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VIRTUALISPOR
Chris Sampson
20MAY2020
Download these slides: tinyurl.com/ISPOR2020-dropdead
● I declare that I have no known conflicts of interest, financial or otherwise.
● I am an employee of the Office of Health Economics, a registered charity, which receives funding from a variety of
sources including the EuroQol Research Foundation and the Association of the British Pharmaceutical Industry.
● I received no specific funding in relation to this presentation.
20 MAY 2020
VIRTUAL ISPOR
Download these slides: tinyurl.com/ISPOR2020-dropdead
● Anchoring is necessary to identify the relative value
of different health states
● A defining feature of TTO
● An awkward reality for DCE
● QALYs
● Facilitates trade-offs between length and quality of
life
● Forms the basis for interpersonal comparisons
● Time
● Being dead constitutes lost time
20 MAY 2020
VIRTUAL ISPOR
1
0
1 = full health*
0 = dead*
A
B
C
D
Time →
HRQoL→
* or a state of equivalent value
● Experience-based valuation is problematic
● No states worse than dead (Bernfort et al, 2018)
20 MAY 2020
VIRTUAL ISPOR
1
0
1 = full health*
0 = dead*
A
B
C
D
Time →
HRQoL→
* or a state of equivalent value
No patient
valuations ‘worse
than dead’
● Experience-based valuation is problematic
● No states worse than dead (Bernfort et al, 2018)
● Gap effect (Stalmeier et al, 2005)
● Few states valued close to ‘dead’
20 MAY 2020
VIRTUAL ISPOR
1
0
1 = full health*
0 = dead*
A
B
C
D
Time →
HRQoL→
* or a state of equivalent value
No patient
valuations ‘worse
than dead’
● Experience-based valuation is problematic
● No states worse than dead (Bernfort et al, 2018)
● Gap effect (Stalmeier et al, 2005)
● Few states valued close to ‘dead’
● States ‘worse than dead’ are not meaningful
● Not associated with severity (Gandhi et al, 2019)
● Confusion about what they mean (Al Sayah et al, 2016)
20 MAY 2020
VIRTUAL ISPOR
1
0
1 = full health*
0 = dead*
A
B
C
D
Time →
HRQoL→
* or a state of equivalent value
No patient
valuations ‘worse
than dead’
● Experience-based valuation is problematic
● No states worse than dead (Bernfort et al, 2018)
● Gap effect (Stalmeier et al, 2005)
● Few states valued close to ‘dead’
● States ‘worse than dead’ are not meaningful
● Not associated with severity (Gandhi et al, 2019)
● Confusion about what they mean (Al Sayah et al, 2016)
● Preferences for ‘dead’ are problematic
● Lexicographic (Flynn et al, 2008)
● Infinite willingness to pay to avoid (Becker et al, 2007)
20 MAY 2020
VIRTUAL ISPOR
?
?
1 = full health*
0 = dead*
A
B
C
D
Time →
HRQoL→
* or a state of equivalent value
No patient
valuations ‘worse
than dead’
● Experience-based valuation is problematic
● No states worse than dead (Bernfort et al, 2018)
● Gap effect (Stalmeier et al, 2005)
● Few states valued close to ‘dead’
● States ‘worse than dead’ are not meaningful
● Not associated with severity (Gandhi et al, 2019)
● Confusion about what they mean (Al Sayah et al, 2016)
● Preferences for ‘dead’ are problematic
● Lexicographic (Flynn et al, 2008)
● Infinite willingness to pay to avoid (Becker et al, 2007)
● Results in questionable data
● People don’t acknowledge ‘dead’ (van Nooten et al, 2014)
● Observations often dropped from studies (Engel et al, 2016)
20 MAY 2020
VIRTUAL ISPOR
?
?
1 = full health*
0 = dead*
A
B
C
D
Time →
HRQoL→
* or a state of equivalent value
No patient
valuations ‘worse
than dead’
● Dead vs death vs dying
● What does it mean to value ‘dead’? (Devlin et al, 2004)
20 MAY 2020
VIRTUAL ISPOR
1
0
1 = full health*
0 = dead*
A
B
C
D
Time →
HRQoL→
* or a state of equivalent value
● Dead vs death vs dying
● What does it mean to value ‘dead’? (Devlin et al, 2004)
● Invokes considerations beyond health
● Time preference, probability of survival (Sharma &
Stano, 2010)
● Views on euthanasia (Augestad et al, 2013)
20 MAY 2020
VIRTUAL ISPOR
1
0
1 = full health*
0 = dead*
A
B
C
D
Time →
HRQoL→
* or a state of equivalent value
Otherstuff→
● Dead vs death vs dying
● What does it mean to value ‘dead’? (Devlin et al, 2004)
● Invokes considerations beyond health
● Time preference, probability of survival (Sharma &
Stano, 2010)
● Views on euthanasia (Augestad et al, 2013)
● Indefinable with respect to time
20 MAY 2020
VIRTUAL ISPOR
1
0
1 = full health*
0 = dead*
A
B
C
D
Time →
HRQoL→
* or a state of equivalent value
Otherstuff→
● Dead vs death vs dying
● What does it mean to value ‘dead’? (Devlin et al, 2004)
● Invokes considerations beyond health
● Time preference, probability of survival (Sharma &
Stano, 2010)
● Views on euthanasia (Augestad et al, 2013)
● Indefinable with respect to time
● The negative scale is limitless
20 MAY 2020
VIRTUAL ISPOR
1
0
1 = full health*
0 = dead*
A
B
C
D
Time →
HRQoL→
* or a state of equivalent value
Otherstuff→
∞
● Dead vs death vs dying
● What does it mean to value ‘dead’? (Devlin et al, 2004)
● Invokes considerations beyond health
● Time preference, probability of survival (Sharma &
Stano, 2010)
● Views on euthanasia (Augestad et al, 2013)
● Indefinable with respect to time
● The negative scale is limitless
● Health state “of equivalent value to being dead” is hard
to conceive
● EQ-5D-5L state 55511?
20 MAY 2020
VIRTUAL ISPOR
1
?
1 = full health*
0 = dead*
A
B
C
D
Time →
HRQoL→
* or a state of equivalent value
Otherstuff→
∞
● Zero can be anything
20 MAY 2020
VIRTUAL ISPOR
1
0
1 = full health*
0 = a very bad state
A
B
C
D
Time →
HRQoL→
* or a state of equivalent value
HRQoL→
● Zero can be anything
● Ratio scale > interval scale
● Requires an absolute zero
20 MAY 2020
VIRTUAL ISPOR
1
0
1 = full health*
0 = a very bad state
A
B
C
D
Time →
* or a state of equivalent value
HRQoL→
● Zero can be anything
● Ratio scale > interval scale
● Requires an absolute zero
● ‘Dead’ can still be zero
● And it must (Roudijk et al, 2018)
20 MAY 2020
VIRTUAL ISPOR
1
0
1 = full health*
0 = a very bad state
(and dead)
A
B
C
D
Time →
* or a state of equivalent value
HRQoL→
● Zero can be anything
● Ratio scale > interval scale
● Requires an absolute zero
● ‘Dead’ can still be zero
● And it must (Roudijk et al, 2018)
● Resource allocation trade-offs are not health vs death
● They are QALYs vs QALYs
20 MAY 2020
VIRTUAL ISPOR
1
0
1 = full health*
0 = a very bad state
(and dead)
A
B
C
D
Time →
* or a state of equivalent value
∑
● Dropping dead makes a big difference (Sutherland et al,
1983; Nord, 1991)
20 MAY 2020
VIRTUAL ISPOR
● Dropping dead makes a big difference (Sutherland et al,
1983; Nord, 1991)
1. Adopt an alternative anchor as an absolute zero
a) Worst health state imaginable
b) Worst health state defined by the measure (e.g. EQ-5D)
c) A minimum endurable health state
20 MAY 2020
VIRTUAL ISPOR
A
B
Health state
being valued
Worst health
state imaginable
Full health
● Dropping dead makes a big difference (Sutherland et al,
1983; Nord, 1991)
1. Adopt an alternative anchor as an absolute zero
a) Worst health state imaginable
b) Worst health state defined by the measure (e.g. EQ-5D)
c) A minimum endurable health state
2. Redefine QALYs as a decision-making tool
a) Zero is a point where no value is generated over time
b) QALYs can be rescaled
20 MAY 2020
VIRTUAL ISPOR
Value→
1
0
1 = maximum value
0 = no value
A
B
C
D
Time →
● Dropping dead makes a big difference (Sutherland et al,
1983; Nord, 1991)
1. Adopt an alternative anchor as an absolute zero
a) Worst health state imaginable
b) Worst health state defined by the measure (e.g. EQ-5D)
c) A minimum endurable health state
2. Redefine QALYs as a decision-making tool
a) Zero is a point where no value is created
b) QALYs can be rescaled
3. Keep calm and carry on estimating QALYs
20 MAY 2020
VIRTUAL ISPOR
Value→
1
0
1 = maximum value
0 = no value
A
B
C
D
Time →
∑
To keep up with the latest news and research, subscribe to our blog.
OHE’s publications may be downloaded free of charge from our website.
OHE
Southside
105 Victoria Street
London SW1E 6QT
United Kingdom
Telephone
+44 (0)20 77478866
FOLLOW US
Toenquire about additional information and analyses,
please contact:
Chris Sampson, BA, MSc, PhD
Principal Economist
csampson@ohe.org
Download these slides: tinyurl.com/ISPOR2020-dropdead
● Should we drop dead from health state valuation?
● Yes
● No
● Which of the following concerns do you have about ‘dropping dead’
● It is important to know the value of death
● It is important to know which states are worse than dead
● There isn’t a meaningful alternative to ‘dead’ for anchoring
● I have no concerns! Drop dead!
Download these slides: tinyurl.com/ISPOR2020-dropdead

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Drop Dead

  • 1. VIRTUALISPOR Chris Sampson 20MAY2020 Download these slides: tinyurl.com/ISPOR2020-dropdead
  • 2. ● I declare that I have no known conflicts of interest, financial or otherwise. ● I am an employee of the Office of Health Economics, a registered charity, which receives funding from a variety of sources including the EuroQol Research Foundation and the Association of the British Pharmaceutical Industry. ● I received no specific funding in relation to this presentation. 20 MAY 2020 VIRTUAL ISPOR Download these slides: tinyurl.com/ISPOR2020-dropdead
  • 3. ● Anchoring is necessary to identify the relative value of different health states ● A defining feature of TTO ● An awkward reality for DCE ● QALYs ● Facilitates trade-offs between length and quality of life ● Forms the basis for interpersonal comparisons ● Time ● Being dead constitutes lost time 20 MAY 2020 VIRTUAL ISPOR 1 0 1 = full health* 0 = dead* A B C D Time → HRQoL→ * or a state of equivalent value
  • 4. ● Experience-based valuation is problematic ● No states worse than dead (Bernfort et al, 2018) 20 MAY 2020 VIRTUAL ISPOR 1 0 1 = full health* 0 = dead* A B C D Time → HRQoL→ * or a state of equivalent value No patient valuations ‘worse than dead’
  • 5. ● Experience-based valuation is problematic ● No states worse than dead (Bernfort et al, 2018) ● Gap effect (Stalmeier et al, 2005) ● Few states valued close to ‘dead’ 20 MAY 2020 VIRTUAL ISPOR 1 0 1 = full health* 0 = dead* A B C D Time → HRQoL→ * or a state of equivalent value No patient valuations ‘worse than dead’
  • 6. ● Experience-based valuation is problematic ● No states worse than dead (Bernfort et al, 2018) ● Gap effect (Stalmeier et al, 2005) ● Few states valued close to ‘dead’ ● States ‘worse than dead’ are not meaningful ● Not associated with severity (Gandhi et al, 2019) ● Confusion about what they mean (Al Sayah et al, 2016) 20 MAY 2020 VIRTUAL ISPOR 1 0 1 = full health* 0 = dead* A B C D Time → HRQoL→ * or a state of equivalent value No patient valuations ‘worse than dead’
  • 7. ● Experience-based valuation is problematic ● No states worse than dead (Bernfort et al, 2018) ● Gap effect (Stalmeier et al, 2005) ● Few states valued close to ‘dead’ ● States ‘worse than dead’ are not meaningful ● Not associated with severity (Gandhi et al, 2019) ● Confusion about what they mean (Al Sayah et al, 2016) ● Preferences for ‘dead’ are problematic ● Lexicographic (Flynn et al, 2008) ● Infinite willingness to pay to avoid (Becker et al, 2007) 20 MAY 2020 VIRTUAL ISPOR ? ? 1 = full health* 0 = dead* A B C D Time → HRQoL→ * or a state of equivalent value No patient valuations ‘worse than dead’
  • 8. ● Experience-based valuation is problematic ● No states worse than dead (Bernfort et al, 2018) ● Gap effect (Stalmeier et al, 2005) ● Few states valued close to ‘dead’ ● States ‘worse than dead’ are not meaningful ● Not associated with severity (Gandhi et al, 2019) ● Confusion about what they mean (Al Sayah et al, 2016) ● Preferences for ‘dead’ are problematic ● Lexicographic (Flynn et al, 2008) ● Infinite willingness to pay to avoid (Becker et al, 2007) ● Results in questionable data ● People don’t acknowledge ‘dead’ (van Nooten et al, 2014) ● Observations often dropped from studies (Engel et al, 2016) 20 MAY 2020 VIRTUAL ISPOR ? ? 1 = full health* 0 = dead* A B C D Time → HRQoL→ * or a state of equivalent value No patient valuations ‘worse than dead’
  • 9. ● Dead vs death vs dying ● What does it mean to value ‘dead’? (Devlin et al, 2004) 20 MAY 2020 VIRTUAL ISPOR 1 0 1 = full health* 0 = dead* A B C D Time → HRQoL→ * or a state of equivalent value
  • 10. ● Dead vs death vs dying ● What does it mean to value ‘dead’? (Devlin et al, 2004) ● Invokes considerations beyond health ● Time preference, probability of survival (Sharma & Stano, 2010) ● Views on euthanasia (Augestad et al, 2013) 20 MAY 2020 VIRTUAL ISPOR 1 0 1 = full health* 0 = dead* A B C D Time → HRQoL→ * or a state of equivalent value Otherstuff→
  • 11. ● Dead vs death vs dying ● What does it mean to value ‘dead’? (Devlin et al, 2004) ● Invokes considerations beyond health ● Time preference, probability of survival (Sharma & Stano, 2010) ● Views on euthanasia (Augestad et al, 2013) ● Indefinable with respect to time 20 MAY 2020 VIRTUAL ISPOR 1 0 1 = full health* 0 = dead* A B C D Time → HRQoL→ * or a state of equivalent value Otherstuff→
  • 12. ● Dead vs death vs dying ● What does it mean to value ‘dead’? (Devlin et al, 2004) ● Invokes considerations beyond health ● Time preference, probability of survival (Sharma & Stano, 2010) ● Views on euthanasia (Augestad et al, 2013) ● Indefinable with respect to time ● The negative scale is limitless 20 MAY 2020 VIRTUAL ISPOR 1 0 1 = full health* 0 = dead* A B C D Time → HRQoL→ * or a state of equivalent value Otherstuff→ ∞
  • 13. ● Dead vs death vs dying ● What does it mean to value ‘dead’? (Devlin et al, 2004) ● Invokes considerations beyond health ● Time preference, probability of survival (Sharma & Stano, 2010) ● Views on euthanasia (Augestad et al, 2013) ● Indefinable with respect to time ● The negative scale is limitless ● Health state “of equivalent value to being dead” is hard to conceive ● EQ-5D-5L state 55511? 20 MAY 2020 VIRTUAL ISPOR 1 ? 1 = full health* 0 = dead* A B C D Time → HRQoL→ * or a state of equivalent value Otherstuff→ ∞
  • 14. ● Zero can be anything 20 MAY 2020 VIRTUAL ISPOR 1 0 1 = full health* 0 = a very bad state A B C D Time → HRQoL→ * or a state of equivalent value
  • 15. HRQoL→ ● Zero can be anything ● Ratio scale > interval scale ● Requires an absolute zero 20 MAY 2020 VIRTUAL ISPOR 1 0 1 = full health* 0 = a very bad state A B C D Time → * or a state of equivalent value
  • 16. HRQoL→ ● Zero can be anything ● Ratio scale > interval scale ● Requires an absolute zero ● ‘Dead’ can still be zero ● And it must (Roudijk et al, 2018) 20 MAY 2020 VIRTUAL ISPOR 1 0 1 = full health* 0 = a very bad state (and dead) A B C D Time → * or a state of equivalent value
  • 17. HRQoL→ ● Zero can be anything ● Ratio scale > interval scale ● Requires an absolute zero ● ‘Dead’ can still be zero ● And it must (Roudijk et al, 2018) ● Resource allocation trade-offs are not health vs death ● They are QALYs vs QALYs 20 MAY 2020 VIRTUAL ISPOR 1 0 1 = full health* 0 = a very bad state (and dead) A B C D Time → * or a state of equivalent value ∑
  • 18. ● Dropping dead makes a big difference (Sutherland et al, 1983; Nord, 1991) 20 MAY 2020 VIRTUAL ISPOR
  • 19. ● Dropping dead makes a big difference (Sutherland et al, 1983; Nord, 1991) 1. Adopt an alternative anchor as an absolute zero a) Worst health state imaginable b) Worst health state defined by the measure (e.g. EQ-5D) c) A minimum endurable health state 20 MAY 2020 VIRTUAL ISPOR A B Health state being valued Worst health state imaginable Full health
  • 20. ● Dropping dead makes a big difference (Sutherland et al, 1983; Nord, 1991) 1. Adopt an alternative anchor as an absolute zero a) Worst health state imaginable b) Worst health state defined by the measure (e.g. EQ-5D) c) A minimum endurable health state 2. Redefine QALYs as a decision-making tool a) Zero is a point where no value is generated over time b) QALYs can be rescaled 20 MAY 2020 VIRTUAL ISPOR Value→ 1 0 1 = maximum value 0 = no value A B C D Time →
  • 21. ● Dropping dead makes a big difference (Sutherland et al, 1983; Nord, 1991) 1. Adopt an alternative anchor as an absolute zero a) Worst health state imaginable b) Worst health state defined by the measure (e.g. EQ-5D) c) A minimum endurable health state 2. Redefine QALYs as a decision-making tool a) Zero is a point where no value is created b) QALYs can be rescaled 3. Keep calm and carry on estimating QALYs 20 MAY 2020 VIRTUAL ISPOR Value→ 1 0 1 = maximum value 0 = no value A B C D Time → ∑
  • 22. To keep up with the latest news and research, subscribe to our blog. OHE’s publications may be downloaded free of charge from our website. OHE Southside 105 Victoria Street London SW1E 6QT United Kingdom Telephone +44 (0)20 77478866 FOLLOW US Toenquire about additional information and analyses, please contact: Chris Sampson, BA, MSc, PhD Principal Economist csampson@ohe.org Download these slides: tinyurl.com/ISPOR2020-dropdead
  • 23. ● Should we drop dead from health state valuation? ● Yes ● No ● Which of the following concerns do you have about ‘dropping dead’ ● It is important to know the value of death ● It is important to know which states are worse than dead ● There isn’t a meaningful alternative to ‘dead’ for anchoring ● I have no concerns! Drop dead! Download these slides: tinyurl.com/ISPOR2020-dropdead