is marked 100 and the worst
health you can imagine is marked 0
Best imaginable
health
100
90
Please write in the box below, the number
between 0 and 100 that you feel best shows
how good your health is today
80
70
Your own health today
60
50
40
30
20
10
0
Worst imaginable
health
Page 3 :
Patient Perspective
Page 2 : 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
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
?
How are EQ-5D data presented ?
• As a profile
– based on reported level
of problem on each
dimension
• As a health state
• As a weighted index
– based on values of the
general public
• As self-rated health
status
EQ-5D
Part I
profile
health state
weighted
index
Part II
self-rated
health status
Some examples
Frequency of reported problems
% of respondents reporting ANY problem
by age group in UK population
60%
under 40
40 to 59
60 and over
50%
40%
30%
20%
10%
0%
Mobility
Self care
Usual
activity
Pain /
discomfort
Anxiety /
depression
Population “norms”
mean EQ-5Dindex
mean EQ-5Dindex
1
0.8
Men
Women
0.6
<20
20 29
30 39
40 49
50 59
age group
Source : Health Survey for England, 1996
60 69
70 79
80 +
EQ-5Dindex
by age / smoking behaviour
mean EQ5Dindex
1
0.9
0.8
0.7
0.6
20 - 29
nonsmoker
smoker
30 - 39
40 - 49
50 - 59 60 - 69
Age group
70 - 79
80 +
EQ-5D
for GP clinic attenders
1
mean weighted index
0
3 or more visits
0.9
0.8
0.7
0.6
under
20
20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79
80 +
Primary care clinic attendees
EQ-5D profile by diagnostic group
% of patients reporting
ANYproblem
100
mental disorder
circulatory
musculoskeletal
pregnancy
all
80
60
40
20
0
mobility
self care
usual activity
pain / discomfort
anxiety /
depression
Choice of provider
mean change in EQ-5Dvas
6
4
NHS - A
private sector
NHS - B
5.2
2.5
2
0
-2
-4
-3.62
-6
mean change from pre-op score
Source : GP audit of patients referred for cataract surgery
Rheumatoid arthritis
Functional Class
• I .. complete functional capacity
– ability to carry out all normal activities
• II .. adequate for normal activities
– despite discomfort or limited motion at 1 or
more joints
• III .. limited functional capacity
– only little or none of duties of normal
occupation or selfcare
• IV .. incapacitated
– largely or wholly bed-ridden or confined to
wheelchair; little or no selfcare
EQ-5Dindex by Functional Class
rheumatoid arthritis patients
Mean EQ-5D value
1.0
.8
.6
.4
.2
Utility index
0.0
N=
Self-rated VAS
59
59
1
63
63
2
58
58
3
Functional Class
49
49
4
EQ-5D in treatment of HIV/AIDS
.86
mean weighted index
.84
.82
.80
.78
.76
Treatment group
.74
Ritonavir
.72
.70
Usual therapy
1
3
5
7
VISIT
9
11
Where are we now ?
Science
• Likely to increase number of response
levels from 3 to 5
• Investigating a “child-friendly” version of
EQ-5D
• Computer-based valuation and selfassessment methods
• Electronic data capture – web based
technologies
5-level or 3-level ?
• One suggested
modification to
existing 3-level
descriptive system
• Place unmarked
level between
existing levels
Where are we now ?
Application
• Nearly 100 language versions available
• Worldwide take-up with many normative
population studies
• Widespread incorporation in clinical
studies that involve economic
evaluation
• Major head:head study in US of the
leading generic HrQoL measures
ends
Paul Kind : [email protected]
EuroQoL Group : http://www.euroqol.org