The lead time tradeoff: the case of health states better than dead

Comparison of Caregiver and General Population Preferences for Dependency-Related Health States

OBJECTIVE

We assess whether the preferences regarding dependency-related health states as stated by informal caregivers are aligned with those expressed by the general population.

METHODS

The preferences of a sample of 139 Spanish informal caregivers of dependent patients are compared with those obtained via a sample of 312 persons, also from the Spanish general population. We assess 24 dependency states extracted from the DEP-6D using the time trade-off method. Descriptive statistics and regression methods are used to explore differences between the two samples.

RESULTS

Mean difference tests establish that, for all but one of the 24 states, there are no significant differences between the samples. The estimated mean values ranged from - 0.64 to 0.60 for the caregiver sample and from - 0.60 to 0.65 for the general population sample, with a correlation of 0.96. On average, the classification of states as better or worse than dead matched in both samples (except for one state). Regression models also show that sample type does not have a significant average impact. After we introduce interaction effects, only the most severe level of two dimensions, cognitive problems and housework, result in significant differences-with the caregiver sample reporting higher values for the former, and lower values for the latter.

CONCLUSION

Caregivers and the general population exhibit quite similar preferences concerning dependency-related health states. This suggests that the results of cost-utility analyses, and the resource allocation decisions based on them, would likewise not be significantly affected by the preferences used to generate the weighting algorithm.

This Dead or That Dead: Framing Effects in the Evaluation of Health States

OBJECTIVES

Current approaches to health state valuation rely on credible classification of states as either "better than dead" or "worse than dead" (WTD). We investigate how such evaluations of health states are affected by the framing in pairwise comparison tasks.

METHODS

We conducted an online survey with 361 participants to compare the propensity to evaluate a state as WTD under 6 frames: (A) using a regular time trade-off (TTO) choice task, (B) using a lead-time TTO choice task, (C) excluding the immediacy of death, (D) avoiding reference to the process of dying, (E) focusing on longevity, and (F) focusing on improvements in quality of life. Each participant evaluated 9 EQ-5D-5L health states using 3 frames. The frames were compared using several statistical approaches to confirm robustness to indirect comparisons or respondent heterogeneity and inattentiveness.

RESULTS

The odds of a state being evaluated as WTD, compared with frame A, increase 2.7-fold and 1.5-fold in frame B and E, respectively, and decrease >5-fold in frame F. Frames C and D do not differ significantly from frame A.

CONCLUSIONS

Different framings for questions about whether a state is WTD or better than dead, even if theoretically equivalent, yield substantially different results. Notably, whether a state is evaluated as WTD differs greatly between the regular TTO and lead-time TTO choice tasks and when either final outcomes or improvements over time are considered.

Decision thresholds with genetic testing

A genetic test is a test for the presence or absence of a genetic mutation. A positive test outcome that reveals a mutation associated with increased risk for a disease may lead a patient to seek preventive treatment provided that the penetrance (probability of developing the disease given the mutation) is sufficiently high. We derive the test threshold and the test-treatment threshold, which confine the mutation probability interval for the use of the genetic test. Test and treatment costs as well as a low penetrance rate of the mutation narrow this interval. We illustrate the model with parameters of the test for BRCA1 and BRCA2 genes as well as of preventive treatment options for breast cancer.

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.

Population-Based Health Utility Assessment of Migraine Headache Symptoms before and after Surgical Intervention

BACKGROUND

Approximately 30 million Americans suffer from migraine headaches. The primary goals of this study are to (1) use Migraine-Specific Symptoms and Disability criteria and Migraine Headache Index to describe the symptomatic improvement following decompressive surgery for refractory migraines, and (2) use the average Migraine Headache Index preoperatively and postoperatively for health utility assessment from a healthy patient's perspective.

METHODS

The Migraine-Specific Symptoms and Disability criteria and the Migraine Headache Index were used to characterize migraine symptoms in the authors' patient population before and after decompressive surgery. Healthy individuals were randomized to a scenario in which they assumed either the preoperative or postoperative average patient symptom profile described by the authors' migraine patients. Health utility assessments were used to quantify the evaluation of health states the authors' patients experienced before and after surgical migraine therapy.

RESULTS

Twenty-five patients underwent surgery for migraine headaches. The Migraine-Specific Symptoms and Disability questionnaire showed a significant decrease in both frequency of headaches per month (p < 0.0001) and overall pain score (p = 0.007). The Migraine Headache Index demonstrated a statistically significant improvement (p = 0.03). Healthy individuals in the preoperative group had significantly lower utility scores compared with the postoperative group in all of the health utility assessments completed for migraine symptoms.

CONCLUSION

This is the first study to use health utility assessments to attest the efficacy of decompressive therapy by demonstrating the population perspective, which perceived a significant improvement in quality of life following the surgical treatment of migraines in the authors' patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.