The EQ-5D and Its Use Internationally


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OHE’s Professor Nancy Devlin has researched, written and spoken widely on the use of the EQ-5D, and related measures, both in her capacity as the Director of Research at the OHE and as Chair of the Executive Committee of the EuroQol Group.

In May, Nancy was invited to participate in the “Workshop on measuring patient-reported outcomes using the EQ-5D”, which was organised by the Swedish National Board of Health and Welfare in collaboration with the EuroQol Group. The workshop brought together policy makers and researchers in Sweden interested in measuring patients’ health outcomes.

Sweden has included the EQ-5D in some of its quality registries and in population health surveys for many years. The Swedish National Board of Health and Welfare now is exploring whether and how to extend use of patient reported outcomes measures in the health care system, including the EQ-5D, to both monitor the quality of providers and services and to facilitate health technology appraisal.

Nancy’s talk, shown below, introduced the EQ-5D instrument; discussed how data from it can be analysed; identified some of the challenges in analysis; and commented on the future of outcomes measurement.

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The EQ-5D and Its Use Internationally

  1. 1. What is the EQ-5D?The use of the EQ-5D internationallyProfessor Nancy J DevlinOffice of Health EconomicsWorkshop on Measuring Patient Reported OutcomesStockholm • 31 May 2013
  2. 2. 1. The EuroQol Group2. Introduction to the EQ-5D instrument3. Values and valuation methods4. Uses of EQ-5D5. Analysing EQ-5D data: profiles, index-weightedprofiles and EQ-VAS6. Some analytical challenges7. The future of outcomes measurementContent
  3. 3. 1. The EuroQol Group
  4. 4. • Established > 25 years ago• Not-for-profit organisation• > 75 researchers internationally; office in Rotterdam• The EuroQol Group aims to improve decisions abouthealth and health care throughout the world bydeveloping, promoting and supporting the use ofinstruments with the widest possible applicability forthe measurement and valuation of health.
  5. 5. • To provide leadership in the research and development of instruments thatdescribe and value health• To promote the use of instruments developed by the EuroQol Group and tosupport individuals and organization across the world seeking to use thoseinstruments• To foster and support an international community of researchers whoseactivity informs the development and application of EuroQol Groupinstruments• To ensure access to the accumulated research expertise of the EuroQolGroup and to actively promote the transfer of knowledge and evidenceregarding the use, analysis, and interpretation of measures developed bythe EuroQol Group• To support promising early career researchers in the field of health andquality of life research through involvement in EuroQol Group activities.Mission
  6. 6. 2. Introduction to the EQ-5D
  7. 7. • EQ-5D comprises two distinct self-report elements,providing three principal approaches to analysis(1) the EQ-5D profile: the patients’ self reported health onthe dimensions/levels of the descriptive system(2) the EQ-VAS: the patients’ own global rating of theiroverall health, on a scale from 0 (worst possible health) to100 (best possible health)• Both types of data can be the focus of analysis, plus(3) Profiles can be summarised using ‘value sets’ (EQ-5DIndex) which reflect the preferences of the general public.
  8. 8. EQ-5D ‘profile’
  9. 9. • EQ-VAS
  10. 10. EQ-5D-5L
  11. 11. 3. Values and valuation methods
  12. 12. Index weighting EQ-5D profilesThis weight depends on:- who is asked- which statedpreference method isused- how the preferencedata are modelled eg theMVH ‘N3’ term
  13. 13. EQ-5D ‘value sets’• Value sets for the 3L areavailable for a range ofcountries.• An interim value set is availablefor the 5L (from a cross-overstudy).• Value set studies for the 5L areunderway or planned in > 10countries.
  14. 14. • Whose values count?• Generally argued that, for resource allocation decisions,it is the preferences of the general public that arerelevant.• What type of methods are used?• The values represent the views (‘preferences’) of peopleabout how good or bad health states are.• Using ‘stated preferences’ methods• The methods available include Time Trade Off (TTO),Discrete Choice Experiments (DCE); Visual AnalogueScale (VAS) and Standard Gamble (SG).Methods for valuing EQ-5D
  15. 15. TTO• The method works by finding how much time people would bewilling to trade off.• Choice between: x years of full health (‘Life A’), followed by death, and t years in the health state to be valued (‘Life B’), followedby death Where x < t X is varied until Life A and Life B are considered equallygood/bad.• Aim is to find the exact x that makes the person indifferentbetween Life A and Life B.• The worse the health state, the more time we expect to betraded (and the lower the value).
  16. 16. DCE
  17. 17. 4. Uses of EQ-5D
  18. 18. 1. HTA• EQ-5D recommended by NICE (clinical trials; obs. studies)• Informs decisions about reimbursement and (from 2014)pricing of new technologies (VBP)2. Population health surveys• E.g. in the NHS, informs ‘needs based’ allocations ofbudgets across regions3. Routine use in the health care system• NHS PROMs programme• Multiple uses of these data e.g. assessing providerperformance; value for money of services.Principal applications of EQ-5D
  19. 19. • EQ-5D widely used in clinical trials and observationalstudies around the world to inform HTA• Widely accepted by HTA agencies; use is expanding ( HTA systems evolve in emerging markets)• And in public health population surveys• its brevity is a big advantage• Routine use in health care systems relatively new• English NHS leading the way• Interest and use elsewhere including: Canada, NewZealand, Sweden, China…International use
  20. 20. 5. Analysing EQ-5D data
  21. 21. • EQ-5D profiles• Simple descriptive stats (number and % problems)• Categories of change• Analyses by dimension.• Index-weighted profiles• Required in estimation of QALYs• Caution required in other applications.• Analysis of EQ-VAS data
  22. 22. • In cost effectiveness analysis, patients’ profiles assigned QoL‘weights’: EQ Index• Reflect preferences (‘utilities’) of the general publicobtained using stated preference methods• Normative judgement – allocation of taxpayer resources• Do the same arguments apply to PROMs?• There is no ‘neutral’ way to summarise profiles.• Each value set will have its own properties.• Can bias statistical inference.Parkin, D., Rice, N. and Devlin, N. (2010) Statistical analysis of EQ-5D profiles: does the use of value sets biasinference? Medical Decision Making (forthcoming).Index weighted profiles
  23. 23. Profiles – simple distributionsFeng, Y., Parkin, D. and Devlin, N.J. (2012) Assessing the performance of the EQ-VAS in the NHS PROMsProgramme. Research Paper 12/01. London: Office of Health Economics.
  24. 24. • Paretian classification of health change• Comparing two EQ-5D, differences between them maybe:- Mixed (better on some dimensions, worse on others)- Better (better on at least one dimension, no worse on others)- Worse (worse on at least one dimension, no better on others)- Exactly the same• % in each categoryProfiles – categorising changeFeng, Y., Parkin, D. and Devlin, N.J. (2012) Assessing the performance of the EQ-VAS in the NHS PROMs Programme.Research Paper 12/01. London: Office of Health Economics.
  25. 25. Hospital performance by profile dimensionUsual activitiesPain/discomfortGutacker, N., Bojke, C., Daidone, S., Devlin, N. and Street, A. (2012) Analysing hospital variations in health outcome at the levelof EQ-5D dimensions. Research Paper No. 74, Centre for Health Economics, University of York.
  26. 26. EQ-VAS and EQ Index distributionsFeng, Y., Parkin, D. and Devlin, N.J. (2012) Assessing the performance of the EQ-VAS in the NHS PROMs Programme.Research Paper 12/01. London: Office of Health Economics.
  27. 27. 6. Some analytical challenges
  28. 28. 1. Adequacy of EQ-5D as a measurement instrument• ‘Missing’ dimensions?• Exploration of ‘bolt on’ dimensions2. EQ-5D and EQ-VAS measure conceptually differentthings3. Differences between description (patients’ self-reported profiles) and valuation (general publicvaluation of those same states)• Potential issue for the 5L?
  29. 29. 4. Other challenges with use of EQ-Index• Value sets potentially bias statistical inference• Bi-modality (‘clustering’) in distributions of EQ Indexdata5. Statistical significance vs. m.i.d6. Challenges specific to use of EQ-5D in PROMs• E.g. the importance of case mix adjustment
  30. 30. 7. The future of outcomesmeasurement
  31. 31. 1. The future of health technology appraisal• HTA as a continuous process?• Evaluation of technologies ‘in the real world, in real time’,rather than a ‘one-off’ reimbursement decision• Not just ‘new’ technologies, but all health care services• ‘Real world data’ – e.g. use of EQ-5D in routine monitoringand evaluation of outcomes and quality of care• Part of the increasing availability and importance of ‘bigdata’ generally.Speculations about the future…
  32. 32. 2. Continued importance of patients’ subjective views oftheir own health• “The use of PRO instruments is part of a generalmovement toward the idea that the patient, properlyqueried, is the best source of information about how heor she feels”. [FDA 2006]• Growing recognition of the importance of the patients’perspective (e.g. on their own health – and maybe onhealth state values?)Speculations about the future…
  33. 33. 3. The health and social care interface• Measurement of outcomes beyond health care• Can measures of HR-QoL capture wider sorts ofoutcomes?• Important to understand how measures of HR-QoL—suchas—EQ-5D correspond to measures of subjectivewellbeing (e.g. ‘happiness’)Speculations about the future…
  34. 34. To enquire about additional information and analyses, please contactProf Nancy Devlin at ndevlin@ohe.orgTo keep up with the latest news and research, subscribe to our blog, OHE News.Follow us on Twitter @OHENews, LinkedIn and SlideShare.Office of Health Economics (OHE)Southside, 7th Floor105 Victoria StreetLondon SW1E 6QTUnited Kingdom+44 20 7747 8850www.ohe.orgOHE’s publications may be downloaded free of charge for registered users of its website.©2013 OHE