A Review of the Development and Application of Generic Multi-Attribute Utility Instruments for Paediatric Populations

Preference-based measures to obtain health state utility values for use in economic evaluations with child-based populations: a review and UK-based focus group assessment of patient and parent choices

Background

No current guidance is available in the UK on the choice of preference-based measure (PBM) that should be used in obtaining health-related quality of life from children. The aim of this study is to review the current usage of PBMs for obtaining health state utility values in child and adolescent populations, and to obtain information on patient and parent–proxy respondent preferences in completing PBMs in the UK.

Methods

A literature review was conducted to determine which instrument is most frequently used for child-based economic evaluations and whether child or proxy responses are used. Instruments were compared on dimensions, severity levels, elicitation and valuation methods, availability of value sets and validation studies, and the range of utility values generated. Additionally, a series of focus groups of parents and young people (11–20 years) were convened to determine patient and proxy preferences.

Results

Five PBMs suitable for child populations were identified, although only the Health Utilities Index 2 (HUI2) and Child Heath Utility 9D (CHU-9D) have UK value sets. 45 papers used PBMs in this population, but many used non-child-specific PBMs. Most respondents were parent proxies, even in adolescent populations. Reported missing data ranged from 0.5 to 49.3%. The focus groups reported their experiences with the EQ-5D-Y and CHU-9D. Both the young persons’ group and parent/proxy groups felt that the CHU-9D was more comprehensive but may be harder for a proxy to complete. Some younger children had difficulty understanding the CHU-9D questions, but the young persons’ group nonetheless preferred responding directly.

Conclusion

The use of PBMs in child populations is increasing, but many studies use PBMs that do not have appropriate value sets. Parent proxies are the most common respondents, but the focus group responses suggest it would be preferred, and may be more informative, for older children to self-report or for child–parent dyads to respond.

Electronic supplementary material

The online version of this article (10.1007/s11136-018-1831-6) contains supplementary material, which is available to authorized users.

Economic Evaluation of Interventions for Children with Neurodevelopmental Disorders: Opportunities and Challenges

Economic evaluation is a tool used to inform decision makers on the efficiency of comparative healthcare interventions and inform resource allocation decisions. There is a growing need for the use of economic evaluations to assess the value of interventions for children with neurodevelopmental disorders (NDDs), a population that has increasing demands for healthcare services. Unfortunately, few evaluations have been conducted to date, perhaps stemming from challenges in applying existing economic evaluation methodologies in this heterogeneous population. Opportunities exist to innovate methods to address key challenges in conducting economic evaluations of interventions for children with NDDs. In this paper, we discuss important considerations and highlight areas for future work. This includes the paucity of appropriate instruments for measuring outcomes meaningful to children with NDDs and their families, difficulties in the measurement of costs due to service utilization in a wide variety of sectors, complexities in the measurement of caregiver and family effects and considerations in estimating long-term productivity costs. Innovation and application of evaluation approaches in these areas will help inform decisions around whether the resources currently spent on interventions for children with NDDs represent good value for money, or whether greater benefits for children could be generated by spending money in other ways.

A Systematic Review and Meta-analysis of Childhood Health Utilities

BACKGROUND

A common feature of most reviews or catalogues of health utilities has been their focus on adult health states or derivation of values from adult populations. More generally, utility measurement in or on behalf of children has been constrained by several methodological concerns. The objective of this study was to conduct the first comprehensive systematic review and meta-analysis of primary utility data for childhood conditions and descriptors, and to determine the effects of methodological factors on childhood utilities.

METHODS

The review followed PRISMA guidelines. PubMed, Embase, Web of Science, PsycINFO, EconLit, CINAHL and Cochrane Library were searched for primary studies reporting health utilities for childhood conditions or descriptors using direct or indirect valuation methods. The Paediatric Economic Database Evaluation (PEDE) Porject was also searched for cost-utility analyses with primary utility values. Mean or median utilities for each of the main samples were catalogued, and weighted averages of utilities for each health condition were estimated, by valuation method. Mixed-effects meta-regression using hierarchical linear modeling was conducted for the most common valuation methods to estimate the utility decrement for each health condition category relative to general childhood population health, as well as the independent effects of methodological factors.

RESULTS

The literature searches resulted in 272 eligible studies. These yielded 3,414 utilities when all sub-groups were considered, covering all ICD-10 chapters relevant to childhood health, 19 valuation methods, 12 respondent types, 8 modes of administration, and data from 36 countries. A total of 1,191 utility values were obtained when only main study samples were considered, and these were catalogued by health condition or descriptor, and methodological characteristics. 1,073 mean utilities for main samples were used for fixed-effects meta-analysis by health condition and valuation method. Mixed-effects meta-regressions estimated that 53 of 76 ICD-10 delineated health conditions, valued using the HUI3, were associated with statistically significant utility decrements relative to general population health, whereas 38 of 57 valued using a visual analog scale (VAS) were associated with statistically significant VAS decrements. For both methods, parental proxy assessment was associated with overestimation of values, whereas adolescents reported lower values than children under 12 y. VAS responses were more heavily influenced by mode of administration than the HUI3.

CONCLUSION

Utilities and their associated distributions, as well as the independent contributions of methodological factors, revealed by this systematic review and meta-analysis can inform future economic evaluations within the childhood context.

Valuing health for oneself versus one's child or elderly parent

The aim of this study was to determine if adults value health states or are willing to accept risk differently for themselves than for their children or elderly parents. Participants (701) were asked to rate four hypothetical health states for themselves using both the standard gamble and time trade-off methodologies. They then did the same assessments for a real or hypothetical child as well as an elderly parent. Participants were willing to take more risk or trade more years of life to avoid bilateral vision loss and mental impairment for themselves than they were for their children and elderly parents.

A cross sectional survey on health-related quality of life of elementary school students using the Korean version of the EQ-5D-Y

Background and Objective

The Korean version of the EQ-5D-Y was launched in 2015 by the EuroQol group. Currently, there is no HRQOL data obtained by using the EQ-5D-Y in Korea. This study aimed to measure health-related quality of life of Korean elementary school students using the EQ-5D-Y.

Methods

Elementary school students were recruited from 11 primary schools in Gyungbuk, South Korea. The EQ-5D-Y was self-administered in the sample population. Demographic characteristics were collected from the subjects’ parents or guardians. The percentage of respondents reporting problems and VAS scores were calculated. Feasibility of the EQ-5D-Y was assessed by analysing the proportion of missing responses. The percentage of reported problems on the dimensions and VAS score between groups were compared by demographic factors.

Results

A total of 2,494 questionnaires were collected. There were 24 (0.96%) missing responses on the EQ-5D-Y and 187 (7.5%) missing VAS score responses. The proportion of reported problems ranged from 2.3% on the mobility dimension to 9.8% on the “having pain or discomfort” dimension. There was no significant difference in the proportion of problems by age group in male participants. However, in females, the older group reported significantly more problems on the “having pain or discomfort” and “feeling worried, sad, or unhappy” dimensions compared to the younger group. Students living with parents with the lowest educational level reported significantly more problems on the “looking after myself” and “doing usual activities” dimensions than did those living with parents with higher levels of education.

Discussion

This study showed the distribution of health-related quality of life and explored the feasibility of the EQ-5D-Y for measuring health-related quality of life in Korean elementary school students. Further studies are required to examine other psychometric properties of the Korean EQ-5D-Y.

The prevalence of child-specific utilities in NICE appraisals for paediatric indications: rise of the economic orphans?

Children are not mini-adults, and thus require studies to be conducted in the population of interest to inform decisions about their care. The paucity of such studies for clinical efficacy lead them to be termed 'therapeutic orphans'. Following the introduction of the 'fourth hurdle' of reimbursement approval on the basis of cost-utility analysis, utility data is now a key requirement for patients to access treatments in England and many other countries. This special report considers whether a paucity of utility valuation studies in children may have made them 'economic orphans' as well and presents results of a review of NICE appraisals as a window on this problem over time.

Valuing the Child Health Utility 9D: Using profile case best worst scaling methods to develop a new adolescent specific scoring algorithm

In contrast to the recent proliferation of studies incorporating ordinal methods to generate health state values from adults, to date relatively few studies have utilised ordinal methods to generate health state values from adolescents. This paper reports upon a study to apply profile case best worst scaling methods to derive a new adolescent specific scoring algorithm for the Child Health Utility 9D (CHU9D), a generic preference based instrument that has been specifically designed for the estimation of quality adjusted life years for the economic evaluation of health care treatment and preventive programs targeted at young people. A survey was developed for administration in an on-line format in which consenting community based Australian adolescents aged 11-17 years (N = 1982) indicated the best and worst features of a series of 10 health states derived from the CHU9D descriptive system. The data were analyzed using latent class conditional logit models to estimate values (part worth utilities) for each level of the nine attributes relating to the CHU9D. A marginal utility matrix was then estimated to generate an adolescent-specific scoring algorithm on the full health = 1 and dead = 0 scale required for the calculation of QALYs. It was evident that different decision processes were being used in the best and worst choices. Whilst respondents appeared readily able to choose 'best' attribute levels for the CHU9D health states, a large amount of random variability and indeed different decision rules were evident for the choice of 'worst' attribute levels, to the extent that the best and worst data should not be pooled from the statistical perspective. The optimal adolescent-specific scoring algorithm was therefore derived using data obtained from the best choices only. The study provides important insights into the use of profile case best worst scaling methods to generate health state values with adolescent populations.