Assessment of the psychometric properties of the EQ-5D-3L and EQ-5D-5L instruments in psoriasis

Patient-Reported Outcome Measures for Health-Related Quality of Life in Patients With Psoriasis: A Systematic Review

Importance

Multiple patient-reported outcome measures (PROMs) for health-related quality of life (HRQL) exist for patients with psoriasis. Evidence for the content validity and other measurement properties of these PROMs is critical to determine which HRQL PROMs could be recommended for use.

Objective

To systematically review the validity of HRQL-focused PROMs used in patients with psoriasis.

Evidence Review

Using PubMed and Embase, full-text articles published in English or Spanish on development or validation studies for psoriasis-specific, dermatology-specific, or generic HRQL PROMs were included. Development studies included original development studies, even if not studied in psoriasis patients per Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) recommendations. If a study included multiple diagnoses, more than 50% of patients had to have psoriasis or psoriasis-specific subgroup analyses available. Data extraction and analysis followed the COSMIN guidelines. Two independent reviewers extracted and analyzed the data, including PROM characteristics, quality of measurement properties (structural validity, internal consistency, cross-cultural validity, reliability, measurement error, criterion validity, construct validity, and responsiveness), and level of evidence. PROMs were classified into 3 levels of recommendations: (1) PROM recommended for use; (2) PROM requires further validation; and (3) PROM not recommended for use.

Findings

Overall, 97 articles were identified for extraction. This included 19 psoriasis-specific, 8 skin-specific, and 6 generic PROMs. According to COSMIN standards, most measures identified received a B recommendation for use, indicating their potential but requiring further validation. Only the Rasch reduced version of the Impact of Psoriasis Questionnaire (IPSO-11 Rasch) received an A recommendation for use given that it had sufficient content validity, structural validity, and internal consistency.

Conclusions and Relevance

This study identified a significant lack of information concerning the quality of HRQL measures in psoriasis. This gap in knowledge can be attributed to the fact that traditional measures were developed using validation criteria that differ from the current standards in use. Consequently, additional validation studies in accordance with contemporary standards will be useful in aiding researchers and clinicians in determining the most suitable measure for assessing HRQL in patients with psoriasis.

Content validity of the EQ-5D-5L with skin irritation and self-confidence bolt-ons in patients with atopic dermatitis: a qualitative think-aloud study

OBJECTIVES

Two bolt-on dimensions (skin irritation, self-confidence) have been developed for the EQ-5D-5L to improve its content validity and responsiveness in psoriasis. However, the two bolt-ons are not strictly psoriasis-specific and are potentially relevant in other skin conditions. This study aims to explore the content validity of the EQ-5D-5L with two bolt-ons in patients with atopic dermatitis (AD).

METHODS

In 2021-2022, qualitative, semi-structured interviews were conducted with 20 adult AD patients at a university dermatology clinic in Hungary. We aimed for a heterogeneous sample in terms of age, gender, education and disease severity. Patients completed the EQ-5D-5L with two bolt-ons using a think-aloud protocol. Probing questions were posed to investigate item relevance, potential conceptual overlaps, missing concepts and the appropriateness of the recall period. Interview transcripts were subjected to thematic analysis.

RESULTS

The EQ-5D-5L with the two bolt-ons covered the most important aspects of health-related quality of life in AD patients. Most patients found both the skin irritation and self-confidence bolt-ons relevant. Fifteen potential missing concepts were identified, but only two (social relationships, judgement by others) were identified by more than one patient. A smaller conceptual overlap was found between the skin irritation and pain/discomfort dimensions in 7 patients (35%). Half the patients expressed a preference for a recall period of 1 week rather than of 'today'.

CONCLUSIONS

The EQ-5D-5L with skin irritation and self-confidence bolt-ons showed good relevance, comprehensiveness and comprehensibility in patients with AD. However, in terms of comprehensiveness, social relationships and judgement by others (stigma) may be missing from the questionnaire.

Health-related quality of life and its determinants in patients with different dermatological disorders at the University of Gondar Comprehensive Specialized Hospital

OBJECTIVES

Evidence shows that majority of dermatological disorders affect the health-related quality of life (HRQoL) of patients. However, the extent of its negative impact and predictors has not been studied in Ethiopia. Thus, this study looked at assessing the HRQoL and determinants in patients with dermatological disorders (DDs) attending the University of Gondar Comprehensive Specialized Hospital (UoGCSH).

RESULTS

Patients with dermatological disorders (n = 400) were included in the final analysis using a systematic random sampling technique. The mean age of the participants was 39.79 (± 17.17) years. The average (± SD) score of EQ-5D-5 L was 1.92 (± 0.74). Regarding domains, pain/discomfort accounted for a higher proportion 59 (22.3%) followed by anxiety/depression 61 (15.3%). Receiving topical preparations (β = -0.399, 95% CI: -0.6, - 0.19; < 0.001), systemic only medication (β = -0.378, 95% CI: -0.607, -0.149; p = 0.002), having slight, mild, and moderate skin diseases found to have an inverse association with impaired HRQoL, (β = -0.654, 95% CI; -1.01, -0.290); p < 0.001), (β = -0.748, 95% CI: -0.960, -0.538; p < 0.001), and (β = -0.465, 95% CI: -0.642, -0.283; p < 0.001), respectively. Furthermore, age (β = 0.011, 95% CI: 0.006, 0.016; p = 0.001), long duration with skin disease (β = 0.046, 95% CI: 0.015, 0.352; p = 0.013), and presence of comorbidity (β = 0.251, 95% CI: 0.096, 0.402; p = 0.002) were significant predictors of HRQoL among dermatological disease patients.

CONCLUSION

Patients with dermatological disease were found to have a compromised HRQoL. Pain /discomfort problems accounted for a higher proportion compared with other domains. Socio-demographic, clinical and medication-related variables were significantly associated with HRQoL.

Psychometric properties of EQ-5D-5L for use in patients with Graves' disease

BACKGROUND

The EQ-5D-5 L is a commonly used generic measure of health. This study aimed to evaluate the psychometric properties of the EQ-5D-5 L in patients with Graves' disease (GD).

METHODS

A prospective cohort of patients with GD recruited at three public hospitals in Hong Kong completed the EQ-5D-5 L and ThyPRO-39 questionnaires at baseline, 1-month, and 6-month follow-ups. Convergent validity was tested by examining the Spearman correlation between EQ-5D-5 L and ThyPRO-39 scores at baseline. 1-month test-retest reliability was assessed by Intraclass Correlation Coefficient (ICC), Gwet's Agreement Coefficient 2 (AC2), and percentage agreement. Responsiveness of EQ-5D-5 L index and EQ-VAS scores was assessed using effect size statistics (standardized effect size [SES] and standardized response mean [SRM]).

RESULTS

Of 125 recruited patients, 101 (80.8%) and 100 (80.0%) patients were followed up at 1- and 6-month, respectively. For convergent validity, there was a moderate negative correlation between EQ-5D-5 L index or EQ-VAS score and ThyPRO-39 overall QoL-impact score (-0.350, -0.451), between EQ-VAS score and composite score (-0.483), and strong negative correlation between EQ-5D-5 L index score and composite score (-0.567). The Gwet's AC2 and percentage agreement were the highest in self-care (0.964 and 0.967), followed by mobility (0.952 and 0.962), usual activities (0.934 and 0.948), pain/discomfort (0.801 and 0.887), and anxiety/depression (0.788 and 0.882). The ICC for the EQ-5D-5 L index and the EQ-VAS was 0.707 and 0.700. For patients who reported having 'worsened' health at 6-month follow-up, the SES and SRM were - 0.66 and - 0.42 for EQ-5D-5 L index and - 1.15 and - 1.00 for EQ-VAS, respectively.

CONCLUSIONS

The EQ-5D-5 L demonstrated convergent validity, test-retest reliability, and responsiveness to worsened health status among patients with GD.

The health gap and HRQoL inequalities in Greece before and during the economic crisis

Objective

The aim of this study was twofold: (i) to assess the health gap among young socio-economic groups generated by the economic crisis in Greece and (ii) to investigate HRQoL (Health Related Quality of Life) inequalities using the Theil index.

Methods

The EQ-5D-5L instrument was administered to a sample of 4,177 young individuals in Greece, mean age 22.3 (±SD 4.8) and 53.8% males, and 46.2% females. The Greek version of the EQ-5D-5L instrument was used in a web-based questionnaire to collect data. Subjects were asked to assess their subjective health status during the economic crisis of 2016 using the EQ-5D-5L instrument, and to recall their health before the crisis of 2009. The health gap was assessed on a Visual Analogue Scale (EQ-VAS), the EQ-5D-5L Index, and the five dimensions of the EQ-5D-5L instrument. Regression analysis was employed to measure the effects of the economic crisis on age, sex, education, and income on the EQ-VAS and EQ-5D-5L. Theil index was used to assess HRQoL inequalities.

Results

The economic crisis brought a significant deterioration in the HRQoL of young Greeks. The EQ-VAS was reduced during the crisis by -10.05% (p < 0.001) and the EQ-5D-5L index declined by -19.61% (p < 0.001). The prevalence of the health gap in each dimension of the EQ-5D-5L was also significant in terms of deterioration of Mobility [change by 66.8% (p < 0.001)], Self-care [change by 61.0% (p < 0.001)], Usual activities [change by 97.1% (p < 0.001)], Pain/discomfort [change by 65.0% (p < 0.001)], and Anxiety/depression [change by 70.5% (p < 0.001)]. Significant reductions in EQ-5D-5L indices were also associated with greater inequalities in the distribution of health among age, gender, income, and educational groups. The EQ-5D-5L health gap among the poor was much greater (0.198), in comparison to richer (0.128) classes. Similar gaps were also found in terms of educational inequalities. The EQ-5D-5L health gap among those with primary education was 0.211, whereas for those with tertiary education it was 0.16. The Theil index indicated an increase in income-related HRQoL inequalities by 222.3% for the EQ-5D-5L index and by 124.2% for the EQ-VAS. The effects of demographic and socioeconomic variables on the EQ-VAS were found statistically significant: sex (p < 0.05), age (p < 0.001), education (p < 0.001), and income (p < 0.001).

Conclusion

The EQ-5D-5L instrument appears to be a powerful tool in assessing the health gap and the HRQoL inequalities among young people in Greece. The findings indicate the importance of developing effective health policies to combat inequalities and mitigate the impact of austerity measures on the quality of life of the young.

Examining the relationship between the Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS) and EQ-5D-5L and comparing their psychometric properties

BACKGROUND

The purpose of this study is to examine the relationship between the Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS) and EQ-5D-5L and compare their psychometric properties in 4 chronic conditions in China.

METHODS

Participants were invited to complete the online survey. Spearman's rank correlation was used to evaluate the correlation between SWEMWBS and EQ-5D-5L; exploratory factor analysis was used to ascertain the number of unique underlying latent factors measured by SWEMWBS and EQ-5D-5L. Next, we assessed the psychometric properties of SWEMWBS and EQ-5D-5L by reporting distributions and examining their known-group validity and convergent validity.

RESULTS

In total, 500 individuals participated the online survey. Spearman's rank correlation showed that EQ-5D-5L dimensions, except for the anxiety/depression dimension, were weakly correlated with all dimensions of SWEMWBS. The two-factor solution for exploratory factor analysis found that all of SWEMWBS dimensions loaded onto one factor, four EQ-5D-5L dimensions (mobility, self-care, usual activities and pain/discomfort) onto another, and the EQ-5D-5L item of anxiety/depression item loaded moderately onto both factors. Patients of four disease groups had different distributions of responses for both SWEMWBS and EQ-5D-5L. In terms of known-group validity, both the F statistic and AUROC value of EQ-5D-5L utility scores were significantly higher than SWEMWBS scores in all four pair-wised comparisons. The Pearson correlation coefficient between EQ-5D-5L utility scores, SWEMWBS scores and EQ-VAS was 0.44 (P < 0.01) and 0.65 (P < 0.01), respectively.

CONCLUSIONS

SWEMWBS and EQ-5D-5L measure different constructs and can be seen as complementary measures. Both measures demonstrated good convergent validity and known-group validity with EQ-5D-5L being a more sensitive measure, even for mental conditions.

Measurement properties of the EQ-5D-5L in sub-health: evidence based on primary health care workers in China

BACKGROUND

Sub-health which is the state between health and disease is a major global public health challenge. As a reversible stage, sub-health can work as a effective tool for the early detection or prevention of chronic disease. The EQ-5D-5L (5L) is a widely used, generic preference-based instrument while its validity in measuring sub-health is not clear. The aim of the study was thus to assess its measurement properties in individuals with sub-health in China.

METHODS

The data used were from a nationwide cross-sectional survey conducted among primary health care workers who were selected on the basis of convenience and voluntariness. The questionnaire was composited of 5L, Sub-Health Measurement Scale V1.0 (SHMS V1.0), social-demographic characteristics and a question assessing the presence of disease. Missing values and ceiling effects of 5L were calculated. The convergent validity of 5L utility and VAS scores was tested by assessing their correlations with SHMS V1.0 using Spearman's correlation coefficient. The known-groups validity of 5L utility and VAS scores was assessed by comparing their values between subgroups defined by SHMS V1.0 scores using the Kruskal-Wallis test. We also did an analysis in subgroups according to different regions of China.

RESULTS

A total of 2063 respondents were included in the analysis. No missing data were observed for the 5L dimensions and only one missing value was for the VAS score. 5L showed strong overall ceiling effects (71.1%). The ceiling effects were slightly weaker on the "pain/discomfort" (82.3%) and "anxiety/depression" (79.5%) dimensions compared with the other three dimensions (nearly 100%). The 5L weakly correlated with SHMS V1.0: the correlation coefficients were mainly between 0.2 and 0.3 for the two scores. 5L was yet not sensitive in distinguishing subgroups of respondents with different levels of sub-health, especially the subgroups with adjacent health status (p > 0.05). The results of subgroup analysis were generally consistent with those of the full sample.

CONCLUSIONS

It appears that the measurement properties of EQ-5D-5L in individuals with sub-health are not satisfactory in China. We thus should be cautious to use it in the population.

Comparing EQ-5D-3L and EQ-5D-5L in measuring the HRQoL burden of 4 health conditions in China

BACKGROUND

EQ-5D-3L has been used in the National Health Services Survey of China since 2008 to monitor population health. The five-level version of EQ-5D was developed, but there lacks evidence to support the use of five-level version of EQ-5D in China. This study was conducted to compare the measurement properties of both the EQ-5D-3L and EQ-5D-5L in quantifying health-related quality of life (HRQoL) burden for 4 different health conditions in China.

METHODS

Participants from China were recruited to complete the 3L and 5L questionnaire via Internet. Quota was set to recruit five groups of individuals, with one group of individuals without any health condition and one group of generalized anxiety disorder (GAD), HIV/AIDS, chronic Hepatitis B (CHB), or depression, respectively. The 3L and 5L were compared in terms of response distributions, percentages of reporting 'no problems', index value distributions, known-group validity and their relative efficiency.

RESULTS

In total, 500 individuals completed the online survey, including 140 healthy individuals, 122 individuals with hepatitis B, 107 with depression, 90 individuals with GAD and 101 with HIV/AIDS. 5L also had smoother and less clustered index value distributions. Healthy group showed different response distributions to the four condition groups. The percentage of reporting 'no problems' decreased significantly in the 5L in all domains (P < 0.01), especially in the pain/discomfort dimension (relative difference: 43.10%). Relative efficiency suggested that 5L had a higher absolute discriminatory power than the 3L version between healthy participant and the other 4 condition groups, especially for the HIV/AIDS group when the 3L results was not significant.

CONCLUSIONS

The 5L version may be preferable to the 3L, as it demonstrated superior performance with respect to higher sensitivity to mild health problems, better relative efficiency and responses and index value distributions.

Effects of online care on functional and psychological outcomes in patients with psoriasis: A randomized controlled trial

BACKGROUND

The impact of online care on patients' functional and psychological outcomes is critical to determine yet still unknown.

OBJECTIVE

To evaluate how a novel online health model that facilitates physician-patient collaboration compares with in-person care for improving functional status and mental health of patients with psoriasis.

METHODS

This 12-month randomized controlled equivalency trial randomly assigned patients with psoriasis 1:1 to receive online or in-person care. Functional impairment and depression were assessed at baseline and at 3-month intervals using the 5-level EuroQol-5 Dimensions index and Patient Health Questionnare-9.

RESULTS

Overall, 296 patients were randomly assigned to the online or in-person groups. The between-group difference in overall improvement in the EuroQol Visual Analogue Scale was -0.002 (95% confidence interval, -2.749 to 2.745), falling within an equivalence margin of ±8. The between-group difference in overall improvement in the 5-level EuroQol-5 Dimensions index was 0 (95% confidence interval, -0.003 to 0.003), falling within an equivalence margin of ±0.1. The between-group difference in overall improvement in Patient Health Questionnare-9 score was -0.33 (95% CI, -1.20 to 0.55), falling within an equivalence margin of ±3.

LIMITATIONS

Slightly different attrition rates between online and in-person arms (11% vs 9%), but no impact on outcomes.

CONCLUSION

The online health model was equivalent to in-person care for reducing functional impairment and depressive symptoms in patients with psoriasis.

Psychometric properties of the EQ-5D-5L compared with EQ-5D-3L in cancer patients in Iran

Background and Objective

Psychometric evidence to support the validity and reliability of the EuroQol-5 Dimensions (EQ-5D) in cancer patients is limited. This study aimed to test the validity and reliability of the EQ-5D-5L (5L) in comparison with EQ-5D-3L (3L) in cancer patients.

Methods

Data of 650 cancer patients were collected through consecutive sampling method from three largest governmental cancer centers in Iran between June 2021 and January 2022. The data were gathered using the 3L, 5L, and the European Organization for Research and Treatment of Cancer quality of life questionnaire (QLQ-C30) instruments. The 3L and 5L were compared in terms of ceiling effect, discriminatory power, convergent and known-groups validity, relative efficiency, inconsistency, agreement, and reliability.

Results

Compared with the 3L, ceiling effect decreased by 27.86%. Absolute and relative informativity of discriminatory power improved by 45.93% and 22.92% in the 5L, respectively. All convergent validity coefficients with 5L were stronger than with 3L. Both 3L and 5L demonstrated good known-groups validity, and the relative efficiency was higher for 5L in 4 out of 7 patients' characteristics. The two instruments showed low overall inconsistency (1.45%) and 92.57% of the differences of observations between the 3L and 5L were within the 95% limit of agreement. The interclass correlation coefficient (ICC) for 3L and 5L indexes were 0.88 and 0.85, respectively, and kappa coefficients in the 3L dimensions (range=0.66-0.92) were higher than the 5L(range=0.64-0.79).

Conclusions

The 5L demonstrated to be better than the 3L in terms of ceiling effect, inconsistency, discriminatory power, convergent validity, relative efficiency.

Comparing the psychometric properties of EQ-5D-3L and EQ-5D-5L proxy ratings by informal caregivers and a health professional for people with dementia

Background

Assessing health-related quality of life (HRQoL) among persons with dementia poses several challenges due to cognitive decline and limited perception. As a result, proxy ratings by family members or health professionals are used. The EQ-5D is the most commonly used generic and preference-based HRQoL instrument. Methodological drawbacks of the three-level version (EQ-5D-3L) prompted the development of the five-level version (EQ-5D-5L) by expanding the range in the domains. However, no comparison of the psychometric properties of both versions and different proxy ratings exist so far. Therefore, the objective of this study was to compare the psychometric properties of the EQ-5D-5L and EQ-5D-3L by application of different proxy ratings in dementia.

Methods

The EQ-5D-3L and -5L were completed by n = 52 family caregivers and one care manager at baseline and three and six months later. In total, 106 caregiver and 133 care manager proxy ratings were completed. The EQ-5D-3L and 5L were evaluated in terms of acceptability (missing values), agreement, ceiling effects, redistribution properties and inconsistency, and informativity (Shannon, H', and Shannon Evenness, J', indices) as well as convergent and discriminative validity.

Results

Mean proxy index scores were higher for the 5L than the 3L. Missing values occurred less frequently in both proxy ratings and versions (< 1%). Agreement between both measures was high but higher in caregiver than care-manager ratings (ICC 0.885 vs. 0.840). The relative ceiling effect decreased from the 3L to the 5L, more intensively in the care-manager (75%) than the caregiver rating (56%). Inconsistency between both versions was low. Informativity increased from the 3L to the 5L version, nearly equally in both proxy ratings. The 5L also demonstrated a better discriminative ability and convergent validity than the 3L, especially in the caregiver rating.

Conclusion

Compared to the EQ-5D-3L, the EQ-5D-5L had higher feasibility and acceptability and was slightly superior by a reduction of ceiling effects and an improvement in informativity, discriminative ability and convergent validity. Proxy ratings by informal caregivers overall demonstrated better psychometric properties than professional care-manager ratings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-02049-y.

Feasibility properties of the EQ-5D-3L and 5L in the general population: evidence from the GP Patient Survey on the impact of age

BACKGROUND

There is evidence to suggest that the proportion of missing values is slightly higher in the older population resulting in lower completion rates of the EQ-5D. However, existing studies rarely provide a within-sample comparison of feasibility properties across age groups to quantify this difference. Hence, this study examines feasibility properties of the EQ-5D-3L and 5L in the general population and explores the impact of age on the completion of EQ-5D instruments.

METHODS

We pool five waves from the English GP Patient Survey, where respondents self-report their health in either EQ-5D-3L or 5L. Descriptive analysis was undertaken to analyse the distribution and proportion of missing values and completion rates stratified by age and EQ-5D version; logistic regression models were specified to quantify the impact of age, gender and potential long-term conditions on the completion of each of the EQ-5D instruments.

RESULTS

The total sample comprises ~ 4.36 million observations, of which 2.88 million respondents report their health in 5L and 1.47 million in 3L, respectively. Respondents over 64 years have slightly more missing values in each dimension than younger respondents. The highest share was observed for the oldest age group in the dimension anxiety/depression (3L 9.1% vs. 5L 7.6%), but was otherwise below 5%. Consequently, completion rates (observed and predicted) decreased with older age and at a higher rate after the age of 64; this was more pronounced for the 3L.

CONCLUSION

Evidence from our study suggests that both the EQ-5D-3L and 5L have good feasibility properties. In comparison to younger populations there appears to be a higher proportion of respondents with incomplete responses beyond the age of 64 years. Overall, the 5L version compares more favourably in terms of missing values, completion rates as well as with regard to the expected probability of an incomplete descriptive system.

Psychometric properties of the EQ-5D-3L in South Australia: a multi-method non-preference-based validation study

OBJECTIVE

Although HRQoL tools such as the EQ-5D-3L are significant in determining health status, these measures have not been validated in general populations in Australia. This study aims to psychometrically validate the EQ-5D-3L in a large population sample in Australia for the first time.

METHODS

The EQ-5D-3L was included in the Dental Care and Oral Health study (DCOHS), conducted in a South Australian population sample. The participants were 23-91 years old, and 44.1% were male. The EQ-5D-3L was responded to on a three-point rating scale ("none"/"no", "some" and "extremely"/"unable"/"confined"). We employed the area under the receiver operating characteristic curve (AUROC) to evaluate whether the EQ-5D-3L total score could identify participants with diagnosed diseases and mental health disorders. Psychometric validation of the EQ-5D-3L investigated dimensionality with Exploratory Graph Analysis, model fit, floor/ceiling effects and criterion validity.

RESULTS

The EQ-5D-3L comprised two dimensions, Activities and Symptoms. According to Root Mean Squared Error of Approximation (RMSEA) (<.05) and Comparative Fit Index (CFI) (>.950), the 2-dimensional structure showed excellent model fit with good reliability for the Activities subscale (Ωc = 0.80-95% CI [0.77, 0.83]), and poor reliability for the Symptom subscale (Ωc = 0.56-95% CI [0.53, 0.58]). The EQ-5D-3L showed adequate reliability (Ωc = 0.70-95% CI [0.67, 0.72]). The EQ-5D-3L showed good discrimination for diagnosed diseases (ranging from 64.3% to 86.3%). Floor/ceiling effects were observed across all items. The EQ-5D-3L total score discriminated between respondents who were experiencing health conditions (e.g. cancer, cardiovascular disease, stroke) from healthy individuals.

DISCUSSION

Despite the ceiling effects, the EQ-5D-3L displayed good psychometric properties as an HRQoL measure and discriminated between health states in the general South Australian population. Further research should investigate the psychometric properties of the EQ-5D-5L in South Australia and whether an increased number of response categories can mitigate the observed ceiling effects.

A qualitative investigation of the relevance of skin irritation and self-confidence bolt-ons and their conceptual overlap with the EQ-5D in patients with psoriasis

Objectives

A number of bolt-ons have been proposed for the EQ-5D, including two psoriasis-specific bolt-ons, skin irritation and self-confidence. The study investigates and compares the relevance and comprehensiveness of these psoriasis-specific bolt-ons and the EQ-5D-5L and explores the potential conceptual overlaps between the existing five dimensions and the two bolt-ons.

Methods

Psoriasis patients were purposively sampled according to age and gender. Semi-structured interviews, where participants were asked to complete the EQ-5D-5L and the bolt-ons while thinking aloud, were conducted. Probes were used to investigate the thought processes of patients regarding the dimensions, wording, recall period and relevant concepts not captured by the EQ-5D-5L and bolt-ons. Data were analysed thematically. A focus group was used to confirm the findings.

Results

Overall, 16 patients completed the interviews. Sixteen and fifteen patients considered skin irritation and self-confidence relevant areas to describe psoriasis problems. Three patients considered itching a form of discomfort, and thus, pointed out a potential overlap between pain/discomfort and skin irritation. Twelve patients reported overall 10 general health- or psoriasis-related concepts that are not captured by the EQ-5D-5L, including itching, social relationships and sex life. Eleven patients reported that the recall period of the EQ-5D-5L might be subject to bias because of the daily or within-day fluctuations of their symptoms.

Conclusions

The skin irritation and self-confidence bolt-ons contribute to improve content validity of the EQ-5D-5L in patients with psoriasis. The qualitative approach taken in this study expands the existing methodological framework for the development and testing validity of bolt-ons for the EQ-5D.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03141-y.

Feasibility of the EQ-5D in the elderly population: a systematic review of the literature

Purpose

The EQ-5D-3L and 5L are widely used generic preference-based instruments, which are psychometrically sound with the general population, but little is known about the instruments’ feasibility in the elderly. Therefore, this systematic review summarises the available literature with regard to the feasibility properties of the instruments in the elderly population.

Methods

We conducted a systematic search in PubMed, PsycInfo and EuroQol databases using pre-specified vocabulary and inclusion/exclusion criteria to identify publications until November 2020. Study characteristics and outcomes referring to the feasibility of the EQ-5D-3L and 5L in the elderly were extracted, if all study participants were at least 65+ years.

Results

We identified 17 studies reporting feasibility outcomes based on four criteria: missing values, completion rates, completion time and broad qualitative statements referring to the completion. Missing values per dimension ranged from 0 to 10.7%, although being mostly below 7%. The completion rate was around 90% or better, whereas the EQ VAS rating was missing from 2.3 to 25.3% of the respondents. Only two of the included studies examined the EQ-5D-5L; 15 studies reported on the EQ-5D-3L.

Conclusion

Comparing our findings against the general population from published literature, we find that feasibility outcomes in older age groups are just below that of younger populations. Furthermore, older respondents have a higher propensity of requiring assistance or even an interviewer-based approach. Nonetheless, the reviewed literature indicates that the EQ-5D-3L still has good feasibility properties and, hence, is highly applicable in older respondents. However, further research is needed to explore feasibility properties of the EQ-5D-5L in this population.

Psychometric Properties of EQ-5D-3L and EQ-5D-5L in Cognitively Impaired Patients Living with Dementia

BACKGROUND

Assessing health-related quality of life in dementia poses challenges due to patients' cognitive impairment. It is unknown if the newly introduced EQ-5D five-level version (EQ-5D-5L) is superior to the 3-level version (EQ-5D-3L) in this cognitively impaired population group.

OBJECTIVE

To assess the psychometric properties of the EQ-5D-5L in comparison to the EQ-5D-3L in patients living with dementia (PwD).

METHODS

The EQ-5D-3L and EQ-5D-5L were assessed via interviews with n = 78 PwD at baseline and three and six months after, resulting in 131 assessments. The EQ-5D-3L and EQ-5D-5L were evaluated in terms of acceptability, agreement, ceiling effects, redistribution properties and inconsistency, informativity as well as convergent and discriminative validity.

RESULTS

Mean index scores were higher for the EQ-5D-5L than the EQ-5D-3L (0.70 versus 0.64). Missing values occurred more frequently in the EQ-5D-5L than the EQ-5D-3L (8%versus 3%). Agreement between both measures was acceptable but poor in PwD with moderate to severe cognitive impairment. The index value's relative ceiling effect decreased from EQ-5D-3L to EQ-5D-5L by 17%. Inconsistency was moderate to high (13%). Absolute and relative informativity increased in the EQ-5D-5L compared to the 3L. The EQ-5D-5L demonstrated a lower discriminative ability and convergent validity, especially in PwD with moderate to severe cognitive deficits.

CONCLUSION

The EQ-5D-5L was not superior as a self-rating instrument due to a lower acceptability and discriminative ability and a high inconsistency, especially in moderate to severe dementia. The EQ-5D-3L had slightly better psychometric properties and should preferably be used as a self-rating instrument in economic evaluations in dementia.

Health-Related Quality of Life in Patients With Different Diseases Measured With the EQ-5D-5L: A Systematic Review

Background: The EQ-5D-5L is a generic preference-based questionnaire developed by the EuroQol Group to measure health-related quality of life (HRQoL) in 2005. Since its development, it has been increasingly applied in populations with various diseases and has been found to have good reliability and sensitivity. This study aimed to summarize the health utility elicited from EQ-5D-5L for patients with different diseases in cross-sectional studies worldwide.

Methods: Web of Science, MEDLINE, EMBASE, and the Cochrane Library were searched from January 1, 2012, to October 31, 2019. Cross-sectional studies reporting utility values measured with the EQ-5D-5L in patients with any specific disease were eligible. The language was limited to English. Reference lists of the retrieved studies were manually searched to identify more studies that met the inclusion criteria. Methodological quality was assessed with the Agency for Health Research and Quality (AHRQ) checklist. In addition, meta-analyses were performed for utility values of any specific disease reported in three or more studies.

Results: In total, 9,400 records were identified, and 98 studies met the inclusion criteria. In the included studies, 50 different diseases and 98,085 patients were analyzed. Thirty-five studies involving seven different diseases were included in meta-analyses. The health utility ranged from 0.31 to 0.99 for diabetes mellitus [meta-analysis random-effect model (REM): 0.83, (95% CI = 0.77–0.90); fixed-effect model (FEM): 0.93 (95% CI = 0.93–0.93)]; from 0.62 to 0.90 for neoplasms [REM: 0.75 (95% CI = 0.68–0.82); FEM: 0.80 (95% CI = 0.78–0.81)]; from 0.56 to 0.85 for cardiovascular disease [REM: 0.77 (95% CI = 0.75–0.79); FEM: 0.76 (95% CI = 0.75–0.76)]; from 0.31 to 0.78 for multiple sclerosis [REM: 0.56 (95% CI = 0.47–0.66); FEM: 0.67 (95% CI = 0.66–0.68)]; from 0.68 to 0.79 for chronic obstructive pulmonary disease [REM: 0.75 (95% CI = 0.71–0.80); FEM: 0.76 (95% CI = 0.75–0.77)] from 0.65 to 0.90 for HIV infection [REM: 0.84 (95% CI = 0.80–0.88); FEM: 0.81 (95% CI = 0.80–0.82)]; from 0.37 to 0.89 for chronic kidney disease [REM: 0.70 (95% CI = 0.48–0.92; FEM: 0.76 (95% CI = 0.74–0.78)].

Conclusions: EQ-5D-5L is one of the most widely used preference-based measures of HRQoL in patients with different diseases worldwide. The variation of utility values for the same disease was influenced by the characteristics of patients, the living environment, and the EQ-5D-5L value set.

Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42020158694.

The measurement performance of the EQ-5D-5L versus EQ-5D-3L in patients with hidradenitis suppurativa

PURPOSE

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that affects up to 1% of the population in Europe. The EQ-5D is the most commonly used generic instrument for measuring health-related quality of life among HS patients. This study aims to compare the measurement properties of the two adult versions of EQ-5D (EQ-5D-3L and EQ-5D-5L) in patients with HS.

METHODS

We recruited 200 consecutive patients with HS (mean age 37 years, 38% severe or very severe HS) to participate in a multicentre cross-sectional survey. Patients completed the EQ-5D-3L, EQ-5D-5L, Dermatology Life Quality Index (DLQI) and Skindex-16 questionnaires.

RESULTS

More than twice as many different health state profiles occurred in the EQ-5D-5L compared to the EQ-5D-3L (101 vs. 43). A significant reduction in ceiling effect was found for the mobility, self-care and usual activities dimensions. A good agreement was established between the EQ-5D-3L and EQ-5D-5L with an intraclass correlation coefficient of 0.872 (95% CI 0.830-0.903; p < 0.001) that was confirmed by a Bland-Altman plot. EQ-5D-5L improved both the absolute and relative informativity in all dimensions except for anxiety/depression. EQ-5D-3L and EQ-5D-5L demonstrated similar convergent validity with DLQI and Skindex-16. EQ-5D-5L was able to better discriminate between known groups of patients based on the number of comorbidities and disease severity (HS-Physician's Global Assessment).

CONCLUSION

In patients with HS, the EQ-5D-5L outperformed the EQ-5D-3L in feasibility, ceiling effects, informativity and known-groups validity for many important clinical characteristics. We recommend using the EQ-5D-5L in HS patients across various settings, including clinical care, research and economic evaluations.

Comparing the measurement properties of the EQ-5D-5L and the EQ-5D-3L in hypertensive patients living in rural China

PURPOSE

The purpose of this study was to compare the measurement properties of two versions of EQ-5D (i.e.EQ-5D-3L and EQ-5D-5L) in hypertensive patients in rural China.

METHODS

A cross-sectional survey was carried out in hypertensive patients in rural China. We compared the ceiling effects, redistribution properties, informativity, known-groups validity, and relative efficiency of the 3L and 5L and examined their agreement.

RESULTS

A total of 11,412 patients were enrolled in our study. The mean EQ-5D index score was 0.84 (SD 0.21) according to the 5L and 0.86 (SD 0.17) according to the 3L. A good agreement was observed between the 3L and 5L. The overall ceiling effect decreased from 46.4% (3L) to 29.4% (5L). The Shannon index, H' improved in all dimensions when used 5L. When used 3L, the median responses of all groups were consistent with 5L across the three dimensions of 'mobility', 'self-care', 'usual activities', while the median responses were inconsistent for the 'pain/discomfort' and 'anxiety/depression' dimensions. The 3L performed better in eight comorbidities in terms of F-statistics and six comorbidities in terms of the area under the receiver operating characteristic curves (AUROCs). The 5L performed better both in terms of the F-statistics and AUROCs in age, education level, anti-hypertensive medication use.

CONCLUSION

Taking all comparisons into account, we recommend the EQ-5D-5L for use in patients with hypertension in rural China.

Psychometric properties of the EQ-5D-5L: a systematic review of the literature

PURPOSE

Although the EQ-5D has a long history of use in a wide range of populations, the newer five-level version (EQ-5D-5L) has not yet had such extensive experience. This systematic review summarizes the available published scientific evidence on the psychometric properties of the EQ-5D-5L.

METHODS

Pre-determined key words and exclusion criteria were used to systematically search publications from 2011 to 2019. Information on study characteristics and psychometric properties were extracted: specifically, EQ-5D-5L distribution (including ceiling and floor), missing values, reliability (test-retest), validity (convergent, known-groups, discriminate) and responsiveness (distribution, anchor-based). EQ-5D-5L index value means, ceiling and correlation coefficients (convergent validity) were pooled across the studies using random-effects models.

RESULTS

Of the 889 identified publications, 99 were included for review, representing 32 countries. Musculoskeletal/orthopedic problems and cancer (n = 8 each) were most often studied. Most papers found missing values (17 of 17 papers) and floor effects (43 of 48 papers) to be unproblematic. While the index was found to be reliable (9 of 9 papers), individual dimensions exhibited instability over time. Index values and dimensions demonstrated moderate to strong correlations with global health measures, other multi-attribute utility instruments, physical/functional health, pain, activities of daily living, and clinical/biological measures. The instrument was not correlated with life satisfaction and cognition/communication measures. Responsiveness was addressed by 15 studies, finding moderate effect sizes when confined to studied subgroups with improvements in health.

CONCLUSIONS

The EQ-5D-5L exhibits excellent psychometric properties across a broad range of populations, conditions and settings. Rigorous exploration of its responsiveness is needed.

Validity of the EQ-5D-5L questionnaire among the general population of Poland

Purpose

We aim to compare the psychometric properties of the EQ-5D-5L questionnaire with the EQ-5D-3L version and EQ VAS, based on a survey conducted in a sample representing the general adult population of Poland.

Methods

The survey comprised health-related quality of life (HRQoL) questionnaires: EQ-5D-5L, EQ VAS, SF-12 and EQ-5D-3L, together with demographic and socio-economic characteristics items. The EQ-5D index values were estimated based on a directly measured value set for Poland. The following psychometric properties were analysed: feasibility, distribution of responses, redistribution from EQ-5D-3L to EQ-5D-5L, inconsistencies, ceiling effects, informativity power and construct validity. We proposed a novel approach to the construct validity assessment, based on the use of a machine learning technique known as the random forest algorithm.

Results

From March to June 2014, 3978 subjects (aged 18–87, 53.2% female) were surveyed. The EQ-5D-5L questionnaire had a lower ceiling effect compared to EQ-5D-3L (38.0% vs 46.6%). Redistribution from EQ-5D-3L to EQ-5D-5L was similar for each dimension, and the mean inconsistency did not exceed 5%. The results of known-groups validation confirmed the hypothesis concerning the relationship between the EQ-5D index values and age, sex and occurrence of diabetes.

Conclusions

The EQ-5D-5L, in comparison with its EQ-5D-3L equivalent, showed similar or better psychometric properties within the general population of a country. We assessed the construct validity of the questionnaire with a novel approach that was based on a machine learning technique known as the random forest algorithm.

Comparing EQ-5D-3L and EQ-5D-5L performance in common cancers: suggestions for instrument choosing

PURPOSE

To compare the performance of three-level EuroQol five-dimensions (EQ-5D-3L) and five-level EuroQol five-dimensions (EQ-5D-5L) among common cancer patients in urban China.

METHODS

A hospital-based cross-sectional survey was conducted in three provinces from 2016 to 2018 in urban China. Patients with breast cancer, colorectal cancer, or lung cancer were recruited to complete the EQ-5D-3L and EQ-5D-5L questionnaires. Response distribution, discriminatory power (indicator: Shannon index [H'] and Shannon evenness index [J']), ceiling effect (the proportion of full health state), convergent validity, and health-related quality of life (HRQoL) were compared between the two instruments.

RESULTS

A total of 1802 cancer patients (breast cancer: 601, colorectal cancer: 601, lung cancer: 600) were included, with the mean age of 55.6 years. The average inconsistency rate was 4.4%. Compared with EQ-5D-3L (average: H' = 1.100, J' = 0.696), an improved discriminatory power was observed in EQ-5D-5L (H' = 1.473, J' = 0.932), especially contributing to anxiety/depression dimensions. The ceiling effect was diminished in EQ-5D-5L (26.5%) in comparison with EQ-5D-3L (34.5%) (p < 0.001), mainly reflected in the pain/discomfort and anxiety/depression dimensions. The overall utility score was 0.790 (95% CI 0.778-0.801) for EQ-5D-3L and 0.803 (0.790-0.816) for EQ-5D-5L (p < 0.001). A similar pattern was also observed in the detailed cancer-specific analysis.

CONCLUSIONS

With greater discriminatory power, convergent validity and lower ceiling, EQ-5D-5L may be preferable to EQ-5D-3L for the assessment of HRQoL among cancer patients. However, higher utility scores derived form EQ-5D-5L may also lead to lower QALY gains than those of 3L potentially in cost-utility studies and underestimation in the burden of disease.

Psychometric properties comparison between EQ-5D-5L and EQ-5D-3L in the general Thai population

PURPOSE

Evidence for the EQ-5D-5L's psychometric properties in the general Thai population is limited. This study aimed to compare ceiling effect, discriminatory power, response redistribution, validity, reliability between the EQ-5D-5L (5L) and the EQ-5D-3L (3L) in the general Thai population.

METHODS

1200 participants were randomly selected. The Shannon index ([Formula: see text] and Shannon evenness index ([Formula: see text] determining discriminatory power of both EQ-5D versions in each dimension were compared. Test-retest reliability was evaluated using weighted kappa (k) and intraclass correlation coefficients (ICCs). Validity was evaluated by correlations between similar dimensions of the EQ-5D, WHOQOL-BREF, and SF-12v2 and known-groups validity. The ceiling effects for the 3L and for the 5L were compared.

RESULTS

The 5L had lower ceiling effects than the 3L (49.08% vs 57.17%, p < 0.01). [Formula: see text] was higher for the 5L than for the 3L, but [Formula: see text] showed otherwise. Moderate correlations were detected between similar dimensions of the EQ-5D and the WHOQOL-BREF and SF-12v2. ICCs and k of the 3L were slightly higher than those of the 5L (ICCs: 0.78 vs 0.71) and (k: 0.42-0.63 vs 0.48-0.61), respectively. Older, female participants and those with comorbidities reported a lower utility index for both versions.

CONCLUSION

Evidence supported use of both EQ-5D versions in the general Thai population. The 5L had better ceiling effects and discriminant activity, while it showed comparable known-groups validity with the 3L. Nevertheless, evidence is limited for the superiority of reliability between these two versions, so more future research is required to investigate it.

Health state utility values derived from EQ-5D in psoriatic patients: a systematic review and meta-analysis

BACKGROUND

To determine pooled EQ-5D utility scores for psoriasis as a general condition, plaque psoriasis, and psoriatic arthritis.

METHODS

A systematic review and meta-analysis of EQ-5D utility scores for psoriatic patients was conducted. Univariate meta-regression was used to explore the degree of heterogeneity.

RESULTS

Seventy-five studies were included in the systematic review. The EQ-5D in psoriatic patients demonstrated decent convergent, known-groups validity, and a degree of responsiveness with a ceiling effect. Among the five EQ-5D dimensions, 'self-care' showed the lowest and 'pain/discomfort' showed the highest percentages of reporting any problems. For meta-analysis, we identified 70 utility scores from 59 studies: 22 for plaque psoriasis, 26 for psoriasis as a general condition, and 22 for psoriatic arthritis. The mean (95% CIs; I²) of the EQ-5D utility scores for psoriasis as a general condition, plaque psoriasis, and psoriatic arthritis was 0.748 (0.718, 0.777; 98.8%), 0.755 (0.727, 0.783; 98.6%), and 0.585 (0.538, 0.632; 98.2%), respectively. For psoriasis as a general condition and plaque psoriasis, factors such as country, psoriasis area and severity index (PASI), dermatology life quality index (DLQI) and questionnaire version (EQ-5D-3L or EQ-5D-5L) all significantly influenced the utility scores.

CONCLUSION

Psoriasis imposes a substantial impairment on patients' quality of life, especially the pain/discomfort dimension. Heterogeneity exists among different EQ-5D utility values found in the literature.

Health-related quality of life and health utilities in insulin-treated type 2 diabetes: the impact of related comorbidities/complications

OBJECTIVE

To evaluate the impact of multiple comorbidities/complications on health-related quality of life (HRQoL) and health utilities in insulin-treated type 2 diabetes (T2DM).

METHODS

In a non-interventional, epidemiological study, data were collected from medical records and via interviews for 938 subjects from various geographical areas of Greece. HRQoL and health utilities were explored with the EQ-5D-5L. Univariate associations were evaluated with the Mann-Whitney and Kruskal-Wallis tests for continuous and Chi-squared tests for nominal variables, and binary logistic regressions were employed to obtain marginal effects. Employing a split sample approach, various specifications of ordinary least squares regression models were evaluated in terms of goodness of fit, model specification, shrinkage and predictive and discriminative performance, to select the best model for mapping health utilities using the whole dataset.

RESULTS

Overall, the most important factors of impaired HRQoL and health utilities were higher age, female gender, obesity, poor glycemic control and increased duration of insulin treatment. History and increasing concurrence of all complications assessed were associated with exacerbated HRQoL problems, decreased health utilities and diminished health state, although it was not always statistically significant. The highest disutilities were associated with stroke (- 0.082), diabetic retinopathy (- 0.066), diabetic neuropathy (- 0.051) and severe hypoglycemia (- 0.050).

CONCLUSIONS

The deleterious impact of comorbidities on insulin-dependent T2DM subjects' HRQoL has been confirmed and clinicians should adapt the priorities of disease management accordingly. The derived health utility estimates may be valuable for conducting economic evaluations of interventions in the area of T2DM when data are not available.

Comparing the performance of the EQ-5D-3 L and the EQ-5D-5 L in an elderly Chinese population

BACKGROUND

This study was conducted to compare the validity and discriminative power of both the EQ-5D-3 L and EQ-5D-5 L in an elderly Chinese population with multiple chronic and acute conditions.

METHODS

A total of 648 retired people from China (mean ± standard deviation: 73.3 ± 6.4 years; male: 55.7%) were recruited and randomized to complete the 3 L or 5 L questionnaire. The 3 L and 5 L were compared in terms of distribution properties, ceiling effects, informativity, validity and discriminatory performance. Convergent validity between the 3 L and 5 L was tested by spearman's rank-order correlation. Discriminatory power was conducted by relative efficiency as assessed by the F statistics.

RESULTS

Most participants answered to "no problems" on both versions of EQ-5D. The 5 L trended towards a slightly lower ceiling compared with the 3 L. The Shannon index improved with the 5 L while the Shannon's Evenness index tended to be similar. Convergent validity was confirmed by the moderate to strong correlation for both 3 L and 5 L. Relative efficiency suggested that 5 L had a higher absolute discriminatory power than the 3 L version in terms of the presence conditions, especially for osteoporosis and metabolic syndrome.

CONCLUSIONS

Both the 3 L and 5 L are demonstrated to be valid based HRQoL instruments in Chinese elderly population. The 5 L system may be preferable to the 3 L, as it demonstrated superior performance with respect to lower ceiling effect and better discriminatory power. Further research is needed to examine the responsiveness of the two EQ-5D instruments in this population.

AURIEL-PsO: a randomized, double-blind phase III equivalence trial to demonstrate the clinical similarity of the proposed biosimilar MSB11022 to reference adalimumab in patients with moderate-to-severe chronic plaque-type psoriasis

BACKGROUND

MSB11022 is a proposed adalimumab biosimilar.

OBJECTIVES

To compare the efficacy, safety and immunogenicity of MSB11022 with reference adalimumab.

METHODS

AURIEL-PsO was a double-blind randomized controlled equivalence trial, in which patients with moderate-to-severe chronic plaque-type psoriasis were randomized 1 : 1 to MSB11022 or reference adalimumab. The primary end point was ≥ 75% improvement in Psoriasis Area and Severity Index (PASI 75) at week 16, with a prespecified equivalence interval of ± 18%. Patients with a ≥50% improvement in PASI at week 16 were eligible to enter a double-blind extension period: patients receiving MSB11022 continued treatment, and patients receiving reference adalimumab were rerandomized 1 : 1 either to continue reference adalimumab or to switch to MSB11022. Other efficacy end points and safety, immunogenicity and pharmacokinetic parameters were evaluated at scheduled visits up to weeks 52 (efficacy and immunogenicity), 54 and 66 (safety).

RESULTS

In total, 443 patients were randomized. The difference in PASI 75 response rates at week 16 between the treatment arms was -1·9%, and the 95% confidence interval (-7·8% to 4·1%) was within the prespecified equivalence interval. No notable difference in the incidence of treatment-emergent adverse events was observed between treatment arms up to the end of the trial, and no new safety signals were observed. Following treatment switch at week 16, no clinically meaningful differences in safety or immunogenicity were seen between treatment arms through to the end of the observation period.

CONCLUSIONS

Therapeutic equivalence between MSB11022 and reference adalimumab was demonstrated. AURIEL-PsO provides evidence to support the similarity of both products with regard to efficacy, safety and immunogenicity. What's already known about this topic? Adalimumab is a fully human antitumour necrosis factor-α monoclonal antibody, indicated for the treatment of multiple inflammatory disorders, including psoriasis, psoriatic arthritis, rheumatoid arthritis, inflammatory bowel diseases and ankylosing spondylitis. MSB11022 is a proposed adalimumab biosimilar that has shown structural and functional similarity to the reference product in an extensive analytical comparability exercise. MSB11022 has demonstrated bioequivalence and comparable safety and immunogenicity profiles in a phase I study in healthy volunteers. What does this study add? This phase III study confirmed equivalent efficacy for MSB11022 and reference adalimumab in patients without any immunomodulation comedication in moderate-to-severe chronic plaque-type psoriasis at week 16. The efficacy, safety and immunogenicity of MSB11022 and reference adalimumab were similar over the respective observation periods (week 52 for efficacy and immunogenicity, week 66 for safety). A switch from reference adalimumab to MSB11022 at week 16 did not impact efficacy, safety or immunogenicity.

The EQ-5D-5L Is Superior to the -3L Version in Measuring Health-related Quality of Life in Patients Awaiting THA or TKA

BACKGROUND

As a generic measure of health-related quality of life among patients awaiting THA or TKA, the three-level version of the EQ-5D (EQ-5D-3L), which has three response levels of severity (no problems, some problems, and extreme problems/unable) to five questions, is widely used. Previous studies indicated that the ceiling effect of the EQ-5D-3L limits its application. The five-level version of the EQ-5D (EQ-5D-5L) was developed to enhance the measurement properties of the tool by adding two levels: slight problems and severe problems. However, only a few small studies have compared the EQ-5D-3L and EQ-5D-5L in patients awaiting THA and TKA.

QUESTIONS/PURPOSES

The purpose of this study was to examine the performance of the EQ-5D-3L and EQ-5D-5L among patients awaiting THA or TKA in terms of (1) response patterns, (2) convergent construct validity, (3) known-group validity, and (4) informativity and discriminatory power.

METHODS

This is a retrospective analysis of the Alberta Bone and Joint Health Data Repository, which recorded information on all patients receiving hip or knee arthroplasties between April 2010 and March 2017 in Alberta, Canada (n = 37,377). Patients receiving THA or TKA and who completed the EQ-5D and WOMAC at baseline (presurgery) were included in this study (n = 24,766). The EQ-5D-3L was administered to all patients in 2010, and was gradually replaced by the EQ-5D-5L between 2013 and 2016; the EQ-5D-5L reached full application in all clinics by 2017.A propensity score was used to match patients 1:1 who completed either the EQ-5D-3L or EQ-5D-5L before surgery. Response patterns have been explored using ceiling and floor effects and distribution across severity levels of each dimension. Convergent construct validity was examined using Spearman's correlation (rho) against the WOMAC. Known-group validity was examined by gender, preoperative risk factors, mental health, obesity, and WOMAC physical function score. Informativity and discriminatory power were examined using the Shannon (H') and Shannon evenness (J') indices. A total of 3446 pairs of patients awaiting THA (55% women; mean age, 66 years) and 5428 pairs of patients awaiting TKA (59% women; mean age 67 years) were included in this analysis; the study group included all patients who were kept in the propensity score matching.

RESULTS

Ceiling and floor effects were comparable and small (less than 0.5%) for both versions; the responses across severity levels for each dimension were more evenly distributed for the EQ-5D-5L. Convergent construct validity was stronger for the EQ-5D-5L as it consistently had stronger correlations with the WOMAC overall and domain scores than the EQ-5D-3L (rho(3L-THA), -0.77 to -0.31; rho(3L-TKA), -0.71 to -0.24; rho(5L-THA), -0.71 to -0.17; rho(5L-TKA), -0.64 to -0.17; all p values < 0.001). The hypotheses of known-group analyses were confirmed for both versions. The EQ-5D-5L demonstrated stronger informativity and discriminatory power than the EQ-5D-3L, particularly for the mobility dimension (THA, H'(5L/3L)=1.66/0.37, J'(5L/3L)=0.72/0.23; TKA, H'(5L/3L)=1.66/0.41, J'(5L/3L)=0.71/0.26).

CONCLUSIONS

This study demonstrates the superior construct validity, and informativity and discriminatory power of the EQ-5D-5L compared with the EQ-5D-3L among patients awaiting THA or TKA.

CLINICAL RELEVANCE

Compared with the three-level version, the five-level version of the EQ-5D differentiates between patients awaiting THA and TKA much better based on their mobility, which is a key health aspect or outcome in these patients. Our findings suggest that the EQ-5D-5L is more appropriate for this population.

A head-to-head comparison of five-level (EQ-5D-5L-Y) and three-level EQ-5D-Y questionnaires in paediatric patients

PURPOSE

The aim of this study was to assess the psychometric properties of a youth version of the EQ-5D five-level questionnaire (5LY) and its three-level version (3LY) in a sample of Chinese paediatric patients.

METHODS

A consecutive sample of idiopathic scoliosis patients were recruited from a referral outpatient scoliosis center at Hong Kong, China in October 2017 and completed the two versions of EQ-5D-Y. Redistribution properties in each dimension of EQ-5D-Y were analyzed between 5LY and 3LY by logistics regressions. Absolute reduction and relative reduction in ceiling effects from the 3LY to the 5LY were calculated. Test-retest reliability was assessed by examining the Gwet's agreement coefficient (Gwet's AC) for five individual dimension responses over the 2-week period.

RESULTS

A total of 129 idiopathic scoliosis patients completed the two versions of EQ-5D-Y at baseline assessment, among which 70 patients completed the test-retest interview in 2-3 weeks after baseline assessment. For redistribution properties, the proportion of inconsistency was low in all the dimensions, ranging from 0.0% ("Usual activities") to 3.9% ("Pain/discomfort"). Ceiling effects were reduced in four dimensions. "Usual activities" dimension showed significant reduction (absolute and relative reductions: 3.9% and 4.3%; p = 0.025) and the "worried/sad/unhappy" dimension showed the largest significant reduction in ceiling effects (absolute and relative reductions: 7.8% and 9.8%; p = 0.012). The 3LY and 5LY showed very good agreement (> 80%) of individual dimension responses between two assessments, except for the "worried/sad/unhappy" dimension in 3LY.

CONCLUSION

Through this head-to-head comparison, the 5LY had significant improvements in ceiling effects in two dimensions when compared to 3LY but other measurement properties of 3LY and 5LY performed similar in the idiopathic scoliosis patient group.

Psychometric performance assessment of Malay and Malaysian English version of EQ-5D-5L in the Malaysian population

PURPOSE

To determine the psychometric properties and performance of Malay and English versions of the EQ-5D-5L descriptive instrument in the general Malaysian population.

METHODS

1137 members of the Malaysian general public were sampled in this national study. Respondents were recruited by quota sampling of urbanicity, gender, age, and ethnicity. In face-to-face interviews, respondents first answered the EQ-5D-5L questionnaire administered using the EQ-Valuation Technology software, and then completed the EQ-5D-3L questionnaire on paper. A subgroup of the respondents were given paper form of EQ-5D-5L for completion within 2 weeks for test-retest reliability. Ceiling effects, response redistribution, informativity, and convergent validity were compared between EQ-5D-5L and ED-5D-3L separately by Malay and English language versions.

RESULTS

The proportion of 'full health' responses (11111) drastically decreased by 25.55% and 15.74% in the Malay and English language versions indicating lower ceiling effects in EQ-5D-5L. Inconsistencies from response redistribution was below 6% for all dimensions across languages. The measure of relative informativity was comparatively higher in EQ-5D-5L than in EQ-5D-3L in both language versions, with the exception of dimensions mobility and pain/discomfort in the English version. Convergent validity in terms of correlation with EQ-VAS was relatively better for EQ-5D-5L dimensions, with pain/discomfort of the Malay version having the strongest correlation (|r| = 0.37). Also, reliability testing revealed moderate to poor agreements on all 5L dimensions.

CONCLUSIONS

EQ-5D-5L fared better in terms of psychometric performance compared to EQ-5D-3L for both language versions. This encourages the application of the EQ-5D-5L in health-related research in Malaysia.

Validity of the EQ-5D-5L and EQ-5D-3L in patients with Crohn's disease

PURPOSE

The EuroQol five-dimension questionnaire (EQ-5D) is the most commonly used instrument to obtain utility values for cost-effectiveness analyses of treatments for Crohn's disease (CD). We aimed to compare the measurement properties of the two adult versions of EQ-5D (EQ-5D-3L and EQ-5D-5L) in patients with CD.

METHODS

Between 2016 and 2017, a multicentre cross-sectional survey was carried out. Consecutive outpatients with CD completed the 3L, 5L and EQ visual analogue scale (VAS). Disease severity was graded by the Crohn's Disease Activity Index (CDAI) and Perianal Disease Activity Index (PDAI). The 3L and 5L were compared in terms of feasibility, agreement, ceiling effect, redistribution properties, discriminatory power, convergent and known-groups validity.

RESULTS

Two-hundred and six patients (54.9% male, mean age 35 ± 11 years) participated in the survey. For 3L, 25 unique health states were observed versus 59 for the 5L. The overall ceiling effect decreased from 29.6% (3L) to 25.5% (5L). Absolute discriminatory power improved (mean Shannon index 0.84 vs. 1.18). The 3L correlated stronger with EQ VAS and CDAI scores, whereas the 5L with PDAI. The 5L demonstrated a better known-groups validity on the basis of age, perianal fistulas, extraintestinal manifestations and disability.

CONCLUSIONS

This is the first study to report the impact of CD on quality of life using the EQ-5D-5L questionnaire. The 5L seems to perform better than 3L in terms of feasibility, ceiling effect, discriminatory power and known-groups validity. Understanding the differences in psychometrics between the 3L and 5L is essential as they have substantial implications for financial decision-making about CD treatments.

Psychometric properties of the EQ-5D-5L in patients with hip or knee osteoarthritis: reliability, validity and responsiveness

PURPOSE

To study the psychometric properties, including reliability, validity and responsiveness, of the Spanish EQ-5D-5L questionnaire for patients with hip or knee osteoarthritis (OA).

METHODS

We included 758 patients with hip or knee OA who completed the EQ-5D-5L and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at baseline, of whom 644 also did 6 months later. The EQ-5D-5L contains five questions from which a utility index is derived. The WOMAC covers three dimensions: pain, stiffness and physical function. Floor and ceiling effects were calculated. Reliability was assessed using Cronbach's alpha. Convergent validity was tested using the Spearman correlation coefficient between EQ-5D-5L and WOMAC. We examined known-groups validity by comparing the EQ-5D-5L between subgroups defined by WOMAC scores using ANOVA or the Kruskal-Wallis test. Effect sizes were calculated to assess responsiveness, and minimal clinically important difference (MCID) was estimated.

RESULTS

The EQ-5D-5L showed minimal floor and ceiling effects (< 3%). Cronbach's alpha was 0.86. The EQ-5D-5L index was strongly correlated with WOMAC pain and function scores (- 0.688 and - 0.782). Patients with higher WOMAC scores had significantly (p < 0.0001) lower EQ-5D-5L index. The 20.19% had hip or knee replacement during the follow-up. Effect sizes were small among non-surgical patients, but > 0.80 among "improved" surgical patients, being the MCID for improvement 0.32 points.

CONCLUSIONS

The results support the reliability, validity and responsiveness of the EQ-5D-5L, overcoming the limitations of the EQ-5D-3L in these patients. Therefore, the EQ-5D-5L could be very useful as an outcome measure, at least in patients with hip or knee OA.

A Systematic Review of Studies Comparing the Measurement Properties of the Three-Level and Five-Level Versions of the EQ-5D

BACKGROUND

Since the introduction of the five-level version of the EQ-5D (5L), many studies have comparatively investigated the measurement properties of the original three-level version (3L) with the 5L version.

OBJECTIVE

The aim of this study was to consolidate the available evidence on the performance of both instruments.

METHODS

A systematic literature search of studies in the English and German languages was conducted (2007-January 2018) using the PubMed, EMBASE, and PsycINFO (EBSCO) databases, as well as the EuroQol Research Foundation website. Data were extracted and assessed on missing values, distributional properties, informativity indices (Shannon's H' and J'), inconsistencies, responsiveness, and test-retest reliability.

RESULTS

Twenty-four studies were included in the review. Missing values and floor effects (percentage reporting the worst health state) were found to be negligible for both 3L and 5L (< 5%). From 18 studies, inconsistencies ranged from 0 to 10.6%, although they were generally well below 5%, with 9 studies reporting the most inconsistencies for Usual Activities (mean percentage 4.1%). Shannon's indices were always higher for 5L than for 3L, and all but three studies reported lower ceiling effects ('11111') for 5L than for 3L. There is mixed and insufficient evidence on responsiveness and test-retest reliability, although results on index values showed better performance for 5L on test-retest reliability.

CONCLUSION

Overall, studies showed similar or better measurement properties of the 5L compared with the 3L, and evidence indicated moderately better distributional parameters and substantial improvement in informativity for the 5L compared with the 3L. Insufficient evidence on responsiveness and test-retest reliability implies further research is needed.