How do individuals value health states? A qualitative investigation

Putting the Choice in Choice Tasks: Incorporating Preference Elicitation Tasks in Health Preference Research

Choice-based preference elicitation methods such as the discrete choice experiment (DCE) present hypothetical choices to respondents, with an expectation that these hypothetical choices accurately reflect a 'real world' health-related decision context and that consequently the choice data can be held to be a true representation of the respondent's health or treatment preferences. For this to be the case, careful consideration needs to be given to the format of the choice task in a choice experiment. The overarching aim of this paper is to highlight important aspects to consider when designing and 'setting up' the choice tasks to be presented to respondents in a DCE. This includes the importance of considering the potential impact of format (e.g. choice context, choice set presentation and size) as well as choice set content (e.g. labelled and unlabelled choice sets and inclusion of reference alternatives) and choice questions (stated choice versus additional questions designed to explore complete preference orders) on the preference estimates that are elicited from studies. We endeavoure to instil a holistic approach to choice task design that considers format alongside content, experimental design and analysis.

Recommendations for Emerging Good Practice and Future Research in Relation to Family and Caregiver Health Spillovers in Health Economic Evaluations: A Report of the SHEER Task Force

BACKGROUND

Omission of family and caregiver health spillovers from the economic evaluation of healthcare interventions remains common practice. When reported, a high degree of methodological inconsistency in incorporating spillovers has been observed.

AIM

To promote emerging good practice, this paper from the Spillovers in Health Economic Evaluation and Research (SHEER) task force aims to provide guidance on the incorporation of family and caregiver health spillovers in cost-effectiveness and cost-utility analysis. SHEER also seeks to inform the basis for a spillover research agenda and future practice.

METHODS

A modified nominal group technique was used to reach consensus on a set of recommendations, representative of the views of participating subject-matter experts. Through the structured discussions of the group, as well as on the basis of evidence identified during a review process, recommendations were proposed and voted upon, with voting being held over two rounds.

RESULTS

This report describes 11 consensus recommendations for emerging good practice. SHEER advocates for the incorporation of health spillovers into analyses conducted from a healthcare/health payer perspective, and more generally inclusive perspectives such as a societal perspective. Where possible, spillovers related to displaced/foregone activities should be considered, as should the distributional consequences of inclusion. Time horizons ought to be sufficient to capture all relevant impacts. Currently, the collection of primary spillover data is preferred and clear justification should be provided when using secondary data. Transparency and consistency when reporting on the incorporation of health spillovers are crucial. In addition, given that the evidence base relating to health spillovers remains limited and requires much development, 12 avenues for future research are proposed.

CONCLUSIONS

Consideration of health spillovers in economic evaluations has been called for by researchers and policymakers alike. Accordingly, it is hoped that the consensus recommendations of SHEER will motivate more widespread incorporation of health spillovers into analyses. The developing nature of spillover research necessitates that this guidance be viewed as an initial roadmap, rather than a strict checklist. Moreover, there is a need for balance between consistency in approach, where valuable in a decision making context, and variation in application, to reflect differing decision maker perspectives and to support innovation.

Exploring older people's understanding of the QOL-ACC, a new preference-based quality-of-life measure, for quality assessment and economic evaluation in aged care: the impact of cognitive impairment and dementia

BACKGROUND

Quality-of-life is an essential outcome for quality assessment and economic evaluation in health and social care. The-Quality-of-Life - Aged Care Consumers (QOL-ACC) is a new preference-based quality-of-life measure, psychometrically validated with older people in aged care. More evidence is needed to inform the self-report reliability of the QOL-ACC in older people with varying levels of cognitive impairment and dementia.

METHODS

A think-aloud protocol was developed and applied with older residents. The Mini Mental State Examination (MMSE) was applied to assign participants to no cognitive impairment (NCI - MMSE score ≥ 27) and cognitive impairment (MMCI - MMSE score < 27) subgroups. Three independent raters utilised a Tourangeau survey response model-based framework to identify response issues. Data were compared across cognition subgroups and synthesized using a 'traffic light' grading to classify frequency and type of response issues. Gradings were utilised to assess self-report reliability according to different levels of cognitive impairment.

RESULTS

Qualitative data from 44 participants (NCI = 20, MMCI = 24) were included for analysis. Response issues were more evident in the cognitive impairment subgroup than the no cognitive impairment subgroup. All participants who received a 'red' grade had an MMSE score of < 20 and 66% of 'amber' grades occurred in the cognitive impairment subgroup.

CONCLUSIONS

The QOL-ACC is able to be completed reliably by older residents with an MMSE score > 17. Future research is needed to assess the generalisability of these findings to other preference-based quality of life instruments and for older people in other care settings including health systems.

Valuation of EQ-5D-5L health states from cancer patients' perspective: a feasibility study

OBJECTIVES

To assess the feasibility of estimating an EQ-5D-5L value set using a small study design in cancer patients and to compare the EQ-5D-5L values based on the preferences of cancer patients with those of the general public.

METHODS

Patients with clinically diagnosed cancers were recruited from two hospitals in Shanghai, China. In face-to-face interviews using the EQ-PVT survey, health states were valued by cancer patients using both cTTO and DCE methods. cTTO data was modelled alone or jointly with DCE data. Forty-eight models using different model specifications (cross-attribute level effect [CALE] and additive models), random/fixed effects model assumptions, data heteroscedasticity and censoring were estimated. The best performed model was identified in terms of monotonicity of estimated model coefficients and out-of-sample prediction accuracy.

RESULTS

Data collected from 221 cancer patients who participated in the study were included. The hybrid CALE model using both TTO and DCE data performed best in terms of prediction accuracy (Lin's concordance coefficient = 0.989; root mean squared error = 0.058) and suggested that pain/discomfort and anxiety/depression were the most undesirable health problems. Compared to values based on general Chinese public's health preferences, the values based on cancer patients' preferences were much higher and lower for health states characterized by extreme mobility problems and severe/extreme pain or discomfort, respectively.

CONCLUSION

This study demonstrated the feasibility of using a small design to develop EQ-5D-5L value sets based on cancer patients' health preferences. Since there were signs of differences between preferences of patients and general population, it may be valuable to develop patient-specific value sets and use them in clinical decision making and economic evaluations.

Do Misconceptions About Health-Related Quality of Life Affect General Population Valuations of Health States?

OBJECTIVES

Healthcare resource allocation decisions are often informed by the expected gains in patients' quality-adjusted life-years. Misconceptions about ill-health's consequences for quality of life (QOL) may however affect evaluations of health states by the general population and hence affect resource allocation decisions informed by quality-adjusted life-years. We examine whether people selectively misestimate the QOL consequences of moderate anxiety or depression compared with other dimensions of health, and we test whether informing people of actual changes in QOL associated with health states changes appraisals of their relative undesirability.

METHODS

UK general population participants (N = 1259; in 2017) expressed preferences over moderate problems: anxiety or depression, self-care, and pain or discomfort. A randomized control trial design was used whereby a control group was given a functional description of each health state, and 2 intervention groups were additionally given information on the actual differences in either life satisfaction (LS) or day affect (DA) associated with experiencing each health state.

RESULTS

The LS (DA) group reported a higher preference for avoiding living with moderate anxiety or depression, being 13.4% (13.9%) more likely to choose it as most undesirable.

CONCLUSION

Informing people of the change in LS or DA associated with health states before they appraise them is a feasible way to obtain informed preferences.

Discrete Choice Experiments in Health State Valuation: A Systematic Review of Progress and New Trends

BACKGROUND

Discrete choice experiments (DCEs) are increasingly used in health state valuation studies.

OBJECTIVE

This systematic review updates the progress and new findings of DCE studies in the health state valuation, covering the period since the review of June 2018 to November 2022. The review reports the methods that are currently being used in DCE studies to value health and study design characteristics, and, for the first time, reviews DCE health state valuation studies published in the Chinese language.

METHODS

English language databases PubMed and Cochrane, and Chinese language databases Wanfang and CNKI were searched using the self-developed search terms. Health state valuation or methodology study papers were included if the study used DCE data to generate a value set for a preference-based measure. Key information extracted included DCE study design strategies applied, methods for anchoring the latent coefficient on to a 0-1 QALY scale and data analysis methods.

RESULTS

Sixty-five studies were included; one Chinese language publication and 64 English language publications. The number of health state valuation studies using DCE has rapidly increased in recent years and these have been conducted in more countries than prior to 2018. Wide usage of DCE with duration attributes, D-efficient design and models accounting for heterogeneity has continued in recent years. Although more methodological consensus has been found than in studies conducted prior to 2018, this consensus may be driven by valuation studies for common measures with an international protocol (the 'model' valuation research). Valuing long measures with well-being attributes attracted attention and more realistic design strategies (e.g., inconstant time preference, efficient design and implausible states design) were identified. However, more qualitative and quantitative methodology study is still necessary to evaluate the effect of those new methods.

CONCLUSIONS

The use of DCEs in health state valuation continues to grow dramatically and the methodology progress makes the method more reliable and pragmatic. However, study design is driven by international protocols and method selection is not always justified. There is no gold standard for DCE design, presentation format or anchoring method. More qualitative and quantitative methodology study is recommended to evaluate the effect of new methods before researchers make methodology decisions.

Hypothetical versus experienced health state valuation: a qualitative study of adult general public views and preferences

OBJECTIVES

Responses from hypothetical and experienced valuation tasks of health-related quality of life differ, yet there is limited understanding of why these differences exist, what members of the public think about them, and acceptable resolutions. This study explores public understanding of, opinions on, and potential solutions to differences between hypothetical versus experienced responses, in the context of allocating health resources.

METHODS

Six focus groups with 30 members of the UK adult public were conducted, transcribed verbatim, and analysed using framework analysis. Participants self-completed the EQ-5D-5L, before reporting the expected consequences of being in two hypothetical EQ-5D-5L health states for ten years. Second, participants were presented with prior results on the same task from a public (hypothetical) and patient (experienced) sample. Third, a semi-structured discussion explored participants': (1) understanding, (2) opinions, and (3) potential resolutions.

RESULTS

Twenty themes emerged, clustered by the three discussion points. Most participants found imagining the health states difficult without experience, with those aligned to mental health harder to understand. Participants were surprised that health resource allocation was based on hypothetical responses. They viewed experienced responses as more accurate, but noted potential biases. Participants were in favour of better informing, but not influencing the public. Other solutions included incorporating other perspectives (e.g., carers) or combining/weighting responses.

CONCLUSION

Members of the UK public appear intuitively not to support using potentially uninformed public values to hypothetical health states in the context of health resource allocation. Acceptable solutions involve recruiting people with greater experience, including other/combinations of views, or better informing respondents.

Urban/rural differences in preferences for EQ-5D-5L health states: a study of a multi-ethnic region in China

OBJECTIVES

This study aimed to compare health preferences for EQ-5D-5L health states between urban and rural populations in China.

METHODS

This study used pooled secondary data from two EQ-5D-5L valuation studies. Participants were recruited from Guizhou province and Chongqing municipality, China using quota sampling. Each participant was interviewed face-to-face to value a set of 15 or 16 out of 30 EQ-5D-5L health states using time trade-off (TTO) methods including composite TTO and other two variants. Regression analysis was used to compare health state preferences between urban and rural participants.

RESULTS

A total of 597 participants (urban: 55.44%; rural: 44.56%) completed the valuation interviews. Both univariate and multivariable linear regression analyses showed that rural participants tended to value health states lower than urban participants regardless of severity of health states. The unadjusted and adjusted overall mean differences between the two groups were - 0.041 (95% confidence interval [CI] - 0.077, - 0.004, p-value = 0.031) and - 0.040 (95% CI - 0.078, - 0.002, p-value = 0.038), respectively. Predictions for the 3125 health states based on rural participants' health preferences were lower than those based on urban participants' health preferences.

CONCLUSION

There were small, yet statistically significant, differences in EQ-5D-5L health states preferences between urban and rural populations in China. Future study aiming at establishing a national value set should pay more attention to the sample representativeness.

Observational study of health utilities in adult primary ciliary dyskinesia patients: preliminary data on associations with molecular diagnosis, clinical phenotype and HRQOL measures

Background

Primary ciliary dyskinesia (PCD) is a congenital disorder characterized by chronic respiratory morbidity. To date, there is no information on PCD-specific preference-based quality of life measures such as health utilities (HU). We cross-sectionally assessed HU in adult PCD patients and explored relationships with genotype, phenotype and quality of life (QOL)-PCD scales.

Methods

Diagnostic testing was performed according to international guidelines, while participants completed the visual analog scale (VAS), time trade off (TTO), standard gamble (SG), and EuroQol 5 dimensions (EQ5D) HU instruments, as well as the QOL-PCD questionnaire. Hierarchical regression was used to identify the QOL-PCD scales that are most predictive of HU.

Results

Among 31 patients, median HU are 0.75 (VAS), 0.86 (EQ5D), 0.91 (TTO) and 0.99 (SG). The underlying genotype is not associated with HU measures. VAS and EQ5D are associated with lung function, while TTO and SG values are not sensitive to any of the examined factors. Among the QOL-PCD scales, physical functioning and lower respiratory symptoms explained much of VAS (R²= 0.419) and EQ5D (R²= 0.538) variability.

Conclusions

Our study demonstrates that HU elicitation in PCD is feasible using both direct and indirect methods. Overall, HU scores are relatively high among adult patients, with higher scores observed in SG and TTO, followed by EQ5D and VAS. VAS and EQ5D HU values are sensitive to lung function as well as to QOL-PCD physical functioning and lower respiratory symptom scores.

Why Do Adults Value EQ-5D-Y-3L Health States Differently for Themselves Than for Children and Adolescents: A Think-Aloud Study

OBJECTIVES

Following protocol, adults value EQ-5D-Y-3L health states from the perspective of a 10-year-old child. It remains unclear why adults value health states differently for themselves than for a 10-year-old child and whether the latter perspective is representative of adults' preferences for the 8 to 15 years age range of the EQ-5D-Y-3L. This study examines the reasons underlying (potential) differences in adults' health-state preferences for themselves, a 10-year-old child, and 15-year-old adolescent.

METHODS

We conducted semistructured interviews using a think-aloud protocol with 25 participants who performed valuation tasks in July 2020 to August 2020. Using the Framework Method, we developed 28 categories grouped under 5 themes that illustrated the differences emerging from the interviews.

RESULTS

Participants (A) deemed it more straining to perform valuation tasks for a 10-year-old child and 15-year-old adolescent than for themselves, (B) had a stable self-image, but varied in whom they imagined as 10-year-old child and 15-year-old adolescent, (C) focused on different dimensions and levels for a 15-year-old adolescent than for a 10-year-old child and themselves, (D) had various thoughts about nonhealth-related factors that influenced their preferences, and (E) gave up relatively few life-years for a 10-year-old child and 15-year-old adolescent, also to avoid others bearing a grudge against them.

CONCLUSIONS

Our results indicate that differences in adults' health-state preferences for themselves and a 10-year-old child largely result from differences in thoughts about nonhealth-related factors. They further indicate that health-state preferences for a 10-year-old child may not be representative of such preferences for the full EQ-5D-Y-3L age range.

Exploration of the Reasons Why Health State Valuation Differs for Children Compared With Adults: A Mixed Methods Approach

OBJECTIVES

Evidence comparing utilities for adults and children consistently report higher utility values for child health states. This study investigates the reasons why child health states are valued differently.

METHODS

A total of 80 respondents (United Kingdom, Belgium, The Netherlands) participated in 1.5-hour face-to-face interviews. Respondents valued 4 health states from 2 perspectives (8-year-old child, 40-year-old adult) using visual analog scale and time trade-off. A total of 32 respondents participated in think-aloud interviews. Audio recordings were analyzed by 2 independent coders using NVIVO software. Statements, nodes, and themes were reviewed cyclically until consensus was reached.

RESULTS

Qualitative results: a total of 5 themes were identified in the data regarding child and adult valuation-intergenerational responsibility and dependency (childhood is crucial for forming life skills based on new experiences; adulthood is an important time to take care of the family), staying alive is important (life is worth living even with impaired health-related quality of life (HRQoL), for children and adults), awareness of poor HRQoL and ability to make decisions (children have difficulties comprehending poor HRQoL and their parents make their healthcare decision; adults can assess their own HRQoL and decide for themselves), coping ability (children are flexible and resilient; adults have experience with dealing with difficulties), and practical organization of care (children are cared for by their parents; adults are able to organize and pay for care). Mixed methods: comparing qualitative statements with respondents' higher utilities for child health states confirmed concordance between results.

CONCLUSIONS

Quality-adjusted life-years are interpreted differently for children and adults. Child-specific value sets are needed to reflect society's preferences and to adequately conduct health technology assessment of pediatric treatments.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Supplementary Information

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

Impact of Including Carer Information in Time Trade-Off Tasks: Results from a Pilot Study

INTRODUCTION

Carer quality of life (QoL) can be included in economic evaluations and captured using EQ-5D. Traditional valuation tasks require participants to imagine living in a health state for a number of years, without being told what to consider. This pilot study sought to investigate whether participants implicitly consider the impact of the health state on others, and the extent to which this may impact health state valuations.

METHODS

Composite time trade-off (TTO) interviews were conducted with a convenience sample. Each interview included a 'traditional' TTO exercise to value three health states, and a 'combined' TTO exercise, where participants valued the same health states again, having been informed that they would require a carer living in a particular health state. Qualitative feedback was collected after each exercise. Paired t-test comparisons of the utilities elicited in each exercise were made.

RESULTS

Thirty-three participants enrolled in the pilot. Mean differences between exercises were not statistically significant and differed in direction, although considerable heterogeneity was observed in individual response trajectories. Overall, 36% (n = 12) of participants expressed an unprompted concern about being a burden on others in the traditional exercise, and 67% (n = 22) of participants would have responded differently had the carer been in full health in the combined exercise.

CONCLUSION

Providing contextual information about carers may impact valuations. Further research is required to better understand the reasons behind the variation in individual response trajectories observed in this pilot study. The insights from this study may be useful for informing the design of related future studies.

What drives differences in preferences for health states between patients and the public? A qualitative investigation of respondents' thought processes

Cost-effectiveness analyses using quality-adjusted life-years (QALYs) are used in decision-making regarding which interventions are available via many national healthcare systems. QALYs are calculated based on health state values provided by preference elicitation techniques. Several national decision-making bodies recommend that health state values should be based on preferences elicited from general populations, rather than from patients. Previous studies have shown systematic differences between health state values elicited from members of the general population and from patients. Various explanations for this phenomenon have been proposed, however empirical evidence for these is scarce. We aimed to explore possible reasons for discrepancies between public and patient valuations by undertaking qualitative cognitive interviews, asking 14 members of the general population and 12 people with multiple sclerosis (MS) to think aloud while completing a preference elicitation task (time trade-off) for MS-related health states. The interviews were undertaken between December 2016 and October 2017 in the South West region of England, and were analysed using the Framework Method. As anticipated, we found that participants with MS had more experience of health problems and used this experience to consider how they might adapt to the health states over time, and which dimensions of health-related quality of life were most important to them. We found no evidence that participants with MS were less affected by framing effects and focusing illusions, more likely to prioritise non-physical dimensions of health, or more prone to loss aversion, endowment effects and non-compensatory decision-making. These findings contribute to our understanding of how patients and members of the general population respond to preference elicitation exercises, and why their preferences may differ, and may help to inform developing areas of research, such as the joint presentation of cost-effectiveness results from multiple perspectives, and the use of preferences elicited from patients for experienced health states.

Reporting and valuing one's own health: a think aloud study using EQ-5D-5L, EQ VAS and a time trade-off question among patients with a chronic condition

Background

The EQ-5D-5L, the EQ VAS, and the time trade-off (TTO) are commonly used to report and value health. Still, there is a need to better understand how these questionnaires and methods are perceived by the respondents, as well as the thoughts and motives behind their responses. The aim of this study was to increase knowledge of how individuals think and reason when reporting and valuing their own current health, using EQ-5D-5L, EQ VAS, and an open-ended TTO question.

Methods

Twenty patients with type 1 diabetes participated in qualitative individual think aloud interviews in Stockholm, Sweden. Participants were asked to describe their thoughts when responding to three assessments. The interviews were transcribed verbatim and analyzed using thematic analysis.

Results

The analysis showed that participants conducted the assessments by contextualizing and interpreting instructions, relating the questions to their own health, using different recall periods and time perspectives, and using personal, interpersonal, or normative comparators. It was challenging to reduce the experience of everyday life into a response option, and the thoughts behind the responses differed between the assessments. Before deciding on what to include, participants thought of the purpose and context of the assessments. Current health or past experiences of health were applied in the EQ-5D descriptive system and in EQ VAS, while participants focused on the future in the TTO. Thoughts about the impact on others, personal goals, and expectations on future health were more clearly integrated in the TTO assessment. All participants considered the trade-off between life years and health. However, despite the use of different comparators, the concept of ‘full health’ was found difficult to imagine or relate to.

Conclusions

This study provides insights as to how responses to the EQ-5D-5L, EQ VAS, and TTO assessments are complementary and where these assessments differ in adults with a chronic condition. The findings may contribute to a better understanding when interpreting the quantitative results and contribute to the literature pertaining to possible explanations for differences in health state values depending on the valuation method.

Comparison of online and face-to-face valuation of the EQ-5D-5L using composite time trade-off

OBJECTIVE

The aim of this study was to compare online, unsupervised and face-to-face (F2F), supervised valuation of EQ-5D-5L health states using composite time trade-off (cTTO) tasks.

METHODS

The official EuroQol experimental design and valuation protocol for the EQ-5D-5L of 86 health states were implemented in interviewer-assisted, F2F and unsupervised, online studies. Validity of preferences was assessed using prevalence of inconsistent valuations and expected patterns of TTO values. Respondent task engagement was measured using number of trade-offs and time per task. Trading patterns such as better-than-dead only was compared between modes. Value sets were generated using linear regression with a random intercept (RILR). Value set characteristics such as range of scale and dimension ranking were evaluated between modes.

RESULTS

Five hundred one online and 1,134 F2F respondents completed the surveys. Mean elicited TTO values were higher online than F2F when compared by health state severity. Compared to F2F, a larger proportion of online respondents did not assign the poorest EQ-5D-5L health state (i.e., 55555) the lowest TTO value ([Online] 41.3% [F2F] 12.2%) (p < 0.001). A higher percentage of online cTTO tasks were completed in 3 trade-offs or fewer ([Online] 15.8% [F2F] 3.7%), (p < 0.001). When modeled using the RILR, the F2F range of scale was larger than online ([Online] 0.600 [F2F] 1.307) and the respective dimension rankings differed.

CONCLUSIONS

Compared to F2F data, TTO tasks conducted online had more inconsistencies and decreased engagement, which contributed to compromised data quality. This study illustrates the challenges of conducting online valuation studies using the TTO approach.

Informing Patient-Centered Care Through Stakeholder Engagement and Highly Stratified Quantitative Benefit-Harm Assessments

OBJECTIVES

In a previous project aimed at informing patient-centered care for people with multiple chronic conditions, we performed highly stratified quantitative benefit-harm assessments for 2 top priority questions. In this current work, our goal was to describe the process and approaches we developed and to qualitatively glean important elements from it that address patient-centered care.

METHODS

We engaged patients, caregivers, clinicians, and guideline developers as stakeholder representatives throughout the process of the quantitative benefit-harm assessment and investigated whether the benefit-harm balance differed based on patient preferences and characteristics (stratification). We refined strategies to select the most applicable, valid, and precise evidence.

RESULTS

Two processes were important when assessing the balance of benefits and harms of interventions: (1) engaging stakeholders and (2) stratification by patient preferences and characteristics. Engaging patients and caregivers through focus groups, preference surveys, and as co-investigators provided value in prioritizing research questions, identifying relevant clinical outcomes, and clarifying the relative importance of these outcomes. Our strategies to select evidence for stratified benefit-harm assessments considered consistency across outcomes and subgroups. By quantitatively estimating the range in the benefit-harm balance resulting from true variation in preferences, we clarified whether the benefit-harm balance is preference sensitive.

CONCLUSIONS

Our approaches for engaging patients and caregivers at all phases of the stratified quantitative benefit-harm assessments were feasible and revealed how sensitive the benefit-harm balance is to patient characteristics and individual preferences. Accordingly, this sensitivity can suggest to guideline developers when to tailor recommendations for specific patient subgroups or when to explicitly leave decision making to individual patients and their providers.

Reasoning in the valuation of health-related quality of life: A qualitative content analysis of deliberations in a pilot study

BACKGROUND

Group deliberation can be a pathway to understanding reasons behind judgement decisions. This pilot study implemented a deliberative process to elicit public values about health-related quality of life. In this study, participants deliberated scales and weights for a German adaption of the Short-Form Six-Dimension (SF-6D) Version 2 from a public perspective.

OBJECTIVE

This article examines the reasons participants stated for health state valuations and investigates the feasibility of eliciting public reasons for judgement decisions in a deliberative setting.

METHODS

The 1-day deliberation was guided by MACBETH as a method of multi-criteria decision analysis and involved qualitative comparisons of SF-6D health states and dimensions. Participants deliberated in parallel small groups and a subsequent plenary assembly. A qualitative content analysis was conducted to assess the value judgements and reasons behind them.

RESULTS

A total of 34 students participated in the study. Common reasoning was the level of impairment, marginal benefit, possibility of adjustment and expectation satisfaction. While the small groups agreed on scales for the SF-6D dimensions, the plenary assembly did not reach consensus on one scale and dimension weights. When dimensions were prioritized, these were pain and mental health.

CONCLUSIONS

While no consented value set was derived, this pilot study presents a promising approach for eliciting public reasoning behind judgements on health state values. Furthermore, it demonstrates that participants consider diverse motives when valuing health-related quality of life.

Hybrid Methodology to Improve Health Status Utility Values Derivation Using EQ-5D-5L and Advanced Multi-Criteria Techniques

This paper presented a new approach to the calculation of quality-adjusted life years (QALY) based on multi-criteria decision-making (MCDM) methods and using the EQ-5D-5L questionnaire. The health status utility values were calculated through a hybrid methodology. We combined the analytic hierarchy process (AHP), the AHP with a D-number extended fuzzy preference relation (D-AHP), the fuzzy analytic hierarchy process (F-AHP), and the technique for order preference by similarity to the ideal solution (TOPSIS) to obtain individual and aggregated utility values. The preference data were elicited using a sample of individuals from a Colombian university. In all tested methods, the ordinal preferences were consistent, and the weights were compared using the Euclidean distance criterion (EDC). We identified F-AHP-TOPSIS as the optimal method; its benefits were associated with modeling the response options of the EQ-5D in linguistic terms, it gave the best approximation to the initial preferences according to EDC, and it could be used as an alternative to the known prioritization method. This hybrid methodology was particularly useful in certain medical decisions concerned with understanding how a specific person values his or her current health or possible health outcomes from different interventions in small population samples and studies carried out in low- and middle-low-income countries.

Effect of Reflection and Deliberation on Health State Values: A Mixed-Methods Study

BACKGROUND

Health economists ask members of the general public to value health states, but it is recognized that individuals construct their preferences during the valuation tasks. Conventional methods rely on one-off interviews that do not give participants time to reflect and deliberate on their preferences.

OBJECTIVE

This study investigates the effect of reflection and deliberation on health state preferences using the EQ-5D questionnaire and time trade-off valuation method.

METHODS

A novel concurrent explanatory mixed-methods design is used to investigate the explanation for the quantitative findings.

RESULTS

A total of 57 participants in the United Kingdom valued health states before and after a group-based deliberation exercise. There were large changes in health state values at the individual level, but the changes canceled out at the aggregate level. The mixed-methods findings suggest deliberation did not reveal new information or reduce inconsistencies in reasoning but rather focused on an exchange of personal subjective beliefs. In cases of disagreement, the participants accepted but did not adopt other participants' opinions. Participants remained uncertain about the relevance of their experiences and about their values.

CONCLUSIONS

The evidence suggests that reflection and deliberation, as designed in this study, are unlikely to result in large systematic changes of health state values. The uncertainties expressed by participants means future research should investigate whether preferences are informed or whether providing participants with more information helps them construct their preferences with more certainty. The mixed-methods design used is a promising design to help elucidate the reasons for quantitative findings.

How Prevalent Are Implausible EQ-5D-5L Health States and How Do They Affect Valuation? A Study Combining Quantitative and Qualitative Evidence

BACKGROUND

When designing a valuation study, a criterion that has been used for selecting health states for direct valuation is whether the health states are plausible for respondents, because it is assumed that inclusion of implausible states would compromise data quality.

OBJECTIVES

To understand which health states are implausible, and how their values differ from the values of the plausible counterparts.

METHODS

One thousand six hundred Chinese students valued all 3125 health states of the 5-level EuroQol 5-dimensional questionnaire (EQ-5D-5L) using the EuroQol visual analogue scale. Of these, 890 students also indicated whether each valued state was implausible or not using a binary scale. Additional qualitative interviews were conducted concerning the thought processes involved in the valuation of implausible states. We calculated an implausible score for each state. Then we examined the effect of implausibility on visual analogue scale values by fitting 2 regression models. Two independent researchers analyzed the qualitative transcripts using thematic analysis.

RESULTS

Approximately 30% of the EQ-5D-5L health states were rated as implausible by at least 50% of the respondents, but there was substantial heterogeneity in views about the plausibility of EQ-5D-5L states. Health states with dimensions that conflicted were more likely to be judged as implausible states. Health states that respondents deemed as implausible were more difficult to value and had lower values.

CONCLUSIONS

When respondents found the EQ-5D states to be implausible, they tended to give them lower values. Nevertheless, completely excluding implausible states from a valuation study is not possible because there is a lack of agreement among respondents on which states are implausible.

A new method for valuing health: directly eliciting personal utility functions

BACKGROUND

Standard methods for eliciting the preference data upon which 'value sets' are based generally have in common an aim to 'uncover' people's preferences by asking them to evaluate a subset of health states, then using their responses to infer their preferences over all dimensions and levels. An alternative approach is to ask people directly about the relative importance to them of the dimensions, levels and interactions between them. This paper describes a new stated preference approach for directly eliciting personal utility functions (PUFs), and reports a pilot study to test its feasibility for valuing the EQ-5D.

METHODS

A questionnaire was developed, designed to directly elicit PUFs from general public respondents via computer-assisted personal interviews, with a focus on helping respondents to reflect and deliberate on their preferences. The questionnaire was piloted in England.

RESULTS

Seventy-six interviews were conducted in December 2015. Overall, pain/discomfort and mobility were found to be the most important of the EQ-5D dimensions. The ratings for intermediate improvements in each dimension show heterogeneity, both within and between respondents. Almost a quarter of respondents indicated that no EQ-5D health states are worse than dead.

DISCUSSION

The PUF approach appears to be feasible, and has the potential to yield meaningful, well-informed preference data from respondents that can be aggregated to yield a value set for the EQ-5D. A deliberative approach to health state valuation also has the potential to complement and develop existing valuation methods. Further refinement of some elements of the approach is required.

Future Directions in Valuing Benefits for Estimating QALYs: Is Time Up for the EQ-5D?

The widespread adoption of the EuroQol 5-dimensional questionnaire (EQ-5D) has been important for the comparability, transparency, and consistency of economic evaluations for informing resource allocation in healthcare. The objectives of this article were to (1) critically assess whether the widespread adoption of the EQ-5D and its time trade-off-based value sets to inform economic evaluation is likely to continue and (2) speculate about how benefits may be measured and valued to inform economic evaluation in the future. Evidence supports the use of the EQ-5D in many areas of health, but there are notable gaps. Furthermore, there has been interest among some policy makers in measuring changes in well-being, and in using common outcomes across sectors. Possibilities for measuring well-being alongside health can be achieved through bolt-on dimensions or an entirely new measure capturing both health and well-being. Nevertheless, there are significant concerns about the logic of estimating a common utility function. The development of online valuation methods has had a major impact on the field, which is likely to continue. We, however, recommend more allowance for respondents to consider their answers. There is an ongoing debate on the role of patient values or experience-based values. To date, this has seen limited take-up by decision makers and there are significant technical problems to obtaining representative and meaningful values. Policy makers and the general population must decide on the focus and scope of benefits that are incorporated into economic evaluation, and current evidence on this is mixed. In part, this will determine whether the widespread adoption will continue.

One Method, Many Methodological Choices: A Structured Review of Discrete-Choice Experiments for Health State Valuation

BACKGROUND

Discrete-choice experiments (DCEs) are used in the development of preference-based measure (PBM) value sets. There is considerable variation in the methodological approaches used to elicit preferences.

OBJECTIVE

Our objective was to carry out a structured review of DCE methods used for health state valuation.

METHODS

PubMed was searched until 31 May 2018 for published literature using DCEs for health state valuation. Search terms to describe DCEs, the process of valuation and preference-based instruments were developed. English language papers with any study population were included if they used DCEs to develop or directly inform the production of value sets for generic or condition-specific PBMs. Assessment of paper quality was guided by the recently developed Checklist for Reporting Valuation Studies. Data were extracted under six categories: general study information, choice task and study design, type of designed experiment, modelling and analysis methods, results and discussion.

RESULTS

The literature search identified 1132 published papers, and 63 papers were included in the review. Paper quality was generally high. The study design and choice task formats varied considerably, and a wide range of modelling methods were employed to estimate value sets.

CONCLUSIONS

This review of DCE methods used for developing value sets suggests some recurring limitations, areas of consensus and areas where further research is required. Methodological diversity means that the values should be seen as experimental, and users should understand the features of the value sets produced before applying them in decision making.

Health-related quality of life and well-being health state values among Dutch oldest old

Background: Valuing hypothetical health states is a demanding personal process, since it involves the psychological evaluation of hypothetical health states. It seems plausible that elderly individuals will value hypothetical health states differently than the general population. It is, however, important to understand the psychological division that oldest old subgroups construct between acceptable and unacceptable health states. This information can produce important evidence regarding well-being and disability conceptualization. Objective: To investigate how Dutch oldest old, conceptualize health-related quality of life health states when compared to well-being health states. In addition, we aim to compare subgroups, based on dependency classification. Methods: Ninety-nine elderly living in the Groningen, Hoogeveen and Veendam areas of the Netherlands participated in the study. Respondents were classified into three groups based on dependency levels. The respondents were asked to value hypothetical health states, a generic preference-based HRQoL and a well-being instrument, using a visual analog scale. Results: All three groups ranked the same health states, from both questionnaires, below the average across the health states. The health-related quality of life health states was consistently ranked lower than the current well-being health states. Conclusions: Health state valuations performed by the oldest old indicate that conceptually, respondents view below average health-related and well-being health states as undesirable. The results indicated that the oldest old do view deficits in health-related health states as more important than deficits in well-being health states. Since the oldest old performed the valuations, focused interventions to improve below average health-related outcomes might be the most cost-effective way to increase oldest old well-being outcomes.

Experience-based utility and own health state valuation for a health state classification system: why and how to do it

In the estimation of population value sets for health state classification systems such as the EuroQOL five dimensions questionnaire (EQ-5D), there is increasing interest in asking respondents to value their own health state, sometimes referred to as "experience-based utility values" or, more correctly, own rather than hypothetical health states. Own health state values differ to hypothetical health state values, and this may be attributable to many reasons. This paper critically examines whose values matter; why there is a difference between own and hypothetical values; how to measure own health state values; and why to use own health state values. Finally, the paper examines other ways that own health state values can be taken into account, such as including the use of informed general population preferences that may better take into account experience-based values.

Are preferences over health states informed?

Background

The use of preference-elicitation tasks for valuing health states is well established, but little is known about whether these preferences are informed. Preferences may not be informed because individuals with little experience of ill health are asked to value health states. The use of uninformed preferences in cost-effectiveness can result in sub-optimal resource allocation. The aim of this study was to pilot a novel method to assess whether members of the public are informed about health states they value in preference-elicitation tasks.

Methods

The general public was said to be informed if the expectations of the public about the effect of ill health on people’s lives were in agreement with the experience of patients. Sixty-two members of the public provided their expectations of the consequences of ill health on five life domains (activities, enjoyment, independence, relationships, and avoiding being a burden). A secondary dataset was used to measure patient experience on those five consequences.

Results

There were differences between the expectations of the public and the experience of patients. For example, for all five life consequences the public underestimated the effects of problems in usual activities compared to problems in mobility. They also underestimated the effect of ‘anxiety or depression’ compared to physical problems on enjoyment of life and on the quality of personal relationships.

Conclusions

This proof-of-concept study showed that it is possible to test whether preferences are informed. This study should be replicated using a larger sample. The findings suggest that preferences over health states in this sample are not fully informed because the participants do not have accurate expectations about the consequences of ill health. These uninformed preferences may not be adequate for allocation of public resources, and research is needed into methods to make them better informed.