Is healthcare any good for patients? Measuring health outcomes using EQ-5D Professor Paul Kind...
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Transcript of Is healthcare any good for patients? Measuring health outcomes using EQ-5D Professor Paul Kind...
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