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Comparing Multi-Attribute Utility Measures: EQ-5D, HUI, and SF-6D Workshop for 6 th World Congress of International Health Economics Association, Lund, Sweden, July 6, 2007

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comparing multi attribute utility measures eq 5d hui and sf 6d
Comparing Multi-Attribute Utility Measures: EQ-5D, HUI, and SF-6D

Workshop for 6th World Congress of International Health Economics Association, Lund, Sweden,

July 6, 2007

  • David Feeny, Kaiser Permanente Northwest Center for Health Research, Institute of Health Economics, University of Alberta, and Health Utilities Inc.
  • John Horsman, McMaster University, and Health Utilities Inc.
  • Assisted by: Keiko Asakawa, Institute of Health Economics and University of Alberta

and Morag Horsman, McMaster University

comparing multi attribute utility measures eq 5d hui and sf 6d2
Comparing Multi-Attribute Utility Measures: EQ-5D, HUI, and SF-6D

Outline

  • Introduction/Administration of Selected Multi-Attribute Utility Measures
  • Conceptual Foundations
  • Direct Approaches to Obtaining Utility Scores for Health States
  • Multi-Attribute or Indirect Approaches to Obtaining Utility Scores for Health States
  • Evidence on Measurement Properties of Utility Measures: Reliability, Construct Validity, Responsiveness, Floor/Ceiling Effects, Predictive Validity, Interpretability
  • Applications in Cost-Effectiveness/Cost-Utility Analyses
  • Comparisons Among Measures
  • Criteria for Selecting an Appropriate Measure for your Study
  • Results from Demonstration
  • Summary
hypothetical health state for valuation
Hypothetical Health State for Valuation

Health State “B”

  • Able to see, hear, and speak normally.
  • Requires mechanical equipment (cane, crutches, braces, wheelchair) to walk or get around independently.
  • Occasionally angry, irritable, anxious, or depressed.
  • Able to learn and remember normally.
  • Eats, bathes, dresses, or uses the toilet independently with difficulty.
  • Free of pain and discomfort.
slide4

Visual Analogue Scale

“Feeling Thermometer”

© Health Utilities Inc. (HUInc.) 2006

slide5

TIME TRADE-OFF BOARD

Your

age

now

Your

age

now

Life “A”

10

10

20

20

30

30

40

40

YEARS OF LIFE

Life “B”

YEARS OF LIFE

A standard, blank, Time Trade-off Board on which you select Life “A” or Life “B” or are they ‘equal’

© Health Utilities Inc. (HUInc.) 2006

slide6

TTO Scoring template - use 1st “Stop sign”

TIME TRADE-OFF

PREFER “A”

EQUAL

PREFER “B”

T1

T2

T3

T4

T5

© Health Utilities Inc. (HUInc.) 2006

slide7

TIME TRADE-OFF BOARD

Your

age

now

Your

age

now

Life “A”

10

10

20

20

30

30

40

40

PERFECT HEALTH

Able to see, hear, and speak normally.

Able to walk, bend, lift, jump, and run normally for age.

Generally happy and free from worry.

Able to learn and remember normally.

Able to eat, bathe, dress, and use the toilet normally.

Free of pain and discomfort.

YEARS OF LIFE

Life “B”

YEARS OF LIFE

T1

Health State “B”

Able to see, hear and speak normally.

Requires mechanical equipment (cane, crutches, braces, wheelchair) to walk or get around.

Occasionally angry, irritable, anxious, or depressed.

Able to learn and remember normally.

Eats, bathes, dresses, or uses the toilet independently with difficulty.

Free of pain and discomfort.

“Life ‘A’ Perfect Health” or “Life ‘B’ Health State B” or “Equal?”

© Health Utilities Inc. (HUInc.) 2006

slide8

TIME TRADE-OFF BOARD

Your

age

now

Your

age

now

Life “A”

10

10

20

20

30

30

40

40

PERFECT HEALTH

Able to see, hear, and speak normally.

Able to walk, bend, lift, jump, and run normally for age.

Generally happy and free from worry.

Able to learn and remember normally.

Able to eat, bathe, dress, and use the toilet normally.

Free of pain and discomfort.

YEARS OF LIFE

Life “B”

YEARS OF LIFE

T2

Health State “B”

Able to see, hear and speak normally.

Requires mechanical equipment (cane, crutches, braces, wheelchair) to walk or get around.

Occasionally angry, irritable, anxious, or depressed.

Able to learn and remember normally.

Eats, bathes, dresses, or uses the toilet independently with difficulty.

Free of pain and discomfort.

“Life ‘A’ Perfect Health” or “Life ‘B’ Health State B” or “Equal?”

© Health Utilities Inc. (HUInc.) 2006

slide9

TIME TRADE-OFF BOARD

Your

age

now

Your

age

now

Life “A”

10

10

20

20

30

30

40

40

PERFECT HEALTH

Able to see, hear, and speak normally.

Able to walk, bend, lift, jump, and run normally for age.

Generally happy and free from worry.

Able to learn and remember normally.

Able to eat, bathe, dress, and use the toilet normally.

Free of pain and discomfort.

YEARS OF LIFE

Life “B”

YEARS OF LIFE

T3

Health State “B”

Able to see, hear and speak normally.

Requires mechanical equipment (cane, crutches, braces, wheelchair) to walk or get around.

Occasionally angry, irritable, anxious, or depressed.

Able to learn and remember normally.

Eats, bathes, dresses, or uses the toilet independently with difficulty.

Free of pain and discomfort.

“Life ‘A’ Perfect Health” or “Life ‘B’ Health State B” or “Equal?”

© Health Utilities Inc. (HUInc.) 2006

slide10

TIME TRADE-OFF BOARD

Your

age

now

Your

age

now

Life “A”

10

10

20

20

30

30

40

40

PERFECT HEALTH

Able to see, hear, and speak normally.

Able to walk, bend, lift, jump, and run normally for age.

Generally happy and free from worry.

Able to learn and remember normally.

Able to eat, bathe, dress, and use the toilet normally.

Free of pain and discomfort.

YEARS OF LIFE

Life “B”

YEARS OF LIFE

T4

Health State “B”

Able to see, hear and speak normally.

Requires mechanical equipment (cane, crutches, braces, wheelchair) to walk or get around.

Occasionally angry, irritable, anxious, or depressed.

Able to learn and remember normally.

Eats, bathes, dresses, or uses the toilet independently with difficulty.

Free of pain and discomfort.

“Life ‘A’ Perfect Health” or “Life ‘B’ Health State B” or “Equal?”

© Health Utilities Inc. (HUInc.) 2006

slide11

TIME TRADE-OFF BOARD

Your

age

now

Your

age

now

Life “A”

10

10

20

20

30

30

40

40

PERFECT HEALTH

Able to see, hear, and speak normally.

Able to walk, bend, lift, jump, and run normally for age.

Generally happy and free from worry.

Able to learn and remember normally.

Able to eat, bathe, dress, and use the toilet normally.

Free of pain and discomfort.

YEARS OF LIFE

Life “B”

YEARS OF LIFE

T5

Health State “B”

Able to see, hear and speak normally.

Requires mechanical equipment (cane, crutches, braces, wheelchair) to walk or get around.

Occasionally angry, irritable, anxious, or depressed.

Able to learn and remember normally.

Eats, bathes, dresses, or uses the toilet independently with difficulty.

Free of pain and discomfort.

“Life ‘A’ Perfect Health” or “Life ‘B’ Health State B” or “Equal?”

© Health Utilities Inc. (HUInc.) 2006

slide12

Standard Gamble Chance Board

Select Life “A” or Life “B” or are they ‘equal?’

© Health Utilities Inc. (HUInc.) 2006

slide14

CHANCE BOARD

S1

Life “A”

100

0

% CHANCE

% CHANCE

PERFECT HEALTH

Able to see, hear and speak normally.

Able to walk, bend, lift, jump, and run normally for age.

Generally happy and free from worry.

Able to learn and remember normally.

Able to eat, bathe, dress, and use the toilet normally.

Free of pain and discomfort.

IMMEDIATE DEATH

Life “B”

Health State “B”

Able to see, hear and speak normally.

Requires mechanical equipment (cane, crutches, braces, wheelchair) to walk or get around.

Occasionally angry, irritable, anxious, or depressed.

Able to learn and remember normally.

Eats, bathes, dresses, or uses the toilet independently with difficulty.

Free of pain and discomfort.

100

% CHANCE

Standard Gamble Chance Board Select Life “A” or Life “B” or are they ‘equal’

© Health Utilities Inc. (HUInc.) 2006

slide15

CHANCE BOARD

S2

Life “A”

10

90

% CHANCE

% CHANCE

PERFECT HEALTH

Able to see, hear and speak normally.

Able to walk, bend, lift, jump, and run normally for age.

Generally happy and free from worry.

Able to learn and remember normally.

Able to eat, bathe, dress, and use the toilet normally.

Free of pain and discomfort.

IMMEDIATE DEATH

Life “B”

Health State “B”

Able to see, hear and speak normally.

Requires mechanical equipment (cane, crutches, braces, wheelchair) to walk or get around.

Occasionally angry, irritable, anxious, or depressed.

Able to learn and remember normally.

Eats, bathes, dresses, or uses the toilet independently with difficulty.

Free of pain and discomfort.

100

% CHANCE

Standard Gamble Chance Board Select Life “A” or Life “B” or are they ‘equal’

© Health Utilities Inc. (HUInc.) 2006

slide16

CHANCE BOARD

S3

Life “A”

90

10

% CHANCE

% CHANCE

PERFECT HEALTH

Able to see, hear and speak normally.

Able to walk, bend, lift, jump, and run normally for age.

Generally happy and free from worry.

Able to learn and remember normally.

Able to eat, bathe, dress, and use the toilet normally.

Free of pain and discomfort.

IMMEDIATE DEATH

Life “B”

Health State “B”

Able to see, hear and speak normally.

Requires mechanical equipment (cane, crutches, braces, wheelchair) to walk or get around.

Occasionally angry, irritable, anxious, or depressed.

Able to learn and remember normally.

Eats, bathes, dresses, or uses the toilet independently with difficulty.

Free of pain and discomfort.

100

% CHANCE

Standard Gamble Chance Board Select Life “A” or Life “B” or are they ‘equal’

© Health Utilities Inc. (HUInc.) 2006

slide17

CHANCE BOARD

S4

Life “A”

20

80

% CHANCE

% CHANCE

PERFECT HEALTH

Able to see, hear and speak normally.

Able to walk, bend, lift, jump, and run normally for age.

Generally happy and free from worry.

Able to learn and remember normally.

Able to eat, bathe, dress, and use the toilet normally.

Free of pain and discomfort.

IMMEDIATE DEATH

Life “B”

Health State “B”

Able to see, hear and speak normally.

Requires mechanical equipment (cane, crutches, braces, wheelchair) to walk or get around.

Occasionally angry, irritable, anxious, or depressed.

Able to learn and remember normally.

Eats, bathes, dresses, or uses the toilet independently with difficulty.

Free of pain and discomfort.

100

% CHANCE

Standard Gamble Chance Board Select Life “A” or Life “B” or are they ‘equal’

© Health Utilities Inc. (HUInc.) 2006

slide18

CHANCE BOARD

S5

Life “A”

80

20

% CHANCE

% CHANCE

PERFECT HEALTH

Able to see, hear and speak normally.

Able to walk, bend, lift, jump, and run normally for age.

Generally happy and free from worry.

Able to learn and remember normally.

Able to eat, bathe, dress, and use the toilet normally.

Free of pain and discomfort.

IMMEDIATE DEATH

Life “B”

Health State “B”

Able to see, hear and speak normally.

Requires mechanical equipment (cane, crutches, braces, wheelchair) to walk or get around.

Occasionally angry, irritable, anxious, or depressed.

Able to learn and remember normally.

Eats, bathes, dresses, or uses the toilet independently with difficulty.

Free of pain and discomfort.

100

% CHANCE

Standard Gamble Chance Board Select Life “A” or Life “B” or are they ‘equal’

© Health Utilities Inc. (HUInc.) 2006

slide19

CHANCE BOARD

S6

Life “A”

30

70

% CHANCE

% CHANCE

PERFECT HEALTH

Able to see, hear and speak normally.

Able to walk, bend, lift, jump, and run normally for age.

Generally happy and free from worry.

Able to learn and remember normally.

Able to eat, bathe, dress, and use the toilet normally.

Free of pain and discomfort.

IMMEDIATE DEATH

Life “B”

Health State “B”

Able to see, hear and speak normally.

Requires mechanical equipment (cane, crutches, braces, wheelchair) to walk or get around.

Occasionally angry, irritable, anxious, or depressed.

Able to learn and remember normally.

Eats, bathes, dresses, or uses the toilet independently with difficulty.

Free of pain and discomfort.

100

% CHANCE

Standard Gamble Chance Board Select Life “A” or Life “B” or are they ‘equal’

© Health Utilities Inc. (HUInc.) 2006

slide20

CHANCE BOARD

S7

Life “A”

70

30

% CHANCE

% CHANCE

PERFECT HEALTH

Able to see, hear and speak normally.

Able to walk, bend, lift, jump, and run normally for age.

Generally happy and free from worry.

Able to learn and remember normally.

Able to eat, bathe, dress, and use the toilet normally.

Free of pain and discomfort.

IMMEDIATE DEATH

Life “B”

Health State “B”

Able to see, hear and speak normally.

Requires mechanical equipment (cane, crutches, braces, wheelchair) to walk or get around.

Occasionally angry, irritable, anxious, or depressed.

Able to learn and remember normally.

Eats, bathes, dresses, or uses the toilet independently with difficulty.

Free of pain and discomfort.

100

% CHANCE

Standard Gamble Chance Board Select Life “A” or Life “B” or are they ‘equal’

© Health Utilities Inc. (HUInc.) 2006

slide21

CHANCE BOARD

S8

Life “A”

40

60

% CHANCE

% CHANCE

PERFECT HEALTH

Able to see, hear and speak normally.

Able to walk, bend, lift, jump, and run normally for age.

Generally happy and free from worry.

Able to learn and remember normally.

Able to eat, bathe, dress, and use the toilet normally.

Free of pain and discomfort.

IMMEDIATE DEATH

Life “B”

Health State “B”

Able to see, hear and speak normally.

Requires mechanical equipment (cane, crutches, braces, wheelchair) to walk or get around.

Occasionally angry, irritable, anxious, or depressed.

Able to learn and remember normally.

Eats, bathes, dresses, or uses the toilet independently with difficulty.

Free of pain and discomfort.

100

% CHANCE

Standard Gamble Chance Board Select Life “A” or Life “B” or are they ‘equal’

© Health Utilities Inc. (HUInc.) 2006

slide22

CHANCE BOARD

S9

Life “A”

60

40

% CHANCE

% CHANCE

PERFECT HEALTH

Able to see, hear and speak normally.

Able to walk, bend, lift, jump, and run normally for age.

Generally happy and free from worry.

Able to learn and remember normally.

Able to eat, bathe, dress, and use the toilet normally.

Free of pain and discomfort.

IMMEDIATE DEATH

Life “B”

Health State “B”

Able to see, hear and speak normally.

Requires mechanical equipment (cane, crutches, braces, wheelchair) to walk or get around.

Occasionally angry, irritable, anxious, or depressed.

Able to learn and remember normally.

Eats, bathes, dresses, or uses the toilet independently with difficulty.

Free of pain and discomfort.

100

% CHANCE

Standard Gamble Chance Board Select Life “A” or Life “B” or are they ‘equal’

© Health Utilities Inc. (HUInc.) 2006

slide23

CHANCE BOARD

S10

Life “A”

50

50

% CHANCE

% CHANCE

PERFECT HEALTH

Able to see, hear and speak normally.

Able to walk, bend, lift, jump, and run normally for age.

Generally happy and free from worry.

Able to learn and remember normally.

Able to eat, bathe, dress, and use the toilet normally.

Free of pain and discomfort.

IMMEDIATE DEATH

Life “B”

Health State “B”

Able to see, hear and speak normally.

Requires mechanical equipment (cane, crutches, braces, wheelchair) to walk or get around.

Occasionally angry, irritable, anxious, or depressed.

Able to learn and remember normally.

Eats, bathes, dresses, or uses the toilet independently with difficulty.

Free of pain and discomfort.

100

% CHANCE

Standard Gamble Chance Board Select Life “A” or Life “B” or are they ‘equal’

© Health Utilities Inc. (HUInc.) 2006

comparing multi attribute utility measures eq 5d hui and sf 6d24
Comparing Multi-Attribute Utility Measures: EQ-5D, HUI, and SF-6D

Outline

Introduction/Administration of Selected Multi-Attribute Utility Measures

Conceptual Foundations

Direct Approaches to Obtaining Utility Scores for Health States

Multi-Attribute or Indirect Approaches to Obtaining Utility Scores for Health States

Evidence on Measurement Properties of Utility Measures: Reliability, Construct Validity, Responsiveness, Floor/Ceiling Effects, Predictive Validity, Interpretability

Applications in Cost-Effectiveness/Cost-Utility Analyses

Comparisons Among Measures

Criteria for Selecting an Appropriate Measure for your Study

Results from Demonstration

Summary

desirable properties for measures of hrql
Desirable Propertiesfor Measures of HRQL

Acceptability

Burden

Reliability

Validity

Responsiveness

Interpretability

Usefulness

major uses of utility measures of hrql
Major Uses of Utility Measures of HRQL

As an Outcome Measure

Input into Economic Evaluations (Cost-Effectiveness, Cost Utility, Cost-Benefit Analyses)

Input into Health Technology Assessments

useful properties of utility measures of hrql
Useful Properties of Utility Measures of HRQL

Comprehensive

Conventional Scale:

Dead = 0.00; Perfect Health = 1.00

Interval-Scale Properties

Permit Broad Comparisons

Integrate Treatment Process and Outcome

Integrate over Time

Integrate Mortality and Morbidity

Link Clinical and Population Health Applications

taxonomy of measures of health related quality of life
Taxonomy of Measures of Health-Related Quality of Life

I. Specific Instruments

II. Generic Instruments

Health-Profile Measures

Utility (Preference-Based) Measures

Source: Guyatt, Feeny, and Patrick (1993).

slide29
Definitions and Concepts

Three Major Paradigms in HRQL Measurement

Psychometric

Clinimetric

Utility/Preference-Based

Purposes of Measurement

Description - Assess Burden of Morbidity

Assess Place of Individual/Group in the Distribution of Health Status

Discrimination

Prediction

Evaluation: Assess Within-Person Change over Time - Individual Patients, Groups, Clinical Trials

Valuation of Health Status - Conventional Scale (Dead = 0.00; Perfect Health = 1.00)

Assist in Informing Resource Allocation Decisions

Approaches to the Assessment of Health-Related Quality of Life (HRQL)

a definition of hrql
A Definition of HRQL

“Health-related quality of life is the value assigned to duration of life as modified by the impairments, functional states, perceptions, and social opportunities that are influenced by disease, injury, treatment, or policy.”

Source: Donald L. Patrick and Pennifer Erickson, Health Status and Health Policy: Quality of Life in Health Care Evaluation and Resource Allocation. New York: Oxford University Press, 1993, p 22.

slide31

Axioms of Cardinal Expected Utility Theory

  • Rational behavior under risk (uncertainty) consists of:
  • Preferences for outcomes exist and are transitive,
  • e.g. if A > B and B > C, then A > C
  • Preferences for a risky prospect are independent of whether it has one stage or two,
  • e.g. if P1 = (0.5A, 0.5P2) where P2 = (0.5A, 0.5B), and P3 = (0.75A, 0.25B), then P1 ~ P3
  • Preferences are continuous (Standard Gamble), e.g. if A > B > C, then there is some probability p such that the person is indifferent between B for sure and a risky prospect (pA, (1-p)C) [Continuity Axiom]
basic underlying heuristic framework from economics
Basic Underlying Heuristic Framework from Economics

Utility = U(C, HS)

where U is the utility function;

C = composite final consumption good;

HS = health status.

Further assume that U/  C > 0;

 U/  HS > 0.

Final “goods” (C, HS) are produced within the household using time and inputs purchased from the market

implications for the valuation of health status
Implications for the Valuation of Health Status

1. Intrinsic Value of Health Status

  Health status is an argument in the utility function; it contributes directly to utility, well being, or life satisfaction.

2. “Indirect” Value of Health Status

  Being healthy reduces time lost due to illness and enhances productivity in market work and household production and thus has “indirect” value.

3.Scope.

Scope of utility measure needs to be specified. Is the measure intended to cover the intrinsic value only or both the intrinsic value and the indirect value?

direct approaches to obtaining utility scores for health states
Direct Approaches to Obtaining Utility Scores for Health States

Rank Ordering of Health States

Category Scaling/Visual Analogue Scale (VAS) - Feeling Thermometer (FT)

Choice-Based Techniques

  Time Tradeoff (TTO)

  Standard Gamble (SG)

Note: CS/VAS/FT and TTO scores technically are value scores; SG scores are utility scores.

feeling thermometer
FeelingThermometer

-- 100 --

-- 95 --

-- 90 --

-- 85 --

-- 80 --

-- 75 --

-- 70 --

-- 65 --

-- 60 --

-- 55 --

-- 50 --

-- 45 --

-- 40 --

-- 35 --

-- 30 --

-- 25 --

-- 20 --

-- 15 --

-- 10 --

-- 5 --

-- 0 --

Most Desirable

Perfect Health

Health State #2

Health State #3

Health State #1

Dead

Least Desirable

time trade off for a chronic health state preferred to dead
Time Trade-Off for a Chronic Health State Preferred to Dead

Value

Alternative 2

HEALTHY

1.0

Alternative 1

STATE i

hi

0.0

DEAD

Time

t

x

TTO Value Score for State i = x*/t (where x* is the indifference time)

Source: Drummond, O’Brien, Stoddart, and Torrance (1997), p. 155.

standard gamble for a chronic health state preferred to dead
Standard Gamble for a Chronic Health State Preferred to Dead

HEALTHY

Probability p

Alternative 1

DEAD

Probability 1-p

Alternative 2

STATE i

Utility of State i = p* (indifference probability)

multi attribute or indirect approaches for obtaining utility scores for health states
Multi-Attribute or Indirect Approaches for Obtaining Utility Scores for Health States
  • Assess Health Status using Existing Multi-Attribute Health Status Classification System
  • Value Health Status using Existing Multi-Attribute Preference Function, typically based on Community Preferences
  • Selected Prominent Systems:

Quality of Well Being Scale (QWB)

EuroQol, EQ-5D

Health Utilities Index (HUI)

Short-Form 6D (SF-6D)

quality of well being sa kaplan and anderson 1996
Number of Attributes

Mobility

Physical Activity

Social Activity

Symptom/Problem Complex

Number of Health States

4

3 Levels

3 Levels

5 Levels

27 Levels

1,215

QUALITY OF WELL-BEING - SA(Kaplan and Anderson 1996)

Scoring Function: Based on VAS Scores; Linear Additive; Scores: 0.00 to1.00

euroqol eq 5d essink bot et at 1993 dolan 1997 shaw et al 2005
Number of Attributes

Mobility

Self-Care

Usual Activities

Pain/Discomfort

Anxiety/Depression

Number of Health States

5

3 Levels

3 Levels

3 Levels

3 Levels

3 Levels

243

EuroQol, EQ-5D(Essink-Bot et at., 1993; Dolan 1997; Shaw et al. 2005)

Scoring Function: Based on TTO; Ad Hoc ModifiedLinear Additive; UK Scores: -0.59 to1.00; US Scores: -0.11 to 1.00

slide41
Number of Attributes

Physical Function

Role Limitation

Social Functioning

Pain

Mental Health

Vitality

Number of Health States

6

6 Levels

4 Levels

5 Levels

6 Levels

5 Levels

5 Levels

18,000

The Short Form 6D(Based on SF-36 and SF-12) (Brazier, Roberts, and Deverill 2002; Brazier and Roberts 2004)

Scoring Function: Based on SG; Ad Hoc Modified Linear Additive; Scores: 0.00 = Dead; 0.30 = all-worst 6D state; 1.00 = perfect health. The version based on SF-12 describes 7,500 health states; see Brazier and Roberts 2004.

hui attributes
HUI® Attributes
  • HUI2

1. Sensation (4 levels) 5. Self-Care (4 levels)

2. Mobility (5 levels) 6. Pain (5 levels)

3. Emotion (5 levels) 7. Fertility (3 levels) - optional

4. Cognition (4 levels)

      • Partial structural independence; 24,000 health states
      • -0.03 for all-worst HUI2 state; 0.00 for Dead; 1.00 for Perfect Health
      • Multiplicative multi-attribute utility function based on VAS and SG
  • HUI3

1. Vision (6 levels) 5. Dexterity (6 levels)

2. Hearing (6 levels) 6. Emotion (5 levels)

3. Speech (5 levels) 7. Cognition (6 levels)

4. Ambulation (6 levels) 8. Pain (5 levels)

      • Full structural independence; 972,000 health states
      • -0.36 for all-worst HUI3 state; 0.00 for Dead; 1.00 for Perfect Health
      • Multiplicative multi-attribute utility function based on VAS and SG

Sources: Horsman et al. 2003; Furlong et al. 2001.

health utilities index mark 3 system hui3
Health Utilities Index Mark 3 System (HUI3)

Attribute Level Level Description

EMOTION

1 Happy and interested in life

2 Somewhat happy

3 Somewhat unhappy

4 Very unhappy

5 So unhappy that life is not worthwhile.

Source: Feeny, Torrance, and Furlong (1996).

major functional forms for multi attribute utility functions
Major Functional Forms for Multi-Attribute Utility Functions

Let uj (xj) = the single attribute utility function for attribute j.

Additive:

u(x) = kj uj (xj)

where  kj = 1

Multiplicative:

u (x) = (1/k) [ (1 + k kj uj (xj)) -1]

where (1 + k) =  (1 + k kj)

Multilinear:

u (x) = k1 u1 (x1) + k2 u2 (x2) + ...

+ k12 u1 (x1) u2 (x2) + k13 u1 (x1) u3 (x3) + ...

K123 u1 (x1) u2 (x2) u3 (x3) + ...

+ ...

where  All k’s = 1

major approaches to the estimation of multi attribute utility functions
Major Approaches to the Estimation of Multi-Attribute Utility Functions
  • Statistical Inference/Regression Models

EQ-5D, SF-6D

  • Decomposed Approach

HUI1, HUI2, HUI3

eq 5d perfect health
EQ-5D “Perfect Health”
  • I have no problems walking about
  • I have no problems with self care
  • I have no problems with performing my usual activities
  • I have no pain or discomfort
  • I am not anxious or depressed
eq 5d all worst state
EQ-5D “All-Worst State”
  • I am confined to bed
  • I am unable to wash or dress myself
  • I am unable to perform my usual activities
  • I have extreme pain or discomfort
  • I am extremely anxious or depressed
slide48

Thought Experiment

Part A. Imagine that you go from perfect health in the EQ-5D system (1,1,1,1,1) to “I have some problems in walking about”, otherwise healthy (2,1,1,1,1)

Please Think About the Decrement in Your Health-Related Quality of Life

Part B. Imagine that you have the health state (1,2,2,2,2): no problems with mobility, but some problems with self-care, usual activities, pain, and anxiety/depression. What score do you attach to this health state?

Now imagine that you go from (1,2,2,2,2) to the health state (2,2,2,2,2), some problems in all 5 dimensions.

Please Think About the Decrement in Your Health-Related Quality of Life

Part C. Please compare the decrement in Part A to the decrement in Part B

eq 5d scoring formula uk tto version
EQ-5D Scoring Formula, UK TTO Version

Source: Drummond, et al. (1997), p 164.

eq 5d scoring formula us tto version
EQ-5D Scoring Formula, US TTO Version

Dimension Coefficient

Mobility, level 2 -0.146

Mobility, level 3 -0.558

Self-care, level 2 -0.175

Self-care, level 3 -0.471

Usual Activity, level 2 -0.140

Usual Activity, level 3 -0.374

Pain/discomfort, level 2 -0.173

Pain/discomfort, level 3 -0.537

Anxiety/depression, level 2 -0.156

Anxiety/depression, level 3 -0.450

D1, # dimensions at level 2 or 3, beyond 1st 0.140

I2-squared -0.011

I3 0.122

I3-squared 0.015

Note: I2-squared = square of # of dimensions at level 2 beyond 1st; I3 = # of dimensions at level 3 beyond 1st.

Source: Shaw et al. 2005, Appendix 2, p 220.

sf 6d scoring formula uk sg version
SF-6D Scoring Formula, UK SG Version

DimensionCoefficient

PF2 -0.053

PF3 -0.011

PF4 -0.040

PF5 -0.054

PF6 -0.111

RL2 -0.053

RL3 -0.055

RL4 -0.050

SF2 -0.055

SF3 -0.067

SF4 -0.070

SF5 -0.087

sf 6d scoring formula uk sg version cont
SF-6D Scoring Formula, UK SG Version, cont.

DimensionCoefficient

Pain2 -0.047

Pain3 -0.025

Pain4 -0.056

Pain5 -0.091

Pain6 -0.167

MH2 -0.049

MH3 -0.042

MH4 -0.109

MH5 -0.128

VIT2 -0.086

VIT3 -0.061

VIT4 -0.054

VIT5 -0.091

Most -0.070

Note: Most takes a value of one if any dimension is at its most severe level.

Source: Brazier et al. 2002, Table 6, column (10), p 288.

slide53

Attribute

Level

Vision

u1

Hearing

u2

Speech

u3

Ambulation

u4

Dexterity

u5

Emotion

u6

Cognition

u7

Pain

u8

1

1.00

1.00

1.00

1.00

1.00

1.00

1.00

1.00

2

0.95

0.86

0.82

0.83

0.88

0.91

0.86

0.92

3

0.73

0.71

0.67

0.67

0.73

0.73

0.92

0.77

4

0.59

0.48

0.41

0.36

0.45

0.33

0.70

0.48

5

0.38

0.32

0.00

0.16

0.20

0.00

0.32

0.00

6

0.00

0.00

n/a

0.00

0.00

n/a

0.00

n/a

HUI3 Single-Attribute Utility Functions

Legend: ux - single-attribute utility function for attribute x;

n/a - not applicable.

Note: - the mean single-attribute utility score for Level 3 Cognition is greater than the mean single-attribute utility score for Level 2 Cognition.

Source: Feeny et al. (2002), Table 4, p. 125

slide54

Attribute

Level

Vision

b1

Hearing

b2

Speech

b3

Ambulation

b4

Dexterity

b5

Emotion

b6

Cognition

b7

Pain

b8

1

1.00

1.00

1.00

1.00

1.00

1.00

1.00

1.00

2

0.98

0.95

0.94

0.93

0.95

0.95

0.92

0.96

3

0.89

0.89

0.89

0.86

0.88

0.85

0.95

0.90

4

0.84

0.80

0.81

0.73

0.76

0.64

0.83

0.77

5

0.75

0.74

0.68

0.65

0.65

0.46

0.60

0.55

6

0.61

0.61

n/a

0.58

0.56

n/a

0.42

n/a

HUI3 Multiplicative Multi-Attribute Utility Function On Dead-Healthy Scale

Legend: bj – model parameter estimate for level of attribute j; n/a - not applicable.

Formula (Dead-Perfect Health Scale) u* = 1.371 x (b1 x b2 x b3 x b4 x b5 x b6 x b7 x b8)-0.371

where u* is the utility of a chronic health state on the utility scale (Dead=0.00, Healthy=1.00)

Source: Feeny et al. (2002), Table 3, p. 124

summary of evidence on test retest reliability of utility measures
Summary of Evidence on Test-Retest Reliability of Utility Measures

VAS: correlations of 0.62 to 0.95

TTO: correlations of 0.63 to 0.81

SG: correlations of 0.53 to 0.83

EQ-5D: correlations of 0.63 to 0.80

HUI: correlations of 0.71 to 0.80

QWB: correlations of 0.90 in many studies

SF-36: correlations of 0.60 to 0.81

concept of construct validity
Concept of Construct Validity

“Construct validity is evaluated through a series of hypotheses and tests of these hypotheses regarding the relationships between an instrument and other measures of similar and dissimilar domains or characteristics.”

Source: Revicki et al. 2000.

Also test hypotheses using known-groups approach.

summary of evidence on measurement properties of utility measures
Summary of Evidence on Measurement Properties of Utility Measures

Cross-sectional Construct Validity

Longitudinal Construct Validity/Responsiveness

Predictive Validity

known groups approach example mean hui2 overall utility scores
Known Groups ApproachExample: Mean HUI2 Overall Utility Scores

Note: CDR = Clinical Dementia Rating Scale; ELBW = extremely low birthweight; ALL = acute lymphoblastic leukemia; SF = standard risk; HR = high risk

Sources: (1) and (8) Saigal et al. 1994; (2) and (3) Barr et al. 1993; (4) Feeny et al. 1993; (5) Barr et al. 1999; (6) Whitton et al. 1997; (7) Glaser et al. 1999; (9) Mathias et al. 1997; (10) Neumann et al. 1999; (11-14) Barr et al. 2002.

known groups approach multiple sclerosis hui2 overall scores
Known Groups Approach: Multiple Sclerosis/HUI2 Overall Scores

Mean Overall HUI2 Score by EDSS Category

EDSS 1-2 EDSS 3-4 EDSS 5-6

0.84 0.71 0.60

Mean HUI2 Score during Relapse: 0.68

Mean HUI2 Score during Remission: 0.75

Note: EDSS = Expanded Disability Status Scale; ordinal scale in which 0 = normal, 10 = death from MS

Source: Grima et al. 2000.

construct validity and responsiveness in recovery after stroke
Construct Validity and Responsiveness in Recovery After Stroke

Overall Scores

Baseline 6 Months Change

Measure

EQ-5D(UK) 0.31 0.62 0.31

EQ-5D(us) 0.47 0.71 0.24

HUI3 0.19 0.44 0.25

SF-6D 0.55 0.68 0.13

Source: Pickard et al. 2004; AS Pickard, personal communication, October 27, 2006.

construct validity and responsiveness in recovery after stroke cont
Construct Validity and Responsiveness in Recovery After Stroke, cont.

Mean Score: Baseline 6 Months

Measure

HUI3 Speech 0.83 0.92

HUI3 Ambulation 0.41 0.68

HUI3 Dexterity 0.51 0.79

HUI3 Emotion 0.83 0.92

HUI3 Vision 0.91 0.90

SF Physical Func. 19 43

SF Role Physical 8 34

SF Role Emotional 48 69

construct validity and responsiveness in recovery after stroke cont64
Construct Validity and Responsiveness in Recovery After Stroke, cont.

EQ-5D, % with Problems by Dimension

Baseline 6 Months

NoSomeUnableNoSomeUnable

Mobility:

17 45 38 40 49 11

Anxiety/Depression:

35 60 4 61 37 2

construct validity and responsiveness in recovery after stroke cont65
Construct Validity and Responsiveness in Recovery After Stroke, cont.

Standardized Response Mean QALYs Gained

EQ-5D (UK) 0.84 0.16

SF-6D 0.87 0.06

HUI3 0.78 0.12

Note: Standardized Response Mean = change/standard deviation of change scores: QALYs = quality-adjusted life years

overall gain in utility associated with elective tha
Overall Gain in Utility Associated with Elective THA
  • SF-6D: 0.10
  • Standard Gamble 0.16
  • HUI2 0.22
  • HUI3 0.23

Source: Feeny et al. 2004.

evidence on floor and ceiling effects
Evidence on Floor and Ceiling Effects
  • Community Sample, York: PH 49% EQ-5D; 25% HUI3 (Macran et al. 2003)
  • Community Sample, Sweden: PH 43% EQ-5D; among those, 32% report occasional problems for mental health and 23% report musculoskeletal pain (Nordlund et al. 2005)
  • Asthma trials: PH 25% EQ-5D; < 1% SF-6D;

% below utility score of 0.5: 27% EQ-5D; 20% SF-6D (Szende et al. 2004)

evidence on floor and ceiling effects cont
Evidence on Floor and Ceiling Effects, cont.
  • EXCITE Trial, HUI3, % at top level by attribute: 11 to ~50%; SF-6D, 5 to 35% (Hatoum et al. 2004)
  • % at Floor: HUI3, 0 to 8%; SF-6D, 2 to 40%
  • Change score from baseline: SF-6D, 0.08; HUI3, 0.15
  • Differences between SF-6D and HUI3 scores more pronounced below 0.6
performance of eq 5d hui2 and hui3 in a us population health survey
Performance of EQ-5D, HUI2, and HUI3 in a US Population Health Survey
  • Random Sample of US population age 18+, conducted in 2002, n = 4048
  • Mean EQ-5D Score 0.87
  • Mean HUI2 Score 0.86
  • Mean HUI3 Score 0.81

Source: Luo et al. 2005.

performance of eq 5d hui2 and hui3 in us population health survey
Performance of EQ-5D, HUI2, and HUI3 in US Population Health Survey
  • Percent of Population in Perfect Health

EQ-5D 50.1%

HUI2 19.9%

HUI3 19.5%

  • Number of Unique Health States:

EQ-5D 91

HUI2 355

HUI3 767

Source: Luo et al. 2005.

slide71
Results from another US Population Health Survey ages 35-89, conducted 2005-2006, n = 3844 (Fryback et al. forthcoming)

Measure Time Minimum % in Mean Score

Score PH for 35-44

EQ-5D 1.9 min -0.11 36.2 0.89

HUI 3.4 min

HUI2 -0.01 10.8 0.87

HUI3 -0.34 11.4 0.83

QWB-SA 11.1 min 0.09 0.0 0.67

SF-6D 7.9 min 0.30 4.3 0.80

slide72
Predictive Validity – Out of Sample: Group-Level Agreement Between Standard Gamble and Multi-Attribute Utility Function Scores for HUI2

GroupMean Utility ScoreSD

ELBW, n = 140

HUI2 0.89 0.14

Standard Gamble 0.90 0.20

Controls, n = 124

HUI2 0.95 0.09

Standard Gamble 0.91 0.16

Combined, n = 264

HUI2 0.92 0.13

Standard Gamble 0.91 0.16

Note: ELBW = extremely low birthweight.

Source: Feeny et al. 2004.

slide73
Predictive Validity – Out of Sample/Group-Level Agreement Between Standard Gamble and Multi-Attribute Utility Function Scores for HUI3

Mean Difference (HUI3 function minus direct SG score) for 73 HUI3 health states:

-0.008 per health state, on 0.00 to 1.00 scale

Mean Absolute Difference:

0.087

Overall Standard Deviation:

0.1032

Intra-Class Correlation Coefficient (95% CI):

0.88 (0.49, 0.92)

Source: Furlong et al. 1998; Feeny et al. 2002.

predictive validity mortality
Predictive Validity: Mortality
  • Statistics Canada Longitudinal National Population Health Survey, 1994/95 and every 2 years thereafter
  • Do Baseline Overall HUI3 Scores Predict Mortality in follow-up through 2002/03?
  • Cox Proportional Hazards Model
  • Control for Standard Determinants of Health at Baseline including Age, Education, Martial Status, Socio-Economic Status, BMI, Smoking, Chronic Conditions, Stress, Physical Activity
  • Analysis of those 65 or older at baseline; separate analyses for males and females
predictive validity of bmi and hui3 mortality
Predictive Validity of BMI and HUI3: Mortality

Results:

  • For Males, Hazard Rate for HUI3:

0.6 [0.3, 0.9]

  • For Males, Hazard Rate for BMI < 18.5:

2.5 [1.2, 4.9]

  • For Females, Hazard Rate for HUI3:

0.5 [0.3, 0.9]

  • For Females, Hazard Rate for BMI < 18.5:

2.3 [1.5, 3.6]

Source: Wilkins 2006.

interpreting utility preference based measures of health related quality of life
Interpreting Utility (Preference-Based) Measures of Health Related Quality of Life

Selected Published Guidelines on Clinically Important Differences/Changes in Utility Scores:

Furlong et al. 1990, SG scores, 0.10 or more is clearly important

Samsa et al. 1999, HUI2 scores, 0.02 to 0.04 or more is clearly important

Grootendorst et al. 2000, HUI3 scores, 0.025 or more is clearly important

Drummond 2001, HUI3 , 0.03 or more clearly important; 0.01 or more may be important

interpreting utility preference based measures of health related quality of life cont
Interpreting Utility (Preference-Based) Measures of Health Related Quality of Life, cont.

Walters and Brazier (2003, 2005) SF-6D scores, 0.033 or more as important

Kaplan suggests for QWB scores, 0.03 or more as important

Marra et al.(2005) suggest 0.03 or more for Eq-5D; provide estimates for SF-6D, EQ-5D, HUI2, and HUI3 ranging from 0.03 to 0.06

For Visual Analog Scale (Feeling Thermometer), Schunemann et al. 2003 suggest 6 to 8 (out of 100)

slide78
Interpreting Utility (Preference-Based) Measures of Health Related Quality of Life: Tentative Guidelines

Clinically Important Difference/Change in Utility Score:

Direct, SG, TTO Scores 0.05

Overall Multi-attribute Utility Scores 0.03

Useful for Study Design, Sample Size Calculation

Caveats:

Context May Matter

Cost of Producing Change Matters

applications of utility scores in cost effectiveness analysis and cost utility analysis
Applications of Utility Scores inCost-Effectiveness Analysis and Cost-Utility Analysis
  • Randomized controlled trial of hylan GF-20 for knee osteoarthritis
  • Hylan GF-20 is injected into the knee as a replacement synovial fluid
  • 255 patients, multi-centred, 1-year pragmatic trial in Canada

Source: Raynauld et al. 2002; Torrance et al. 2002.

data collection
Data Collection
  • HRQOL
    • Disease Specific: WOMAC
    • Generic: SF-36
    • Utility: HUI3
  • Costs (societal perspective, related to OA)
  • Data gathered at baseline and at 1, 2, 4, 6, 8, 10, 12 months
  • Data gathered primarily by telephone to minimize protocol driven activities like clinic visits
data collection patient feedback
Data Collection: Patient Feedback
  • How clear was the WOMAC? the SF-36? the HUI?
    • Clear or very clear 88% 89% 95%
    • Indifferent 6% 6% 3%
    • Unclear or very 6% 5% 2%
  • Interview (minutes): mean 52; min 22; max 95
  • According to patients:
    • 96% enjoyed the interviews
    • 98% length of interviews reasonable
    • 85% HRQOL and health care resources clear and easy to complete
results womac pain score

13

12

11

Appropriate care

10

9

WOMAC pain score (Likert scale)

8

*

7

6

Appropriate care with hylan G-F 20

5

4

0

10

6

8

4

12

Baseline

1

2

Month

*P = 0.0001

Results:WOMAC Pain Score
results clinical effectiveness
Results:Clinical Effectiveness
  • Primary: Change in mean WOMAC pain score

Change Baseline Month 12 (% of baseline)

T 11.35 6.95 –38.41

C 11.94 10.10 –13.34

T - C –25.07 (P = 0.0001)

results clinical effectiveness84
Results:Clinical Effectiveness
  • Secondary: Patients Improved

Percent of Patients Improved

Treatment 68.5%

Control 40.0%

T - C 28.5% (P = 0.0001)

results costs
Results:Costs

Annual Costs per Patient (1999 Canadian $)

Societal Perspective

Exchange rate in 1999: Cdn $1.00 = US $0.67

Treatment $2125

Control $1415

T – C $710

results cost effectiveness
Results:Cost-Effectiveness

Incremental cost/pt = $710 (Canadian)

Incremental effectiveness/pt = 0.28 pts improved

Incr’l cost-effectiveness ratio =$710 / 0.28

= $2,505/pt improved

results sf 36
Results:SF-36

Change (% from baseline)

T C T - C

Physical Component Summary (PCS) 20.31 1.07 19.24*

Mental Component Summary (MCS) 11.53 5.40 6.13

*p < 0.0001

results hui3
Results:HUI3

Change (absolute change from baseline)

T C T – C

HUI3 total score 0.13 0.03 0.10 (p<0.0001)

a typical patient profile for the hui3 score showing area under the curve calculation for qalys
A Typical Patient Profile for the HUI3 ScoreShowing Area-Under-the-Curve Calculationfor QALYs

1

Patient utility score

0

0

1

2

4

6

8

10

12

Baseline

Time (months)

health utilities index 3
Health Utilities Index 3

0.20

0.20

Appropriate care + hylan G-F 20

0.15

0.15

Change from baseline in HUI3 score

0.10

0.10

s= 0.071 QALYs

kdfjdkfjdkfjkdjf

0.05

0.05

Appropriate care

0

12

0

1

2

4

6

8

10

Months

results cost utility
Results:Cost-Utility

Incremental cost/pt=$710 (Canadian)

Incremental QALY/pt = 0.071 QALYs gained

Incr’l cost-utility ratio =$710 / 0.071

= $10,000/QALY gained

cumulative distribution of hui3 scores by the type of residence and disability level
Cumulative Distribution of HUI3 Scores by the Type of Residence and Disability Level

Adjusted for age and gender according to the structure by age and gender of private households population.

Source: Statistics Canada, 1996-97 National Population Health Survey

slide93

Mean HUI3 calculated from the 1996 - 97 National Population Health Survey (Canada)

Source: Statistics Canada

slide94

Criteria for Selecting an Appropriate Measure for your Study

Advantages of Multi-Attribute Approach

  • Low Respondent Burden
  • Inexpensive to Use
  • Availability of Standardized Questionnaires in Multiple Formats, Multiple Languages, Algorithms, Manuals, etc.
  • Use of Community Preferences Facilitates Broad Comparison (Reference Case)
  • Interpretation of overall HRQL scores enhanced by availability of single-attribute utility scores for each dimension of health status
  • Interpretation Enhanced by the Availability of Data on Population Norms

Disadvantages of MA Approach

  • Health-Status Description may omit Dimensions or Levels that are Important in a Particular Context
  • Multi-Attribute Measure May not be as Responsive as Specific Measure
slide95

Criteria for Selecting, cont’d

Psychometric, Clinimetric, and Utility Measures are often Complementary:

  • Utility Measures Focus on Cardinal Value of Health States
  • Utility Measures Provide Scores on the Generic Dead =0.00 to Perfect Health = 1.00 Scale

Useful for:

  • Individual Patients, Clinical Decision Making
  • Clinical Groups, Clinical Policy
  • Informing Management of Patients
  • Informing Clinical Policy
  • Population Health
  • Informing Resource Allocation Decisions/Economic Evaluation
  • Health Technology Assessment
report on results from demonstration administration of selected utility measures
Report on Results from Demonstration Administration of Selected Utility Measures

n Mean Min Max SD

VAS

TTO

SG

EQ-5DUS

EQ-5DUK

HUI2

HUI3

SF-6D

summary
Summary
  • Utility Measures Useful to Assess Outcome and for Economic Evaluation/Health Technology Assessment
  • Broad Comparisons; Integrate Mortality and Morbidity
  • Often Useful to Complement Utility Measures with Specific Measures
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