1

EQ-5D, HUI and SF-36

Of the shelf instruments….

2

Direct valuation

3

…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

4

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

5

The Rosser & Kind Index

6

The Rosser & Kind index

One of the oldest valuation 1978: Magnitude estimation

Magnitude estimation PTO

N = 70: Doctors, nurses, patients and general public

1982: Transformation to “utilities” 1985: High impact article

Williams A. For Debate... Economics of Coronary Artery Bypass Grafting. British Medical Journal 291: 326-28, 1985.

Survey at the celebration of 25 years of health economics: chosen most influential article on health economics

7

More health states

Criticism on the Rosser & Kind index Sensitivity (only 30 health states)

The unclear meaning of “distress”

The compression of states in the high values

The involvement of medical personnel

New initiatives Higher sensitivity (more then 30 states)

More and better defined dimensions

Other valuation techniques

• Standard Gamble, Time Trade-Off

Values of the general public

8

Validated questionnaires

Questionnaire Number of health state

Rosser 30

EuroQol EQ-5D 243

QWB 2,200

SF-36 (SF-6D) 9,000

HUI Mark 2 24,000

HUI Mark 3 972,000

15D 3,052,000,000

9

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)

10

Statistically inferred strategies

Value a sample of states empirically Extrapolation

Statistical methods, like linear regression

11111 = 1.00

11113 = .70

11112 = ?

11

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

12

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%

13

Explicitly Decomposed Methods

Combine values of dimensions and levels with specific assumptions Multi Attribute Utility Theory (MAUT)

• Mutual utility independence

• Structural independence

14

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)

Exercise EQ-5D: 12311

15

The EQ-5D

For each of the following question, please mark the circle that best describes your answer, still imagining of course that you require a wheelchair to get around. By placing a tick (thus ) in one box in each group below, please indicate which statements best describe your own health state today, imagining that you require a wheelchair to get around independently. 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

X

X

X

X

X

Scoring EQ-5D state 123111. COMPUTE MVH_A1 = 1.00. 2. IF (MAX(eq_mobility,eq_selfcare,eq_usual activities,eq_pain, eq_anxiety/depression)

> 1) MVH_A1 = MVH_A1 - .081 . 3. IF (eq_mobility = 2) MVH_A1 = MVH_A1 - .069. 4. IF (eq_mobility = 3) MVH_A1 = MVH_A1 - .314. 5. IF (eq_selfcare = 2) MVH_A1 = MVH_A1 - .104. 6. IF (eq_selfcare = 3) MVH_A1 = MVH_A1 - .214. 7. IF (eq_usual activities = 2) MVH_A1 = MVH_A1 - .036. 8. IF (eq_usual activities = 3) MVH_A1 = MVH_A1 - .094. 9. IF (eq_pain = 2) MVH_A1 = MVH_A1 - .123. 10. IF (eq_pain = 3) MVH_A1 = MVH_A1 - .386. 11. IF (eq_anxiety/depression = 2) MVH_A1 = MVH_A1 - .071. 12. IF (eq_anxiety/depression = 3) MVH_A1 = MVH_A1 - .236. 13. IF (MAX(eq_mobility,eq_selfcare,eq_usual activities,eq_pain, eq_anxiety/depression)

> 2) MVH_A1 = MVH_A1 - .269 .

For instance state 12311:

Line 1: You start with 1.00 Line 2: at least one of the dimensions is above 1: subtract 0.081; 1,00 – 0.081 = 0.919 Line 3: does not apply: mobility is 1 and not 2 Line 4: does not apply: mobility is 1 and not 3 Line 5: self care is 2: subtract 0.104; 0.919 – 0.104 = 0.815 Line 6: does not apply Line 7: does not apply: usual activities is 3 and not 2 Line 8: subtract 0.094; 0.815 – 0.094 = 0.721 Line 9: does not apply Line 10: does not apply Line 11: does not apply Line 12: does not apply Line 13: at least one of the dimensions is above 3: subtract 0.269; 0.721 – 0,269 = 0,452 16

Converting SF-36 into SF-6D

17

Does your health limit you in these activities? If so, how much

SF # Question Yes,

limited a lot

Yes, limited a

little

No, not

limited at all

SF 3 Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports

1 2 3

SF 4 Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf

1 2 3

SF 12 Bathing and dressing yourself 1 2 3 Take the highest score possible from the scoring rules: If SF3 = 3 Physical Functioning =1 does not apply If SF3 = 1 or 2 Physical Functioning =2 does apply If SF4 = 2 Physical Functioning =3 does not apply If SF4 = 1 Physical Functioning =4 does not apply If SF12 = 2 Physical Functioning =5 does not apply If SF12 = 1 Physical Functioning =6 does apply and is the highest score

X

X

X

X

Scoring the SF-6D

18

Dimension: Physical Functioning (PF) If PF=1 decrement: 0 If PF=2 decrement: - 0.056 If PF=3 decrement: - 0.056 If PF=4 * decrement: - 0.072 If PF=5 * decrement: - 0.080 If PF=6 * decrement: - 0.134 Dimension: Role Limitations (RL) If RL=1 decrement: 0 If RL=2 decrement: - 0.073 If RL=3 * decrement: - 0.073 If RL=4 * decrement: - 0.073

19

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

20

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?

21

More health states, more assumptions

General public values at the most 50 states The ratios empirical (50) versus extrapolated

Rosser & Kind 1:1

EuroQol 1:5

QWB 1:44

SF-36 1:180

HUI (Mark III) 1:19,400

15D 1:610,000,000

What is the critical ratio for a valid validation?

22

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

23

Conflicting evidence sensitivity SF-36

Liver transplantation, Longworth et al., 2001

24

EQ-5D

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

25

HUI

Strong punts Sensitive

Measures objective burden (outside the skin)

Well developed proxy versions

Well developed child versions

Weak points Expensive

26

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

27

Conclusions

More states better sensitivity The three leading questionnaires

have different strong and weak points