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The development and current status of EQ-5D
Professor Paul KindCentre for Health Economics,
University of York, York England
Lecture #2
Objectives
• To describe the origins and development of EQ-5D over the past 25 years
• To review the current status of the EQ-5D “technology”
• To demonstrate the practical potential of EQ-5D in different decision-making situations
• To consider issues in establishing national value sets for EQ-5D health states
The EuroQoL Group• FoundersFinlandNetherlands(Norway)SwedenUK
Extended networkArgentinaCanadaChileChinaDenmarkFranceGermanyGreece HungaryItalyJapan
KoreaNew Zealand PortugalPoland SloveniaSpainTaiwanThailandUSA
EQ-5D• A generic measure of health status
(health-related quality of life) capable of being represented as a single index
• Health is defined in terms of 5 dimensions- mobility- self care- usual activity- pain / discomfort- anxiety / depression
• Each dimension is divided into 3 levels- none- some- extreme
EQ-5D descriptive system
• 243 unique combinations formed from 5 dimensions / 3 levels
• 2 additional states (unconscious and dead)
• Total of 245 states
State 1 2 2 1 3 Mobility (1)no problems in walking about
Self care (2)some problems washing self
Usual activities (2)some problems with usual activity
Pain / discomfort (1)no pain or discomfort
Anxiety / depression (3)extreme anxiety or depression
• Tick one box for each group of statements. Mobility
I have no problems in walking about � I have some problems in walking about � I am confined to bed � Self-Care
I have no problems with self-care � I have some problems washing or dressing myself � I am unable to wash or dress myself �
Usual Activities
I have no problems with performing my usual activities � (e.g. work, study, housework, family or leisure activities)
I have some problems with performing my usual activities � I am unable to perform my usual activities �
Pain/Discomfort
I have no pain or discomfort � I have moderate pain or discomfort � I have extreme pain or discomfort �
Anxiety/Depression
I am not anxious or depressed � I am moderately anxious or depressed � I am extremely anxious or depressed �
Logicallybest state11111
Logicallyworst state33333
This state
12223
100
0Worst imaginable
health
Best imaginablehealth
10
60
50
40
30
20
90
80
70
Think about how good or bad your own health is today. •This scale may help. The best health you can imagine is marked 100 and the worst health you can imagine is marked 0 • Please write in the box below, the number between 0 and 100 that you feel best shows how good your health is today
Your own health today
How are EQ-5D data presented ?• As a profile
– based on reported level of problem on each dimension
• As a health state• As a weighted index
– based on values of the general public
• As self-rated health status
EQ-5D
profile
health state
weighted index
self-ratedhealth status
page 2 page 3
0
1
2
3
mob
ility
self
care
usua
lac
tivi
ty
pain
/di
scom
fort
anxi
ety
/de
pres
sion
0
1
2
3
mob
ility
self
care
usua
lac
tivi
ty
pain
/di
scom
fort
anxi
ety
/de
pres
sion
Profile A : 1 1 2 2 3 Profile B : 1 1 3 2 2
Does moving from A to B benefit a patient? If so, then by how much?
EQ-5D valuation
• The standard valuation methodology adopted by the EuroQoL Group and used in all countries is based on a valuation questionnaire distributed by postal survey
• 2-part questionnaire captures – Self-rated health status (EQ-5D)– VAS ratings of 16 health states presented as
2 pages of 8 states per page
Health state D
Health state E
3 3 3 3 3
Health state F
VAS rating of EQ-5D health states
Health state A
Health state E
1 1 1 1 1
Health state C
Measurement and Valuation of Health (MVH) Project
• Important milestone research (1989-93)• Funded by UK Department of Health• Comparative study of several valuation
methods– Standard gamble (SG)– Time Trade-Off (TTO)– Magnitude estimation– Ranking / paired comparisons– Visual analogue scale (VAS) rating
MVH final protocol
• SURVEY METHOD• National
representative sample
• N~3,400• Face : face
interviews (n~80 interviewers)
• Conducted at home
VALUATION TASKSSelected subset of 43/243 EQ-5D statesEach respondent handled 153 tasksRanking
Rating (0-100 VAS)
TTO
TIME TRADE-OFF BOARDLife “A”
Life “B”
No problems with mobilityNo problems with self careNo problems with usual activitiesNo problems with pain / discomfortNo problems with anxiety / depression
Less than full health as defined by EQ-5D descriptive system
YEARS OF LIFE
0 1 2 3 4 5 6 7 8 9 10
YEARS OF LIFE
0 1 2 3 4 5 6 7 8 9 10
Valuation studies based on MVH
• Germany• Netherlands• Denmark• Spain• United States• Japan• South Korea• Thailand• Taiwan
SingaporeSloveniaZimbabweFrancePolandArgentinaChile NigeriaBrazil
• (Russia) • (Italy) • (Hungary)• (Canada)• (Trinidad & Tobago)• Colombia ?
0
1
2
3m
obili
ty
self
care
usua
lac
tivi
ty
pain
/di
scom
fort
anxi
ety
/de
pres
sion
0
1
2
3
mob
ility
self
care
usua
lac
tivi
ty
pain
/di
scom
fort
anxi
ety
/de
pres
sion
0.25
0.36
0.11
0
0.1
0.2
0.3
0.4
State A State B Difference
Populationpreference
weights
Profile A : 1 1 2 2 3
Profile B : 1 1 3 2 2
Population “norms”mean EQ-5Dindex
0.6
0.8
1
< 20 20 -29
30 -39
40 -49
50 -59
60 -69
70 -79
80 +
age group
mea
n EQ
-5D
inde
x
MenWomen
Source : Health Survey for England, 1996
Health inequalities by educationmean EQ-5Dindex
0.6
0.7
0.8
0.9
1
20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80 +age group
mea
n EQ
5Din
dex
basicintermediatehigher
* *** *** *** *** ns ns
EQ-5D health statusby age / smoking behaviour
0.6
0.7
0.8
0.9
1
20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80 +
Age group
mea
n EQ
5Din
dex
non-smoker
smoker
Health status in GP clinic patients
0.6
0.7
0.8
0.9
1
under20
20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80 +
mea
n E
Q-5
Din
dex
03 or more visits
Attenders at primary care clinicEQ-5Dprofile by diagnostic group
0
20
40
60
80
100
mobility self care usualactivity
pain /discomfort
anxiety /depression%
of p
atie
nts
repo
rtin
g AN
Ypro
blem
mental disordercirculatory musculoskeletalpregnancyall patients
EQ-5D in Rheumatoid Arthritisby disease severity
Choice of providermean change in EQ-5Dvas
-3.62
2.5
5.2
-6
-4
-2
0
2
4
6
mean change from pre-op score
NHS - Aprivate sectorNHS - B
GP audit of patients referred for cataract surgery
Outcomes in surgeryEQ-5Dvas
0
20
40
60
80
100
cholycystectomy hysterectomy TURPS
mea
n EQ
-5D
vas
pre post change
60.050.0
40.030.0
20.010.0
0.0-10.0
-20.0-30.0
-40.0-50.0
No.
of
patie
nts
14
12
10
8
6
4
2
0
Std. Dev = 22.25 Mean = 8.1N = 57.00
Change in EQ-5DVAS in hysterectomy
EQ-5D in treatment of HIV/AIDSweighted index for 2 treatment groups
Treatment group
Ritonavir
Usual therapy
VISIT
mea
n we
ight
ed in
dex
1197531
.86
.84
.82
.80
.78
.76
.74
.72
.70
AcneAcupunctureAlcohol dependencyAngioplastyAngina (treatment options)Anorectal reconstructionAsthmaBlood transfusion Bone marrow transplant Breast cancer Breast cancer screeningBronchitisCardiac surgeryCardiologyCardiovascular diseaseCataract surgeryChemotherapy (impact)Chronic fatigue Chronic illnessCochlear implantationColles fractureColorectal carcinomaCongestive heart failureConservation work (benefits of)Cosmetic surgeryCystic fibrosisDementiaDetoxificationDiabetesDrug monitoring (nursing home residents)
DyspepsiaDystoniaElderly (QOL)EndometriosisEnteral nutritionEpilepsyErectile dysfunctionFabry’s diseaseGastro-enteritisGeneral practiceGeriatricsGilles de la TouretteGraves eye disease Growth HormoneHaemophiliaHip fracture/replacementHIV infectionHodgkin’s dis.HomeopathyHormone replacement therapyHospital waiting lists HysterectomyImperforate anusInguinal herniaIncontinenceIntensive careIntestinal failureIschaemic heart diseaseJoint replacementLeg ulcer clinicsLiver diseaseLiver transplantation
Low back painLung cancerLung embolismLung transplantationLymphoedemaMagnetic Resonance ImagingMelanoma (stage III)MenorrhagiaMigraineMultiple SclerosisMyeloid LeukaemiaMyocardial infarctionNeonatal surgeryNeural tube defectsNeurosurgeryNon-Hodgkin’s diseaseLupusLymphomaNutritionObstructive sleep apnoeaOrthopaedic medicineOsteoarthritisPainPancreatic cancerParenteral nutritionPeripheral arterial disease Peripheral vascular diseasePhysiotherapyPicture archiving and Communication systems (PACS)
Population health surveys Primary careProstatic hypertrophyProstate cancerPsoriasisPsychiatric problems in GP practiceRedundancy (impact of)Rehabilitation (effects of)Renal disease (end-stage)Renal oncologyRenal (kidney stone disease)Respiratory illness Rheumatoid arthritisRhinitisRoad accidents (non-fatal)SchizophreniaSepsisSinusitisSmoking (impact of)StentStrokeTraumaTuberculosis (prevention in HIV)Turner’s syndromeUrologyVascular surgeryVenous leg ulcersVisual impairmentWeight loss (treatment for)Women’s surgery
Examples of clinical areas in which EQ-5D has been applied
5L English (UK) version
EQ-5D-Y
Practical issues in valuation of EQ-5D
• Sampling frame– Social preferences ?– Patient preferences ?
• Preference elicitation method– TTO– Other ?
• Mode of administration– Interviewer– Computer / web based
Descriptive classification3 level
5 level
Selection of statesFactorial block design
Number / choice of states
Form of analysisIndividual
Aggregate (mean / median)
Slide 1ObjectivesThe EuroQoL GroupEQ-5DEQ-5D descriptive systemSlide 6Slide 7How are EQ-5D data presented ?Slide 9EQ-5D valuationSlide 11Measurement and Valuation of Health (MVH) ProjectMVH final protocolSlide 14Valuation studies based on MVHSlide 16Population “norms” mean EQ-5DindexHealth inequalities by education mean EQ-5DindexEQ-5D health status by age / smoking behaviourHealth status in GP clinic patientsSlide 21Slide 22Choice of provider mean change in EQ-5DvasOutcomes in surgery EQ-5DvasSlide 25Slide 26Examples of clinical areas in which EQ-5D has been applied5L English (UK) versionEQ-5D-YPractical issues in valuation of EQ-5D