Is healthcare any good for patients? Measuring health outcomes using EQ-5D

Professor Paul KindPrincipal Investigator

Outcomes Research GroupCentre for Health Economics

University of YorkEngland

Health care

• Designed / delivered with the intention of altering the “natural” health status of patients over time

• Relieving pain, suffering

• Prolonging (enabling) life

• Easing process of dying

• Cure (sometimes)

Hippocratic Oath : First, do no harm

• Fundamental question : how do you know if you are helping / harming the patient ?

• You need to know– does treatment CHANGE anything ?– what is the DIRECTION of change ?– what is the MAGNITUDE of change ?

Health care intervention

Patient consults GP

Patient takes medication

GP diagnoses / prescribes

No

Symptomatic relief,cure, palliation ?

Yes

Problem

Measuring health outcomesthe biomedical model

(a) [ FEV1 ]t0 - [ FEV1 ]t1 FEV1

(b) [ health]t0 - [ health ]t1 health status

there is a calibrated test procedure for (a)

what do we use for (b) ?

Outcome measures'Classical' indicators

• Survival rates

• Readmission rates

• Symptom counts

• Employment status

• Days lost through sickness

• Clinical parameters

Grading angina severityNew York Heart Association

• Grade I• ordinary physical activity does not cause undue fatigue,

palpitation or anginal pain

• Grade II• comfortable at rest. Ordinary physical activity results in

fatigue, palpitation, dyspnoea or anginal pain

• Grade III• comfortable at rest. Less than ordinary physical activity

causes fatigue, palpitation, dyspnoea or anginal pain

• Grade IV• inability to carry on physical activity without discomfort.

Symptoms of cardiovascular insufficiency or the anginal syndrome may be present even at rest

Karnofsky Performance Scale

Description Score

Normal 100

Normal activity ; minor signs / symptoms 90

Subnormal activity ; some signs / symptoms 80

Unable to work or to continue normal activities 70

Requires occasional assistance 60

Requires considerable assistance and frequent care

50

Disabled ; requires special care 40

Severely disabled ; hospitalised 30

Very sick ; hospitalised with active support treatment

20

Moribund 10

Dead 0 40

FACT-L

PHYSICAL WELL-BEING

Not at all

A little bit

Some-what

Quite a bit

Very much

GP1 I have a lack of energy .......................................................... 0

0 1 2 3 4

GP2 I have nausea......................................................................... 0

0 1 2 3 4

GP3 Because of my physical condition, I have trouble meeting the needs of my family............................................ 0

0

1

2

3

4

GP4 I have pain............................................................................. 0

0 1 2 3 4

GP5 I am bothered by side effects of treatment ............................ 0

0 1 2 3 4

GP6 I feel ill .................................................................................. 0

0 1 2 3 4

GP7 I am forced to spend time in bed........................................... 0

0 1 2 3 4

Health-related quality of lifea specialised measure of outcome

Health-related quality of life

What are the health outcomes ?

EQ-5D

The EuroQoL Group

• Set up in 1987 by a multidisciplinary group of researchers concerned with EVALUATION in health and health care– Clinicians– Health economists– Others (sociology, psychology …)

The EuroQoL Group

• Founders

Finland

Netherlands

(Norway)

Sweden

UK

• Extended networkArgentinaCanadaChinaDenmarkGermanyGreece HungaryItalyJapan

KoreaNew Zealand PortugalRussiaSlovenia SpainTaiwanUSA. . . .Poland ?

So .. what is 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

What is EQ-5D ?

• A generic, single indexmeasure of health status

• Based on 5 dimensions

MobilitySelf-CareUsual ActivityPain / DiscomfortAnxiety / Depression

• Defines a total of 35

= 243 health states

Mobility

Self-Care

Usual Activity

Pain / Discomfort

Anxiety / Depression

Healthstate

Mobility

Self-carePain / discomfort

Anxiety / depression

Health state

Usualactivities

For example : no problems in walking about (1) some problems washing self (2) some problems with usual activity (2) no pain or discomfort (1) moderately anxiety or depression (2)

State 12212

• In general we know NOTHING about the order or values of EQ-5D health states

• There is a logical ordinal relationship between some states– For example 11111 is logically better than

33333– But what is the distance between these

states ?

0

1

2

3

mob

ility

self

car

e

usu

al a

ctiv

ity

pai

n /

dis

com

fort

anxi

ety

/d

epre

ssio

n

0

1

2

3

mob

ility

self

car

e

usu

al a

ctiv

ity

pai

n /

dis

com

fort

anxi

ety

/d

epre

ssio

n

Profile A : 1 1 2 2 3 Profile B : 1 1 3 2 2

Does moving from state A to state B constitute a patient benefit ? If so, then by how much?

Shared objective : Valuing health

• Needed a simple method

• Self-administered

• Capable of being used in population surveys

• Relatively quick

• Able to produce cardinal values

Valuation method(s)

• EuroQoL Group standard– Visual analogue scale rating using a vertical

20cm scale– Range 0 – 100 corresponding to “worst

imaginable” and “best imaginable” health

• Individual experimentation– Time Trade-Off (York MVH Project)– Ranking– Paired comparisons– Standard Gamble

Health state E

Health state F

3 3 3 3 3

Health state H

VAS rating of EQ-5D health states

Health state A

Health state C

1 1 1 1 1

Health state D

0

1

2

3m

obilit

y

self c

are

usu

al

act

ivit

y

pain

/dis

com

fort

anxie

ty /

depre

ssio

n

0

1

2

3

mobilit

y

self c

are

usu

al

act

ivit

y

pain

/dis

com

fort

anxie

ty /

depre

ssio

n

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

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

       For each group of statements please indicate the one that best describes your health today

   Please tick one box for each group of statements.

100

0Worst imaginable

health

Best imaginablehealth

10

60

50

40

30

20

90

80

70

TThink 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

                       

Page 3 : Patient 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

Page 2 : 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

?

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

Part I Part II

Some examples

0%

10%

20%

30%

40%

50%

60%

Mobility Self care Usualactivity

Pain /discomfort

Anxiety /depression%

of re

spondents

report

ing A

NY p

roble

m

under 4040 to 5960 and over

Frequency of reported problemsby age group in UK population

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

mean E

Q-5

Din

dex

MenWomen

Source : Health Survey for England, 1996

EQ-5Dindex by 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

mean E

Q5D

index

non-smokersmoker

EQ-5Dfor GP clinic attenders

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 w

eigh

ted

inde

x

0 3 or more visits

Primary care clinic attendees EQ-5D profile by diagnostic group

0

20

40

60

80

100

mobility self care usual activity pain / discomfort anxiety /depression

% o

f p

atie

nts

rep

ort

ing

A

NY

pro

ble

m

mental disorder

circulatory

musculoskeletal

pregnancy

all

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

Source : GP audit of patients referred for cataract surgery

Rheumatoid arthritisFunctional Class

• I .. complete functional capacity– ability to carry out all normal activities

• II .. adequate for normal activities– despite discomfort or limited motion at 1 or more

joints

• III .. limited functional capacity– only little or none of duties of normal occupation

or selfcare

• IV .. incapacitated– largely or wholly bed-ridden or confined to

wheelchair; little or no selfcare

Utility index

Self-rated VAS49586359 49586359N =

Functional Class

4321

Me

an

EQ

-5D

va

lue

1.0

.8

.6

.4

.2

0.0

EQ-5Dindex by Functional Classrheumatoid arthritis patients

EQ-5D in treatment of HIV/AIDS

Treatment group

Ritonavir

Usual therapy

VISIT

mea

n w

eigh

ted

inde

x

1197531

.86

.84

.82

.80

.78

.76

.74

.72

.70

Where are we now ?Science

• Likely to increase number of response levels from 3 to 5

• Investigating a “child-friendly” version of EQ-5D

• Computer-based valuation and self-assessment methods

• Electronic data capture – web based technologies

5-level or 3-level ?

• One suggested modification to existing 3-level descriptive system

• Place unmarked level between existing levels

Where are we now ?Application

• Nearly 100 language versions available• Worldwide take-up with many normative

population studies• Widespread incorporation in clinical

studies that involve economic evaluation• Major head:head study in US of the

leading generic HrQoL measures

ends

Paul Kind : pk1@york.ac.uk

EuroQoL Group : http://www.euroqol.org