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.

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.

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

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.

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

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.

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.

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.

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.

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.

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 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.

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.

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.

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.

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.