Review of Valuation Methods of Preference-Based Measures of Health for Economic Evaluation in Child and Adolescent Populations: Where are We Now and Where are We Going?

Cost-effectiveness of a transdiagnostic psychotherapy program for youth with common mental health problems

OBJECTIVES

Our objective was to evaluate the cost-effectiveness of the transdiagnostic psychotherapy program Mind My Mind (MMM) for youth with common mental health problems using a cost-utility analysis (CUA) framework and data from a randomized controlled trial. Furthermore, we analyzed the impact of the choice of informant for both quality-of-life reporting and preference weights on the Incremental Cost-Effectiveness Ratio (ICER).

METHODS

A total of 396 school-aged (6-16 years) youth took part in the 6-month trial carried out in Denmark. CUAs were carried out for the trial period and four one-year extrapolation scenarios. Costs were based on a combination of budget and self-reported costs. Youths and parents were asked to report on the youth's quality-of-life three times during the trial using the Child Health Utility 9D (CHU9D). Parental-reported CHU9D was used in the base case together with preference weights of a youth population. Analyses using self-reported CHU9D and preference weights of an adult population were also carried out.

RESULTS

The analysis of the trial period resulted in an ICER of €170,465. The analyses of the one-year scenarios resulted in ICERs between €23,653 and €50,480. The ICER increased by 24% and 71% compared to the base case when using self-reported CHU9D and adult preference weights, respectively.

CONCLUSION

The MMM intervention has the potential to be cost-effective, but the ICER is dependent on the duration of the treatment effects. Results varied significantly with the choice of informant and the choice of preference weights indicating that both factors should be considered when assessing CUA involving youth.

Measurement Properties of the EQ-5D-Y: A Systematic Review

OBJECTIVES

This study aimed to perform a systematic review of published evidence on the psychometric properties of 3-level version of EQ-5D-Y and 5-level version of EQ-5D-Y (EQ-5D-Y-5L).

METHODS

A literature search on the MEDLINE, Embase, and EuroQol website (until June 2021) was conducted. Original studies on EQ-5D-Y psychometric properties such as feasibility, distribution properties (ceiling and floor effects), reliability (test-retest, interrater, intermodal), validity (known-groups, convergent), and responsiveness, published as full-text articles in English, were included. Studies on experimental EQ-5D-Y versions were excluded. The following data were pooled using random effects models: missing values, the ceiling effect, and correlations coefficients with other measures.

RESULTS

A total of 47 studies (inclusive of 7 on EQ-5D-Y-5L) containing data from 45 310 children and 2690 proxy respondents representing 15 countries were included. These studies were characterized as being high quality according to the quality index. The most represented areas were school populations and musculoskeletal diseases and orthopedics. The EQ-5D-Y dimensions, EQ visual analog scale, and EQ index were reported in 89%, 77%, and 26% of studies, respectively. Most articles addressed validity (known-groups, n = 27; convergent, n = 21) and reliability (test-retest and interrater, n = 10 each). Convergent validity studies showed that, where the assessment of the child's functioning at school is required, EQ-5D-Y should be supplemented with other school-specific measures.

CONCLUSIONS

This systematic review provides a summary of measurement properties and the psychometric performance of 3-level version of EQ-5D-Y and EQ-5D-Y-5L. The existing evidence supports using the EQ-5D-Y descriptive system and EQ visual analog scale in children and adolescent populations. Further research on test-retest reliability and the responsiveness of the EQ-5D-Y index obtained with child-specific value sets is needed.

Using stated-preferences methods to develop a summary metric to determine successful treatment of children with a surgical condition: a study protocol

INTRODUCTION

Wide variation in the management of key paediatric surgical conditions in the UK has likely resulted in outcomes for some children being worse than they could be. Consequently, it is important to reduce unwarranted variation. However, major barriers to this are the inability to detect differences between observed and expected hospital outcomes based on the casemix of the children they have treated, and the inability to detect variation in significant outcomes between hospitals. A stated-preference study has been designed to estimate the value key stakeholders place on different elements of the outcomes for a child with a surgical condition. This study proposes to develop a summary metric to determine what represents successful treatment of children with surgical conditions.

METHODS AND ANALYSIS

Preferences from parents, individuals treated for surgical conditions as infants/children, healthcare professionals and members of the public will be elicited using paired comparisons and kaizen tasks. A descriptive framework consisting of seven attributes representing types of operations, infections treated in hospital, quality of life and survival was identified. An experimental design has been completed using a D-efficient design with overlap in three attributes and excluding implausible combinations. All participants will be presented with an additional choice task including a palliative scenario that will be used as an anchor. The survey will be administered online. Primary analysis will estimate a mixed multinomial logit model. A traffic light system to determine what combination of attributes and levels represent successful treatment will be created.

ETHICS AND DISSEMINATION

Ethics approval to conduct this study has been obtained from the Medical Sciences Inter-Divisional Research Ethics Committee (IDREC) at the University of Oxford (R59631/RE001-05). We will disseminate all of our results in peer-review publications and scientific presentations. Findings will be additionally disseminated through relevant charities and support groups and professional organisations.

A scoping review of outcomes commonly reported in obesity prevention interventions aiming to improve obesity-related health behaviors in children to age 5 years

This scoping review was undertaken as the first stage of development of the Core Outcome Sets for Early Prevention of Obesity in CHildhood (COS-EPOCH). The aim of this review is to identify the outcomes collected and reported in randomized controlled trials of early childhood obesity prevention interventions. A systematic scoping review was undertaken following published guidelines. Trial registries and Medline were searched, and records retrieved were screened by two reviewers. Included trials aimed to prevent childhood obesity in the first 5 years of life and were randomized. Data were extracted using a standardized form. Outcomes were assigned to outcome domains, and similar definitions within each domain were merged, based on key literature and expert consensus. Outcome and domain frequencies were estimated and presented in outcome matrices. Eighteen outcome domains were identified from 161 included studies: "anthropometry," "dietary intake," "physical activity," "sedentary behaviour," "emotional functioning/wellbeing," "feeding," "cognitive/executive functioning," "sleep," "other," "study-related," "parenting practices," "motor skill development," "environmental," "blood and lymphatic system," "perceptions and preferences," "quality of life," and "economic," "oral health." The most frequently reported outcome domain was anthropometry (92% of studies), followed by dietary intake (77%) and physical activity (60%). 221 unique outcomes were identified, indicating a high degree of heterogeneity. Body mass index was the only outcome reported in >50% of studies. The considerable heterogeneity in outcomes supports the need for the development of COS-EPOCH.

Exploring the Issues of Valuing Child and Adolescent Health States Using a Mixed Sample of Adolescents and Adults

Preferences for child and adolescent health states used to generate health state utility values can be elicited from adults, young adults, adolescents, or combinations of these. This commentary paper provides a critical overview of issues and implications arising from valuing child and adolescent health states using a novel approach of a mixed sample of adolescents and adults. The commentary is informed by critical analysis of normative, ethical, practical and theoretical arguments in the health state valuation literature. Discussion focusses upon adolescent empowerment, understanding and psychosocial maturity; ethical concerns; elicitation tasks; perspective; and selection of sample proportions across adolescents and adults. It is argued that valuation of child and adolescent health states by both adolescents and adults could involve all participants completing the same preference elicitation task using the same perspective (e.g. time trade-off imagining they are living in the health state), and all preferences being modelled to generate a combined value set that reflects both adolescent and adult preferences. It is concluded that the valuation of child and adolescent health states by a mixed adolescent and adult sample appears feasible and has the advantage that it includes some of the population who can potentially experience the health states, thus enabling adolescents to express their views around matters that may affect them, and the population that are taxpayers and voters. However, both the relative proportion of adults and adolescents to include in a valuation sample and the elicitation technique require careful consideration.

Exploring EQ-5D-Y-3L Experience-Based VAS Values Derived Among Adolescents

OBJECTIVES

The EQ-5D-Y-3L is a generic health-related quality of life (HRQoL) instrument, developed from the adult version to be suitable for children and adolescents aged 8-15 years. To derive values for the EQ-5D-Y-3L different valuation methods and perspectives have been applied. The aim of this study was to explore EQ-5D-Y-3L experience-based visual analogue scale (VAS) values derived among adolescents.

METHODS

Data were derived from a cross-sectional population survey administered via schools in 2014 to adolescents aged 13-18 years, in Sweden. Regression analyses were performed on individual data with the VAS value as dependent variable. Ordinary least-squares (OLS) and generalised linear models (GLM) were estimated with two dummy variables for each of the EQ-5D-Y-3L dimensions. Interaction variables were tested. One way of anchoring VAS at dead and full health by using the predicted values for worst and best health states defined by the EQ-5D-Y-3L descriptive system was explored.

RESULTS

Of the 243 possible health states in EQ-5D-Y-3L, 92 were reported by the 6,468 respondents. The largest decrements in VAS values were observed for the dimension 'feeling worried, sad or unhappy' followed by 'doing usual activities'. All models performed similarly in terms of monotonicity and goodness of fit but in terms of simplicity and understandability, the OLS main effect model was superior.

CONCLUSIONS

We have explored experience-based VAS values for the EQ-5D-Y-3L derived among adolescents. The findings suggest that it is possible for adolescents to value their own health state using the VAS, which makes it possible to capture aspects that are important for young people.

Systematic Review of Conceptual, Age, Measurement and Valuation Considerations for Generic Multidimensional Childhood Patient-Reported Outcome Measures

BACKGROUND AND AIMS

Patient-reported outcome measures (PROMs) for children (aged ≤ 18 years) present methodological challenges. PROMs can be categorised by their diverse underlying conceptual bases, including functional, disability and health (FDH) status; quality of life (QoL); and health-related quality of life (HRQoL). Some PROMs are designed to be accompanied by preference weights. PROMs should account for childhood developmental differences by incorporating age-appropriate health/QoL domains, guidance on respondent type(s) and design. This systematic review aims to identify generic multidimensional childhood PROMs and synthesise their characteristics by conceptual basis, target age, measurement considerations, and the preference-based value sets that accompany them.

METHODS

The study protocol was registered in the Prospective Register of Systematic Reviews (CRD42021230833), and reporting followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We conducted systematic database searches for generic multidimensional childhood PROMs covering the period 2012-2020, which we combined with published PROMs identified by an earlier systematic review that covered the period 1992-2011. A second systematic database search identified preference-based value sets for generic multidimensional PROMs. The PROMs were categorised by conceptual basis (FDH status, QoL and HRQoL) and by target age (namely infants and pre-schoolers aged < 5 years, pre-adolescents aged 5-11, adolescents aged 12-18 and multi-age group coverage). Descriptive statistics assessed how PROM characteristics (domain coverage, respondent type and design) varied by conceptual basis and age categories. Involvement of children in PROM development and testing was assessed to understand content validity. Characteristics of value sets available for the childhood generic multidimensional PROMs were identified and compared.

RESULTS

We identified 89 PROMs, including 110 versions: 52 FDH, 29 QoL, 12 HRQoL, nine QoL-FDH and eight HRQoL-FDH measures; 20 targeted infants and pre-schoolers, 29 pre-adolescents, 24 adolescents and 37 for multiple age groups. Domain coverage demonstrated development trajectories from observable FDH aspects in infancy through to personal independence and relationships during adolescence. PROMs targeting younger children relied more on informant report, were shorter and had fewer ordinal scale points. One-third of PROMs were developed following qualitative research or surveys with children or parents for concept elicitation. There were 21 preference-based value sets developed by 19 studies of ten generic multidimensional childhood PROMs: seven were based on adolescents' stated preferences, seven were from adults from the perspective of or on behalf of the child, and seven were from adults adopting an adult's perspective. Diverse preference elicitation methods were used to elicit values. Practices with respect to anchoring values on the utility scale also varied considerably. The range and distribution of values reflect these differences, resulting in value sets with notably different properties.

CONCLUSION

Identification and categorisation of generic multidimensional childhood PROMs and value sets by this review can aid the development, selection and interpretation of appropriate measures for clinical and population research and cost-effectiveness-based decision-making.

'Like holding the axe on who should live or not': adolescents' and adults' perceptions of valuing children's health states using a standardised valuation protocol for the EQ-5D-Y-3L

Purpose

There is an increasing interest for using qualitative methods to investigate peoples’ cognitive process when asked to value health states. A standardised valuation protocol for the EQ-5D-Y-3L instrument was recently developed. Little is known regarding how people think, reason, and feel when asked to value health states for children. The aim was to explore how adolescents and adults perceive the task of valuing children’s health states using the standardised valuation protocol.

Methods

This was a qualitative study where adults (n = 10) and adolescents (n = 10) from the general population participated in individual video-interviews. Initially, participants reported their own health with the EQ-5D-3L instrument. Then they were asked to complete several valuations tasks for a 10-year-old child according to the standardised valuation protocol, followed by a semi-structured interview with open-ended questions to further explore participants’ perceptions. A qualitative content analysis was performed.

Results

The two main categories that emerged from the data were ‘Thoughts and feelings when valuing children’s health states’ and ‘Strategies when valuing children’s health states’. Participants expressed feeling doubt, awfulness and being reluctant to trade-off life years, and questioned who has the right to value health states for children. Experience and point of view were strategies participants used to complete the valuation tasks.

Conclusion

The findings from the present study can contribute to the understanding and interpretation of quantitative results where the standardised valuation protocol has been used to derive values for the EQ-5D-Y-3L. Furthermore, results of the study support the feasibility of including adolescents in valuation studies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03107-0.

Adolescent valuation of CARIES-QC-U: a child-centred preference-based measure of dental caries

Objectives

This study develops an adolescent value set for a child-centred dental caries-specific measure of oral health-related quality of life (OHRQoL) based upon CARIES-QC (Caries Impacts and Experiences Questionnaire for Children). This study develops a new approach to valuing child health by eliciting adolescent preferences and anchoring these onto the 1–0 full health-dead QALY (quality adjusted life year) scale using ordinal adult preferences.

Methods

Two online surveys were created to elicit preferences for the CARIES-QC classification system. The first comprised best–worst scaling (BWS) tasks for completion by adolescents aged 11–16 years. The second comprised discrete choice experiment tasks with a duration attribute (DCE_TTO) for completion by adults aged over 18 years. Preferences were modelled using the conditional logit model. Mapping regressions anchored the adolescent BWS data onto the QALY scale using adult DCE_TTO values, since the BWS survey data alone cannot generate anchored values.

Results

723 adolescents completed the BWS survey and 626 adults completed the DCE_TTO survey. The samples were representative of UK adolescent and adult populations. Fully consistent and robust models were produced for both BWS and DCE_TTO data. BWS preferences were mapped onto DCE_TTO values, resulting utility estimates for each health state defined by the classification system.

Conclusion

This is the first measure with predetermined scoring based on preferences to be developed specifically for use in child oral health research, and uses a novel technique to generate a value set using adolescent preferences. The estimates can be used to generate QALYs in economic evaluations of interventions to improve children’s oral health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-01918-w.

How are Child-Specific Utility Instruments Used in Decision Making in Australia? A Review of Pharmaceutical Benefits Advisory Committee Public Summary Documents

Measuring and valuing health-related quality of life (HRQOL) in children can be challenging but is an important component for providing decision makers with accurate information to fund new interventions, including medicines and vaccines for public subsidy. We review funding submissions of medicines made to the Pharmaceutical Benefits Advisory Committee contained in public summary documents to examine the use of child-specific HRQOL measures in decision making in Australia. A sample frame of medicines used by children was derived from four sources. Public summary documents relating to these medicines were searched in the Pharmaceutical Benefits Advisory Committee web resources for whether they related to children (aged under 18 years) and contained HRQOL information and/or cost-utility analyses. Data about the use of utilities in decision making were extracted and analysed. Of the 1889 public summary documents available, 62 public summary documents (29 medicines) contained information pertaining to children and utilities. Of these, four public summary documents included child-specific HRQOL measures, 16 included adult HRQOL measures, 11 included direct elicitation and the HRQOL source was not defined in 31 documents. Excluding documents using child-specific HRQOL measures, we considered that in 85% of medicines, decision making uncertainty might have been reduced by using child-specific HRQOL measures. Despite the growing literature on economic analysis in paediatric populations, the use of child-specific HRQOL measures in submissions to the Pharmaceutical Benefits Advisory Committee was minimal. Submissions involved inconsistent approaches, use of adult measures and weights, and substantial gaps in evidence. We recommend the consistent use of child-specific measures to improve the evidence base for decisions about medicines for children in Australia.

Expect Nothing: The (Lack of) Influence of Subjective Life Expectancy on Valuation of Child Health States

Objective

Earlier research has shown that individuals' subjective life expectancy (SLE) affects health state valuation with time trade-off (TTO). Individuals with longer expected life durations are less willing to trade-off life duration, which yields higher utilities. In this article, the influence of SLE is explored in the valuation of EQ-5D-Y-3L with a proxy perspective, i.e., adults' valuation of health states considering the life of a 10-year-old child. As SLE for children is likely higher, this might explain earlier findings suggesting that individuals are less willing to trade-off years of life for children than for adults.

Methods

A total of 197 respondents were recruited to take part in digital TTO interviews, facilitated by trained interviewers. TTO interviews were implemented in accordance with the recommended protocol for the valuation of EQ-5D-Y-3L. Respondents valued 10 EQ-5D-Y-3L health states for a 10-year-old child, after which they were asked to report how old they themselves expected to become and also how old they expected a 10-year-old child to become.

Results

Generally, adult respondents reported higher SLE for children than for themselves. Neither SLE was systematically associated with the willingness to trade lifetime or the number of life years traded off in TTO tasks. This null-result was substantiated by regression analyses per health state.

Conclusion

The results of this study suggest that individuals' expectations about longevity are not associated with EQ-5D-Y-3L valuation. This lack of association is in contrast to earlier work and might be explained by the psychological distance introduced with proxy perspective valuation, or by the methodological differences with earlier work.

International guidelines for self-report and proxy completion of paediatric health-related quality of life measures: a protocol for a systematic review

INTRODUCTION

Measures of health-related quality of life (HRQoL), accompanied by the values (or utilities) required to estimate quality-adjusted life-years, are crucial for determining health benefits within economic evaluation and health technology assessment. Several generic and condition-specific measures or instruments of HRQoL, accompanied by values, currently exist for application with child populations. However, there is a lack of a structured summary of guidelines and recommendations for applying these measures in practice. This protocol describes a systematic review of guidelines and recommendations for child and proxy completion of child-specific measures of HRQoL. The aims of the review are to (1) identify and summarise published guidelines and recommendations for existing child-specific measures of HRQoL, (2) determine whether the identified guidelines and recommendations differ by instrument and child characteristics, (3) identify current gaps in these guidelines and recommendations and (4) identify best practices for child self and proxy assessment in paediatric HRQoL measurement for economic evaluation and health technology assessment.

METHODS AND ANALYSIS

The review will identify, collate and synthesise published guidelines and recommendations for existing child-specific utility measures of HRQoL. Electronic databases to be searched include the Cochrane Library, Medline, Scopus, Web of Science, EconLit, PsycINFO, CINAHL, Embase and Informit. The search will be extended to websites of (1) international organisations for health technology assessment, (2) regulation, health economics and HRQoL outcomes research and (3) instrument developers. Three reviewers will independently screen titles and abstracts against the inclusion criteria. A narrative synthesis will describe the key features of the guidelines identified.

ETHICS AND DISSEMINATION

Ethical approval is not required as the proposed systematic review will not use primary data. A paper of the systematic review will be submitted to a peer-reviewed journal for publication.

PROSPERO REGISTRATION NUMBER

CRD42020207160.

Self vs. other, child vs. adult. An experimental comparison of valuation perspectives for valuation of EQ-5D-Y-3L health states

OBJECTIVES

EQ-5D-Y-3L health states are valued by adults taking the perspective of a 10-year-old child. Compared to valuation of adult EQ-5D instruments, this entails two changes to the perspective: (i) child health states are valued instead of adult health states and: (ii) health states are valued for someone else instead of for oneself. Although earlier work has shown that these combined changes yield different values for child and adult health states that are otherwise equal, it currently remains unclear why. Hence, we aimed to disentangle the effects of both changes.

METHODS

A sample of 205 students (mean age: 19.48) was surveyed. Each respondent completed visual analogue scale (VAS) and time trade-off (TTO) tasks for five EQ-5D-Y-3L states, using four randomly ordered perspectives: (i) self-adult (themselves), (ii) other-adult (someone their age), (iii) self-child (themselves as a 10-year-old), (iv) other-child (a child of 10 years old). We compared how each perspective impacted outcomes, precision and quality of EQ-5D-Y-3L valuation.

RESULTS

Overall, differences between perspectives were consistent, with their direction being dependent on the health states and respondents. For VAS, the effect on outcomes of valuation depended on severity, but variance was higher in valuation with child perspectives. For TTO, we observed that EQ-5D-Y-3L states valued on behalf of others (i.e., children or adults) received higher valuations, but lower variances.

CONCLUSION

The use of a different perspective appears to yield systematic differences in EQ-5D-Y-3L valuation, with considerable heterogeneity between health states and respondents. This may explain mixed findings in earlier work.

Developing a preference-based measure for weight-specific health-related quality of life in adolescence: the WAItE UK valuation study protocol

INTRODUCTION

Adolescent obesity is a public health problem in the UK. The Weight-Specific Adolescent Instrument for Economic Evaluation (WAItE) has been developed as the first weight-specific health-related quality of life measure appropriate for economic evaluation, but currently cannot be used to generate quality-adjusted life years (QALYs), which are the basis of cost-utility analysis. Generic measures (such as the EQ-5D-Y or CHU-9D) may be insensitive to small but important health changes in overweight or obese adolescents. This study aims to generate a preference-based scoring algorithm for the WAItE.

METHODS AND ANALYSIS

A discrete choice experiment (DCE) will be administered to value health states described by the WAItE classification system. These health states will be presented to members of the adult general population of the UK via an online survey. A range of regression models will be used to produce the utility algorithm for the WAItE. The DCE-visual analogue scale and time trade-off (TTO) anchoring methods will be used anchor the value set on to the 0-1 QALY scale.

ETHICS AND DISSEMINATION

The Newcastle University Medical School Ethics Committee approved the study (references 4772/2020 (DCE) and 9978/2020 (TTO)). The developed algorithm can be applied to future economic evaluations of weight management interventions and treatments for adolescents.

Deriving a Preference-Based Measure for People With Duchenne Muscular Dystrophy From the DMD-QoL

OBJECTIVES

This study generates a preference-based measure for capturing the quality of life of people with Duchenne muscular dystrophy (DMD) from a new measure of quality of life, DMD-QoL.

METHODS

A health state classification system was derived from the DMD-QoL based on psychometric performance of items, factor analysis, and item response theory analysis. Preferences for health states described by the classification system were elicited using an online discrete choice experiment survey with life years as an additional attribute, from members of the UK general population (n = 1043). Discrete choice experiment data was modeled using a conditional fixed-effects logit model and utility estimates were directly anchored on the 1 to 0 full health-dead scale.

RESULTS

The health state classification system has 8 dimensions: mobility, difficulty using hands, difficulty breathing, pain, tiredness, worry, participation, and feeling good about yourself. The standard model had mostly statistically significant coefficients and reflected the instrument's monotonic structure. However, 2 dimensions had inconsistent coefficients (where utility increased as health worsened) and a consistent model was estimated that merged adjacent inconsistent severity levels. The best state defined by the classification system has a value of 1 and the worst state has a value of -0.559.

CONCLUSION

The modeled results enable DMD-QoL-8D utility values to be generated using DMD-QoL or DMD-QoL-8D data to generate QALYs for people with DMD. QALYs can then be used to inform economic models of the cost-effectiveness of interventions in DMD. Future research comparing the psychometric performance of DMD-QoL-8D to existing generic preference-based measures, including EQ-5D-5L, is recommended.

Valuing child and adolescent health: a qualitative study on different perspectives and priorities taken by the adult general public

BACKGROUND

Quantitative health preference research has shown that different "perspectives", defined here as who is imagined to be experiencing particular health states, impact stated preferences. This qualitative project aimed to elucidate this phenomenon, within the context of adults' valuation of child and adolescent health states.

METHODS

Six focus groups with 30 members of the UK adult public were conducted between December 2019 and February 2020 and analysed using framework analysis. Each focus group had two stages. First, participants individually completed time trade-off tasks and a pairwise task (mirroring a discrete choice experiment without duration) for two EQ-5D-Y health states, assuming a series of perspectives: (a) themselves at current age; (b) another adult; (c) 10-year old child; (d) themselves as a 10-year old child. Second, a semi-structured discussion explored their responses.

RESULTS

Participants' views were often heterogeneous, with some common themes. Qualitatively, participants expressed a different willingness to trade-off life years for a 10-year old child versus themselves or another adult, and this differed by the health profile and child imagined. The same health states were often viewed as having a different impact on utility for a 10-year old child than adults. Imagining a 10-year old child is difficult and there is variation in who is imagined. Participants found answering based on their own-adult perspective most acceptable. There were no strong preferences for prioritising child health over working-age adults' health.

CONCLUSIONS

If an adult sample is used to value child- and adolescent-specific health states it is important to consider the perspective employed. Members of the adult public provide different responses when different perspectives are used due to differences in the perceived impact of the same health states. If adults are asked to imagine a child, we recommend that sampling is representative for parental status, since this can affect preferences.

Comparison of Adult and Adolescent Preferences Toward EQ-5D-Y-3L Health States

OBJECTIVES

The international EQ-5D-Y-3L valuation protocol suggests obtaining preferences for EQ-5D-Y-3L health states from a sample of the general adult population. There is discussion around involving children and adolescents in the processes of preference elicitation and decision making. The objective of this study was to compare the preferences for EQ-5D-Y-3L obtained from adolescents for themselves to those of adults considering a hypothetical 10-year-old child in Germany, Slovenia, and Spain.

METHODS

A sample of a minimum of 700 adolescents and 1000 adults in each country was recruited through online panels. An online discrete choice experiment was used to obtain health-state preferences. For the purposes of comparison, all coefficients were rescaled to a 1 (best) to 0 (worst) scale. The differences between preferences in both samples were analyzed via the relative attribute importance of health dimensions from the mixed logit models.

RESULTS

Statistically significant differences between the preferences for EQ-5D-Y-3L states given by the 2 samples were observed in all 3 countries. The overall relative attribute importance was similar between adolescents and adults; adolescents usually gave more importance to mobility and self-care, and less to anxiety/depression. The rank-order of the dimension levels between adults and adolescents differs in all 3 countries.

CONCLUSIONS

Preferences toward EQ-5D-Y-3L states differ if estimated by adults taking the perspective of a child or by the adolescents themselves. Although it seems possible to obtain adolescents' preferences for inclusion in EQ-5D-Y-3L value sets, the desirability and acceptance of their preferences by researchers and decision makers need to be explored further.

Challenges in developing capability measures for children and young people for use in the economic evaluation of health and care interventions

Methods for measuring outcomes suitable for economic evaluations of health and care interventions have primarily focused on adults. The validity of such methods for children and young people is questionable in areas including the outcome domains measured and how they are measured and valued, with most existing measures narrowly focusing on health. Novel methods for assessing benefits beyond health by focusing on a person's capability have also concentrated on adults to date. This paper aims to set out the rationale for capability measures in children and young people. It argues for the need to expand the evaluative space beyond health functioning towards broader capabilities, with children and young people playing an integral role in capability measure development. Drawing from existing literature, specific challenges related to the identification, measurement, and valuation of capabilities in children and young people are also discussed. Finally, the practical implications for conducting economic evaluation when measuring and valuing capabilities at different stages across the life-course are illustrated. We develop an alternative framework based on conceiving capabilities as evolving across the life-course. This framework may also be helpful in thinking about how to model health outcomes across the life-course.

The Challenges of Measuring and Valuing Quality of Life in Preschool Children: A Retrospective Review of NICE Appraisals

Health technology assessment agencies evaluate interventions across the lifespan. However, there is no consensus about best-practice methods to measure health-related quality of life (HRQoL) in preschool children (<5 years) and data are often scarce. We reviewed methods used to capture the HRQoL of preschool children in past National Institute for Health and Care Excellence (NICE) appraisals to establish whether there is a need for better methods in this area and if so, to identify priority research areas. We identified past NICE appraisals that included preschool children, examining the methods used to generate utility values and whether committees believed these captured HRQoL adequately. Of the 12 appraisals, most used generic HRQoL measures designed for adults. Measures were usually completed by adult patients or clinical experts. Committees frequently commented on limitations in the HRQoL data. While acknowledging that data collection may be challenging, committees would value evidence based on HRQoL data from parents or guardians collected as part of a clinical trial. We identified several research priorities including the psychometric properties of existing measures; the feasibility and validity of valuation studies; and mapping. Progress in these areas will help ensure that the aspects of HRQoL which matter to children and their families are captured in NICE evaluations.

Use of health-related quality-of-life measures for Indigenous child and youth populations: a scoping review protocol

INTRODUCTION

Measures of health-related quality-of-life (HRQoL) are increasingly important for evaluating healthcare interventions and treatments, understanding the burden of disease, identifying health inequities, allocating health resources and for use in epidemiological studies. Although many HRQoL measures developed for use in adult populations are robust, they are not necessarily designed, or appropriate, to measure HRQoL for children/youth. Furthermore, the appropriateness of HRQoL measures for use with Indigenous child/youth populations has not been closely examined. The aims of this scoping review are to (1) identify and describe empirical studies using HRQoL measures among children/youth (aged 8-17 years) from Indigenous populations within the Pacific Rim, (2) summarise the study designs and modes of HRQoL measure administration, (3) describe the key dimensions of the identified HRQoL measures used among Indigenous populations, including specifically among Māori and (4) map the HRQoL measure dimensions to commonly used Māori models of health.

METHODS AND ANALYSIS

The scoping review framework developed by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews guidelines will be followed for best practice and reporting. An iterative search of peer-reviewed published empirical research reporting the use of child/youth HRQoL measures among Indigenous populations will be conducted. This literature will be identified across the following five databases: Ovid (Medline), PubMed, Scopus, Web of Science and CINHAL. The search will be restricted to papers published in English between January 1990 and June 2020. Two reviewers will independently review the papers in two stages. A third reviewer will resolve any discrepancies that arise. A data charting form will be completed using data extracted from each paper.

ETHICS AND DISSEMINATION

Ethical approval was not required for this scoping review. Dissemination will include publication of the scoping review in a peer-reviewed journal. This scoping review will inform a larger research project (HRC 20/166).

Development of a preference-based heart disease-specific health state classification system using MacNew heart disease-related quality of life instrument

PURPOSE

The MacNew Heart Disease Health-Related Quality of Life Instrument (MacNew) is a validated, clinically sensitive, 27-item disease-specific questionnaire. This study aimed to develop a new heart disease-specific classification system for the MacNew amenable for use in health state valuation.

METHODS

Patients with heart disease attending outpatient clinics and inpatient wards in Brisbane, Australia, completed MacNew. The development of the new disease-specific classification system included three stages. First, a principal component analysis (PCA) established dimensionality. Second, Rasch analysis was used to select items for each dimension. Third, Rasch analysis was used to explore response-level reduction. In addition, clinician and patient judgement informed item selection.

RESULTS

Participants included 685 patients (acute coronary 6%, stable coronary 41%, chronic heart failure 20%). The PCA identified 4 dimensions (restriction, emotion, perception of others, and symptoms). The restriction dimension was divided into physical and social dimensions. One item was selected from each to be included in the classification system. Three items from the emotional dimension and two symptom items were also selected. The final classification system had seven dimensions with four severity levels in each: physical restriction; excluded from doing things with other people; worn out or low in energy; frustrated, impatient or angry; unsure and lacking in self-confidence; shortness of breath; and chest pain.

CONCLUSION

This study generated a brief heart disease-specific classification system, consisting of seven dimensions with four severity levels in each. The classification system is amenable to valuation to enable the generation of utility value sets to be developed for use in economic evaluation.

Valuation Survey of EQ-5D-Y Based on the International Common Protocol: Development of a Value Set in Japan

BACKGROUND

EQ-5D-Y is a preference-based measure for children and adolescents (aged 8-15 y). This is the first study to develop an EQ-5D-Y value set for converting EQ-5D-Y responses to index values.

METHODS

We recruited 1047 respondents (aged 20-79 y) from the general population, stratified by gender and age group, in 5 Japanese cities. All data were collected through face-to-face surveys. Respondents were asked to value EQ-5D-Y states for a hypothetical 10-y-old child from a proxy perspective using composite time tradeoff (cTTO) and a discrete choice experiment (DCE). The discrete choice data were analyzed using a mixed logit model. Latent DCE values were then converted to a 0 (death)/1 (full health) scale by mapping them to the cTTO values.

RESULTS

The mean observed cTTO value of the worst health state [33333] was 0.20. Analysis of the DCE data showed that the coefficients of the domains related to mental functions ("Having pain or discomfort" and "Feeling worried, sad, or unhappy") were larger than those for the domains related to physical and social functions. By converting latent DCE values to a utility scale, we constructed a value set for EQ-5D-Y. No inconsistencies were observed. The minimum predicted score was 0.288 [33333], and the second-best score was 0.957 [12111].

CONCLUSION

A value set for EQ-5D-Y was successfully constructed. This is the first survey of an EQ-5D-Y value set. Interpreting the differences between EQ-5D-Y and EQ-5D-5L value sets is a future task with implications for health care policy.

Valuing EQ-5D-Y-3L Health States Using a Discrete Choice Experiment: Do Adult and Adolescent Preferences Differ?

Background

An important question in the valuation of children’s health is whether the preferences of younger individuals should be captured within value sets for measures that are aimed at them. This depends on whether younger individuals can complete valuation exercises and whether their preferences differ from those of adults. This study compared the preferences of adults and adolescents for EQ-5D-Y-3L health states using latent scale values elicited from a discrete choice experiment (DCE).

Methods

An online DCE survey, comprising 15 pairwise choices, was provided to samples of UK adults and adolescents (aged 11–17 y). Adults considered the health of a 10-year-old child, whereas adolescents considered their own health. Mixed logit models were estimated, and comparisons were made using relative attribute importance (RAI) scores and a pooled model.

Results

In total, 1000 adults and 1005 adolescents completed the survey. For both samples, level 3 in pain/discomfort was most important, and level 2 in self-care the least important, based on the relative magnitudes of coefficients. The RAI scores (normalized on self-care) indicated that adolescents gave less weight relative to adults to usual activities (1.18 v. 1.51; P < 0.05), pain/discomfort (1.77 v. 3.12; P < 0.01), and anxiety/depression (1.64 vs. 2.65; P < 0.01). The pooled model indicated evidence of differences between the two samples in both levels in pain/discomfort and anxiety/depression.

Limitations

The perspective of the DCE task differed between the 2 samples, and no data were collected to anchor the DCE data to generate value sets.

Conclusions

Adolescents could complete the DCE, and their preferences differed from those of adults taking a child perspective. It is important to consider whether their preferences should be incorporated into value sets.

Discrete choice experiments or best-worst scaling? A qualitative study to determine the suitability of preference elicitation tasks in research with children and young people

BACKGROUND

Ordinal tasks are increasingly used to explore preferences for health states. This study aimed to determine the suitability of two ordinal preference elicitation tasks (discrete choice experiments (DCE) and best-worst scaling (BWS)) for use with children and young people to generate health state utility values. The study explored children's understanding, the relationship between their age and level of understanding, and how many tasks they felt they could complete.

METHODS

Children aged 11-16 years were recruited from a secondary school in South Yorkshire, UK. Participants were asked to 'think aloud' as they completed a computer-based survey that contained both DCE and BWS tasks relating to dental caries (tooth decay) health states. Health states involved descriptions of the impact of tooth decay on children's daily lives. One-to-one semi-structured interviews were then held with participants, with use of a topic guide. Qualitative data were transcribed verbatim and analysed thematically.

RESULTS

A total of 33 children (12 male, 21 female) participated, comprising 5-6 children from each school year group. Children expressed a preference for BWS and demonstrated a better understanding of these tasks than DCE. There was no clear relationship between children's level of understanding and age. Children felt they could manage between 8 and 10 BWS tasks comfortably.

CONCLUSION

This study suggests that BWS tasks are the most appropriate type of preference elicitation task to value health states for children and young people aged 11-16 years to complete.

Economic evaluation of computerised interpretation of fetal heart rate during labour: a cost-consequence analysis alongside the INFANT study

OBJECTIVE

Economic evaluation of computerised decision-support software intended to assist in the interpretation of a cardiotocography (CTG) during birth.

DESIGN

Individual patient level data from the INFANT study (an unmasked randomised controlled trial).

SETTING

Maternity units in the UK and Ireland.

POPULATION

Singleton or twin pregnancy women of 35 weeks' gestation or more and receiving continuous electronic fetal monitoring during labour.

INTERVENTION

Computerised decision-support software.

METHODS

Cost-consequence analysis presenting costs and outcomes with a time horizon of 2 years from a government healthcare perspective. Unit cost data collected from a combination of primary and secondary sources.

MAIN OUTCOME MEASURES

Primary clinical outcomes were (i) composite 'poor neonatal outcome' and (ii) developmental assessment at age 2 years in a subset of surviving children. Mean cost per mother and infant dyad from birth to hospital discharge, and from hospital discharge to 24 months follow-up. Maternal health-related quality of life was assessed at 12 and 24 months follow-up using the EuroQol three-level health-related quality of life instrument (EQ-5D-3L).

RESULTS

Data were analysed for 46 042 women and 46 614 infants. No statistically significant differences were detected between trial arms in any of the primary clinical outcomes or maternal quality of life. No statistically significant differences in costs were detected in maternal or infant costs from trial entry to hospital discharge or overall from hospital discharge to 2-year follow-up.

CONCLUSIONS

Decision-support software during labour is not associated with additional maternal or infant benefits and over a 2-year period the software did not lead to additional costs or savings to the National Health Service.

TRIAL REGISTRATION NUMBER

ISRCTN98680152.

A Review of the Psychometric Performance of Selected Child and Adolescent Preference-Based Measures Used to Produce Utilities for Child and Adolescent Health

OBJECTIVE

This review examined the psychometric performance of 4 generic child- and adolescent-specific preference-based measures that can be used to produce utilities for child and adolescent health.

METHODS

A systematic search was undertaken to identify studies reporting the psychometric performance of the Child Health Utility (CHU9D), EQ-5D-Y (3L or 5L), and Health Utilities Index Mark 2 (HUI2) or Mark 3 (HUI3) in children and/or adolescents. Data were extracted to assess known-group validity, convergent validity, responsiveness, reliability, acceptability, and feasibility. Data were extracted separately for the dimensions and utility index where this was reported.

RESULTS

The review included 76 studies (CHU9D n = 12, EQ-5D-Y-3L n = 20, HUI2 n = 26,HUI3 n = 43), which varied considerably across conditions and sample size. EQ-5D-Y-3L had the largest amount of evidence of good psychometric performance in proportion to the number of studies examining performance. The majority of the evidence related to EQ-5D-Y-3L was based on dimensions. CHU9D was assessed in fewer studies, but the majority of studies found evidence of good psychometric performance. Evidence for HUI2 and HUI3 was more mixed, but the studies were more limited in sample size and statistical power, which was likely to have affected performance.

CONCLUSIONS

The heterogeneity of published studies means that the evidence is based on studies across a range of countries, populations and conditions, using different study designs, different languages, different value sets and different statistical techniques. Evidence for CHU9D in particular is based on a limited number of studies. The findings raise concerns about the comparability of self-report and proxy-report responses to generate utility values for children and adolescents.

The longitudinal validity of proxy-reported CHU9D

Objectives

The Child Health Utility 9D (CHU9D) currently represents the only preference-based health-related quality-of-life instrument designed exclusively from its inception for application with children. The objective of this study was to examine the construct validity and responsiveness of the proxy-reported (parent) CHU9D in a mental health setting using utility weights derived from an adult and adolescent population, respectively.

Methods

The discriminant validity and convergent validity were examined using the mental health-specific ‘The Strengths and Difficulties Questionnaire’ (SDQ) and the generic KIDSCREEN-27. Responsiveness was assessed by examining the floor-ceiling effects, the magnitude of change over time, and the ability to differentiate between improvement and no improvement.

Results

The study included 396 children with mental health problems. CHU9D showed good construct validity, with correlation coefficients ranging between 0.329 and 0.571 for SDQ Impact score and KIDSCREEN-27 Psychological Well-being. CHU9D was able to distinguish between groups of children with different levels of mental health problems (p < 0.001). The absolute magnitudes of the group mean differences were larger using adolescent weights. No evidence of a floor/ceiling effect was found at the baseline. A standardized response mean of 0.634–0.654 was found for the children who experienced clinically significant improvements. CHU9D was able to discriminate between children who experienced positive and no health improvements (p < 0.001).

Conclusion

This study provides the first evidence on responsiveness for CHU9D in a mental health context. The findings demonstrate that CHU9D is an appropriate HRQOL measure for use in mental health trials. Furthermore, the results show that the preference weights generated from an adolescent population resulted in the larger mean differences between groups.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-021-02774-9.

Problematic cost-utility analysis of interventions for behavior problems in children and adolescents

Cost–utility analyses are slowly becoming part of randomized control trials evaluating physical and mental health treatments and (preventive) interventions in child and adolescent development. The British National Institute of Health and Care Excellence, for example, insists on the use of gains in Quality Adjusted Life Years (QALYs) to compute the “value for money” of interventions. But what counts as a gain in quality of life? For one of the most widely used instruments, the EuroQol 5 Dimensions scale (EQ‐5D), QALYs are estimated by healthy individuals who provide utility scores for specific health states, assuming that the best life is a life without self‐experienced problems in five domains: mobility, self‐care, usual activities, pain/discomfort, and anxiety/depression. The worst imaginable outcome is defined as “a lot of problems” in each of these five domains. The impact of the individual's problems on the social network is not weighted, and important social–developmental domains (externalizing problems, social competence) are missing. Current cost–utility computations based on EQ‐5D favor physical health over mental health, and they rely on adult weights for child and adolescent quality of life. Thus, a level playing field is absent, and developmental expertise is sorely missing.

Health State Utility Values in Juvenile Idiopathic Arthritis: What is the Evidence?

OBJECTIVES

The objectives of this systematic review were to identify health state utility values (HSUV) of children and adults with juvenile idiopathic arthritis in the literature and to assess whether HSUV were appropriately reported and could be used to inform parameter inputs for a model-based cost-utility analysis to inform decision making.

METHODS

MEDLINE, EMBASE, PsycINFO, EconLit and CINAHL databases were searched in July 2019. Inclusion criteria were studies using preference-based instruments, targeting children or adults with juvenile idiopathic arthritis, and in the English language. The quality of studies was assessed using a modified checklist that included relevant sources of bias and assessment of quality of HSUV valuation and measurement. A descriptive analysis was conducted, including assessment on reporting of population characteristics and stratification of HSUV by potential health states or population subgroup.

RESULTS

From 620 identified articles, ten reported HSUV. Seven studies reported HSUV of children with juvenile idiopathic arthritis, and three of adults with a history of juvenile idiopathic arthritis. Population disease activity status and drug treatment were reported in less than half of the studies. Six (out of ten) studies stratified HSUV results for at least one of the potential health state categories, but they represent very specific situations or interventions (e.g. patients receiving different types of physiotherapy or treated with etanercept over time).

CONCLUSIONS

We have identified critical gaps in the literature reporting HSUV in patients with juvenile idiopathic arthritis including a lack of HSUV measures for distinct health states, particularly in adults with a history of juvenile idiopathic arthritis. The current reported HSUV data in juvenile idiopathic arthritis are insufficient for a full cost-utility analysis with a short or lifetime horizon.

A Review of the Methods Used to Generate Utility Values in NICE Technology Assessments for Children and Adolescents

OBJECTIVE

This review summarizes and critically examines methods used to generate utilities for child and adolescent health states in previous National Institute for Health and Care Excellence (NICE) technology assessments (TA) and highly specialized technology (HST) evaluations.

METHODS

We identified all NICE TA and HST evaluations in which the licensed indication for the technology included people younger than 18 and included in the review all evaluations using a cost-utility analysis.

RESULTS

The review includes 40 TA and HST evaluations. Most assessments generated utility values with the EQ-5D scored using the adult version of the EQ-5D either exclusively (n = 16) or alongside other utility measures and direct elicitation methods of patient own utility (n = 17), although 7 did not use the EQ-5D. Eight assessments used both the EQ-5D child- and adolescent-specific preference-based measures: Health Utilities Index Mark 2 (n = 6), child- and adolescent-specific preference-based measure for atopic dermatitis (n = 1), and youth version of the EQ-5D (EQ-5D-Y) valued using the adult EQ-5D value set (n = 1) or generated using mapping and valued using the adult EQ-5D value set (n = 2). Some cost-utility analyses used age adjustment (utility subtractions, weights, and published mapping formulae) from the adult EQ-5D UK population norms to reflect the general population or disease-free health for children and adolescents (n = 9), and 1 assessment assumed full health (utility value of 1).

CONCLUSION

The review found limited use of child and adolescent population-specific measures to generate health state utility values for children and adolescents in NICE technology assessments. Often assessments involve the use of an adult-specific measure to reflect the health of children.

International Valuation Protocol for the EQ-5D-Y-3L

The EQ-5D-Y-3L is a generic, health-related, quality-of-life instrument for use in younger populations. Some methodological studies have explored the valuation of children's EQ-5D-Y-3L health states. There are currently no published value sets available for the EQ-5D-Y-3L that are appropriate for use in a cost-utility analysis. The aim of this article was to describe the development of the valuation protocol for the EQ-5D-Y-3L instrument. There were several research questions that needed to be answered to develop a valuation protocol for EQ-5D-Y-3L health states. Most important of these were: (1) Do we need to obtain separate values for the EQ-5D-Y-3L, or can we use the ones from the EQ-5D-3L? (2) Whose values should we elicit: children or adults? (3) Which valuation methods should be used to obtain values for child's health states that are anchored in Full health = 1 and Dead = 0? The EuroQol Research Foundation has pursued a research programme to provide insight into these questions. In this article, we summarized the results of the research programme concluding with the description of the features of the EQ-5D-Y-3L valuation protocol. The tasks included in the protocol for valuing EQ-5D-Y-3L health states are discrete choice experiments for obtaining the relative importance of dimensions/levels and composite time-trade-off for anchoring the discrete choice experiment values on 1 = Full Health and 0 = Dead. This protocol is now available for use by research teams to generate EQ-5D-Y-3L value sets for their countries allowing the implementation of a cost-utility analysis for younger populations.

A Systematic Review of the Use and Quality of Qualitative Methods in Concept Elicitation for Measures with Children and Young People

BACKGROUND

Qualitative research is recommended in concept elicitation for patient-reported outcome measures to ensure item content validity, and those developing measures are encouraged to report qualitative methods in detail. However, in measure development for children and young people, direct research can be challenging due to problems with engagement and communication.

OBJECTIVES

The aim of this systematic review was to (i) explore the qualitative and adapted data collection techniques that research teams have used with children and young people to generate items in existing measures and (ii) assess the quality of qualitative reporting.

METHODS

Three electronic databases were searched with forward citation and reference list searching of key papers. Papers included in the review were empirical studies documenting qualitative concept elicitation with children and young people. Data on qualitative methods were extracted, and all studies were checked against a qualitative reporting checklist.

RESULTS

A total of 37 studies were included. The quality of reporting of qualitative approaches for item generation was low, with information missing on sampling, data analysis and the research team, all of which are key to facilitating judgements around measure content validity. Few papers reported adapting methods to be more suitable for children and young people, potentially missing opportunities to more meaningfully engage children in concept elicitation work.

CONCLUSIONS

Research teams should ensure that they are documenting detailed and transparent processes for concept elicitation. Guidelines are currently lacking in the development and reporting of item generation for children, with this being an important area for future research.

Feasibility, Validity and Differences in Adolescent and Adult EQ-5D-Y Health State Valuation in Australia and Spain: An Application of Best-Worst Scaling

BACKGROUND

The measurement and valuation of health-related quality of life for and by young people are increasingly important, yet research on the impact of study perspective and validity of preferences obtained from young populations remains limited.

OBJECTIVE

The objective of this study was to evaluate the feasibility and validity of collecting EQ-5D Youth version (EQ-5D-Y) preferences from adolescents, adults, and adults from a child perspective.

METHODS

A profile case best-worst scaling (BWS) online survey was administered to representative Australian and Spanish adult (age ≥ 18 years) and child (age 11-17 years) samples. Adults were told to either answer from their own perspective or for a hypothetical 10-year-old child. Marginal best- and worst-choice frequencies, analysis of dominant choices, self-reported difficulty completing the tasks, and time to complete tasks were used to determine the validity of responses.

RESULTS

In Australia, 2134 adults and 1010 adolescents completed the survey. In Spain, 2007 adults and 1000 adolescents completed it. Analysis of marginal choice frequencies and dominant choices indicated that the pattern of responses between adolescents and adults was similar. For Australian respondents, having no mobility problems was rated as best by adolescents, while adults rated having no pain and discomfort as 'best'. In Spain, both adults and adolescents rated no pain or discomfort as 'best'. Australian adolescents rated very worried, sad or unhappy as 'worst', while Spanish adolescents, Spanish adults and Australian adults rated a lot of pain and discomfort as 'worst'.

CONCLUSIONS

Results suggest preferences from adolescents using direct BWS are valid. Our descriptive analysis also suggest that there are age-related and country-specific differences in elicitation values for the EQ-5D-Y.