Koonal Shah

Valuing health-related quality of life: An EQ-5D-5L value set for England

Abstract A new version of the EQ‐5D, the EQ‐5D‐5L, is available. The aim of this study is to produce a value set to support use of EQ‐5D‐5L data in decision‐making. The study design followed an international research protocol. Randomly selected members of the English general public completed 10 time trade‐off and 7 discrete choice experiment tasks in face‐to‐face interviews. A 20‐parameter hybrid model was used to combine time trade‐off and discrete choice experiment data to generate values for the 3,125 EQ‐5D‐5L health states. Valuation data are available for 996 respondents. Face validity of the data has been demonstrated, with more severe health states generally given lower values. Problems with pain/discomfort and anxiety/depression received the greatest weight. Compared to the existing EQ‐5D‐3L value set, there are considerably fewer “worse than dead” states (5.1%, compared with over one third), and the minimum value is higher. Values range from −0.285 (extreme problems on all dimensions) to 0.950 (for health states 11211 and 21111). Results have important implications for users of the EQ‐5D‐5L both in England and internationally. Quality‐adjusted life year gains from interventions seeking to improve very poor health may be smaller using this value set and may previously have been overestimated.

Severity of illness and priority setting in healthcare: A review of the literature

BACKGROUND It is widely assumed that the principal objective of healthcare is to maximise health. However, people may be willing to sacrifice aggregate health gain in order to direct resources towards those who are worst off in terms of the severity of their pre-treatment health state. OBJECTIVES This paper reviews the literature on severity in the context of economic evaluation, with the aim of establishing the extent to which popular preferences concerning severity imply a departure from the health maximisation objective. METHODS Data were obtained using a keyword search of major databases and a hand search of articles written by leading researchers in the subject area. RESULTS The empirical evidence suggests that people are, on the whole, willing to sacrifice aggregate health in order to give priority to the severely ill. However, there remain unresolved issues regarding the elicitation and interpretation of severity preferences (and indeed popular preferences generally). CONCLUSIONS The use of severity as a priority setting criterion is supported by a large number of empirical studies of popular preferences. Further work is needed, however, to accurately estimate the strength of this support.

Using QALYs in Cancer: A Review of the Methodological Limitations

The objective of this paper is to examine how well the QALY captures the health gains generated by cancer treatments, with particular focus on the methods for constructing QALYs preferred by the UK National Institute for Health and Clinical Excellence (NICE). Data were obtained using a keyword search of the MEDLINE database and a hand search of articles written by leading researchers in the subject area (with follow up of the references in these articles). Key arguments were discussed and developed at an oncology workshop in September 2009 at the Office of Health Economics. Three key issues emerged. First, the EQ-5D, NICEs preferred measure of health-related quality of life (QOL) in adults, has been found to be relatively insensitive to changes in health status of cancer patients. Second, the time trade-off, NICEs preferred technique for estimating the values of health states, involves making assumptions that are likely to be violated in end-of-life scenarios. Third, the practice of using valuations of members of the general population, as recommended by NICE, is problematic because such individuals typically display a misunderstanding of what it is really like for patients to live with cancer. Because of the way in which it is constructed, the QALY shows important limitations in terms of its ability to accurately capture the value of the health gains deemed important by cancer patients. A research agenda for addressing these limitations is proposed.

Using QALYs in Cancer

The objective of this paper is to examine how well the QALY captures the health gains generated by cancer treatments, with particular focus on the methods for constructing QALYs preferred by the UK National Institute for Health and Clinical Excellence (NICE). Data were obtained using a keyword search of the MEDLINE database and a hand search of articles written by leading researchers in the subject area (with follow up of the references in these articles). Key arguments were discussed and developed at an oncology workshop in September 2009 at the Office of Health Economics.Three key issues emerged. First, the EQ-5D, NICE’s preferred measure of health-related quality of life (QOL) in adults, has been found to be relatively insensitive to changes in health status of cancer patients. Second, the time trade-off, NICEs preferred technique for estimating the values of health states, involves making assumptions that are likely to be violated in end-of-life scenarios. Third, the practice of using valuations of members of the general population, as recommended by NICE, is problematic because such individuals typically display a misunderstanding of what it is really like for patients to live with cancer.Because of the way in which it is constructed, the QALY shows important limitations in terms of its ability to accurately capture the value of the health gains deemed important by cancer patients. A research agenda for addressing these limitations is proposed.

Valuing health at the end of life: an empirical study of public preferences

In 2009, the National Institute for Health and Clinical Excellence (NICE) issued supplementary advice to its Appraisal Committees to be taken into account when appraising life-extending, ‘end-of-life’ treatments. This indicated that if certain criteria are met, it may be appropriate to recommend the use of such treatments even if they would not normally be considered cost-effective. However, NICE’s public consultation revealed concerns that there is little scientific evidence to support such a policy. This study examines whether there is public support for giving higher priority to life-extending, end-of-life treatments than to other types of treatment. In face-to-face interviews, respondents answered six questions asking them to choose which of two hypothetical patients they would prefer to treat, assuming that the health service has enough funds to treat one but not both of them. The various scenarios were designed so as to control for age- and time-related preferences. Fifty members of the general public in England were interviewed in July 2011. We find some evidence of support for giving priority to the patient with shorter remaining life expectancy, but note that a nontrivial minority of respondents expressed the opposite preference. Substantial preference for quality-of-life improvement over life extension was observed. Very few respondents expressed indifference or unwillingness to choose between the patients. Whilst there cannot be described to be a single ‘consensus’ set of preferences, we conclude that there are ways in which the results suggest that the current NICE policy may be insufficient.

NICE’s social value judgements about equity in health and health care

The National Institute for Health and Clinical Excellence (NICE) routinely publishes details of the evidence and reasoning underpinning its recommendations, including its social value judgements (SVJs). To date, however, NICEs SVJs relating to equity in the distribution of health and health care have been less specific and systematic than those relating to cost-effectiveness in the pursuit of improved total population health. NICE takes a pragmatic, case-based approach to developing its principles of SVJ, drawing on the cumulative experience of its advisory bodies in making decisions that command respect among its broad range of stakeholders. This paper aims to describe the SVJs about equity in health and health care that NICE has hitherto used to guide its decision making. To do this, we review both the general SVJs reported in NICE guidance on methodology and the case-specific SVJs reported in NICE guidance about particular health care technologies and public health interventions.

Multinational evidence of the applicability and robustness of discrete choice modeling for deriving EQ-5D-5L health-state values.

Aims:To investigate the feasibility of discrete choice experiments for valuing EQ-5D-5L states using computer-based data collection, the consistency of the estimated regression coefficients produced after modeling the preference data, and to examine the similarity of the values derived across countries. Methods:Data were collected in Canada, England, The Netherlands, and the United States (US). Interactive software was developed to standardize the format of the choice tasks across countries, except for face-to-face interviewing in England. The choice task required respondents to choose between 2 suboptimal health states. A Bayesian design was used to generate 200 pairs of states that were randomly grouped into 20 blocks. Each respondent completed 1 block of 10 pairs. A main-effects probit model was used to estimate regression coefficients and to derive values. Results:Approximately 400 respondents participated from each country. The mean time to perform 1 choice task was between 29.2 (US) and 45.2 (England) seconds. All regression coefficients were statistically significant, except level 2 for Usual Activities in The Netherlands (P=0.51). Predictions for the complete set of 3125 EQ-5D-5L health states were similar for the 4 countries. Intraclass correlation coefficients between the countries were high: from 0.80 (England vs. US) through 0.98 (Canada vs. US). Conclusions:Derivation of value sets from the general population using computer-based choice tasks for the EQ-5D-5L is feasible. Parameter estimates were generally consistent and logical, and health-state values were similar across the 4 countries.

Is the aim of the English health care system to maximize QALYs

Objectives: To compare the types of benefit considered relevant by the English Department of Health with those included by the National Institute for Health and Clinical Excellence (NICE) when conducting economic evaluations of options for spending limited health care resources. Methods: We analysed all policy Impact Assessments (IAs)carried out by the Department of Health(DH)in 2008 and 2009. The stated benefits of each policy were extracted and thematic analysis was used to categorise these. Results: 51 Impact Assessments were analysed, eight of which mentioned quality-adjusted life year (QALY) gains as a benefit. 18 benefits other than QALY gains were identified. Apart from improving health outcomes, commonly referred to benefits included: reducing costs, improving quality of care, and enhancing patient experience. Many of the policies reviewed were implemented on the basis of benefits unrelated to health outcome. The methods being used to apply a monetary valuation to QALY gains (in cost-benefit calculations) are not consistent across Impact Assessments or with NICEs stated threshold range. Conclusions: The Department of Health and NICE approach resource allocation decisions in different ways, based upon overlapping but not congruent considerations and underlying principles. Given that all these decisions affect the allocation of the same fixed health care budget, there is a case for establishing a uniform framework for option appraisal and priority setting so as to avoid allocative inefficiency. The same applies to any other national health care system.

One-to-one versus group setting for conducting computer-assisted TTO studies: Findings from pilot studies in England and the Netherlands

We compare two settings for administering time trade-off (TTO) tasks in computer-assisted interviews (one-to-one, interviewer-led versus group, self-complete) by examining the quality of the data generated in pilot studies undertaken in England and the Netherlands. The two studies used near-identical methods, except that in England, data were collected in one-to-one interviews with substantial amounts of interviewer assistance, whereas in the Netherlands, the computer aid was used as a self-completion tool in group interviews with lesser amounts of interviewer assistance. In total, 801 members of the general public (403 in England; 398 in the Netherlands) each completed five TTO valuations of EQ-5D-5L health states. Respondents in the Netherlands study showed a greater tendency to give ‘round number’ values such as 0 and 1 and to complete tasks using a minimal number of iterative steps. They also showed a greater tendency to skip the animated instructions that preceded the first task and to take into account assumptions that they were specifically asked not to take into account. When faced with a pair of health states in which one state dominated the other, respondents in the Netherlands study were more likely than those in the England study to give a higher value to the dominant health state. On the basis of these comparisons, we conclude that the one-to-one, interviewer-led setting is superior to the group, self-complete setting in terms of the quality of data generated and that the former is more suitable than the latter for TTO studies being used to value EQ-5D-5L.

Does Society Place Special Value on End of Life Treatments

There is a growing body of empirical evidence that members of the general public are willing to sacrifice aggregate health gains in order to direct resources towards those who are worst off in terms of the severity of their condition. This implies that the social value of a QALY accruing to a severely ill patient is greater than that of a QALY accruing to a patient who is not severely ill. A number of studies have examined whether the social value of a QALY varies according to how the QALYs are distributed, the characteristics of the patients receiving the QALYs or the characteristics of the health effect itself. This chapter describes the policy context in relation to the social value of a QALY in the UK, focusing on the way in which NICE appraises life-extending end of life treatments. It presents a summary of recent UK and non-UK studies examining priority-setting preferences regarding end of life treatments, before noting some of the discussion points arising from the evidence and finishing with recommendations for future research.