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Expanding the Scope of Value for Economic Evaluation: The EQ-HWB

Open AccessPublished:March 16, 2022DOI:https://doi.org/10.1016/j.jval.2022.02.001

      Expanding the Scope of Value for Economic Evaluation

      This themed section of Value in Health reports the international development of a new health-related quality of life instrument, the EQ-HWB (EQ Health and Wellbeing) instrument. The “Extending the QALY” project, which has inspired this extensive body of work, began as a UK initiative driven by the need for an outcome measure for use in social and community care.
      The University of Sheffield School of Health and Related Research
      Extending the QALY.
      Relative to existing generic preference-based measures (GPBMs), this new instrument is designed to capture a broader notion of health and wellbeing. This ability to operate across dimensions, which was flagged in Brazier et al,
      • Brazier J.
      • Tsuchiya A.
      Improving cross-sector comparisons: going beyond the health-related QALY.
      is a key advance of the EQ-HWB. It is noticeable that items not widely seen in other GPBMs, such as exhaustion, loneliness, concentration, and control, capture important aspects of wellbeing in significant patient and community populations and would risk being undervalued using existing instruments.
      The aim of the “Extending the QALY” project was to develop a new broader generic measure of health and wellbeing for use in economic evaluation across health, social care, and public health, based on the views of users and beneficiaries of these services, including informal carers.

      Brazier J, Peasgood T, Mukuria C, et al. The EQ-HWB: overview of the development of a measure of health and well-being and key results. Value Health. In press.

      The 6 articles published in this themed section present lessons from the first stage of research: the development of the descriptive system. The research covers key issues in this development process and includes a qualitative review of potential domains (Mukuria et al

      Mukuria C, Connell J, Carlton J, et al. A qualitative review on domains of quality of life important for patients, social care users and informal carers to inform the development of the EQ-HWB. Value Health. In press

      ), the process for generating and selection of items for the instrument (Carlton et al

      Carlton J, Peasgood T, Mukuria C, et al. Generation, selection, and face validation of items for a new generic measure of quality of life: the EQ Health and Well-Being (EQ-HWB). Value Health. In press.

      ), and psychometric data for the EQ-HWB (Peasgood et al

      Peasgood T, Mukuria C, Brazier J, et al. Developing a new generic health and well-being measure: psychometric survey results for the EQ Health and Well-Being (EQ-HWB). Value Health. In press.

      ). Given that the EQ-HWB remains a topic for active research, we would like to share some reflections on potential improvements in its descriptive system and other considerations that should be addressed if the instrument is to have broad uptake in policy.

      Some Issues for Consideration

      One consideration with the EQ-HWB in its current form is the different ways that the levels are described. We believe some users will find it cognitively demanding to switch between descriptions in terms of frequencies, severities, and difficulties. This affects both on the self-reporting of EQ-HWB health states and in the valuation tasks that will be needed to generate quality-adjusted life-year (QALY) weights for economic evaluation.
      Second, lessons from the development of the 5-level version of EQ-5D value sets showed that many respondents find it hard to distinguish between the 2 most severe levels; this may be less concerning in the self-report context when the entire scale is shown, but is certainly an issue in valuation. Thus, we suggest there is merit in testing a 4-level descriptive system by the use of a simple coherent grading such as “no problems, slight/mild, moderate, or severe.” If chosen, it would save space and response time, reduce complexity, and reduce the challenge associated with estimating preference weights for a large number of health state combinations. In the short 9-item version, it would mean 49 rather than 59 combinations.
      Furthermore, the full 25-item version of the EQ-HWB should raise some general concerns on lengthy instruments. Not only do they involve methodological challenges in the elicitation of preference weights, but they do not seem attractive in applied studies. Reviews on the uptake of GPBMs in published cost-utility analyses
      • Richardson J.
      • McKie J.
      • Bariola E.
      Multi attribute utility instruments and their use.
      ,
      • Wisløff T.
      • Hagen G.
      • Hamidi V.
      • Movik E.
      • Klemp M.
      • Olsen J.A.
      Estimating QALY gains in applied studies: a review of cost-utility analyses published in 2010.
      tell that the 3 shortest instruments (EQ-5D, Health Utilities Index, Short Form 6-Dimension) were used in approximately 87%, with the remaining 13% shared among 3 long instruments (15D, Quality of Wellbeing, Assessment of Quality of Life). To extend this point, the shortest instrument of them all (the 3-level version of EQ-5D) had two-thirds of the market. Brevity should not be the main criterion on which decision of instrument is chosen, but it does seem to have significant impact. The question of whether the short form of the EQ-HWB can be used as a stand-alone instrument will be important here. If it can provide similar responses to those derived from the long form version, then this would significantly reduce the response burden and increase uptake.
      We certainly acknowledge the need for extending the QALY to account for important psychosocial domains. Previous attempts have been made by the Assessment of Quality of Life and most recently in the Patient-Reported Outcomes Measurement Information System. Nevertheless, the more variety in the dimensions included, the more important it is to strive for brevity (word count) and cognitive simplicity.

      The Policy Landscape

      A question that remains open is where research and policy using the EQ-HWB should go next. Clearly, there is policy demand for, and value in having, more inclusive instruments. The circumstances in which the EQ-HWB should be used in preference to something like the EQ-5D are yet to be determined. The data presented in the study by Monteiro et al

      Monteiro A, Kuharic M, Pickard AS. A comparison of a preliminary version of the EQ-HWB and the EQ-5D-5L. Value Health. In press.

      give us early signs around the relationship between the short form of the EQ-HWB and the widely used 5-level version of EQ-5D, but this is only part of the conversation that needs to be had to support EQ-HWB uptake. The EQ-HWB is not intended to replace the EQ-5D; nevertheless, to have impact, it must be used under certain circumstances and definition of these circumstances needs consideration. Similarly, we would encourage exploring the presence of context-specific preference weights among typical user groups in the many subsectors that constitute the wider health and care sector. Furthermore, focusing on the estimation of QALYs, it is important that we as a field identify the difference in incremental QALYs in a range of practical situations when using the EQ-HWB and other more health-focused instruments. For those working in cost-utility analysis, do our rules of thumb around acceptable thresholds for cost/QALY metrics remain reliable using a different instrument? This is uncertain and should be considered as a key piece of our field’s uptake of the instrument.
      A further issue is whether the findings (both in this issue and in future work) translate across cultures and languages. The Argentina data reported in this issue

      Augustovski F, Argento F, Rodríguez B, Gibbons L, Mukuria C, Belizán M. The development of a new international generic measure (EQ-HWB): face validity and psychometric stages in Argentina. Value Health. In press.

      give a useful framework to establish face validity in non-English speaking settings, and we believe that translation and face validity should be a key part of the expansion of the instrument to other settings.
      To conclude, we would like to congratulate the author teams on assembling an important body of work and look forward to seeing the next stages of this research. We believe that the challenging valuation stage, whereby preferences are to be elicited over several extensively described health state combinations, is likely to feed back some important lessons on where to further refine and simplify the descriptive system. Finally, we would like to take the opportunity to thank the peer reviewers and journal staff for their thoughtful and timely inputs into this themed section, particularly in what has been such a difficult year for so many.

      Article and Author Information

      Author Contributions: Concept and design: Norman, Olsen
      Drafting of the manuscript: Norman, Olsen
      Critical revision of the paper for important intellectual content: Norman, Olsen
      Conflict of Interest Disclosures: All authors reported serving as members of the EuroQol Group. Dr Norman is an editor for Value in Health and had no role in the peer-review process of this article. No other disclosures were reported.
      Funding/Support: The authors received no financial support for this research.

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        Extending the QALY.
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        Improving cross-sector comparisons: going beyond the health-related QALY.
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        Multi attribute utility instruments and their use.
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