Is healthcare any good for patients Measuring health outcomes

Is healthcare any good for patients? Measuring health outcomes using EQ-5D Professor Paul Kind Principal Investigator Outcomes Research Group Centre for Health Economics University of York England Health care • Designed / delivered with the intention of altering the “natural” health status of patients over time • Relieving pain, suffering • Prolonging (enabling) life • Easing process of dying • Cure (sometimes) Hippocratic Oath : First, do no harm • Fundamental question : how do you know if you are helping / harming the patient ? • You need to know – does treatment CHANGE anything ? – what is the DIRECTION of change ? – what is the MAGNITUDE of change ? Health care intervention Symptomatic relief, cure, palliation ? No Yes Problem Measuring health outcomes the biomedical model (a) [ FEV1 ]t0 - [ FEV1 ]t1  FEV1 (b) [ health]t0 - [ health ]t1 status  health there is a calibrated test procedure for (a) what do we use for (b) ? Outcome measures 'Classical' indicators • • • • • • Survival rates Readmission rates Symptom counts Employment status Days lost through sickness Clinical parameters Grading angina severity New York Heart Association • Grade I • ordinary physical activity does not cause undue fatigue, palpitation or anginal pain • Grade II • comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnoea or anginal pain • Grade III • comfortable at rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnoea or anginal pain • Grade IV • inability to carry on physical activity without discomfort. Symptoms of cardiovascular insufficiency or the anginal syndrome may be present even at rest Karnofsky Performance Scale Description Normal Normal activity ; minor signs / symptoms Subnormal activity ; some signs / symptoms Unable to work or to continue normal activities Requires occasional assistance Requires considerable assistance and frequent care Disabled ; requires special care Severely disabled ; hospitalised Very sick ; hospitalised with active support treatment Moribund Dead 40 Score 100 90 80 70 60 50 40 30 20 10 0 FACT-L PHYSICAL WELL-BEING GP1 Not at all A little Somebit what Quite a bit Very much I have a lack of energy.......................................................... 0 I have nausea......................................................................... 0 Because of my physical condition, I have trouble meeting the needs of my family............................................ 0 I have pain............................................................................. 0 I am bothered by side effects of treatment............................ 0 I feel ill.................................................................................. 0 I am forced to spend time in bed........................................... 0 1 1 1 1 1 1 1 2 2 2 2 2 2 2 3 3 3 3 3 3 3 4 4 4 4 4 4 4 GP2 GP3 GP4 GP5 GP6 GP7 Health-related quality of life a specialised measure of outcome What are the health outcomes ? EQ-5D Health-related quality of life The EuroQoL Group • Set up in 1987 by a multidisciplinary group of researchers concerned with EVALUATION in health and health care – Clinicians – Health economists – Others (sociology, psychology …) The EuroQoL Group • Founders Finland Netherlands (Norway) Sweden UK • Extended network Argentina Canada China Denmark Germany Greece Hungary Italy Japan Korea New Zealand Portugal Russia Slovenia Spain Taiwan USA .... Poland ? So .. what is EQ-5D ? • A generic measure of health status (health-related quality of life) capable of being represented as a single index • Health is defined in terms of 5 dimensions - mobility - self care - usual activity - pain / discomfort - anxiety / depression • Each dimension is divided into 3 levels - none - some - extreme What is EQ-5D ? • A generic, single index measure of health status • Based on 5 dimensions Mobility Self-Care Usual Activity Pain / Discomfort Anxiety / Depression • Defines a total of 35 = 243 health states Anxiety / Depression Mobility Pain / Discomfort Health state Self-Care Usual Activity Self-care Mobility Pain / discomfort Health state Usual activities Anxiety / depression For example : no problems in walking about (1) some problems washing self (2) some problems with usual activity (2) no pain or discomfort (1) moderately anxiety or depression (2) State 12212 • In general we know NOTHING about the order or values of EQ-5D health states • There is a logical ordinal relationship between some states – For example 11111 is logically better than 33333 – But what is the distance between these states ? Does moving from state A to state B constitute a patient benefit ? If so, then by how much? 3 2 3 2 1 1 usual activity pain / discomfort mobility pain / discomfort usual activity Profile A : 1 1 2 2 3 anxiety / depression Profile B : 1 1 3 2 2 anxiety / depression mobility self care self care 0 0 Shared objective : Valuing health • Needed a simple method • Self-administered • Capable of being used in population surveys • Relatively quick • Able to produce cardinal values Valuation method(s) • EuroQoL Group standard – Visual analogue scale rating using a vertical 20cm scale – Range 0 – 100 corresponding to “worst imaginable” and “best imaginable” health • Individual experimentation – Time Trade-Off (York MVH Project) – Ranking – Paired comparisons – Standard Gamble VAS rating of EQ-5D health states Health state A Health state E Health state F 33333 Health state H 11111 Health state C Health state D 0 1 2 3 0 1 2 3 mobility mobility Population preference weights self care self care usual activity pain / discomfort anxiety / depression usual activity pain / discomfort anxiety / depression Profile A : 1 1 2 2 3 Profile B : 1 1 3 2 2 0.1 0 State A State B 0.11 Difference 0.2 0.3 0.25 0.36 0.4 MOBILITY I have no problems in walking about I have some problems in walking about I am confined to bed SELF-CARE I have no problems with self-care I have some problems washing or dressing myself           For each group of statements please indicate the one that best describes your health today  Please tick one box for each group of statements. I am unable to wash or dress myself USUAL ACTIVITIES I have no problems with performing my usual activities (e.g. work, study, housework, family or leisure activities) I have some problems with performing my usual activities I am unable to perform my usual activities PAIN / DISCOMFORT I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort ANXIETY / DEPRESSION            I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed TThink about how good or bad your own health is today This scale may help. The best health you can imagine is marked 100 and the worst health you can imagine is marked 0 Please write in the box below, the number between 0 and 100 that you feel best shows how good your health is today Best imaginable health 100 90 80 70 Your own health today 60 50 40 30 20 10 0 Worst imaginable health Page 3 : Patient Perspective Page 2 : Societal Perspective MOBILITY  I have no problems in walking about  I have some problems in walking about  I am confined to bed SELF-CARE  I have no problems with self-care  I have some problems washing or dressing myself  I am unable to wash or dress myself USUAL ACTIVITIES (e.g. work, study, housework family or leisure activities)  I have no problems with performing my usual activities  I have some problems with performing my usual activities  I am unable to perform my usual activities PAIN/DISCOMFORT  I have no pain or discomfort  I have moderate pain or discomfort  I have extreme pain or discomfort ANXIETY/DEPRESSION  I am not anxious or depressed  I am moderately anxious or depressed  I am extremely anxious or depressed MOBILITY  I have no problems in walking about  I have some problems in walking about  I am confined to bed SELF-CARE  I have no problems with self-care  I have some problems washing or dressing myself  I am unable to wash or dress myself USUAL ACTIVITIES (e.g. work, study, housework family or leisure activities)  I have no problems with performing my usual activities  I have some problems with performing my usual activities  I am unable to perform my usual activities PAIN/DISCOMFORT  I have no pain or discomfort  I have moderate pain or discomfort  I have extreme pain or discomfort ANXIETY/DEPRESSION  I am not anxious or depressed  I am moderately anxious or depressed  I am extremely anxious or depressed ? How are EQ-5D data presented ? • As a profile – based on reported level of problem on each dimension EQ-5D Part I profile Part II self-rated health status • As a health state • As a weighted index – based on values of the general public health state weighted index • As self-rated health status Some examples Frequency of reported problems by age group in UK population % of respondents reporting ANY problem 60% 50% 40% 30% 20% 10% 0% Mobility Self care Usual activity Pain / discomfort Anxiety / depression under 40 40 to 59 60 and over Population “norms” mean EQ-5Dindex 1 mean EQ-5Dindex 0.8 Men Women 0.6 <20 20 29 30 39 40 49 50 59 60 69 70 79 80 + age group Source : Health Survey for England, 1996 EQ-5Dindex 1 by age / smoking behaviour mean EQ5Dindex 0.9 0.8 0.7 0.6 20 - 29 nonsmoker smoker 30 - 39 40 - 49 50 - 59 60 - 69 Age group 70 - 79 80 + EQ-5D 1 for GP clinic attenders 0 3 or more visits mean weighted index 0.9 0.8 0.7 0.6 under 20 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80 + Primary care clinic attendees EQ-5D profile by diagnostic group 100 % of patients reporting ANYproblem 80 60 40 20 0 mobility mental disorder circulatory musculoskeletal pregnancy all self care usual activity pain / discomfort anxiety / depression mean change in EQ-5Dvas 6 4 2 0 -2 -4 -6 mean change from pre-op score -3.62 NHS - A private sector NHS - B 5.2 2.5 Choice of provider Source : GP audit of patients referred for cataract surgery Rheumatoid arthritis Functional Class • I .. complete functional capacity – ability to carry out all normal activities • II .. adequate for normal activities – despite discomfort or limited motion at 1 or more joints • III .. limited functional capacity – only little or none of duties of normal occupation or selfcare • IV .. incapacitated – largely or wholly bed-ridden or confined to wheelchair; little or no selfcare EQ-5Dindex by Functional Class rheumatoid arthritis patients 1.0 Mean EQ-5D value .8 .6 .4 .2 0.0 N= 59 59 63 63 58 58 49 49 Utility index Self-rated VAS 1 2 3 4 Functional Class EQ-5D in treatment of HIV/AIDS .86 .84 mean weighted index .82 .80 .78 .76 .74 .72 .70 1 3 5 7 9 11 Treatment group Ritonavir Usual therapy VISIT Where are we now ? Science • Likely to increase number of response levels from 3 to 5 • Investigating a “child-friendly” version of EQ-5D • Computer-based valuation and selfassessment methods • Electronic data capture – web based technologies 5-level or 3-level ? • One suggested modification to existing 3-level descriptive system • Place unmarked level between existing levels Where are we now ? Application • Nearly 100 language versions available • Worldwide take-up with many normative population studies • Widespread incorporation in clinical studies that involve economic evaluation • Major head:head study in US of the leading generic HrQoL measures ends Paul Kind : pk1@york.ac.uk EuroQoL Group : http://www.euroqol.org