Transcript The clinical perspective

EuroQol EQ-5D
• Jan J. V. Busschbach, Ph.D
• Psychotherapeutic Centrum ‘De Viersprong’,
Halsteren
– [email protected]
• Department of Medical Psychology and
Psychotherapy, Erasmus MC
– [email protected]
1
EQ-5D
•
MOBILITY
–
–
–
•
SELF-CARE
–
–
–
•
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 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 in walking about
I have some problems in walking about
I am confined to bed
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
2
The clinical perspective
• It is not the doctor who reports
• Quality of life is subjective…..
– “Given its inherently subjective nature, consensus was quickly
reached that quality of life ratings should, whenever possible,
be elicited directly from patients themselves. “ (Aaronson, in B
Spilker (Ed): Quality of life and Pharmacoeconomics in
Clinical Trails, 1996, page 180)
– As a CONSUMER of care, the patient is the best judged
about the quality of care
• The patient values count in clinical quality of
life research
3
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….?
4
Health care is not a normal market
•
•
•
•
Supply induced demands
Subsidies (egalitarian structure)
Government control
Health care is an insurance market
– A compulsory insurance market
• The patient does not pay
– Patient  Consumer
– Potential patients are paying
– Consumer = General public
5
Who determines the payments
of unemployment insurance?
• Civil servant
– Knowledge: professional
– But strategy
» more money, less problems
» identify with unemployed persons
• The unemployed persons themselves
– Knowledge: specific
– But strategy
• General public (politicians)
– Knowledge: experience
– Payers
6
Who’s values (of quality of life) should
count in the health insurance?
• Doctors
– Knowledge: professional
– But strategy
– But see only selection of patient (the complainers)
• Patients
– Knowledge: disease specific
– But strategy
– But coping
• General public
– Knowledge: experience
– Payers
7
Patient values seem high
• 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
– Controls: 8.3
8
Is there a problem?
• There is no
problem...
– if effect is linear
– In the past, the general
perspective was seen as
a proxy for patient
perspective
• There is a problem...
– If there is no linear
transformation
– Patient and general
public perspective reveal
different results
– Loss of power in patient
perspective
45
40
35
30
25
20
15
General public
10
Patient no coping
Patient with coping
5
0
baseline
T1
9
Patient Perspective
10
The Societal Perspective
•
MOBILITY
–
–
–
•
SELF-CARE
–
–
–
•
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 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 in walking about
I have some problems in walking about
I am confined to bed
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
• Describe health states
• Have values from the general public
–
–
–
–
–
–
Rosser
QWB
15D
HUI Mark 2
HUI Mark 3
EuroQol EQ-5D
12
EQ-5D
•
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
13
EuroQol
• EuroQol Group
• Latest version: EQ-5D
– 5 dimensions
» Mobility, self-care, usual activities, pain /
discomfort, anxiety / depression
– 3 levels per dimension
– 243 health states
• Validation
– Finland, Netherlands, Norway, Sweden, UK, Spain,
Germany, Greece, US, Japan, New Zealand,
Zimbabwe, Denmark
– N = 200 - 3000
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How to get these
societal values?
• Patient fills in
questionnaire
• Choose the value
function from the
literature
• Calculate societal value
COMPUTE MVH_A1 = 1.
VARIABLE LABELS MVH_A1 'York A1 tariff'.
DO IF (NVALID(mo, sc, ua, pd, ad) < 5 ).
RECODE
MVH_A1 (1 = SYSMIS).
END IF.
IF (MAX(mo, sc, ua, pd, ad) > 1) MVH_A1 = MVH_A1 -.081.
IF (mo = 2) MVH_A1 = MVH_A1 - .069.
IF (mo = 3) MVH_A1 = MVH_A1 - .314.
IF (sc = 2) MVH_A1 = MVH_A1 - .104.
IF (sc = 3) MVH_A1 = MVH_A1 - .214.
IF (ua = 2) MVH_A1 = MVH_A1 - .036.
IF (ua = 3) MVH_A1 = MVH_A1 - .094.
IF (pd = 2) MVH_A1 = MVH_A1 - .123.
IF (pd = 3) MVH_A1 = MVH_A1 - .386.
IF (ad = 2) MVH_A1 = MVH_A1 - .071.
IF (ad = 3) MVH_A1 = MVH_A1 - .236.
IF (MAX(mo, sc, ua, pd, ad) > 2) MVH_A1 = MVH_A1 - .269.
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An example of a value function
* SPSS syntax Dolan 1997, Medical Care, 1997;35:1095-108.
* mo = mobility, sc= self care, ua = usual activities, pd = pain & discomfort , ad = anxiety and depression.
COMPUTE MVH_A1 = 1.
VARIABLE LABELS MVH_A1 'York A1 tariff'.
DO IF (NVALID(mo, sc, ua, pd, ad) < 5 ).
RECODE
MVH_A1 (1 = SYSMIS).
END IF.
IF (MAX(mo, sc, ua, pd, ad) > 1) MVH_A1 = MVH_A1 -.081.
IF (mo = 2) MVH_A1 = MVH_A1 - .069.
IF (mo = 3) MVH_A1 = MVH_A1 - .314.
IF (sc = 2) MVH_A1 = MVH_A1 - .104.
IF (sc = 3) MVH_A1 = MVH_A1 - .214.
IF (ua = 2) MVH_A1 = MVH_A1 - .036.
IF (ua = 3) MVH_A1 = MVH_A1 - .094.
IF (pd = 2) MVH_A1 = MVH_A1 - .123.
IF (pd = 3) MVH_A1 = MVH_A1 - .386.
IF (ad = 2) MVH_A1 = MVH_A1 - .071.
IF (ad = 3) MVH_A1 = MVH_A1 - .236.
IF (MAX(mo, sc, ua, pd, ad) > 2) MVH_A1 = MVH_A1 - .269.
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Some values
• Broken arm
• 12211
–
–
–
–
–
no problems in walking about
some problems washing or dressing
some problems with performing usual activities
no pain or discomfort
not anxious or depressed
• Societal value = 0.779
17
Some values
• Broken hip
• 22222
–
–
–
–
–
some problems in walking about
some problems washing or dressing
some problems with performing usual activities
moderate pain or discomfort
moderately anxious or depressed
• Societal value = 0.516
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Impact on quality of life
Patent graft
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Symptomatic occlusion
Primary amputation
Secondary amputation
Cerebrovascular accident
Myocardial infarction
Intake clinic psychotherapy
EQ-5D utilities
19
Effect psychotherapy
Clinic 12 months
Clinic 6 months
Clinic 3 months
Out-patient clinic
1.0
EQ-5D social values
0.9
0.8
0.7
0.6
0.5
Intake
1 year after
2 years
20
Reimbursement arguments
• Dunning’s Funnel
– 1990
– Government declaration
2002
– Necessary care
» Need
» Equity elements
– Efficacy
– Cost effectiveness
– Own account and
responsibility
21
Reimbursement arguments
Impact on QoL
Effect on QoL
Cost effectiveness ?
1
0.9
0.81.0
0.7
0.9
0.6
EQ-5D social values
0.5
0.8
0.4
QALYs
0.3
0.7
0.2
0.10.6
0
EQ-5D utilities
0.5
Intake
1 year after
2 years
22
Quality Adjusted Life Years
(QALY)
• Multiply life years with quality index
• Quality of life index
– 1.0 = normal health
– 0.0 = extremely bad health (death)
• Example
–
–
–
–
Losing sense of sight
Quality of life index is 0.5
Life = 80 years
0.5 x 80 = 40 QALYs
• Accepted measure of health
– Used by the WHO (DALY)
23
QALY league table
Intervention
$ / QALY
GM-CSF in elderly with leukemia
235,958
EPO in dialysis patients
139,623
Lung transplantation
100,957
End stage renal disease management
53,513
Heart transplantation
46,775
Didronel in osteoporosis
32,047
PTA with Stent
17,889
Breast cancer screening
5,147
Viagra
5,097
Treatment of congenital anorectal malformations
2,778
24
EQ-5D and cost effectiveness
• EQ-5D specially designed
– Social perspective
– Generic
– 0 to 1 scale
• Use EQ-5D for QALY analysis
25