1

EuroQol EQ-5D

• Jan J. V. Busschbach, Ph.D

• Psychotherapeutic Centrum ‘De Viersprong’, Halsteren

– Jan.Busschbach@deviersprong.net

• Department of Medical Psychology and Psychotherapy, Erasmus MC

– Busschbach@mpp.fgg.eur.nl

2

EQ-5D

• 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 (e.g. work, study, housework family or leisure activities)

– I have no problems with performing my usual 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

3

The clinical perspective

• It is not the doctor who reports

• Quality of life is subjective…..– “Given its inherently subjective nature, consensus was quickly

reached that quality of life ratings should, whenever possible, be elicited directly from patients themselves. “ (Aaronson, in B Spilker (Ed): Quality of life and Pharmacoeconomics in Clinical Trails, 1996, page 180)

– As a CONSUMER of care, the patient is the best judged about the quality of care

• The patient values count in clinical quality of life research

4

The economic perspective

• In a normal market: the consumer values count

• The patient seems to be the consumer– Thus the values of the patients….

• If indeed health care is a normal market…

• But is it….?

5

Health care is not a normal market

• Supply induced demands

• Subsidies (egalitarian structure)

• Government control

• Health care is an insurance market– A compulsory insurance market

• The patient does not pay– Patient Consumer

– Potential patients are paying

– Consumer = General public

6

Who determines the payments of unemployment insurance?

• Civil servant– Knowledge: professional

– But strategy

» more money, less problems

» identify with unemployed persons

• The unemployed persons themselves– Knowledge: specific

– But strategy

• General public (politicians)– Knowledge: experience

– Payers

7

Who’s values (of quality of life) should count in the health insurance?

• Doctors– Knowledge: professional

– But strategy

– But see only selection of patient (the complainers)

• Patients– Knowledge: disease specific

– But strategy

– But coping

• General public– Knowledge: experience

– Payers

8

Patient values seem high

• Stensman– Scan J Rehab Med

1985;17:87-99.

• Scores on a visual analogue scale

– 36 subjects in a wheelchair

– 36 normal matched controls

• Mean score– Wheelchair: 8.0

– Controls: 8.3

9

Is there a problem? • There is no

problem...– if effect is linear– In the past, the general

perspective was seen as a proxy for patient perspective

• There is a problem...– If there is no linear

transformation– Patient and general public

perspective reveal different results

– Loss of power in patient perspective 0

5

10

15

20

25

30

35

40

45

baseline T 1

General public

Patient no coping

Patient with coping

10

Patient Perspective

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The Societal Perspective

• 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 (e.g. work, study, housework family or leisure activities)

– I have no problems with performing my usual 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

12

Validated Questionnaires

• Describe health states

• Have values from the general public– Rosser

– QWB

– 15D

– HUI Mark 2

– HUI Mark 3

– EuroQol EQ-5D

13

EQ-5D

• 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 (e.g. work, study, housework family or leisure activities)– I have no problems with performing my usual 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

14

EuroQol

• EuroQol Group

• Latest version: EQ-5D– 5 dimensions

» Mobility, self-care, usual activities, pain / discomfort, anxiety / depression

– 3 levels per dimension

– 243 health states

• Validation– Finland, Netherlands, Norway, Sweden, UK, Spain,

Germany, Greece, US, Japan, New Zealand, Zimbabwe, Denmark

– N = 200 - 3000

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How to get these societal values?

• Patient fills in questionnaire

• Choose the value function from the literature

• Calculate societal value

COMPUTE MVH_A1 = 1.VARIABLE LABELS MVH_A1 'York A1 tariff'. DO IF (NVALID(mo, sc, ua, pd, ad) < 5 ).RECODE MVH_A1 (1 = SYSMIS).END IF.IF (MAX(mo, sc, ua, pd, ad) > 1) MVH_A1 = MVH_A1 -.081.IF (mo = 2) MVH_A1 = MVH_A1 - .069.IF (mo = 3) MVH_A1 = MVH_A1 - .314.IF (sc = 2) MVH_A1 = MVH_A1 - .104.IF (sc = 3) MVH_A1 = MVH_A1 - .214.IF (ua = 2) MVH_A1 = MVH_A1 - .036.IF (ua = 3) MVH_A1 = MVH_A1 - .094.IF (pd = 2) MVH_A1 = MVH_A1 - .123.IF (pd = 3) MVH_A1 = MVH_A1 - .386.IF (ad = 2) MVH_A1 = MVH_A1 - .071.IF (ad = 3) MVH_A1 = MVH_A1 - .236.IF (MAX(mo, sc, ua, pd, ad) > 2) MVH_A1 = MVH_A1 - .269.

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An example of a value function

* SPSS syntax Dolan 1997, Medical Care, 1997;35:1095-108.* mo = mobility, sc= self care, ua = usual activities, pd = pain & discomfort , ad = anxiety and depression.

COMPUTE MVH_A1 = 1.VARIABLE LABELS MVH_A1 'York A1 tariff'. DO IF (NVALID(mo, sc, ua, pd, ad) < 5 ).RECODE MVH_A1 (1 = SYSMIS).END IF.IF (MAX(mo, sc, ua, pd, ad) > 1) MVH_A1 = MVH_A1 -.081.IF (mo = 2) MVH_A1 = MVH_A1 - .069.IF (mo = 3) MVH_A1 = MVH_A1 - .314.IF (sc = 2) MVH_A1 = MVH_A1 - .104.IF (sc = 3) MVH_A1 = MVH_A1 - .214.IF (ua = 2) MVH_A1 = MVH_A1 - .036.IF (ua = 3) MVH_A1 = MVH_A1 - .094.IF (pd = 2) MVH_A1 = MVH_A1 - .123.IF (pd = 3) MVH_A1 = MVH_A1 - .386.IF (ad = 2) MVH_A1 = MVH_A1 - .071.IF (ad = 3) MVH_A1 = MVH_A1 - .236.IF (MAX(mo, sc, ua, pd, ad) > 2) MVH_A1 = MVH_A1 - .269.

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Some values

• Broken arm

• 12211– no problems in walking about

– some problems washing or dressing

– some problems with performing usual activities

– no pain or discomfort

– not anxious or depressed

• Societal value = 0.779

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Some values

• Broken hip

• 22222– some problems in walking about

– some problems washing or dressing

– some problems with performing usual activities

– moderate pain or discomfort

– moderately anxious or depressed

• Societal value = 0.516

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Impact on quality of life

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

EQ-5D utilities

Patent graft

Symptomatic occlusion

Primary amputation

Secondary amputation

Cerebrovascular accident

Myocardial infarction

Intake clinic psychotherapy

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Effect psychotherapy

0.5

0.6

0.7

0.8

0.9

1.0

Intake 1 year after 2 years

EQ

-5D

soc

ial v

alu

es

Clinic 12 monthsClinic 6 monthsClinic 3 monthsOut-patient clinic

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Reimbursement arguments

• Dunning’s Funnel– 1990

– Government declaration 2002

– Necessary care

» Need

» Equity elements

– Efficacy

– Cost effectiveness

– Own account and responsibility

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Reimbursement arguments

Impact on QoL

Effect on QoL

Cost effectiveness ?

0

0.1

0.2

0.3

0.4

0.5

0.6

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0.8

0.9

1

EQ-5D utilities0.5

0.6

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0.8

0.9

1.0

Intake 1 year after 2 years

EQ

-5D

so

cia

l va

lue

s

QALYs

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Quality Adjusted Life Years (QALY)

• Multiply life years with quality index

• Quality of life index– 1.0 = normal health

– 0.0 = extremely bad health (death)

• Example – Losing sense of sight

– Quality of life index is 0.5

– Life = 80 years

– 0.5 x 80 = 40 QALYs

• Accepted measure of health – Used by the WHO (DALY)

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QALY league tableIntervention $ / QALY

GM-CSF in elderly with leukemia 235,958

EPO in dialysis patients 139,623

Lung transplantation 100,957

End stage renal disease management 53,513

Heart transplantation 46,775

Didronel in osteoporosis 32,047

PTA with Stent 17,889

Breast cancer screening 5,147

Viagra 5,097

Treatment of congenital anorectal malformations 2,778

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EQ-5D and cost effectiveness

• EQ-5D specially designed– Social perspective

– Generic

– 0 to 1 scale

• Use EQ-5D for QALY analysis