The utility assessment method order influences measurement of parents' risk attitude

Preference Elicitation Techniques Used in Valuing Children's Health-Related Quality-of-Life: A Systematic Review

BACKGROUND AND OBJECTIVES

Valuing children's health states for use in economic evaluations is globally relevant and is of particular relevance in jurisdictions where a cost-utility analysis is the preferred form of analysis for decision making. Despite this, the challenges with valuing child health mean that there are many remaining questions for debate about the approach to elicitation of values. The aim of this paper was to identify and describe the methods used to value children's health states and the specific issues that arise in the use of these methods.

METHODS

We conducted a systematic search of electronic databases to identify studies published in English since 1990 that used preference elicitation methods to value child and adolescent (under 18 years of age) health states. Eligibility criteria comprised valuation studies concerning both child-specific patient-reported outcome measures and child health states defined in other ways, and methodological studies of valuation approaches that may or may not have yielded a value set algorithm.

RESULTS

A total of 77 eligible studies were identified from which data on country setting, aims, condition (general population or clinically specific), sample size, age of respondents, the perspective that participants were asked to adopt, source of values (respondents who completed the preference elicitation tasks) and methods questions asked were extracted. Extracted data were classified and evaluated using narrative synthesis methods. The studies were classified into three groups: (1) studies comparing elicitation methods (n = 30); (2) studies comparing perspectives (n = 23); and (3) studies where no comparisons were presented (n = 26); selected studies could fall into more than one group. Overall, the studies varied considerably both in methods used and in reporting. The preference elicitation tasks included time trade-off, standard gamble, visual analogue scaling, rating/ranking, discrete choice experiments, best-worst scaling and willingness to pay elicited through a contingent valuation. Perspectives included adults' considering the health states from their own perspective, adults taking the perspective of a child (own, other, hypothetical) and a child/adolescent taking their own or the perspective of another child. There was some evidence that children gave lower values for comparable health states than did adults that adopted their own perspective or adult/parents that adopted the perspective of children.

CONCLUSIONS

Differences in reporting limited the conclusions that can be formed about which methods are most suitable for eliciting preferences for children's health and the influence of differing perspectives and values. Difficulties encountered in drawing conclusions from the data (such as lack of consensus and poor reporting making it difficult for users to choose and interpret available values) suggest that reporting guidelines are required to improve the consistency and quality of reporting of studies that value children's health using preference-based techniques.

Behavioral Theories That Have Influenced the Way Health State Preferences Are Elicited and Interpreted: A Bibliometric Mapping Analysis of the Time Trade-Off Method With VOSviewer Visualization

Aim

The aim of this paper is to develop an understanding of how behavioral theories have influenced the way preferences for health-related quality of life are elicited and interpreted. We focus on the Time Trade-off (TTO) method given it represents the quality-adjusted life-year (QALY) concept-that survival in less-than-full health can be deemed equivalent to a shorter survival in full health. To our knowledge this is the first review using a combination of systematic scoping review, bibliometrics and VOSviewer visualization to map the development of ideas in health economics.

Methods

A priori, we selected three behavioral theories to explore within our review, referred to here as Expected Utility Theory, Non-Expected Utility Theory and Probabilistic Choice Theory. A fourth topic, Order Effects, is defined broadly to encompass behavioral theories around timing/sequence of events. For the main search, Scopus was used to identify literature that had (a) elicited TTO values and/or (b) contributed to the way TTO values were elicited and interpreted, from inception to July 2021. Papers that focused on the latter category were given the label "behavioral" and underwent additional analyses. A two stage-screening was applied to assess eligibility. Co-citation, co-authorship and co-occurrence of keywords was used to chart the development of TTO over time.

Results

A total of 1,727 records were retrieved from Scopus and were supplemented by an additional 188 papers. There were 856 applied and 280 behavioral papers included in the final corpus, with the behavioral set split equally into four sets of 70 papers to chart the development of keywords over time: (1) 1972-1999; (2) 2000-2010, (3) 2010-2015 and (4) 2015-2021.

Discussion

The keyword analysis suggested that whilst some ideas transition quickly from economic theory to the TTO literature, such as the impact of Order Effects, others take longer to be assimilated, for example Non-Expected Utility models or failure of constant discounting. It is therefore important that researchers within health economics work more closely with those in mainstream economics and keep abreast of the wider economics and behavioral sciences to expedite the uptake of new and relevant ideas.

Health and Economic Outcomes of Home Maintenance Allergen Immunotherapy in Select Patients with High Health Literacy during the COVID-19 Pandemic: A Cost-Effectiveness Analysis During Exceptional Times

BACKGROUND

Allergen immunotherapy (AIT) is safe and effective but is typically administered under strict clinic observation to mitigate the risk of a systemic reaction to immunotherapy (SRIT). However, in the setting of the global coronavirus disease 2019 pandemic, alternative care models should be explored.

OBJECTIVE

To evaluate the cost-effectiveness of home immunotherapy self-administration (HITSA) in a highly idealized circumstance for provision of maintenance AIT in a shelter-in-place or other scenarios of unforeseen reduction in nonessential medical services.

METHODS

Markov modeling was used to compare in-office clinic AIT in selected patients using cohort analysis and microsimulation from the societal and health care perspectives.

RESULTS

Assuming similar SRIT rates, HITSA was found to be a cost-effective option with an incremental cost-effectiveness ratio of $44,554/quality-adjusted life-year when considering both incremental epinephrine autoinjector costs and coronavirus disease 2019 risks. Excluding epinephrine autoinjector costs, HISTA dominated other options. However, outside of pandemic considerations, HITSA was not cost-effective (incremental cost-effectiveness ratio, $198,877,286) at annual epinephrine autoinjector costs above $287. As the incremental HITSA SRIT rate increased above 15%, clinic AIT was the most cost-effective strategy. Excluding both pandemic risks and risk of motor vehicle accident fatality from round-trip clinic transit, clinic AIT dominated other strategies. Clinic AIT was the more cost-effective option at very high fatality relative risk for HITSA or at very low annual risk of contracting coronavirus disease 2019.

CONCLUSIONS

Under idealized assumptions HITSA can be a safe and cost-effective option during a global pandemic in appropriately selected patients provided home rates of SRIT remain stable.

Automated Tool for Health Utility Assessments: The Gambler II

Background. The Gambler II is a web-based utility assessment tool supporting visual analogue scale (VAS), standard gamble (SG), and time trade-off (TTO) utility assessments. It contains novel features, including an easy to use project development authoring tool and use of multimedia clips for health state descriptions. Objectives. Evaluate the usability and understandability of the patient-facing side of The Gambler. Investigate the feasibility of using The Gambler and evaluate its impact on patient knowledge regarding the relevant health states. Materials and Methods. We used The Gambler to assess utilities on a convenience sample of 55 users for common long-term complications of type 2 diabetes mellitus: diabetic neuropathy, diabetic retinopathy, and diabetic foot infection requiring transmetatarsal amputation. Using VAS, SG, and TTO, we collected metadata, such as time spent on each assessment and the entire assessment process. We evaluated usability with an adaptation of the System Usability Scale survey and understandability. We evaluated impact on knowledge gained through knowledge assessments about these complications before and after use of The Gambler. Results. Overall satisfaction with The Gambler was high, 4.02 on a 5-point scale. Usability rated highly at 84.93 on a normalized scale between 0 and 100. Knowledge scores increased significantly following use of The Gambler from pretest mean of 68% to posttest mean of 76% (P < 0.01). Average time using the software: ∼7½ minutes. Conclusions. The Gambler is an easy to use and understand computer-based tool for utility assessment. It is feasible to use within clinical encounters to support shared decision making, and it has unique features that make it a powerful tool for investigators interested in research on health utilities.

A primer on cost-effectiveness in the allergy clinic

OBJECTIVE

To provide a cost-effectiveness primer for the practicing allergist.

DATA SOURCES

Articles assessing use of decision analysis and cost-effective healthcare delivery.

STUDY SELECTIONS

A narrative review detailing approaches to incorporate evidence based medicine into individualized patient-centered cost-effective practice.

RESULTS

Resources in medicine are finite and it has been estimated that more than 30% of healthcare spending is directed toward low-value care. Insurers and government agencies are increasingly looking to maximize health value. Cost-effective analyses (CEA) is a complex valuation that grades health outcomes and economic benefits of a specific aspect of clinical care over a particular time horizon. In the US, therapies are generally considered cost-effective at ceilings between $50,000 - $150,000 per QALY. Critical components of CEA include model development to accurately represent clinical decisions and outcomes, evidence-based inputs, appropriate sensitivity analyses, and clarity in selecting the target population, perspective, comparators, time horizon, discount rate, and health outcomes. CEA can better inform trade-offs in patient care and add clarity in the translation of evidence to medical recommendations. Future research is likely to provide a more complete understanding of variation across population health state utilities for allergic conditions to more accurately reflect quality adjusted life years for patients with allergies.

CONCLUSION

Viewing healthcare options through an economic lens has become the standard of care across the United States and internationally, whether mandated through government agencies or third party payers. Decision analysis with cost-utility models can provide a useful perspective for both individual practice and public health.

Utility Measures in Pediatric Temporary Health States: Comparison of Prone Positioning Valuation Through 5 Assessment Tools

BACKGROUND

Assessment of health-related quality of life (HRQOL or utility) is a complex issue especially in children with temporary health states.

OBJECTIVES

To assess the utility of prone positioning as a prophylactic postsurgical approach with the aid of 5 frequently used general instruments.

METHODS

Visual analogue scale (VAS), time trade-off (TTO), modified TTO (m-TTO), standard gamble (SG), and chain of gambles (ChGs) instruments and interview with the parent caregivers were used to measure the HRQOL (utility value) of patients who were admitted in the surgical wards of Children's Medical Center Hospital between July and November 2015.

RESULTS

A total of 74 parent caregivers with a mean age of 30.48 ± 6.66 years were enrolled. On the basis of the Gaussian model of the repeated VAS measures, we classified the behavior of the participants into 4 clusters. Cumulative study of all these clusters demonstrated that TTO has the highest utility measure for prone positioning (0.682 ± 0.359), whereas the lowest utility value was measured by VAS2 (0.132 ± 0.569). In addition, all VAS measures underestimated the preferences. Overall, values of TTO, m-TTO, and ChGs remained consistent through each of these 4 clusters (intracluster consistency) and within each cluster (intercluster consistency). The adopted utility value of prone positioning based on these 3 instruments was estimated as 0.68 ± 0.21.

CONCLUSIONS

We recommended a model for assessment of HRQOL in children with temporary health states to overcome the challenges of each isolated instrument and used this model to measure the utility value of prone positioning in pediatric patients.

Computer-Assessed Preference-Based Quality of Life in Patients with Spinal Cord Injury

Objectives

Our aims were to (1) measure quality of life (QoL) in spinal cord injury (SCI) patients using different methods and analyze differences; (2) enable targeted treatments by identifying variables that affect QoL; and (3) provide decision-makers with useful data for cost-utility analyses in SCI population.

Methods

Seventy-one participants were enrolled. The computer-based tool UceWeb was used to elicit QoL in terms of utility coefficients, through the standard gamble, time trade-off, and rating scale methods. The SF36 questionnaire was also administered. Statistical analyses were performed to find predictors of QoL among collected variables.

Results

Median values for rating scale, time trade-off, and standard gamble were 0.60, 0.82, and 0.85, respectively. All scales were significantly correlated. Rating scale and SF36 provided similar values, significantly lower than the other methods. Impairment level, male gender, older age, living alone, and higher education were correlated with lower QoL but accounted for only 20% of the variation in utility coefficients.

Conclusions

Demographic and clinical variables are useful to predict QoL but do not completely capture utility coefficients variability. Therefore, direct preference-based utility elicitation should be strengthened. Finally, this is the first study providing data that can be used as a reference for cost-utility analyses in the Italian SCI population.

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.