Valuing Health-Related Quality of Life: An EQ-5D-5L Value Set for England

Objectives: Measures of patient-reported health are increasingly used in clinical and health system decisions, and the EQ-5D is one of the most widely used questionnaires. It is recommended by NICE and is widely used in clinical trials, as well as in population health surveys and the NHS PROMs programme. A new version, the EQ-5D-5L, is now available. The objective of this study is to establish how important different sorts of health problems are to overall quality of life, and to produce the set of scores (‘value set’) required to use EQ-5D-5L data in decision-making and priority setting in the English NHS. Design: The study design followed an international research protocol. Each participant valued 10 health states using a time trade-off approach and completed seven discrete choice tasks. The data are used to model values for all 3,125 states described by the EQ-5D-5L. Setting: England general population. Participants: Data were collected in face-to-face interviews with 996 adult members of the general public, selected at random from residential postcodes. The sample is broadly representative of the general population. Results: The data obtained from participants had good face validity. Problems with pain/discomfort and anxiety/depression were the most important factor in overall quality of life. Values ranged from -0.281 (for extreme problems on all dimensions) to 0.951. Conclusions: The value set reported here will have important implications for public decisions made using EQ-5D-5L data. There are considerably fewer states judged to be ‘worse than dead’ compared to the current EQ-5D value set (4.93%, compared with over one-third) and the minimum value is higher (-0.281 compared to -0.594). The results imply that QALY gains for interventions seeking to improve very poor health will be smaller using the EQ-5D-5L tariff, and may previously have been overestimated

Cost-utility analysis of different treatments for post-traumatic stress disorder in sexually abused children

<p>Abstract</p> <p>Background</p> <p>Post-traumatic stress disorder (PTSD) is diagnosed in 20% to 53% of sexually abused children and adolescents. Living with PTSD is associated with a loss of health-related quality of life. Based on the best available evidence, the NICE Guideline for PTSD in children and adolescents recommends cognitive behavioural therapy (TF-CBT) over non-directive counselling as a more efficacious treatment.</p> <p>Methods</p> <p>A modelled economic evaluation conducted from the Australian mental health care system perspective estimates incremental costs and Quality Adjusted Life Years (QALYs) of TF-CBT, TF-CBT combined with selective serotonin reuptake inhibitor (SSRI), and non-directive counselling. The "no treatment" alternative is included as a comparator. The first part of the model consists of a decision tree corresponding to 12 month follow-up outcomes observed in clinical trials. The second part consists of a 30 year Markov model representing the slow process of recovery in non-respondents and the untreated population yielding estimates of long-term quality-adjusted survival and costs. Data from the 2007 Australian Mental Health Survey was used to populate the decision analytic model.</p> <p>Results</p> <p>In the base-case and sensitivity analyses, incremental cost-effectiveness ratios (ICERs) for all three active treatment alternatives remained less than A$7,000 per QALY gained. The base-case results indicated that non-directive counselling is dominated by TF-CBT and TF-CBT + SSRI, and that efficiency gain can be achieved by allocating more resources toward these therapies. However, this result was sensitive to variation in the clinical effectiveness parameters with non-directive counselling dominating TF-CBT and TF-CBT + SSRI under certain assumptions. The base-case results also suggest that TF-CBT + SSRI is more cost-effective than TF-CBT.</p> <p>Conclusion</p> <p>Even after accounting for uncertainty in parameter estimates, the results of the modelled economic evaluation demonstrated that all psychotherapy treatments for PTSD in sexually abused children have a favourable ICER relative to no treatment. The results also highlighted the loss of quality of life in children who do not receive any psychotherapy. Results of the base-case analysis suggest that TF-CBT + SSRI is more cost-effective than TF-CBT alone, however, considering the uncertainty associated with prescribing SSRIs to children and adolescents, clinicians and parents may exercise some caution in choosing this treatment alternative.</p

Decision modeling to inform decision making: Seeing the wood for the trees

We have made 2 recommendations for the conduct of decision modeling to inform decisions by 3rd-party payers who are interested in the health benefits that their health dollars buy. First, modelbased estimates of cost-effectiveness should incorporate costs and benefits over an appropriate time horizon (e.g., lifetime) for all patients included in a model. This requirement is not achieved using the AP modeling approach, which includes only costs and benefits in the 1st year of treatment for incident cases in the final year of the model. There may be information value to 3rd-party payers in presenting cost estimates based on the AP approach, but these estimates should be presented in addition to the IC-based estimates of costeffectiveness. Second, separate cost-effectiveness analyses of relevant identifiable patient groups should be presented, rather than broad analyses that combine such groups, where relevancy refers to the ability of clinicians to differentiate between diagnoses (e.g., stable angina and acute myocardial infarction). There is a risk that actual use of a drug may not be cost-effective, even if it has been demonstrated to be cost-effective in a particular population. Leakage is a well-known problem with the implementation of reimbursement policies,7 but the level of leakage will vary from country to country and with the policies adopted. Analyses of cohorts that include all potentially eligible patient groups assume 100% leakage across all patient groups. This is a worstcase scenario, which may be of interest to decision makers (i.e., if an intervention remains cost-effective in the worst-case leakage scenario, we can have more confidence in our reimbursement decision). However, such confidence is not necessarily required to support a positive reimbursement decision for a patient subgroup.Jonathan Karnon, Alan Brennan, Ron Akehurs