Health literacy and logical inconsistencies in valuations of hypothetical health states: results from the Canadian EQ-5D-5L valuation study

Objectives

To examine the association of health literacy with logical inconsistencies in time trade-off valuations of hypothetical health states described by the EQ-5D-5L classification system.

Methods

Data from the EQ-5D-5L Canadian Valuation study were used. Health literacy was assessed using the Brief Health Literacy Screen. A health state valuation was considered logically inconsistent if a respondent gave the same or lower value for a very mild health state compared to the value given to 55555, or gave the same or lower value for a very mild health state compared to value assigned to the majority of the health states that are dominated by the very mild health state.

Results

Average age of respondents (N?=?1209) was 48 (SD?=?17) years, 45% were male, 7% reported inadequate health literacy, and 11% had a logical inconsistency. In adjusted analysis, participants with inadequate health literacy were 2.2 (95%CI: 1.2, 4.0; p?=?0.014) times more likely to provide an inconsistent valuation compared to those with adequate health literacy. More specifically, those who had problems in “understanding written information” and “reading health information” were more likely to have a logical inconsistency compared to those who did not. However, lacking “confidence in completing medical forms” was not associated with logical inconsistencies.

Conclusions

Health literacy was associated with logical inconsistencies in valuations of hypothetical health states described by the EQ-5D-5L classification system. Valuations studies should consider assessing health literacy, and explore better ways to introduce the valuation tasks or use simpler approaches of health preferences elicitation for individuals with inadequate health literacy.

     

Head-to-head comparison between the EQ-5D-5L and the EQ-5D-3L in general population health surveys

Background

The EQ-5D has been frequently used in national health surveys. This study is a head-to-head comparison to assess how expanding the number of levels from three (EQ-5D-3L) to five in the new EQ-5D-5L version has improved its distribution, discriminatory power, and validity in the general population.

Methods

A representative sample (N?=?7554) from the Catalan Health Interview Survey 2011–2012, aged ≥18, answered both EQ-5D versions, and we evaluated the response redistribution and inconsistencies between them. To assess validity of this redistribution, we calculated the mean of the Visual Analogue Scale (VAS), which measures perceived health. The discriminatory power was examined with Shannon Indices, calculated for each dimension separately. Spanish preference value sets were applied to obtain utility indices, examining their distribution with statistics of central tendency and dispersion. We estimated the proportion of individuals reporting the best health state in EQ-5D-5L and EQ-5D-3L within groups of specific chronic conditions and their VAS mean.

Results

A very small reduction in the percentage of individuals with the best health state was observed, from 61.8% in EQ-5D-3L to 60.8% in EQ-5D-5L. In contrast, a large proportion of individuals reporting extreme problems in the 3 L version moved to severe problems (level 4) in the 5 L version, particularly for pain/discomfort (75.5%) and anxiety/depression (66.4%). The average proportion of inconsistencies was 0.9%. The pattern of the perceived health VAS mean confirmed the hypothesis established a priori, supporting the validity of the observed redistribution. Shannon index showed that absolute informativity was higher in the 5 L version for all dimensions. The means (SD) of the Spanish EQ-5D-3L and EQ-5D-5L indices were 0.87 (0.25) and 0.89 (0.22). The proportion of individuals with the best health state within each specific chronic condition was very similar, regardless of the EQ-5D version (≤?30% in half of the 28 chronic conditions).

Conclusion

Although the proportion of individuals with the best possible health state is still very high, our findings support that the increase of levels provided by the EQ-5D-5L contributed to the validity and discriminatory power of this new version to measure health in general population, as in the national health surveys.

     

Measurement properties of the EQ-5D-5L compared to the EQ-5D-3L across eight patient groups: a multi-country study

Purpose

The aim of this study was to assess the measurement properties of the 5-level classification system of the EQ-5D (5L), in comparison with the 3-level EQ-5D (3L).

Methods

Participants (n = 3,919) from six countries, including eight patient groups with chronic conditions (cardiovascular disease, respiratory disease, depression, diabetes, liver disease, personality disorders, arthritis, and stroke) and a student cohort, completed the 3L and 5L and, for most participants, also dimension-specific rating scales. The 3L and 5L were compared in terms of feasibility (missing values), redistribution properties, ceiling, discriminatory power, convergent validity, and known-groups validity.

Results

Missing values were on average 0.8 % for 5L and 1.3 % for 3L. In total, 2.9 % of responses were inconsistent between 5L and 3L. Redistribution from 3L to 5L using EQ dimension-specific rating scales as reference was validated for all 35 3L–5L-level combinations. For 5L, 683 unique health states were observed versus 124 for 3L. The ceiling was reduced from 20.2 % (3L) to 16.0 % (5L). Absolute discriminatory power (Shannon index) improved considerably with 5L (mean 1.87 for 5L versus 1.24 for 3L), and relative discriminatory power (Shannon Evenness index) improved slightly (mean 0.81 for 5L versus 0.78 for 3L). Convergent validity with WHO-5 was demonstrated and improved slightly with 5L. Known-groups validity was confirmed for both 5L and 3L.

Conclusions

The EQ-5D-5L appears to be a valid extension of the 3-level system which improves upon the measurement properties, reducing the ceiling while improving discriminatory power and establishing convergent and known-groups validity.     

Comparing EQ-5D-3L and EQ-5D-5L performance in common cancers: suggestions for instrument choosing

Purpose

To compare the performance of three-level EuroQol five-dimensions (EQ-5D-3L) and five-level EuroQol five-dimensions (EQ-5D-5L) among common cancer patients in urban China.

Methods

A hospital-based cross-sectional survey was conducted in three provinces from 2016 to 2018 in urban China. Patients with breast cancer, colorectal cancer, or lung cancer were recruited to complete the EQ-5D-3L and EQ-5D-5L questionnaires. Response distribution, discriminatory power (indicator: Shannon index [H′] and Shannon evenness index [J′]), ceiling effect (the proportion of full health state), convergent validity, and health-related quality of life (HRQoL) were compared between the two instruments.

Results

A total of 1802 cancer patients (breast cancer: 601, colorectal cancer: 601, lung cancer: 600) were included, with the mean age of 55.6 years. The average inconsistency rate was 4.4%. Compared with EQ-5D-3L (average: H′?=?1.100, J′?=?0.696), an improved discriminatory power was observed in EQ-5D-5L (H′?=?1.473, J′?=?0.932), especially contributing to anxiety/depression dimensions. The ceiling effect was diminished in EQ-5D-5L (26.5%) in comparison with EQ-5D-3L (34.5%) (p?<?0.001), mainly reflected in the pain/discomfort and anxiety/depression dimensions. The overall utility score was 0.790 (95% CI 0.778–0.801) for EQ-5D-3L and 0.803 (0.790–0.816) for EQ-5D-5L (p?<?0.001). A similar pattern was also observed in the detailed cancer-specific analysis.

Conclusions

With greater discriminatory power, convergent validity and lower ceiling, EQ-5D-5L may be preferable to EQ-5D-3L for the assessment of HRQoL among cancer patients. However, higher utility scores derived form EQ-5D-5L may also lead to lower QALY gains than those of 3L potentially in cost-utility studies and underestimation in the burden of disease.

     

EQ-5D-5L versus EQ-5D-3L: The Impact on Cost Effectiveness in the United Kingdom

Objectives

To model the relationship between the three-level (3L) and the five-level (5L) EuroQol five-dimensional questionnaire and examine how differences have an impact on cost effectiveness in case studies.

A comparison of United Kingdom and Spanish general population time trade-off values for EQ-5D health states.

Few studies have compared preference values for health states obtained in different countries. The present study compared Spanish and United Kingdom (UK) time trade-off values for EuroQol-5D health states. The same preference elicitation protocol was followed in both countries. Differences in values for 43 health states rated directly were analyzed using t tests, and regression coefficients generated by random effects modeling were compared by aggregating the 2 value sets and using dummy variables to analyze country effect by dimension and level of severity. For the milder health states, Spanish and UK value assignation was similar; for intermediate health states, Spanish values were both higher and lower than UK values, whereas for health states worse than death, UK values were generally higher than Spanish values. There were statistically significant differences (P < 0.01) in values for 34.9% of health states rated directly, and some preference reversals between countries. UK raters ascribed greater importance to dimensions of pain/discomfort and anxiety/depression, whereas Spanish raters placed more importance on functional dimensions of mobility and self-care. Further analysis is required to determine how these differences affect cost-effectiveness and cost-utility analyses.     

An International Comparison of EQ-5D-5L and EQ-5D-3L for Use in Cost-Effectiveness Analysis

ObjectivesTo estimate the impact of using EQ5D-5L (5L) compared with EQ5D-3L (3L) in cost-effectiveness analyses in 6 countries with 3L and 5L values: Germany, Japan, Korea, The Netherlands, China, and Spain.MethodsEight cost-effectiveness analyses based on clinical studies with 3L provided 11 pairwise comparisons. We estimated cost-effectiveness by applying the appropriate country values for 3L to observed responses. We re-estimated cost-effectiveness for each country by predicting the 5L tariff score for each respondent, for each country, using a previously published mapping method. We compared results in terms of impact on estimated incremental quality-adjusted life-year (QALY) gain and cost-effectiveness ratios.ResultsFor most countries the impact of moving from 3L to 5L is to lower the incremental QALY gain in the majority of comparisons. The only exception to this was Japan, where 4 out of 11 cases (37%) saw lower QALYs gained when using 5L. The mean and median reductions in health gain, in those case studies where 5L does lead to lower health gain, are largest in The Netherlands (84% mean reduction, 41% median reduction), Germany (68% and 27%), and Spain (30% and 31%). For most countries, those studies where 5L leads to lower health gain see larger reductions than the gains in studies showing the opposite tendency.ConclusionsOverall, 3L and 5L are not interchangeable in these countries. Differences between results are large, but the direction of change can be unpredictable. These findings should prompt further investigation into the reasons for differences.     

A social preference valuations set for EQ-5D health states in Flanders, Belgium

This study aimed at deriving a preference valuation set for EQ-5D health states from the general Flemish public in Belgium. A EuroQol valuation instrument with 16 health states to be valued on a visual analogue scale was sent to a random sample of 2,754 adults. The initial response rate was 35%. Eventually, 548 (20%) respondents provided useable valuations for modeling. Valuations for 245 health states were modeled using a random effects model. The selection of the model was based on two criteria: health state valuations must be consistent, and the difference with the directly observed valuations must be small. A model including a value decrement if any health dimension of the EQ-5D is on the worst level was selected to construct the social health state valuation set. A comparison with health state valuations from other countries showed similarities, especially with those from New Zealand. The use of a single preference valuation set across different health economic evaluations within a country is highly preferable to increase their usability for policy makers. This study contributes to the standardization of outcome measurement in economic evaluations in Belgium.     

Comparison between the EQ-5D-5L and the EQ-5D-3L in patients with hepatitis B

Objectives

The purpose of the study was to compare psychometric properties of the EQ-5D-5L (5L) and the EQ-5D-3L (3L) health outcomes assessment instruments in patients with hepatitis B in China.

Methods

Patients, including hepatitis B virus carriers and those with active or inactive chronic hepatitis B, compensated cirrhosis, decompensated cirrhosis or hepatocellular carcinoma, answered a questionnaire composed of 5L, socio-demographic information, 3L, and the visual analog scale (VAS), respectively. After 1 week, a retest was conducted for inpatients. We compared acceptability, face validity, redistribution properties, convergent validity, known-group validity, discriminatory power, ceiling effect, test–retest reliability, and responsiveness of 5L and 3L.

Results

A total of 369 outpatients and 276 inpatients were recruited for the first interview. Of the inpatients, 183 were used in the retest. Most patients preferred 5L–3L. The 3L–5L response pairs had an inconsistency rate of 2.4 %. Correlation with the VAS was greater with 5L than with 3L. Age, education, and comorbidity were associated with health-related quality of life (HRQoL). 5L discriminated more infectious conditions than 3L. In all dimensions, the Shannon’s index from 5L was larger while in three dimensions the Shannon’s evenness index from 5L was slightly larger. The ceiling effect was reduced in 5L. In patients with stable health states, no significant difference was detected in the weighted kappa between 5L and 3L, but intraclass correlation coefficient of 5L was higher than that of 3L. In patients with improved health states, HRQoL was seen as increased in both 5L and 3L, without significant difference.

Conclusions

The EQ-5D-5L was more suitable than the EQ-5D-3L in the patients with hepatitis B in China.     

Japanese population norms for preference-based measures: EQ-5D-3L,EQ-5D-5L,and SF-6D

Quality of Life Research - The purpose of this study was to measure the population norms for the Japanese versions of preference-based measures (EQ-5D-3L, EQ-5D-5L, and SF-6D). We also considered...     

Psychometric properties comparison between EQ-5D-5L and EQ-5D-3L in the general Thai population

Quality of Life Research - Evidence for the EQ-5D-5L’s psychometric properties in the general Thai population is limited. This study aimed to compare ceiling effect, discriminatory power,...     

Comparing the psychometric properties of the EQ-5D-3L and EQ-5D-5L in cancer patients in Korea

Purpose

This study was conducted to assess the redistribution properties of the EQ-5D-3L when using the EQ-5D-5L and to compare the validity, informativity, and reliability of both EQ-5D-3L and EQ-5D-5L in Korean cancer patients.

Methods

Patients visiting one ambulatory cancer center self-administered the two versions of the EQ-5D and the EORTC QLQ-C30 questionnaire. Redistribution properties in each dimension of EQ-5D were analyzed between EQ-5D-3L and EQ-5D-5L. Informativity was evaluated using the Shannon entropy and ceiling effect. Convergent validity was evaluated by comparing the EQ-VAS, ECOG performance status, and EORTC QLQ-C30 subscales. Reliability was also evaluated in terms of test?Cretest reliability.

Results

All levels of the EQ-5D-3L substantially partitioned into associated levels of the EQ-5D-5L. The average inconsistency rate of the two versions was 3.5%. Absolute informativity was higher for the EQ-5D-5L than for the EQ-5D-3L, but their informative efficiency tended to be similar. The proportion of ??perfect health?? (11111) decreased from 16.8% in the EQ-5D-3L to 9.7% in the EQ-5D-5L. EQ-5D-5L demonstrated similar or higher correlations with the EQ-VAS, ECOG performance status, and EORTC QLQ-C30, than the EQ-5D-3L. The intraclass correlation coefficient of the EQ-5D-5L index was 0.77.

Conclusions

The EQ-5D-5L had greater informativity and lower rate in the ceiling effect than those values of the EQ-5D-3L. The EQ-5D-5L showed good construct validity and reasonable reliability. Therefore, considering these findings, the EQ-5D-5L may be preferable to the EQ-5D-3L.     

Racial/ethnic differences in preferences for the EQ-5D health states: results from the U.S. valuation study

OBJECTIVE: We examined differences in preferences for the EQ-5D health states among blacks, Hispanics, and others living in the United States. STUDY DESIGN AND SETTING: A multi-stage probability sample was selected from the adult U.S. population. Each respondent valued a subset of the 243 EQ-5D health states. Regression analysis was used to analyze differences in mean valuations for 13 health states among the racial/ethnic groups. First, we compared unadjusted mean valuations among the three groups. Second, we evaluated differences in mean valuations among the groups after adjusting for other sociodemographic characteristics. Third, we evaluated the impact of race/ethnicity on estimates derived from the U.S. health state valuation (i.e., D1) model. RESULTS: Valuations differed among the groups for seven of the 13 health states, and these differences persisted after adjusting for other sociodemographic factors. Blacks appeared to perceive extreme health problems to be associated with less disutility than did members of the other two groups. CONCLUSION: Within the United States, there exist racial/ethnic differences in the perceived desirability of the EQ-5D health states that cannot be readily explained by socioeconomic disparities.     

Validation and comparison of the psychometric properties of the EQ-5D-3L and EQ-5D-5L instruments in Greece

Purpose

To validate and compare the psychometric properties of the EQ-5D-3L with the EQ-5D-5L classification systems in Greece.

Methods

Participants (n = 2279) over 40 years old, sampled from the greater area of Athens using a multistage stratified quota sampling method, completed both EQ-5D versions, while information was also collected on socio-demographics and health-related characteristics. The EQ-5D-5L and EQ-5D-3L were evaluated in terms of agreement, ceiling effects, redistribution and inconsistency, informativity, and convergent and known-groups validity.

Results

The agreement between the EQ-5D-3L and EQ-5D-5L was high (ICC = 0.85). Ceiling effects decreased significantly in the EQ-5D-5L in all domains (P < 0.001), with “usual activities” (?21.4 %) and “self-care” (?20.1 %) showing the highest absolute and “anxiety/depression” the highest relative reduction (?32.46 %). Inconsistency was low (5.7 %). The increase in prevalence of problems was larger than the decrease in their severity, resulting in a lower mean health utility for the EQ-5D-5L. Overall absolute and relative informativity improved by 70.5 % and 16.4 %, respectively, in the EQ-5D-5L. Both instruments exhibited good convergent and known-groups validity, with evidence of a considerably better convergent performance and discriminatory ability of the EQ-5D-5L.

Conclusions

Both EQ-5D versions demonstrated good construct validity and had consistent redistribution. The EQ-5D-5L system may be preferable to the EQ-5D-3L, as it exhibited superior performance in terms of lower ceiling effects, higher absolute and relative informativity, and improved convergent and known-groups validity efficiency.