1. Effect of framing of death on health state values obtained from DCEs Dr. Esther W. de Bekker-Grob e.debekker@erasmusmc.nl www.eur.nl/ecmc by Jonker, de Bekker-Grob, Donkers, Stolk

2. 2 Introduction   Discrete choice experiment (DCE) is considered a promising technique for health state valuation  Nevertheless, the method is still in its infancy  Compared to TTO, DCE classifies more states as worse than dead and produces lower values www.eur.nl/ecmc

3. 3 Hypothesis Differences between health state values based on TTO and DCE may at least in part be reconciled by harmonizing their framings TTO includes an endowment, whereas DCE involves a neutral choice between option A and option B www.eur.nl/ecmc

4. 4 Aim   To determine how alternative framing of the DCE questions affects  EQ-5D-5L health state values www.eur.nl/ecmc

5. 5 Methods www.eur.nl/ecmc  9 different study arms:  5 different ‘DCE duration’ framings  4 different ‘DCE death’ framings

6. 6 DCE health-state valuations  latent utility scale QALY scale 1-1-1-1-1 5-5-5-5-5 1-1-1-1-1 = 1 5-5-5-5-5 death = 0

7. 7 Specific ways to obtain QALY values  1-1-1-1-1 = 1 5-5-5-5-5 death = 0   Including “duration” as an additional attribute in the DCE (zero duration of life = death) Including “death” as an alternative- specific health state in the DCE

8. 8 Methods www.eur.nl/ecmc  9 different study arms:  5 different ‘DCE duration’ framings  4 different ‘DCE death’ framings

9. Which health state do you prefer, A or B? 10 years in this health state, followed by death Mobility A B no problems in walking about no problems washing or dressing moderate problems doing usual activities severe pain or discomfort extremely anxious or depressed no problems in walking about 10 years in this health state, followed by death moderate problems doing usual activities extreme pain or discomfort slightly anxious or depressed no problems washing or dressing Self-care Usual activities Pain Anxiety Base case (A vs B) C

10. Which health state do you prefer, B or C? 10 years in this health state, followed by death Mobility A B no problems in walking about no problems washing or dressing moderate problems doing usual activities severe pain or discomfort extremely anxious or depressed no problems in walking about 10 years in this health state, followed by death moderate problems doing usual activities extreme pain or discomfort slightly anxious or depressed no problems washing or dressing Self-care Usual activities Pain Anxiety Base case (B vs C) C

11. Which health state do you prefer, B or C? 10 years in this health state, followed by death Mobility CB no problems in walking about no problems washing or dressing moderate problems doing usual activities severe pain or discomfort extremely anxious or depressed no problems in walking about 10 years in this health state, followed by death moderate problems doing usual activities extreme pain or discomfort slightly anxious or depressed no problems washing or dressing Self-care Usual activities Pain Anxiety Base case (DCE duration) no problems in walking about 7 years in this health state, followed by death

12. Which health state do you prefer, B or C? 10 years in this health state, followed by death Mobility CB no problems in walking about no problems washing or dressing moderate problems doing usual activities severe pain or discomfort extremely anxious or depressed no problems in walking about 10 years in this health state, followed by death moderate problems doing usual activities extreme pain or discomfort slightly anxious or depressed no problems washing or dressing Self-care Usual activities Pain Anxiety Base case (DCE death) You die immediately

13. You will live 20 years, of which 10 in full health and 10 years in this health below Which health state do you prefer, A or B? You will live 20 years, of which 10 in full health and 10 years in this health below Mobility no problems in walking about no problems washing or dressing moderate problems doing usual activities severe pain or discomfort extremely anxious or depressed no problems in walking about moderate problems doing usual activities extreme pain or discomfort slightly anxious or depressed no problems washing or dressing Self-care Usual activities Pain Anxiety Framing 1: lead time C no problems in walking about You will live 10 years in perfect health, followed by death

14. Assume you live 10 years in health state A. Which health state do you prefer, health state A or do you want to substitute for health state B? 10 years in this health state, followed by death Mobility A B no problems in walking about no problems washing or dressing moderate problems doing usual activities severe pain or discomfort extremely anxious or depressed no problems in walking about 10 years in this health state, followed by death moderate problems doing usual activities extreme pain or discomfort slightly anxious or depressed no problems washing or dressing Self-care Usual activities Pain Anxiety Framing 2: endowment health state C

15. Assume you live 7 years in perfect health. Which health state do you prefer, health state A or do you want to substitute for health state B? 7 years in this health state, followed by death Mobility A B no problems in walking about no problems washing or dressing no problems in walking about 10 years in this health state, followed by death moderate problems doing usual activities extreme pain or discomfort slightly anxious or depressed no problems washing or dressing Self-care Usual activities Pain Anxiety Framing 3: endowment perfect health no problems washing or dressing C no problems in walking about 10 years in this health state, followed by death moderate problems doing usual activities extreme pain or discomfort slightly anxious or depressed no problems washing or dressing

16. Assume you would die immediately. Which health state do you prefer, health state A or do you want to substitute for health state B? You die immediately Mobility A B no problems in walking about 10 years in this health state, followed by death moderate problems doing usual activities extreme pain or discomfort slightly anxious or depressed no problems washing or dressing Self-care Usual activities Pain Anxiety Framing 3: endowment death C no problems in walking about 10 years in this health state, followed by death moderate problems doing usual activities extreme pain or discomfort slightly anxious or depressed no problems washing or dressing

17. Which health state do you prefer, B or C? 10 years in this health state, followed by death Mobility CB no problems in walking about no problems washing or dressing moderate problems doing usual activities severe pain or discomfort extremely anxious or depressed no problems in walking about 10 years in this health state, followed by death moderate problems doing usual activities extreme pain or discomfort slightly anxious or depressed no problems washing or dressing Self-care Usual activities Pain Anxiety Framing 4: years of life lost no problems in walking about You loose 3 out of the remaining 10 years

18. 18 Methods www.eur.nl/ecmc Sample:  Online panel (Dutch general population)  2,700 respondents (300 per arm)  Respondents were randomly assigned to one of the 9 study arms

19. 19 Methods www.eur.nl/ecmc Sample:  Online panel (Dutch general population)  2,700 respondents (300 per arm)  Respondents were randomly assigned to one of the 9 study arms Experimental DCE design:  Bayesian D-efficient design consisting of 8 sub-designs of 2*15 choices  jointly optimized for ‘DCE duration’ and ‘DCE death’  Keeping all aspects of the DCE design constant except for the framing (!)

20. 20 Methods www.eur.nl/ecmc DCE analyses:  Bayesian mixed logit models  QALY transformation  Comparison between 9 study arms in terms of QALY tariff

21. 21 Results DCE duration QALY tariff For example: QALY health state 55555 = 1.00 + (mo5 + sc5 + ua5 + pd5 + ad5)

22. 22 Results DCE death QALY tariff For example: QALY health state 55555 = 1.00 + (mo5 + sc5 + ua5 + pd5 + ad5)

23. 23 Results – QALY scale www.eur.nl/ecmc 11111 55555

24. 24 Results – QALY scale www.eur.nl/ecmc 11111 55555

25. 25 Results – QALY scale www.eur.nl/ecmc 11111 55555

26. 26 Conclusion  Framing effects were substantial Our harmonizing framings did not reconcile differences between health state values based on TTO and DCE Interestingly, we found something else: our base case values were not that different anymore from TTO values

27. 27 Further research needed 1) Our design was jointly optimized for ‘DCE duration’ and ‘DCE death’  impact on using QALY-balanced design for DCE health state valuation?

28. 28 Further research needed 2) Our results showed that the TTO values lay exactly between ‘DCE duration’ and ‘DCE death’ results  How to “tweak” DCE to reach similar values as TTO? 1) Our design was jointly optimized for ‘DCE duration’ and ‘DCE death’  impact on using QALY-balanced design for DCE health state valuation?

29. 29 www.eur.nl/ecmc Acknowledgement