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