It’s driving her mad: gender differences in the effects of commuting on psychological well-being

Title: It’s driving her mad: gender differences in the effects of commuting on psychological well-being
Authors: Roberts, J., Hodgson, R. and Dolan, P.
Publisher: Journal of Health Economics
ISSN:
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Abstract: In this paper, we seek to explore the effects of commuting time on the psychological well-being of men and women in the UK. We use annual data from the British Household Panel Survey in a fixed effects panel framework that includes variables known to determine well-being, as well as factors which may provide compensation for commuting such as income, job satisfaction and housing quality. Our results show that, even after all these variables are considered, commuting still has an important detrimental effect on the well-being of women, but not men, and this result is robust to numerous different specifications. We explore possible explanations for this gender difference and can find no evidence that it is due to women´s shorter working hours or weaker occupational position. Rather women´s greater sensitivity to commuting time seems to be a result of their larger responsibility for day-to-day household tasks, including childcare.

Destruction and distress: using a quasi-experiment to show the effects of the September 11 attacks on mental well-being in the United Kingdom

Title: Destruction and distress: using a quasi-experiment to show the effects of the September 11 attacks on mental well-being in the United Kingdom
Authors: Metcalfe, Robert and Powdthavee, Nattavudh and Dolan, Paul
Publisher: The economic journal, 121 (550)
ISSN: 1468-0297
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Abstract: Using a longitudinal household panel dataset in the United Kingdom, where a significant proportion of the interviews are conducted in September each year, we are able to show that the attacks of September 11 resulted in lower levels of subjective well-being for those interviewed after that date in 2001 compared to those interviewed before it. This quasi-experiment provides one of the first examples of the impact of a terrorist attack in one country on well-being in another country.

Getting used to it: the adaptive global utility model

Title: Getting used to it: the adaptive global utility model
Authors: Bradford, W. David and Dolan, Paul
Publisher: Journal of health economics, 29 (6). pp. 811-820
ISSN: 0167-6296
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Abstract: This paper expands the standard model of utility maximization to endogenize the ubiquitous phenomenon of adaptation. We assume that total utility is an aggregate function of the utility associated with different domains of life, with relative weights that are optimized according to the effort that the individual expends on producing utility in each domain. Comparative statics from the general maximization problem demonstrate that the traditional Slutsky equation should incorporate an additional response term to account for adaptation processes. Our adaptive global utility maximization model can be used to explain responses to changes in health.

Thinking about it: thoughts about health and valuing QALYs

Title: Thinking about it: thoughts about health and valuing QALYs
Authors: Dolan, Paul
Publisher: Health economics
ISSN: 1057-9230
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Abstract: When valuing health states (e.g. for use in the assessment of health technologies), health economists often ask respondents how many years of life in poor health they would be willing to trade-off in order to live in full health. Problems with preferences of this kind have led to calls for the use of more direct measures of the utility associated with experiencing a health state. The fact remains, however, that individuals are often willing to make large sacrifices in life expectancy to alleviate conditions for which there appears to be a considerable degree of hedonic adaptation. The purpose of this study is to investigate this important discrepancy in more detail. Data from 1173 internet and telephone surveys in the United States suggest that time trade-off responses are related to the frequency and intensity of negative thoughts about health in ways that may not be very well captured by any of the proposed valuation methods.

‘Oops…I did it again’: repeated focusing effects in reports of happiness

Title: ‘Oops…I did it again’: repeated focusing effects in reports of happiness
Authors: Dolan, Paul and Metcalfe, Robert
Publisher: Journal of economic psychology, 31 (4). pp. 732-737
ISSN: 0167-4870
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Abstract: We use an experiment (relating to a major European soccer match) to replicate previous studies that show forecasts of the impact of an event on happiness are often greatly exaggerated. In addition, by randomising respondents into one of two groups (assessing happiness before and after the event or only after), we are also able to show that previously focusing on an event can affect subsequent happiness responses. From a final sample of 309 soccer fans contacted via a social networking site, the happiness ratings of the fans of the losing team who answered before and after the soccer match is a whole point lower (on a 0–10 scale) than similar fans who rated their happiness only after the event. The potential spillover of a focusing effect from one survey to the next has important implications for how we interpret happiness responses from longitudinal surveys.

Determining the parameters in social welfare function using stated preference data: an application to health

Title: Determining the parameters in social welfare function using stated preference data: an application to health
Authors: Dolan, Paul and Tsuchiya , Aki
Publisher: Applied economics, pp. 1466-4283
ISSN: 0003-6846
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Abstract: One way in which economists might determine how best to balance the competing objectives of efficiency and equity is to specify a social welfare function (SWF). This paper looks at how the stated preferences of a sample of the general public can be used to estimate the shape of the SWF in the domain of health benefits. The results suggest that it is possible to determine the parameters in a social welfare function from stated preference data, but show that people are sensitive to what inequalities exist and to the groups across which those inequalities exist.

Accounting for the richness of daily activities

Title: Accounting for the richness of daily activities
Authors: White, Mathew P. and Dolan, Paul
Publisher: Psychological Science, 20 (8). pp. 1000-1008
ISSN: 0956-7976
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Abstract: Serious consideration is being given to the impact of private behavior and public policies on people’s subjective well-being (SWB). A new approach to measuring well-being, the day reconstruction method (DRM), weights the affective component of daily activities by their duration in order to construct temporal aggregates. However, the DRM neglects the potentially important role of thoughts. By adapting this method to include thoughts as well as feelings, we provide perhaps the most comprehensive measure of SWB to date. We show that some activities relatively low in pleasure (e.g., work and time with children) are nonetheless thought of as rewarding and therefore contribute to overall SWB. Such information may be important to policymakers wishing to promote behaviors that are conducive to a broader conception of SWB. In general terms, there are three approaches to assessing how well people’s lives are going. The first focuses on a range of objective indicators (e.g., freedoms and liberties, health and education level; Nussbaum & Sen, 1993). The second concerns the degree to which people are able to satisfy their desires, as (albeit somewhat badly) indexed by income (Griffin, 1986; Harsanyi, 1982). The third focuses on subjective well-being (SWB) and is generally defined as how people think and feel about their lives (Diener, Suh, Lucas, & Smith, 1999). There is considerable debate about how to weight these three kinds of measures, but all are important, especially for policy purposes (Diener, Lucas, Schimmack, & Helliwell, 2008; Diener & Seligman, 2004; Dolan & Kahneman, 2008; Dolan & White, 2007). Rather than address this issue here, we focus on the comprehensiveness of measures of SWB. Much of the research on SWB that has involved large samples has investigated the thinking, or evaluative, component, focusing on judgments of overall life satisfaction (Dolan, Peasgood, & White, 2008). Research concerning the moment-to-moment feelings, or affect, associated with specific activities has largely been confined to smaller samples because of practical considerations (Hektner, Schmidt, & Csikszentmihalyi, 2007). Both approaches have tended to neglect how long people spend in activities associated with these thoughts and feelings, and this is a potentially serious omission because “time is the ultimate finite resource and the question of how well people spend it is a legitimate issue in the study of well-being” (Kahneman, Schkade, Fischler, Krueger, & Krilla, 2008, p. 11). In response to this concern, Kahneman, Krueger, Schkade, Schwarz, and Stone (2004) developed the day reconstruction method (DRM). This approach brings together measures that examine the feelings associated with specific activities (Hektner et al., 2007) with measures of how people spend their time (e.g., Bianchi, Robinson, & Milkie, 2006; Juster & Stafford, 1985). Specifically, it asks people to recall their previous day and divide it into episodes “like a series of scenes in a film”; for each episode, they record its duration, what they were doing, who they were with, and how they were feeling (using adjectives such as “happy” and “anxious”). In this way, the DRM allows subjective assessments of feelings to be weighted by their duration to derive a “hedonic calculus” for each episode and ultimately a person’s affective profile for an entire day. Because information about an entire day can be gathered at one time, responses can be obtained from reasonably large samples. However, the DRM has one major weakness: its focus on feelings. This has produced a number of puzzling and contentious findings. For instance, the data suggest that people spend considerable amounts of time in activities that provide relatively little SWB, such as commuting and spending time with their children. Richer people spend more time commuting, and Kahneman, Krueger, Schkade, Schwarz, and Stone (2006) suggested that this fact partly explains why income has a small effect on feelings. The relatively low levels of positive feelings reported for spending time with children are claimed to be a more accurate reflection of experience than belief-based generic judgments, such as “I enjoy my kids” (Kahneman et al., 2004). However, it is possible that driving to work or playing with one’s children brings SWB benefits that are not captured by measures of feelings alone. These activities may be absorbing (Csikszentmihalyi, 1990), have purpose (Ryff, 1989; Seligman, 2002), connect one to other people (Ryan & Deci, 2001), and contribute to important personal goals (Cantor & Sanderson, 1999). In other words, commuting and spending time with one’s children may be thought of as rewarding and may contribute to one’s SWB every bit as much as some of the more pleasurable activities (like sex and watching TV) appear to. It may be entirely rational and reasonable for people to choose activities that generate relatively low levels of moment-to-moment affect if this outcome is compensated for by positive evaluations. The aim of the research we report here, then, was to provide a more complete account of SWB that captures feelings, thoughts, and their duration.

Valuing health directly

Title: Valuing health directly
Authors: Dolan, Paul and Lee, Henry and King, Dominic and Metcalfe, Robert
Publisher: British medical journal, 339 (jul20 )
ISSN: 0959-8138
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Abstract: Valuing the relative benefits of different treatments helps us to allocate scarce healthcare resources to where they do the most good. The National Institute for Health and Clinical Excellence (NICE) advises on the cost effectiveness of treatments and recommends that health benefits should be valued in terms of gains in quality adjusted life years (QALYs). This approach assigns a value between 0 (for death) and 1 (for full health) to each health state and then multiplies that value by how long the state lasts. It makes good sense to value health benefits by accounting for duration in this way. We do, however, have serious concerns about NICE’s recommendations for the “quality adjustment” part of the QALY. NICE suggests asking members of the general public to think about how many years of life they would be willing to trade to avoid different states of health. The trouble is that these hypothetical preferences often bear little relation to the real experiences of those in the health states. This article offers an alternative means of valuation that could help direct resources to treatments in proportion to the real suffering they alleviate.

The social welfare function and individual responsibility: some theoretical issues and empirical evidence

Title: The social welfare function and individual responsibility: some theoretical issues and empirical evidence
Authors: Dolan, Paul and Tsuchiya , Aki
Publisher: Journal of health economics, 28 (1). pp. 210-220
ISSN: 0167-6296
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Abstract: The literature on income distribution has attempted to evaluate different degrees of inequality using a social welfare function (SWF) approach. However, it has largely ignored the source of such inequalities, and has thus failed to consider different degrees of inequity. The literature on egalitarianism has addressed issues of equity, largely in relation to individual responsibility. This paper builds upon these two literatures, and introduces individual responsibility into the SWF. Results from a small-scale study of people’s preferences in relation to the distribution of health benefits are presented to illustrate how the parameter values of a SWF might be determined.

Equality of what in health? Distinguishing between outcome egalitarianism and gain egalitarianism

Title: Equality of what in health? Distinguishing between outcome egalitarianism and gain egalitarianism
Authors: Tsuchiya, Aki and Dolan, Paul
Publisher: Health economics, 18 (2). pp. 147-159
ISSN: 1057-9230
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Abstract: When deciding how to weigh benefits to different groups, standard economic models assume that people focus on the final distribution of utility, health or whatever. Thus, an egalitarian is assumed to be an egalitarian in the outcome space. But what about egalitarianism in the gains space, such that people focus instead on how equally benefits are distributed? This paper reports on a study in which members of the public were asked to rank a number of health programmes that differed in the distribution of benefits and final outcomes in ways that enabled us to distinguish between different types of egalitarianism. The results suggest that outcome egalitarianism dominates, particularly for differences in health by social class, but a sizeable minority of respondents appear to be gain egalitarians, especially when the health differences are by sex. These results have important implications for how we think about outcome-based social welfare functions in economics.

Examining the attitudes and preferences of health care decision-makers in relation to access, equity and cost-effectiveness: a discrete choice experiment

Title: Examining the attitudes and preferences of health care decision-makers in relation to access, equity and cost-effectiveness: a discrete choice experiment
Authors: Ratcliffe , Julie and Bekker , Hilary L. and Dolan , Paul and Edlin, Richard
Publisher: Health policy, 90 (1). pp. 45-57
ISSN: 0168-8510
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Abstract: To describe the views of health care decision-makers and providers operating in the UK National Health Service (NHS) concerning the concepts of cost-effectiveness, equity and access through a series of attitudinal questions; to evaluate the preferences of health care providers in relation to each of these concepts using a discrete choice experiment (DCE); to assess the impact of prior completion of an attitude questionnaire on preferences elicited through a DCE.

Interpretations of utility and their implications for the valuation of health.

Title: Interpretations of utility and their implications for the valuation of health.
Authors: Dolan, Paul and Kahneman, Daniel
Publisher: Economic journal, 118 (525). pp. 215-234
ISSN: 1468-0297
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Abstract: The term utility can be interpreted in terms of the hedonic experience of an outcome (experienced utility) or in terms of the preference or desire for that outcome (decision utility). It is this second interpretation that lies at the heart of the methods that economists have developed to value non-market goods, such as health. In this article, we argue that decision utility is unlikely to generate meaningful data on the utility associated with different experiences, and instead economists should look towards developing measures that focus more directly on experienced utility.

Do we really know what makes us happy? A review of the economic literature on the factors associated with subjective well-being

Title: Do we really know what makes us happy? A review of the economic literature on the factors associated with subjective well-being
Authors: Dolan, Paul and Peasgood, Tessa and White, Mathew
Publisher: Journal of economic psychology, 29 (1). pp. 94-122
ISSN: 0167-4870
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Abstract: There is increasing interest in the “economics of happiness”, reflected by the number of articles that are appearing in mainstream economics journals that consider subjective well-being (SWB) and its determinants. This paper provides a detailed review of this literature. It focuses on papers that have been published in economics journals since 1990, as well as some key reviews in psychology and important unpublished working papers. The evidence suggests that poor health, separation, unemployment and lack of social contact are all strongly negatively associated with SWB. However, the review highlights a range of problems in drawing firm conclusions about the causes of SWB; these include some contradictory evidence, concerns over the impact on the findings of potentially unobserved variables and the lack of certainty on the direction of causality. We should be able to address some of these problems as more panel data become available.

Valuing lives and life years: anomalies, implications, and an alternative

Title: Valuing lives and life years: anomalies, implications, and an alternative
Authors: Dolan, Paul and Metcalfe, Robert and Munro, Vicki and Christensen, Michael C.
Publisher: Health economics, policy and law, 3 (03). pp. 277-300
ISSN: 1744-1331
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Abstract: Many government interventions seek to reduce the risk of death. The value of preventing a fatality (VPF) is the monetary amount associated with each statistical death that an intervention can be expected to prevent. The VPF has been estimated using a preference-based approach, either by observingmarket behaviour (revealed preferences) or by asking hypothetical questions that seek to replicate the market (stated preferences). The VPF has been shown to differ across and within these methods. In theory, the VPF should vary according to factors such as baseline and background risk, but, in practice, the estimates vary more by theoretically irrelevant factors, such as the starting point in stated preference studies. This variation makes it difficult to choose one unique VPF. The theoretically irrelevant factors also affect the estimates of the monetary value of a statistical life year and the value of a quality-adjusted life year. In light of such problems, it may be fruitful to focus more research efforts on generating the VPF using an approach based on the subjective well-being associated with different states of the world.

Measuring wellbeing for public policy: preferences or experiences?

Title: Measuring wellbeing for public policy: preferences or experiences?
Authors: Dolan, Paul and Peasgood, Tessa
Publisher: The Journal of legal studies, 37 (S2)
ISSN: 0047-2530
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Abstract: Policy makers seeking to enhance well-being are faced with a choice of possible measures that may offer contrasting views about how well an individual’s life is going. We suggest that choice of well-being measure should be based on three general criteria: (1) the measure must be conceptually appropriate (that is, are we measuring the right sort of concept for public policy?), (2) it must be valid (that is, is it a good measure of that concept?), and (3) it must be empirically useful (that is, does it provide information in a format that can be readily used by policy makers?). Preference-based measures (as represented by income) are compared to experience-based measures (as represented by subjective evaluations of life) according to these criteria. Neither set of measures meets ideal standards, but experiences do fare at least as well as preferences, and subjective evaluations perform much better than income alone as a measure of well-being.

Developing methods that really do value the ‘Q’ in the QALY

Title: Developing methods that really do value the ‘Q’ in the QALY
Author: Dolan, Paul
Publisher: Health economics, policy and law, 3 (01). pp. 69-77
ISSN: 1744-1331
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Abstract: Most health economists recommend that improvements in health be valued by asking members of the general public to imagine themselves in different states of health and then to think about how many years of life they would give up or what risk of death they would be willing to accept in order to be in full health. In this paper, I argue that preferences are not a very good guide to future experiences and a more suitable way to value health is to ask people in different states of health how they think and feel about their lives. Valuing health in this way may result in greater priority being given to mental health services. Whatever the precise implications, it is my contention that it is much better to ration health care according to real experiences rather than according to hypothetical preferences.

Do NHS clinicians and members of the public share the same views about reducing inequalities in health?

Title: Do NHS clinicians and members of the public share the same views about reducing inequalities in health?
Authors: Tsuchiya , Aki and Dolan, Paul
Publisher: Social science & medicine, 64 (12). pp. 2499-2503
ISSN: 0277-9536
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Abstract: Decisions about how to allocate resources in health care are as much about social value judgements as they are about getting the medical facts right. In this context, it is important to compare the social preferences of members of the general public with those of National Health Service (NHS) staff involved in service delivery. A questionnaire eliciting peoples’ preferences over maximising life expectancy and reducing inequalities in life expectancy between the highest and lowest social classes was completed by 271 members of the UK public and 220 NHS clinicians. The two samples have different preferences with the general public showing a greater willingness than clinicians to sacrifice total health for a more equal distribution of health. These differences may highlight tensions between what the public wants and what clinicians want, and should be subject to further investigation.

How can measures of subjective well-being be used to inform public policy?

Title:  How can measures of subjective well-being be used to inform public policy?
Authors: Dolan, Paul and White, Mathew P.
Publisher: Perspectives on psychological science, 2 (1). pp. 71-85
ISSN: 1745-6916

Abstract: The debate surrounding the use of subjective measures of well-being for policy purposes has intensified in recent years. Many social scientists are arguing that the time is right for policymakers to extend their traditional focus on material well-being and economic development to include the impact policies have on how people think and feel about their lives. However, policymakers may have many legitimate goals beyond making people happy. In this article, we begin by presenting three archetypal accounts of well-being that policymakers could use to guide policy (mental-state, objective-list, and desire-fulfillment accounts) and discussing some of the normative and methodological limitations of each. We discuss how a subjective (mental-state) approach could be used to aid the achievement of objective-list and desire-fulfillment policy goals. We then consider ways in which a subjective approach may benefit policymakers in its own right, such as by aiding the valuation of hard-to-quantify costs and benefits, providing a standard unit of measurement for comparisons of well-being across domains, and helping to set policy defaults. We conclude with a discussion of some of the remaining measurement issues and general policy implications.

It ain’t what you do, it’s the way that you do it: characteristics of procedural justice and their importance in social decision-making

Title: It ain’t what you do, it’s the way that you do it: characteristics of procedural justice and their importance in social decision-making
Authors: Dolan, Paul and Edlin, Richard and Tsuchiya , Aki and Wailoo, Allan
Publisher: Journal of economic behavior & organization, 64 (1). pp. 157-170
ISSN: 0167-2681
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Abstract: Standard welfare economic analysis evaluates all actions by their consequences. However, evidence from other disciplines suggests that the procedures by which decisions are made also affects the welfare of individuals. This paper outlines six characteristics on which judgements about procedural justice may be based. Using the example of health care rationing, we examine the importance of each characteristic using qualitative and quantitative methods. We further consider the importance of each of these characteristics relative to one another and examine whether they are important for consequential or non-consequential reasons.

Estimating the economic and social costs of the fear of crime

Title: Estimating the economic and social costs of the fear of crime
Authors: Dolan, Paul and Peasgood, Tessa
Publisher: British journal of criminology, 47 (1). pp. 121-132
ISSN: 0007-0955
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Abstract: A recent article in this journal, Dolan et al. (2005) provided a methodology for estimating the intangible costs (or losses in quality of life) from violent crime. Here, we develop that methodology to provide estimates of the intangible costs arising from the anticipation of possible victimisation; that is, estimates of the costs of fear of crime. These costs are categorised according to whether they result in non-health losses or health losses. Non-health losses are associated with a) changes in behaviour and/or b) changes in how society is viewed. Possible methods for measuring and valuing these non-health losses are discussed. However, the paper focuses on measuring and providing a provisional monetary valuation for the health losses arising from anticipating crime

Does the whole equal the sum of the parts? Patient-assigned utility scores for IBS-related health states and profiles

Title: Does the whole equal the sum of the parts? Patient-assigned utility scores for IBS-related health states and profiles
Authors: Brazier, John and Dolan, Paul and Karampela, Korina and Towers, Isabel
Publisher: Health economics, 15 (6). pp. 543-551
ISSN: 1057-9230
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Abstract: The quality-adjusted life year (QALY) assumes that the value of a health state is linearly related to the time spent in it, which implies that the value of a health state is independent of the states which precede or follow it. Irritable bowel syndrome (IBS) is a suitable condition to test this assumption since it is subject to considerable fluctuations over time. Forty-nine IBS patients were asked to rate their own health using generic measures of health and a condition specific classification. They were then asked to value five IBS states and four profiles using a self-completed version of the standard gamble technique. The implied value of each profile was estimated using the QALY assumption of linearity over time and compared with the direct profile valuations. The directly elicited profile values suggest that reductions in the duration of IBS symptoms has less of an impact on the value of quality of life than would be implied by the QALY assumption of linearity over time, though the differences were small. There are a number of competing explanations for this finding, including possible sequence effects, quantity effects or time preference, or it might be due to gestalt effects resulting in a neglect of time spent in symptomatic states of health

Dynamic well-being: connecting indicators of what people anticipate with indicators of what they experience

Title: Dynamic well-being: connecting indicators of what people anticipate with indicators of what they experience
Authors: Dolan, Paul and White, Mathew
Publisher: Social indicators research, 75 (2). pp. 303-333
ISSN: 0303-8300
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Abstract: There are many indicators of a person’s well-being that could be used for policy purposes. Few would argue that any single indicator of well-being is appropriate in all contexts and, increasingly, social scientists are attempting to integrate the various indicators. Further successful integration depends on understanding how the various indicators of well-being relate to one another in a dynamic way. This paper attempts to connect indicators of what people anticipate to indicators of what is actually experienced and, in so doing, inform the normative debate about the appropriateness of different indicators in policy contexts.

Estimating the intangible victim costs of violent crime.

Title: Estimating the intangible victim costs of violent crime.
Authors: Dolan, Paul and Loomes, G. and Peasgood, Tessa and Tsuchiya, Aki
Publisher: British journal of criminology, 45 (6). pp. 958-976
ISSN: 0007-0955
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Abstract: Current estimates of the intangible costs of violent crime, such as the pain, grief and suffering experienced by victims, are not very robust. This paper sets out the different methods that can be used to provide more defensible cost estimates, and that use data that are currently available. One of these methods involves estimating the number of quality-adjusted life years (QALYs) that victims of crime lose. The estimates suggest that rape results in the biggest losses, followed (in descending order) by: other wounding, common assault, serious wounding, murder, robbery and sexual assault.

Health priorities and public preferences: the relative importance of past health experience and future health prospects

Title: Health priorities and public preferences: the relative importance of past health experience and future health prospects
Authors: Dolan, Paul and Tsuchiya , Aki
Publisher: Journal of health economics, 24 (4). pp. 703-714
ISSN: 0167-6296
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Abstract: We explore people’s choices where the preference for those with worse future health prospects and the preference for the young over the old conflict. The empirical study used scenarios with four attributes: past years, past health, future years without treatment, and future health without treatment. One hundred respondents ranked various patient groups described in these terms. The results suggest a strong effect of past years: younger groups (40-year-olds) were always chosen over older ones (60-year-olds). Past health was significant in one question but not the other and future health and years without treatment were both non-significant

Developing a relativities approach to valuing the prevention of non-fatal work-related accidents and ill health

Title: Developing a relativities approach to valuing the prevention of non-fatal work-related accidents and ill health
Authors: Karnon, Jonathan and Tsuchiya , Aki and Dolan, Paul
Publisher: Health economics, 14 (11). pp. 1103-1115
ISSN: 1057-9230
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Abstract: The aim of the current explorative study is to define and test a process for the valuation of the benefits associated with the prevention of non-fatal work-related accidents and ill health. A relativities approach is adopted, and monetary values for the prevention of three forms of work-related illness are estimated. The approach involves describing relevant attributes of alternative events (accidents or occurrences of ill health), their causes, the characteristics of the relevant working population, and the number of events that are avoidable, and asking respondents to make pair wise choices between alternatives options for prevention. Indirect monetary valuations are obtained against a peg event for which a reliable valuation exists (road deaths). A series of discussion groups were held to identify relevant factors affecting potential valuations and to test the presentation of information. The predicted magnitude of responses for three-case study events (and road deaths) was estimated in a pilot study. These preliminary stages informed the final survey instrument that described five attributes in addition to a statement of the event and occupation, and the likely intervention effect, which was administered by post. Based on a small sample, the results show that virtually all respondents passed the inserted consistency test. The median respondent altered their choice according to the number of events avoided for all three comparisons, such that the estimated valuations appear sensible. Potential amendments are suggested, but the general relativities approach warrants further investigation for the valuation of non-fatal work-related accidents and ill health

Procedural justice in public health care resource allocation

Title: Procedural justice in public health care resource allocation
Authors: Dolan, Paul and Tsuchiya , Aki and Miguel, Luis and Edlin, Richard and Wailoo, Allan
Publisher: Applied health economics and health policy, 4 (2). pp. 119-127
ISSN: 1175-5652
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Abstract: Introduction: The legal studies literature on procedural justice identifies six key characteristics of procedural justice: accuracy, consistency, impartiality, reversibility, transparency and voice. However, the relative importance of these in the context of public healthcare resource allocation is unclear, as is whether they are valuable instrumentally (because it contributes to better outcomes) or inherently (for its own sake). Methods: A survey of 80-odd members of the UK public determined the following: the ranking of all the six characteristics; the pairwise comparisons of the characteristics; and whether each characteristic was important for instrumental reasons, for intrinsic reasons or for both. Results: Respondents ranked the procedures in the order of accuracy, consistency, impartiality, reversibility and transparency. Procedural justice was valued for both instrumental and inherent reasons. Discussion/conclusion: A robust ranking of five of the six procedural characteristics was found. The ranking for voice was sensitive to the question format, which has methodological implications. Around a quarter to a third of respondents regarded a procedural characteristic to have entirely intrinsic value.

Inconsistency and health state valuations.

Title: Inconsistency and health state valuations
Authors: Dolan, Paul and Kind, Paul.  In: Kind, Paul and Brooks, Richard and Rabin, Rosalind, (eds.)
Publisher: EQ-5D concepts and methods: a developmental history. Springer Netherlands, Rotterdam, The Netherlands, pp. 139-146
ISSN: 9781402037115
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Abstract: The comparison of scaling methods used to value health states sometimes rests upon an analysis of aggregate scores. This analysis is usually undertaken once “inconsistent’ respondents have been excluded from the data. However, it is important to be able to judge the extent to which respondents as a whole are logically consistent when assigning values to health states. The degree of inconsistency will depend on how the health states are described, how the questionnaire is administered and who the respondents are. This paper analyses the inconsistency rates from two studies in which valuations for EuroQol health states were elicited using the visual analogue scale (VAS) method. The studies differed in design and incorporated several different variants of the standard EuroQol questionnaire, thus providing an opportunity to examine the relative importance of the different factors that were thought to affect inconsistency rates. Our general conclusions are that inconsistency rates are higher for interviewer-based than for postal surveys, possibly due to response bias, and that inconsistency rates are positively related to age and negatively related to educational attainment.

9781402037115

QALY maximisation and people’s preferences: a methodological review of the literature

Title: QALY maximisation and people’s preferences: a methodological review of the literature
Authors: Dolan, Paul and Shaw, Rebecca and Tsuchiya , Aki and Williams, Alan
Publisher: Health economics, 14 (2). pp. 197-208
ISSN: 1057-9230
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Abstract: In cost-utility analysis, the numbers of quality-adjusted life years (QALYs) gained are aggregated according to the sum-ranking (or QALY maximisation) rule. This requires that the social value from health improvements is a simple product of gains in quality of life, length of life and the number of persons treated. The results from a systematic review of the literature suggest that QALY maximisation is descriptively flawed. Rather than being linear in quality and length of life, it would seem that social value diminishes in marginal increments of both. And rather than being neutral to the characteristics of people other than their propensity to generate QALYs, the social value of a health improvement seems to be higher if the person has worse lifetime health prospects and higher if that person has dependents. In addition, there is a desire to reduce inequalities in health. However, there are some uncertainties surrounding the results, particularly in relation to what might be affecting the responses, and there is the need for more studies of the general public that attempt to highlight the relative importance of various key factors.

Should patients have a greater role in valuing health states?

Title: Should patients have a greater role in valuing health states?
Authors: Brazier, J. and Akehurst, Ron and Brennan, Alan and Dolan, Paul and Claxton, Karl and McCabe, Chris and Sculpher, Mark and Tsuchyia, Aki
Publisher: Applied health economics and health policy, 4 (4). pp. 201-208
ISSN: 1175-5652
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Abstract: Currently, health state values are usually obtained from members of the general public trying to imagine what the state would be like rather than by patients who are actually in the various states of health. Valuations of a health state by patients tend to vary from those of the general population, and this seems to be due to a range of factors including errors in the descriptive system, adaptation to the state and changes in internal standards. The question of whose values are used in cost-effectiveness analysis is ultimately a normative one, but the decision should be informed by evidence on the reasons for the differences. There is a case for obtaining better informed general population preferences by providing more information on what it is like for patients (including the process of adaptation).

The QALY model and individual preferences for health states and health profiles over time: a systematic review of the literature

Title: The QALY model and individual preferences for health states and health profiles over time: a systematic review of the literature
Authors: Tsuchiya, A. and Dolan, Paul
PublisherMedical decision making, 25 (4). pp. 460-467, 2005
ISSN: 1552-681X
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Abstract: The numbers of quality-adjusted life years (QALYs) gained are increasingly being used to represent the gains in individual utility from treatment. This requires that the value of a health improvement to an individual is a simple product of gains in quality of life and length of life. The article reports on a systematic review of the literature on 2 issues: whether the value of a state is affected by how long the state lasts, and by states that come before or after it. It was found that individual preferences over health are influenced by the duration of health states and their sequence. However, although there is much variation across individual respondents, the assumptions tend to hold much better when valuations are aggregated across respondents, which is encouraging for economic evaluations that rely on using average (mean or median) values.

 

Discrete choice experiments in health economics

Title: Discrete choice experiments in health economics
Authors: Bryan, Stirlin and Dolan, Paul
PublisherEuropean journal of health economics, 5 (3). pp. 199-202
ISSN: 618-7598
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Abstract: One method that is increasingly being used in health economics to elicit stated preferences concerning health matters is the discrete choice experiment (DCE). This editorial explores four sets of issues facing researchers who wish to employ DCE techniques: (a) normative issues about how data from DCE studies might be used to inform policy, (b) psychological issues concerning the meaningfulness of the data generated, (d) technical issues relating to how the data are generated and (d) issues relating to the generalisability of the data from DCE studies. Given current uncertainties surrounding these issues, it is our view that more caution and greater circumspection towards DCE is appropriate at this stage.

Explaining attitudes towards ambiguity: an experimental test of the comparative ignorance hypothesis

Title: Explaining attitudes towards ambiguity: an experimental test of the comparative ignorance hypothesis
Authors: Dolan, Paul and Jones, Martin
PublisherScottish journal of political economy, 51 (3). pp. 281-301
ISSN: 0036-9292
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Abstract: Many theories have been put forward to explain attitudes towards ambiguity. This paper reports on an experiment designed to test for the existence of Comparative Ignorance when it is tested over events with a range of different likelihoods. A total of 93 subjects valued a series of gambles, one of which was played out for real. The results do not lend support to the theory, although the relationship between risk and ambiguity does appear to correspond with other theories and previous empirical work.

A note on a discussion group study of public preferences regarding priorities in the allocation of donor kidneys

Title: A note on a discussion group study of public preferences regarding priorities in the allocation of donor kidneys
Authors: Dolan, Paul and Shaw, Rebecca
PublisherHealth policy, 68 (1). pp. 31-36
ISSN: 0168-8510
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Abstract: Objective: To explore whether and how people wish to give differential priority based on certain characteristics of the potential recipient of a donor kidney. Design: A random sample of people resident in York was invited to attend two focus group meetings each, a fortnight apart. Setting: The City of York. Participants: Twenty-three randomly chosen people meeting in four groups of five or six. Main outcome measures: Those factors that people think should be taken into account when allocating donor kidneys, in addition to the expected benefits from transplantation. Results: People are willing and able to distinguish between potential recipients of a kidney transplantation according to a range of characteristics beyond the expected benefits from treatment. There is a clear consensus across the four groups that one of the most important considerations is what will happen to the patient without treatment, and so priority is given to those with a poor prognosis. There is also a strong view that priority should be given to younger patients and to those with dependants. The time spent waiting for a transplant is also important, but less so. Conclusions: A sample of the general public, after discussion and debate, wish to take account of a number of patient characteristics when allocating donor kidneys. There is some degree of consensus about what these factors should be and this suggests that it might be possible to develop a set of guidelines for the allocation of donor kidneys.

To what extent do people prefer health states with higher values? A note on evidence from the EQ-5D valuation set

Title: To what extent do people prefer health states with higher values? A note on evidence from the EQ-5D valuation set
Authors: Roberts, Jennifer and Dolan, Paul
Publisher: Health economics, 13 (7). pp. 733-737
ISSN: 1057-9230
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Abstract: The EQ-5D general population valuation set (or ‘tariff’) is increasingly being used in the evaluation of health care interventions and has been recommended by the National Institute for Clinical Excellence (NICE) for use in cost-utility analyses of health technologies. To be of use to decision-makers, the health gain implied by changes in health state values must reflect individual preferences. At the simplest level, if State A has a higher mean value than State B, then the majority of people should consider a move from B to A to be a good thing. In this paper, we examine the extent to which this is true by re-analysing data from the general population study used to derive the EQ-5D tariff. We show that, on average, the difference in value between two states has to be as large as 0.20 (on a scale where one represents full and zero represents death) for 70% of respondents to agree with the sign of that difference (never mind its size). Results such as these have important implications for the use of the EQ-5D tariff that has been generated from these data.

The moral relevance of personal characteristics in setting health care priorities

Title: The moral relevance of personal characteristics in setting health care priorities
Authors: Olsen, Jan Abel and Richardson, Jeff and Dolan, Paul and Menzel, Paul
Publisher: Social science & medicine, 57 (7). pp. 1163-1172
ISSN: 0277-9536
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Abstract: This paper discusses the moral relevance of accounting for various personal characteristics when prioritizing between groups of patients. After a review of the results from empirical studies, we discuss the ethical reasons which might explain–and justify–the views expressed in these studies. The paper develops a general framework based upon the causes of ill health and the consequences of treatment. It then turns to the question of the extent to which a personal characteristic–and the eventual underlying ethical justification of its relevance–could have any relationships to these causes and consequences. We attempt to disentangle those characteristics that may reflect a potentially relevant justification from those which violate widely accepted principles of social justice.

A single European currency for EQ-5D health states.

Title: A single European currency for EQ-5D health states.
Authors: Greiner, Wolfgang and Weijnen, Tom and Nieuwenhuizen, Martin and Oppe, Siem and Badia, Xavier and Busschbach, Jan and Buxton, Martin and Dolan, Paul and Kind, Paul and Krabbe, Paul and Ohinmaa, Arto and Parkin, David and Roset, Montserat and Sintonen, Harri and Tsuchiya , Aki and de Charro, Frank
Publisher: The European journal of health economics, 4 (3). pp. 222-231
ISSN: 1618-7598
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Abstract: The EQ-5D questionnaire is a widely used generic instrument for describing and valuing health that was developed by the EuroQol Group. A primary objective of the EuroQol Group is the investigation of values for health states in the general population in different countries. As part of the EuroQol enterprise 11 population surveys were carried out in six Western European countries (Finland, Germany, The Netherlands, Spain, Sweden and the UK) to value health states as defined by the EQ-5D using a standardised visual analogue scale (EQ-5D VAS).This contribution reports how a European set of general population preference weights was derived from the data collected in the 11 valuation studies. The scores from this set of preference weights can be applied to generate a VAS-based weighted health status index for all the potential 243 EQ-5D health states for use in multi-national studies. To estimate the preference weights a multi-level regression analysis was performed on 82,910 valuations of 44 EQ-5D health states elicited from 6,870 respondents. Stable and plausible solutions were found for the model parameters.TheR2 value was 75%.The analysis showed that the major source of variance, apart from ‘random error’, was variance between individuals (28.3% of the total residual variance). These results suggest that VAS values for EQ-5D health states in six Western European countries can be described by a common model.

The validity of time trade-off values in calculating QALYs: constant proportional time trade-off versus the proportional heuristic

Title: The validity of time trade-off values in calculating QALYs: constant proportional time trade-off versus the proportional heuristic
Authors: Dolan, Paul and Stalmeier, Peep
Publisher: Journal of health economics, 22 (3). pp. 445-458
ISSN: 0167-6296
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Abstract: In order to calculate quality adjusted life years (QALYs) from time trade-off (TTO) responses, individual preferences are required to satisfy the constant proportional time trade-off (CPTTO) assumption. Respondents who use a simple proportional heuristic may appear to satisfy CPTTO but will in fact generate preference reversals for states that are associated with a maximal endurable time (MET). Using data from 91 respondents, the study reported here examines the extent to which valuations satisfy the CPTTO assumption and the extent to which they might be generated by the proportional heuristic. The results suggest that respondents are using a proportional heuristic that casts doubt on the validity of using the TTO method to calculate QALYs for health states that are associated with MET preferences.

A note on the relative importance that people attach to different factors when setting priorities in health care

Title: A note on the relative importance that people attach to different factors when setting priorities in health care
Authors: Dolan, Paul and Shaw, Rebecca
Publisher: Health expectations, 6 (1). pp. 53-59
ISSN: 1369-6513
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Abstract: Objective To explore whether and to what extent people wish to give differential priority when asked to choose between providing health care treatment for different individuals or groups, on the basis of a range of factors, ranging from health gain to the number of dependants a person has. Design A sample of people resident in York self-completed a questionnaire. Setting The City of York. Participants Twenty-three members of the general public and 29 undergraduate students. Main outcome measures The relative importance of factors that people think should be taken into account when choosing between providing health care treatment for individuals or groups. Results The results suggest that health gain and the consequences for health without treatment are two of the most important considerations. Conclusions A sample of the general public and undergraduate students wish to take account of a number of personal characteristics when setting priorities in health care.

Measuring people’s preferences regarding ageism in health: some methodological issues and some fresh evidence

Title: Measuring people’s preferences regarding ageism in health: some methodological issues and some fresh evidence
Authors: Tsuchiya , Aki and Dolan, Paul and Shaw, R.
Publisher: Social science & medicine, 57 (4). pp. 687-696
ISSN: 0277-9536
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Abstract: In this paper, we outline the three main concepts of ‘ageism’; health maximisation ageism, productivity ageism, and fair innings ageism. We provide a methodological overview of the existing empirical literature on people’s preferences regarding age and classify these studies according to the types of questions that have been asked. We consider some of the methodological issues involved in eliciting preferences regarding ageism and propose using a fixed duration of benefit rather than, as some studies have done, a benefit that lasts for a full lifetime. Informed by this discussion, we present the results from our own empirical study, carried out in the UK, which combines qualitative and quantitative methods to explore the reasons people have for choosing one age over another. In so doing, we are able to consider the extent to which respondents might bring extraneous factors to bear on their responses and/or disregard relevant information (such as that relating to the fixed nature of the benefit). The results suggest that people are broadly in favour of giving priority to younger over older people, based on arguments relating to both productivity ageism and fair innings ageism. However, respondents appear to assume that a benefit would last for a full lifetime (even if they are told to assume a fixed benefit), unless they are asked to consider a ‘full-life’ benefit first. This particular framing effect has important implications for preference elicitation studies, suggesting that if you want people to answer the question you have in mind, first ask them the question you think they may have in mind.

The person trade-off method and the transitivity principle: an example from preferences over age weighting

Title: The person trade-off method and the transitivity principle: an example from preferences over age weighting
Authors: Dolan, Paul and Tsuchiya , Aki
Publisher: Health economics, 12 (6). pp. 505-510
ISSN: 1057-9230
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Abstract: The person trade-off (PTO) is increasingly being used to elicit preferences in health. This paper explores the measurement properties of the PTO method in the context of a study about how members of the public prioritise between patients of different ages. In particular, it considers whether PTO responses satisfy the transitivity principle; that is, whether one PTO response can be inferred from two other PTO responses. The results suggest that very few responses to PTO questions satisfy cardinal transitivity condition. However, this study has produced results that suggest that cardinal transitivity will hold, on average, when respondents who fail to satisfy the ordinal transitivity condition have been excluded from the analysis. This suggests that future PTO studies should build in checks for ordinal transitivity.

The role of adaptation to disability and disease in health state valuation: a preliminary normative analysis

Title: The role of adaptation to disability and disease in health state valuation: a preliminary normative analysis
Authors: Menzel, Paul and Dolan, Paul and Richardson, Jeff and Olsen, Jan Abel
Publisher: Social science & medicine, 55 (12). pp. 2149-2158
ISSN: 0277-9536
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Abstract: Chronically ill and disabled patients generally rate the value of their lives in a given health state more highly than do hypothetical patients imagining themselves to be in such states. Much of this difference may be due to actual patients’ adaptation to their health states, a phenomenon that would not typically affect the ratings of persons who only hypothetically imagine themselves to be patients. This article pursues a non-empirical, normative question: does such adaptation render actual patients’ ratings of quality of life morally questionable for purposes of resource allocation? Distinguishing the different basic elements in patient adaptation reveals why, and in what respects, people are pulled strongly in opposite directions in responding to this question. Several more explicit moral arguments against using adapted patients’ ratings have been articulated by economists and philosophers, and others are developed by the authors. While most of these arguments do not survive careful analysis, several do. Given the subsequent complexity of the matter, it is argued that: (1) Neither solely actual nor solely hypothetical patient perspectives should be used for rating quality of life. (2) Even if representatives of the general public acting as hypothetical patients provide ultimately the best perspective from which to discern societal values about health states, patients’ values that are often influenced by adaptation must still be conveyed to and clearly understood by public representatives as a critically important fact about health-related quality of life. The article also points to the need for much additional work on adaptation, both empirical research and normative analysis.

An inquiry into the different perspectives that can be used when eliciting preferences in health

Title: An inquiry into the different perspectives that can be used when eliciting preferences in health
Authors: Dolan, Paul and Olsen, Jan Abel and Menzel, Paul and Richardson, Jeff
Publisher: Health economics, 12 (7). pp. 545-551
ISSN:  1057-9230
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Abstract: There are a number of perspectives that an individual could be asked to adopt in studies designed to elicit preferences for use in informing resource allocation decisions in health care. This paper develops a conceptual framework that clearly distinguishes between six different perspectives. It is argued that the appropriate perspective to use depends on normative considerations and the particular policy context to which it will be applied. We suggest a future research agenda that explicitly addresses these considerations and which involves direct empirical investigation into the effect of perspective on preferences.

Is it really possible to build a bridge between cost-benefit analysis and cost-effectiveness analysis?

Title: Is it really possible to build a bridge between cost-benefit analysis and cost-effectiveness analysis?
Authors: Dolan, Paul and Edlin, Richard
Publisher: Journal of health economics, 21 (5). pp. 827-843
ISSN: 0167-6296
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Abstract: Cost-benefit analysis (CBA) is a recognised as the economic evaluation technique that accords most with the underlying principles of standard welfare economic theory. However, due to problems associated with the technique, economists evaluating resources allocation decisions in health care have most often used cost-effective analysis (CEA), in which health benefits are expressed in non-monetary units. As a result, attempts have been made to build a welfare economic bridge between cost-benefit analysis (CBA) and cost-effectiveness analysis (CEA). In this paper, we develops these attempts and finds that, while assumptions can be made to facilitate a constant willingness-to-pay per unit of health outcome, these restrictions are highly unrealistic. We develop an impossibility theorem that shows it is not possible to link CBA and CEA if: (i) the axioms of expected utility theory hold; (ii) the quality-adjusted life-year (QALY) model is valid in a welfare economic sense; and (iii) illness affects the ability to enjoy consumption. We conclude that, within a welfare economic framework, it would be unwise to rely on a link between CBA and CEA in economic evaluations.

Modelling valuations for EQ-5D health states: an alternative model using differences in valuations

Title: Modelling valuations for EQ-5D health states: an alternative model using differences in valuations
Authors: Dolan, Paul and Roberts, Jennifer
Publisher: Medical care, 40 (5). pp. 442-446
ISSN: 0025-7079
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Abstract: Objectives. The EQ-5D is a preference-based measure of health and is increasingly being used in the evaluation of health technologies. A ‘tariff’ of values for all 243 EQ-5D health states has been generated using direct valuations on a subset of these states. The tariff is used to express the value of differences between health states, and so this paper explores whether a tariff with better predictive ability can be calculated using differences between values rather than using the values themselves. Methods. The original tariff (reported in this journal) was based on valuations for 42 EQ-5D states elicited from a representative sample of 2997 members of the UK general population using the time trade-off method. This same data are used to estimate a tariff based upon the differences in value between the worst possible state (33333) and all other states. Results. A simple model that fits the data well is one in which the differences in value between 33333 and all other states are explained in terms of the change in each dimension plus a term to pick up whether some dimensions change by the maximum amount whereas others do not change at all. The mean absolute difference between the actual values and those predicted by this model is 0.03 (compared with 0.039 in the original model). Conclusion. The model presented in this paper predicts the difference between 33333 and all other states remarkably well and can be used to generate a tariff for all EQ-5D health states. In fact, this model more accurately predicts the values of states for which there are direct observations, and so we recommend its comparison with the original model in evaluative studies.

To what extent can we explain time trade-off values from other information about respondents?

Title: To what extent can we explain time trade-off values from other information about respondents?
Authors: Dolan, Paul and Roberts, Jennifer
Publisher: Social science & medicine, 54 (6). pp. 919-929
ISSN: 0277-9536
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Abstract: The time trade-off (TTO) is one of the most widely used health state valuation methods and was recently used to develop a set of values for the EQ-5D descriptive system from 3000 members of the UK general population. However, there is currently very little understanding of precisely what determines responses to TTO questions. The data that were used to generate this set of values are ideal for addressing this question since they contain a plethora of information relating to the respondents and their cognition during the TTO exercise. A particularly useful characteristic of this dataset is the existence of visual analogue scale (VAS) valuations on the same states for the same respondents. The results suggest that age, sex and marital status are the most important respondent characteristics determining health state valuations. The VAS valuations were found to add very little to the explanatory power of the models.

The measurement of preferences over the distribution of benefits: the importance of the reference point

Title: The measurement of preferences over the distribution of benefits: the importance of the reference point
Authors: Dolan, Paul and Robinson, Angela
Publisher: European economic review, 45 (9). pp. 1697-1709
ISSN: 0014-2921
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Abstract: This paper uses the Atkinson method, which was initially developed to measure the shape of the social welfare function (SWF) in the domain of income, to measure the shape of the SWF with respect to the distribution of health benefits. Two separate studies were conducted involving a total of 71 respondents. A comparison of the results across the two studies suggests that reference point effects play an important role in determining responses. Thus, more research is needed on the role that reference point effects ought to and do play in determining the nature and extent of the efficiency – equity trade-off before the results of studies of this kind can be interpreted as ‘equity parameters’ which may simply be ‘plugged into’ an appropriately specified SWF.

Equity in health: the importance of different health streams

Title:  Equity in health: the importance of different health streams
Authors: Dolan, Paul and Olsen, Jan Abel
Publisher: Journal of health economics, 20 (5). pp. 823-834
ISSN: 0167-6296
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Abstract: This paper develops a conceptual framework in which preferences about the distribution of future health gains depend on differences in four ‘health streams’. These are as follows: (1) the amount of health to be gained; (2) the no-treatment profiles; (3) the amount of health experienced thus far; and (4) the amount of health gained previously as a result of public health interventions. This classification puts the well-established concerns for severity (stream 2) and age weights (stream 3) into a more complete analytical framework. Stream 4 has not been discussed to date and the paper suggests some moral arguments about the distributive relevance of this stream of health.

Utilitarianism and the measurement and aggregation of quality: adjusted life years

Title: Utilitarianism and the measurement and aggregation of quality: adjusted life years
Authors: Dolan, Paul
Publisher: Health care analysis, 9 (1). pp. 65-76
ISSN: 065-3058
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Abstract: It is widely accepted that one of the main objectives of government expenditure on health care is to generate health. Since health is a function of both length of life and quality of life, the quality-adjusted life-year (QALY) has been developed in an attempt to combine the value of these attributes into a single index number. The QALY approach – and particularly the decision rule that healthcare resources should be allocated so as to maximise the number of QALYs generated – has often been equated with the utilitarian philosophy of maximising `the greatest happiness of the greatest number’. This paper considers the extent to which the measurement and aggregation of QALYs really is utilitarian by developing a new taxonomy in order to classify utilitarianism and the different aspects of the QALY approach.It is shown that the measurement of QALYs is consistent with a number of different moral positions and that QALYs do not have to be aggregated according to the maximisation rule. Therefore it is inappropriate to necessarily equate QALYs with utilitarianism. It is shown that much turns on what in principle the QALY represents and how in practice it can be operationalised. The paper highlights the category confusion that is often present here and suggests possible avenues for future theoretical and empirical research.

A qualitative study of the extent to which health gain matters when choosing between groups of patients

Title: A qualitative study of the extent to which health gain matters when choosing between groups of patients
Authors: Dolan, Paul and Cookson, Richard
Publisher: Health Policy, 51 (1). pp. 19-30
ISSN: 0168-8510
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Abstract: There is considerable debate about the appropriateness of allocating health care resources on the basis of the size of the health improvement that they generate. The aim of this study was to elicit the general public’s views about the extent to which health gain matters vis-à-vis other considerations. A total of 60 respondents took part in group discussions designed to enable them to raise, discuss, and reflect upon, different arguments. The qualitative data showed that many responses were being generated by factors that were not directly included in the questions, and so it is difficult to meaningfully interpret the results of other studies which have asked similar questions but which have not looked at the reasons underlying the responses. However, a clear message did come through from the data; namely, that equality of access should prevail over the maximisation of benefits. However, this was subject to the outcome constraint that treatments are sufficiently effective. An important question for future research, then, is ‘how effective do treatments have to be for the principle of equal access to apply?’

A note on QALYs versus HYEs: health states versus health profiles

Title: A note on QALYs versus HYEs: health states versus health profiles
Author: Dolan, Paul
Publisher: International journal of technology assessment in health care, 16 (4). pp. 1220-1224
ISSN: 0266-4623
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Abstract: This paper considers the question of what ought to be valued in the context of measuring the outcomes of healthcare interventions. The answer is discrete health states in the case of the quality-adjusted life-year (QALY) model and an entire health profile in the case of the healthy-years equivalent (HYE) approach. How well the weighted average of values attached to the former approximates the overall value attached to the latter depends on the validity of the assumptions of the QALY model. The paper considers some of the empirical literature relating to them. One of the most important assumptions, which from the limited evidence available appears not to hold, is additive separability. However, it is argued that violation of this assumption does not in itself invalidate the QALY approach, since in some circumstances it might be more appropriate to elicit the value of a health state independently of the states that succeed it. Investigation into this issue is identified as one of the key areas where future research efforts should be directed.

Principles of justice in health care rationing

Title: Principles of justice in health care rationing
Authors: Cookson, Richard and Dolan, Paul
Publisher: Journal of medical ethics, 26 (5). pp. 323-329
ISSN: 0306-6800
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Abstract: This paper compares and contrasts three different substantive (as opposed to procedural) principles of justice for making health care priority-setting or “rationing” decisions: need principles, maximising principles and egalitarian principles. The principles are compared by tracing out their implications for a hypothetical rationing decision involving four identified patients. This decision has been the subject of an empirical study of public opinion based on small-group discussions, which found that the public seem to support a pluralistic combination of all three kinds of rationing principle. In conclusion, it is suggested that there is room for further work by philosophers and others on the development of a coherent and pluralistic theory of health care rationing which accords with public opinions.

Whose preferences count?

Title: Whose preferences count?
Author: Dolan, Paul
Publisher: edical decision making, 19 (4). pp. 482-486
ISSN: 1552-681X
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Abstract: An important consideration when choosing how to allocate health care resources is the improvements in patients’ health-related quality of life (HRQoL) that alternative allocations generate. There is considerable debate about whose preferences should be used when measuring and valuing HRQoL. This debate has usually been in terms of whether the values of patients or the general public are the most appropriate. It is argued in this paper that this is a false dichotomy that does not facilitate understanding of empirical evidence. Nor, more importantly, does it address one of the most important issues in the debate about whose preferences count, that is, whether the fact that many people adapt to poor health states should be taken into account when ascribing values to those states. A conceptual framework is developed to facilitate a more fruitful discussion of the issues relating to the question of whose preferences should count.

Public views on health care rationing: a group discussion study

Title: Public views on health care rationing: a group discussion study
Authors: Cookson, Richard and Dolan, Paul
Publisher: Health policy, 49 (1-2). pp. 63-74
ISSN: 0168-8510
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Abstract: This small-scale study develops a new methodology for investigating which ethical principles of health care rationing the public support after discussion and deliberation. In ten groups of about six people, members of the public are asked to discuss a hypothetical rationing choice, concerning four identified patients who are described in general terms but without detailed information. It is explained to respondents that the purpose of the exercise is to find out what general ethical principles they support. Discussions are chaired by an academic specialising in health policy, whose role is to encourage debate but not actively to participate. On the basis of an innovative qualitative data analysis, which translates what people say into ethical principles identified in the theoretical literature, the public appear to support three main rationing principles: (1) a broad ‘rule of rescue’ that gives priority to those in immediate need, (2) health maximisation and (3) equalisation of lifetime health. To our knowledge, this pluralistic viewpoint on rationing has never been developed into a coherent theoretical position, nor into a quantifiable model that health care managers can use for guidance.

Costs of breast cancer treatment in the United Kingdom

Title: Costs of breast cancer treatment in the United Kingdom
Authors: Dolan, Paul and Torgerson, D. and Wolstenholme, J.
Publisher: The breast, 8 (4). pp. 205-207
ISSN: 0960-9776
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Abstract: Breast cancer is a major source of mortality and morbidity to women in the UK. In this paper we estimate the costs of treating breast cancer using random samples of secondary and primary care records. We estimate the average cost per case of breast cancer to be £7247 which gives a total cost of £243 million per annum for the whole of the UK.

Effect of discussion and deliberation on the public’s views of priority setting in health care: focus group study

Title: Effect of discussion and deliberation on the public’s views of priority setting in health care: focus group study
Authors: Dolan, Paul and Cookson, Richard and Ferguson, Brian
Publisher: British medical journal, 318 (7188). pp. 916-919
ISSN: 0959-8138
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Abstract: Objective: To investigate the extent to which people change their views about priority setting in health care as a result of discussion and deliberation. Design: A random sample of patients from two urban general practices was invited to attend two focus group meetings, a fortnight apart. Setting: North Yorkshire Health Authority. Subjects: 60 randomly chosen patients meeting in 10 ugroups of five to seven people. Main outcome measures: Differences between people’s views at the start of the first meeting and at the end of the second meeting, after they have had an opportunity for discussion and deliberation, measured by questionnaires at the start of the first meeting and the end of the second meeting. Results: Respondents became more reticent about the role that their views should play in determining priorities and more sympathetic to the role that healthcare managers play. About a half of respondents initially wanted to give lower priority to smokers, heavy drinkers, and illegal drug users, but after discussion many no longer wished to discriminate against these people. Conclusion: The public’s views about setting priorities in health care are systematically different when they have been given an opportunity to discuss the issues. If the considered opinions of the general public are required, surveys that do not allow respondents time or opportunity for reflection may be of doubtful value.

Health-related quality of life of Colles’ fracture patients

Title: Health-related quality of life of Colles’ fracture patients
Authors: Dolan, Paul and Torgerson, D. and Kumar Kakarlapudi, T
Publisher: Osteoporosis international , 9 (3). pp. 196-199
ISSN: 0937-941X
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Abstract: Recent guidelines published by the National Osteoporosis Foundation (NOF) make extensive use of quality-adjusted life-years (QALYs). Crucial to these guidelines, therefore, are the assumptions that are made about the health-related quality of life (HRQoL) gained from the avoidance of osteoporotic fractures. This paper reports on a study in which 50 Colles’ fracture patients were asked to describe their health at each visit during treatment using the EuroQol descriptive system and to value their own health using the visual analogue scale (VAS). By applying a set of population-derived valuations to the states reported by the patients, the QALY loss is shown to be about 2%. This is about half of the loss, based upon clinician judgement, that is contained in the NOF guidelines. In addition, the results suggest that it may be possible to use VAS scores to predict treatment requirements, since those patients who require fewer visits have, on average, higher initial VAS scores.

Valuing health-related quality of life: issues and controversies

Title: Valuing health-related quality of life: issues and controversies
Author: Dolan, Paul
Publisher: Pharmacoeconomics, 15 (2). pp. 119-127
ISSN:1170-7690
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Abstract: An important consideration when establishing priorities in healthcare is the likely effect that alternative allocations will have on the health-related quality of life (HR-QOL) of the relevant population. This paper considers some of the important issues and controversies surrounding the valuation of HR-QOL. It considers the theoretical and empirical evidence regarding 3 crucial questions: * what is to be valued?; * how is it to be valued?; and * who is to value it? Many important yet unresolved issues emerge and directions for future research are suggested. It is argued that this research agenda should have the gathering and analysis of qualitative data at its forefront.

Using the person trade-off approach to examine differences between individual and social values

Title: Using the person trade-off approach to examine differences between individual and social values
Authors: Dolan, Paul and Green, Colin
Publisher: Health economics, 7 (4). pp. 307-312
ISSN: 1057-9230
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Abstract: Health state valuations, elicited by methods such as the standard gamble and the time trade-off, give an indication of the value that an individual attaches to particular health states. As measures of individual values, it has been argued that such valuations serve as poor proxies for social preferences, which, it is suggested, are a function of other factors, such as the initial severity of the patient’s health state. The person trade-off (PTO) method has been proposed as a technique which takes account of many of these other factors. This paper reports on a study using the PTO to investigate whether an individual’s preferences over treatments for themselves differ from their preferences when they are asked to think about the treatment of other people. The results suggest that there is indeed a difference, although qualitative data suggests that health gain is an important determinant of social value. This latter finding runs counter to those of a number of other studies which suggest that concerns about pre-treatment severity are as, if not more, important. Possible explanations for the differences are put forward.

Variations in population health status: results from a UK survey

Title: Variations in population health status: results from a UK survey
Authors: Kind, Paul and Dolan, Paul and Gudex, Claire and Williams, Alan
Publisher: British medical journal, 316 (7133)
ISSN: 0959-8138
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Abstract: Objective: To measure the health of a representative sample of the population of the United Kingdom by using the EuroQoL EQ-5D questionnaire. Design: Stratified random sample representative of the general population aged 18 and over and living in the community. Setting: United Kingdom. Subjects: 3395 people resident in the United Kingdom. Main outcome measures: Average values for mobility, self care, usual activities, pain or discomfort, and anxiety or depression. Results: One in three respondents reported problems with pain or discomfort. There were differences in the perception of health according to the respondent’s age, social class, education, housing tenure, economic position, and smoking behaviour. Conclusions: The EQ-5D questionnaire is a practical way of measuring the health of a population and of detecting differences in subgroups of the population.

The measurement of individual utility and social welfare

Title: The measurement of individual utility and social welfare
Author: Dolan, Paul
Publisher: Journal of health economics, 17 (1). pp. 39-52
ISSN: 0167-6296
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Abstract: It has been suggested by a number of economists that decisions about how to allocate scarce health care resources should be informed by the cost per quality-adjusted life-years (QALYs) of the different alternatives. One of the criticisms of the QALY approach is that it is based on the measurement of individual utility; yet the values elicited are used to inform social choice. In this respect, it is argued that the QALY approach fails to take account of distributional issues that are known to be important in the context of health care. This paper addresses this issue and presents an approach grounded in microeconomic theory that is flexible enough to deal with a wide range of efficiency-equity trade-offs, while making the nature of the trade-off transparent. In addition, it is an approach that is relatively simple to investigate empirically, and the results of a preliminary study are presented as illustration of this.

Prescribing by general practitioners after an osteoporotic fracture

Title: Prescribing by general practitioners after an osteoporotic fracture
Authors: Torgerson, D. J and Dolan, Paul
PublisherAnnals of the rheumatic diseases, 57 (6). pp. 378-379.
ISSN: 0003-4967
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Abstract: OBJECTIVES Osteoporosis is a major cause of morbidity and cost. Patients sustaining one osteoporotic fracture are at increased risk of having another fracture. The objective of this study was to examine the use of “bone drugs” for the prevention of further osteoporotic fractures among patients who have had a “typical” osteoporotic fracture. METHODS This study took a random sample of 300 women aged 50 and over who had sustained either a vertebral, hip or Colles fracture in 1995 from the General Practice Research Database (GPRD) and compared their use of bone drugs with 300 age and practice matched controls. RESULTS Compared with age and practice matched control patients only vertebral fracture patients showed a statistically significant increase in the use of bone drugs in the year after fracture (39% and 2% for cases and controls respectively; 95% CI of difference 27% to 47%). Etidronate was the most commonly used compound. CONCLUSION The majority of patients sustaining an osteoporotic fracture are not prescribed any pharmaceutical agents for the secondary prevention of fracture one year after a primary fracture.

On the contingent valuation of safety and the safety of contingent valuation: part 1-caveat investigator

Title: On the contingent valuation of safety and the safety of contingent valuation: part 1-caveat investigator
Authors: Beattie, Jane and Covey, Judith and Dolan, Paul and Hopkins, Lorraine and Jones-Lee, Michael and Loomes, G. and Pidgen, Nick and Robinson, Angela and Spencer, Anne
Publisher: Journal of risk and uncertainty, 17 (1). pp. 5-26
ISSN: 0895-5646
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Abstract: This article reports the results of two studies aimed at testing and refining a procedure for estimating willingness to pay based monetary values of safety using the contingent valuation method. In spite of the fact that respondents were given the opportunity to discuss various safety issues and key concepts in focus group meetings held in advance of individual interviews, and were also given ample opportunity to revise their responses in the light of the overall pattern of these responses, the results show clear evidence of extensive and persistent insensitivity to the scale and scope of the safety improvements that were specified in the contingent valuation questions, as well as vulnerability to framing effects. This clearly casts serious doubt on the reliability and validity of willingness-to-pay based monetary values of safety estimated using conventional contingent valuation procedures.

The cost of treating osteoporotic fractures in the UK female population

Title: The cost of treating osteoporotic fractures in the UK female population
Authors: Dolan, Paul and Torgerson, D. J.
Publisher: Osteoporosis international , 8 (6). pp. 611-617
ISSN: 0937-941X
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Abstract: Osteoporotic fractures represent a significant burden to society. The costs of osteoporotic fractures to the UK health care system have not previously been accurately described. In this paper, we quantify the health care and social care costs of fractures occurring in women aged 50 years and over in the UK. We used a variety of data sources. For acute hospital hip fracture costs existing published estimates were used whilst for social care costs a survey of resource use among fracture patients before and after hip fracture was utilized. We undertook a case-control study using the General Practice Research Database to estimate primary care costs. From these data we estimated that the cost of a hip fracture is about 12,000 Pounds, with non-acute hospital costs representing the larger proportion. The other fractures were less expensive, at 468 Pounds, 479 Pounds and 1338 Pounds for wrist, vertebral and other fractures, respectively. For all fractures the annual cost to the UK is 727 million Pounds. Assuming each male hip fracture costs the same as a female fracture, including these would increase the total costs to 942 million Pounds.

Valuing health states: interviews with the general public

Title: Valuing health states: interviews with the general public
Authors: Gudex, Claire and Dolan, Paul and Kind, Paul and Thomas, Roger and Williams, Alan
Publisher: The European journal of public health, 7 (4). pp. 441-448
ISSN: 1101-1262
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Abstract: The objective of this study was to develop methods to elicit the general public’s views on the comparative subjective value of different states of health. The resulting valuations form the basis for a set of British social preferences for use in clinical and economic evaluation of health care. The methods have proved extremely successful in generating complete data of high quality. Since the approach used is generally applicable for use in other national surveys, it is described here to encourage others to take the opportunity to generate comparable sets of social preferences. Face to face interviews, lasting approximately 1h, were conducted in the respondents’ own homes. There were 3, 395 interviews achieved (a response rate of 64%) and the sample was representative of the British general population in terms of age, sex, education, social class and geographical location. Each respondent valued 15 EuroQol health states using ranking, visual analogue scale (VAS) and time trade-off (TTO) methods, with 45 states being valued in all. Two hundred and twenty-one reinterviews were conducted after an average time of 10 weeks. Several methodological issues had to be confronted during the course of the study. These included the structure and format of the interview, the choice of health states to be valued, the determination of the sample size required, the achievement of a representative sample of the British adult population, interviewer training, data processing and data quality. Since few valuation studies have been undertaken on such a large scale, much time and effort was spent in resolving these issues. The methods used are recommended to others considering similar surveys.

The time trade-off: a note on lifetime reallocation of consumption and discounting

Title: The time trade-off: a note on lifetime reallocation of consumption and discounting
Authors: Dolan, Paul and Jones-Lee, Michael
Publisher: Journal of health economics, 16 (6). pp. 731-739
ISSN: 0167-6296
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Abstract: This paper considers the extent to which responses to time trade-off (TTO) questions can provide unbiased estimates of ratios of individual marginal rates of substitution (MRS) of wealth for risk of various health state impairments relative to the corresponding MRS for risk of death. It is shown that if there is reallocation of lifetime consumption and/or discounting of future utilities, then a TTO response that is not adjusted for these effects will unambiguously overestimate the ratios of individual MRS. While the effect of reallocation is likely to be very small, discounting can lead to significant overestimation, the magnitude of which depends in part upon the severity of the health state impairment.

Modelling valuations for health states

Title: Modelling valuations for health states
Authors: Dolan, Paul
Publisher: Medical care, 35 (11). pp. 1095-1108
ISSN: 0025-7079
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Abstract: OBJECTIVES: It has become increasingly common for preference-based measures of health-related quality of life to be used in the evaluation of different health-care interventions. For one such measure, The EuroQol, designed to be used for these purposes, it was necessary to derive a single index value for each of the 243 health states it generates. The problem was that it was virtually impossible to generate direct valuations for all of these states, and thus it was necessary to find a procedure that allows the valuations of all EuroQol states to be interpolated from direct valuations on a subset of these. METHODS: In a recent study, direct valuations were elicited for 42 EuroQol health states (using the time trade-off method) from a representative sample of the UK population. This article reports on the methodology that was adopted to build up a “tariff” of EuroQol values from this data. RESULTS: A parsimonious model that fits the data well was defined as one in which valuations were explained in terms of the level of severity associated with each dimension, an intercept associated with any move away from full health, and a term that picked up whether any dimension in the state was at its most severe level. CONCLUSIONS: The model presented in this article appears to predict the values of the states for which there are direct observations and, thus, can be used to interpolate values for the states for which no direct observations exist.

Valuing health states using VAS and TTO: what lies behind the numbers?

Title: Valuing health states using VAS and TTO: what lies behind the numbers?
Authors: Robinson, Angela and Dolan, Paul and Williams, Alan
Publisher: Social science & medicine, 45 (8). pp. 1289-1297
ISSN: 0277-9536
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Abstract: It is well known that different methods of eliciting the valuations attached to various health states, such as the Visual Analogue Scale (VAS) and the Time Trade Off (TTO), yield different results. This study gathers qualitative data from a group of 43 respondents who had previously taken part in a large scale national study which set out to elicit the values attached by individuals to various health states using both the VAS and the TTO techniques. The findings of this study raised three questions which are of particular interest here: (1) Why are some states that are rated better than dead on the VAS often rated as worse than dead in TTO? (2) Why are some respondents unwilling to trade off any time at all in order to avoid a health state that they place below full health on the VAS? (3) Why are TTO valuations of older respondents for the more severe health states lower than those of the younger age groups? This study has uncovered qualitative evidence on each of these three key issues. Regarding the first question, many respondents did not appear to interpret a better than dead VAS score as a strict preference for spending 10 years in a health state over immediate death. Several different factors appeared to contribute towards this, an important one being the tendency of respondents to ignore the duration of the health state during the VAS task. Regarding the second question, there is evidence of the existence of a “threshold of tolerability” below which states would have to fall before some respondents would be willing to give up any time at all on the TTO. Regarding the last question, it appears that older respondents are less likely to find the worse than dead TTO scenario plausible than those in the younger age groups. However, whilst this may explain why older respondents attach lower worse than dead valuations to health states, it does not appear to account for the entire difference in TTO valuations between the two age groups. In addition, it appears that older respondents may be less prepared to live for the next 10 years in a diminished health state.

Aggregating health state valuations

Title: Aggregating health state valuations
Author: Dolan, Paul
Publisher: Journal of health services research and policy, 2 (3). pp. 166-167
ISSN: 1355-8196

Abstract: It is now recognized that preference-based measures of health status have an important role to play in determining priorities in health care. A number of methodological and ethical issues have been raised, but one that has as yet received little attention is the question of how individual responses should be aggregated when attempting to express the valuations of a given group. In a recent study of over 3000 members of the British general public, valuations were elicited for health states defined in terms of the EuroQol Descriptive System using the time trade-off method. A EuroQol ‘tariff’ of valuations has been generated which, because of the methodology employed, provides a good approximation of mean values. The purpose of this paper is to present a tariff based on median values. The nature of the distributions of values results in a median-based tariff which, compared to the mean-based one, has higher values for less severe states and lower values for more severe states. This is likely to have important implications for resource allocation decisions.

Quality of life analysis in patients with lower limb ischaemia: suggestions for European standardisation

Title: Quality of life analysis in patients with lower limb ischaemia: suggestions for European standardisation
Authors: Chetter, I. C. and Spark, J. and Dolan, Paul and Scott, D. J. A. and Kester, R. C.
Publisher: European journal of vascular and endovascular surgery, 13 (6). pp. 597-604
ISSN: 10785884
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Abstract: Introduction and Objectives: In this era of evidence-based medicine and limited resources we seem obliged, on clinical and economic grounds, to demonstrate that we improve not only patient survival but also the quality of patients’ lives. This study aims to determine the impact of increasing lower limb ischaemia on quality of life (QOL) and which of three commonly used generic QOL instruments is the most valid, reliable, and responsive to change in patients with lower limb ischaemia. Patients and Methods: Two hundred and thirty-five patients, 144 men and 91 women, median age 68 years (range 41–87 years) were graded according to ISCVS suggested reporting standards, i.e. 16 mild, 116 moderate and 25 severe claudicants; 33 patients had rest pain and 45 tissue loss. Patients completed Short Form 36 (SF36), EuroQol (EQ-5D) and Nottingham Health Profile (NHP) questionnaires at interview. Additional copies of questionnaires were posted to 80 patients prior to attendance. Correlation between the two sets of responses reflects test-retest reliability. Correlation between domains measured by the three instruments reflects convergent and divergent validity. Kruskal Wallis ANOVA detected QOL changes across the whole group. Spearman Rank was used to analyse validity and reliability. Responsiveness was analysed using the Mann-Whitney U-test. Results: Increasing lower limb ischaemia confers significant (p<0.05) deterioration in: SF36 measured: physical functioning, physical role, pain, general health, vitality, social functioning and mental health. EQ-5D measured: mobility, self-care, usual activities, pain and anxiety/depression. NHP measured: energy, pain, emotional reaction, sleep, social isolation and physical mobility. All three instruments are significantly reliable (rs>0.7). The validity of SF36 and NHP (rs=0.68–0.78) is superior to EQ-5D (rs=0.37–0.7). SF36 & NHP are equally responsive to changes in physical activity and pain. SF36 and EQ-5D are most responsive to changes in social activity. SF36 is most responsive to changes in psychological status. Conclusion: QOL deteriorates markedly with increasing lower limb ischaemia. The SF36 would appear to be the most appropriate generic QOL analysis tool for these patients. We recommend its widespread adoption throughout Europe, thus providing a standardised tool for reporting generic QOL.

Mapping visual analogue scale health state valuations onto standard gamble and time trade-off values

Title: Mapping visual analogue scale health state valuations onto standard gamble and time trade-off values
Authors: Dolan, Paul and Sutton, M.
Publisher: Social science & medicine, 44 (10). pp. 1519-1530
ISSN: 0277-9536
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Abstract: Despite becoming increasingly common in evaluations of health care, different methods of quantitatively measuring health status appear to produce different valuations for identical descriptions of health. This paper reports on a study that elicited health state valuations from the general public using three different methods: the visual analogue scale (VAS), the standard gamble (SG) and the time trade-off (TTO). Two variants of the SG and TTO were tested: Props (using specially designed boards and cards); and No Props (using a self-completion booklet). This paper focuses on empirical relationships between health state valuations from the VAS and the (four) other methods. The relationships were estimated using Tobit regression of individual-level data. In contrast to a priori expectations, the mapping functions estimated suggest that differences are more pronounced across variant than across method. Furthermore, relationships with VAS scores are found to depend on the severity of the state: TTO Props valuations are higher than VAS responses for mild states and lower for more severe states; SG Props valuations are broadly similar to VAS scores over a wide range; and No Props responses are consistently higher than VAS valuations, particularly for more severe states. Explanations are proposed for these findings.

Correlating clinical indicators of lower-limb ischaemia with quality of life

Title: Correlating clinical indicators of lower-limb ischaemia with quality of life
Authors: Chetter, I. C. and Dolan, Paul and Spark, J. and Scott, D. J. A. and Kester, R. C.
Publisher: Cardiovascular surgery, 5 (4). pp. 361-366.
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Abstract: The objectives of the study were to analyse the impact of increasing lower-limb ischaemia upon quality of life and to assess the correlation between clinical indicators of lower-limb ischaemia and such quality. A prospective observational study of a consecutive series of 235 patients (144 men and 91 women; median age 68 (range 41-87) years presenting with varying degrees of lower-limb ischaemia graded according to ISCVS criteria was performed. Data was collected at interview before any intervention. Clinical indicators of lower-limb perfusion included: intermittent claudication and maximum walking distance on standardized treadmill testing; ankle:brachial pressure indices and isotope limb blood flow. Quality of life analysis was performed using the EuroQol (EQ) questionnaire. This is a standardized generic instrument for describing health-related quality of life and consists of a descriptive system of five dimensions, each measured on three levels. Thus, a profile and two single indices of quality of life were derived using different methods. Increasing lower-limb ischaemia results in a statistically significant deterioration in both global quality of life and in all EQ-measured quality of life dimensions (P < 0.01 Kruskal-Wallis, ANOVA). The correlation between clinical indicators and quality of life is statistically significant but not sufficiently close (correlation coefficients < 0.6) to assume that variations in clinical indicators result in reciprocal variations in quality of life. In conclusion, as might be expected, a significant correlation exists between clinical indicators of lower-limb ischaemia and health-related quality of life. However, the low correlation coefficients emphasize how tenuous the association is. Thus, a significant improvement in the clinical indicators of lower-limb ischaemia cannot be assumed to impart a similar benefit on quality of life. The latter concept must therefore be analysed independently.

 

Modelling valuations for health states: the effect of duration

Title: Modelling valuations for health states: the effect of duration
Author: Dolan, Paul
Publisher: Health policy, 38 (3). pp. 189-203
ISSN: 0168-8510
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Abstract: An important issue which has been raised in the measurement of health status is the effect that the time spent in a health state may have on the way that state is perceived. Recently a set of valuations for health states defined in terms of the EuroQol Descriptive System was generated from a study of over 3000 members of the UK general public. The valuations were elicited using the visual analogue scale (VAS) and time trade-off (TTO) methods and were for states that lasted for 10 years. Using VAS valuations for states lasting 1 month, 1 year and 10 years derived from a subset of respondents to the general population study, this paper presents valuation ‘tariffs’ for all EuroQol states based on the different durations. The results support those of previous studies which suggest that poor states of health become more intolerable the longer they last. Such findings suggest that the results of studies in which the value given to a health state is assumed to be linearly related to the time spent in that health state should be treated with caution and subjected to sensitivity analysis over an appropriate range of values.

The effect of experience of illness on health state valuations

Title: The effect of experience of illness on health state valuations
Author: Dolan, Paul
Publisher: Journal of clinical epidemiology, 49 (5). pp. 551-564
ISSN: 08954356
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Abstract: There is increasing interest in health status measurement and the relative weights that patients and the general public attach to different states of health and illness. One important question that has been raised is whether preferences differ according to the characteristics of the respondents, such as their experience of illness. The results presented in this article suggest that current health status has an important effect on the valuations attached to different health states, with those in poorer health generally giving higher valuations. Past experience of illness, on the other hand, appears to have a negligible effect on valuations. These findings pose real problems for policy makers. To the problem of whose values should count can be added the problem of when these values should count, since the results imply that different valuations may be given by the same respondent depending on how recent their experience of illness was.

Valuing health states: a comparison of methods

Title: Valuing health states: a comparison of methods
Authors: Dolan, Paul and Gudex, Claire and Kind, Paul and Williams, Alan
Publisher: Journal of health economics, 15 (2). pp. 209-231
ISSN: 0167-6296
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Abstract: In eliciting health state valuations, two widely used methods are the standard gamble (SG) and the time trade-off (TTO). Both methods make assumptions about individual preferences that are too restrictive to allow them to act as perfect proxies for utility. Therefore, a choice between them might instead be made on empirical grounds. This paper reports on a study which compared a “props” (using specially-designed boards) and a “no props” (using self-completion booklets) variant of each method. The results suggested that both no props variants might be susceptible to framing effects and that TTO props outperformed SG props.

The time trade-off method: results from a general population study

Title: The time trade-off method: results from a general population study
Authors: Dolan, Paul and Gudex, Claire and Kind, Paul and Williams, Alan
Publisher: Health economics, 5 (2). pp. 141-154
ISSN: 1057-9230
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Abstract: An important consideration when establishing priorities in health care is the likely effects that alternative allocations of resources will have on health-related quality-of-life (HRQoL). This paper reports on a large-scale national study that elicited the relative valuations attached by the general public to different states of health (defined in HRQoL terms). Health state valuations were derived using the time trade-off (TTO) method. The data from 3395 respondents were highly consistent, suggesting that it is feasible to use the TTO method to elicit valuations from the general public. The paper shows that valuations for severe health states appear to be affected by the age and the sex of the respondent; those aged 18-59 have higher valuations than those aged 60 or over and men have higher valuations than women. These results contradict those reported elsewhere and suggest that the small samples used in other studies may be concealing real differences that exist between population sub-groups. This has important implications for public policy decisions.

Inconsistency and health state valuations

Title: Inconsistency and health state valuations
Authors: Dolan, Paul and Kind, Paul
Publisher: Social science & medicine, 42 (4). pp. 609-615
ISSN: 0277-9536
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Abstract: The comparison of scaling methods used to value health states sometimes rests upon an analysis of aggregate scores. This analysis is usually undertaken once “inconsistent’ respondents have been excluded from the data. However, it is important to be able to judge the extent to which respondents as a whole are logically consistent when assigning values to health states. The degree of inconsistency will depend on how the health states are described, how the questionnaire is administered and who the respondents are. This paper analyses the inconsistency rates from two studies in which valuations for EuroQol health states were elicited using the visual analogue scale (VAS) method. The studies differed in design and incorporated several different variants of the standard EuroQol questionnaire, thus providing an opportunity to examine the relative importance of the different factors that were thought to affect inconsistency rates. Our general conclusions are that inconsistency rates are higher for interviewer-based than for postal surveys, possibly due to response bias, and that inconsistency rates are positively related to age and negatively related to educational attainment.

Health state valuations from the general public using the visual analogue scale

Title: Health state valuations from the general public using the visual analogue scale
Authors: Gudex, Claire and Dolan, Paul and Kind, Paul and Williams, Alan
Publisher: Quality of life research, 5 (6). pp. 521-531
ISSN: 0962-934
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Abstract: In the clinical and economic evaluation of health care, the value of benefit gained should be determined from a public perspective. The objective of this study was to establish relative valuations attached to different health states to form the basis for a social tariff for use in quantifying patient benefit from health care. Three thousand three hundred and ninety-five interviews were conducted with a representative sample of the adult British population. Using the EuroQol health state classification and a visual analogue scale (VAS), each respondent valued 15 health states producing, in total, direct valuations for 45 states. Two hundred and twenty-one re-interviews were conducted approximately 10 weeks later. A near complete, and logically consistent, VAS data set was generated with good test-retest reliability (mean ICC=0.78). Both social class and education had a significant effect, where higher median valuations were given by respondents in social classes III–V and by those with intermediate or no educational qualifications. These effects were particularly noticeable for more severe states. The use of such valuations in a social tariff raises important issues regarding the use of the VAS method itself to elicit valuations for hypothetical health states, the production of separate tariffs according to social class and/or education and the appropriate measure of central tendency.

Risk-risk versus standard gamble procedures for measuring health state utilities

Title: Risk-risk versus standard gamble procedures for measuring health state utilities
Authors: Dolan, Paul and Jones-Lee, Michael and Loomes, G.
PublisherApplied economics, 27 (11). pp. 1103-1111
ISSN: 0003-6846
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Abstract: Contingent valuation (CV) has been widely used to measure the potential benefits derived from different policy decisions. However, doubt now exists about the validity of the CV method and alternative approaches to benefit valuation have been proposed. The paper reports on the results of a study which was designed to test the viability of two of the most prominent of the alternatives: the risk-risk (RR) and standard gamble (SG) approaches. If individual preferences are consistent with the axioms of von Neumann-Morgenstern expected utility theory (EUT) then the two methods should generate the same interval scales for any given set of health states. However, the results show that SG utilities are substantially higher than RR ones, thus casting doubt on these axioms. The paper discusses alternatives to EUT which might better expalin the discrepancies found. It also considers whether the results might be explained in terms of status-quo bias and/or by the relative difficulty of RR questions. The results presented may have important implications for other areas of applied research in which there exists uncertainty about outcomes.

 

 

 

Time preference, duration and health state valuations

Title: Time preference, duration and health state valuations.
Authors: Dolan, Paul and Gudex, Claire
PublisherHealth economics 4 (4). pp. 289-299
ISDN: 1057-9230

AbstractThere is increasing interest in health status measurement and the relative weights that people attach to different states of health and illness. One important issue which has been raised is the effect that the time spent in a health state may have on the way that state is perceived. Previous studies have suggested that the worse a state is, the more intolerable it becomes as it lasts longer. However, for most of these studies, it is impossible to determine how much of what was observed is attributable to the time spent in the state and how much is attributable to when it was occurring. This paper reports on a pilot study designed to test the feasibility of using the Time Trade-Off (TTO) method to isolate the effect of pure time preference from the effect of duration per se. Interviews were conducted with 39 members of the general population who were asked to rate 5 health states for durations of one month, one year and ten years. In aggregate, rates of time preference were very close to zero which suggests that the implicit assumption of the TTO method that there is no discounting may be a valid one. However, that more respondents had negative (rather than positive) rates, casts some doubt on the axions of discounted utility theory. In addition, implied valuations for states lasting for short periods were often counter-intuitive which questions the feasibility of using the TTO method to measure preferences for temporary health states.

 

 

The effect of past and present illness experience on health state valuations

Title: The effect of past and present illness experience on health state valuations
Authors: Kind, Paul and Dolan, Paul
Publisher: Medical care, 33 (4 (S)). pp. 255-263
ISSN: 0025-7079
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Abstract: The effects of age, sex, income, and other socioeconomic factors on valuations for health states have been reported in the literature. However, little attention has been paid to the influence of illness experience, either current or past, on valuations for of states. This paper addresses that question using six separate data sets covering some 1,900 subjects. Each data set contains information on self-reported current health status and experience of serious illness in self, family, and others. Past experience of illness has not been found to affect valuations, but there is some evidence to suggest that, compared with those who claim to be in full health, those who describe their current health as dysfunctional give higher valuations (i.e., closer to good health) for all health states, and particularly so for the more severe states. The most striking result, however, concerns the relationship between respondents’ valuations of their own health and their subsequent valuations of hypothetical health states. In all studies, it has been observed that a low self-rated health status is associated with significantly lower valuations of less severe states, including full health. The findings of this paper suggest a real dilemma for health services researchers and policy makers. The importance of the choice of valuations used in the evaluation of health care now must be recognized, because different results may be obtained according to the current health status of those respondents from whom valuations are.