EuroQol Research Foundation

BackgroundA cognition bolt-on version for EQ-5D is needed to comprehensively assess health states of the general population.ObjectiveTo experimentally evaluate the valuation methods of the EQ-5D-5L bolt-ons using scaling factor and conventional models, we used the cognition bolt-on version of the Japanese EQ-5D-5L (EQ-5D-5L + C) and two previously developed cognition dimensions Remembering things and Thinking clearly.MethodsEligible participants, recruited from the general Japanese population, included adults living in three cities. Interviews were conducted from June to August 2023. Participants were randomized to Arms 1 (EQ-5D-5L + C), 2 (EQ-5D-5L + Remembering things), and 3 (EQ-5D-5L + Thinking clearly). Preferences were collected using a composite time trade-off (cTTO). The "1-cTTO" data were modeled using the scaling factor model, with EQ-5D-5L disutility weights estimated from the existing value sets. We also fitted the data into the conventional main-effects additive model. Both models used a tobit model and maximum likelihood estimation. Model performance was assessed using indices of fit.ResultsOverall, 864 individuals participated in the study. Addition of cognition dimensions to EQ-5D-5L expanded the scaling factor model coefficients in all arms. The observed mean and predicted "1-cTTO" values of the scaling factor model were not largely different in all three arms. The mean absolute errors of the scaling factor and conventional models were 0.0720 and 0.1305, 0.0748 and 0.0885, and 0.0985 and 0.0685 in Arms 1, 2, and 3, respectively.ConclusionsThe performance of the two models did not appear greatly different. Further experimental valuation studies using the scaling factor model and cognition items are warranted.

This study tested the stability of Danish population health preferences by comparing data collected in 2024 with data from the 2019 Danish EQ-5D-5L valuation study. This period included the COVID-19 pandemic and the war in Ukraine. Data were collected through (1) 100 virtual interviews following the standardized EQ-VT protocol generating composite time trade-off (cTTO) and discrete choice experiment (DCE) data as in the 2019 study, and (2) an online survey of 1000 respondents generating DCE data. Both samples were matched to the 2019 study. Mean cTTO values were compared between 2019 and 2024. Mixed logit models were estimated for the 2019 and 2024 DCE data, and dimension order was compared. The DCE values were anchored on the quality-adjusted life-years scale using the respective cTTO data and the equivalent states from 2019 and subsequently compared using Bland-Altman plots. In 2024, 100 EQ-VT interviews were successfully completed, and 1003 respondents had completed the online survey passing quality control. Mean cTTO values did not differ significantly between 2019 and 2024 for the 10 health states valued, although the overall mean was slightly higher in 2024. In the DCE, dimension order was the same in 2019 and 2024; however, the relative importance of mobility and self-care was higher in 2024 at the expense of pain/discomfort and anxiety/depression. Bland-Altman plots showed higher values for severe states and lower values for moderate states in 2024. Danish population health preferences appeared stable over the 5-year period, providing evidence for the shelf-life of EQ-5D-5L value sets.

BackgroundPrior to total hip and knee arthroplasty (THA/TKA), patients with low socioeconomic status (SES) report worse Patient-Reported Outcome Measures (PROMs), persisting postoperatively. This study explores which self-reported PROMs and their specific domains are most involved.MethodsWe obtained data from the Dutch Arthroplasty Registry (2014–2022), including over 100,000 THA/TKA patients with complete preoperative and 12-month follow-up PROMs. The EQ-5D-3L and EQ-5D-5L, EQ Visual Analogue Scale (VAS), Oxford Hip and Oxford Knee Score (OHS/OKS), and Numerical Rating Scales (NRS) for pain and satisfaction (TKA only, at 12-month follow-up) were obtained. The PROMs were transformed to a 0-100 scale for direct comparison. A SES-indicator based on neighborhood income, unemployment rate, and education level was divided into quintiles, which are equal groups representing 20% of the Dutch population, and was ranked from least to most deprived. Through linear regression we contrasted the most and least deprived groups, adjusting for patient and surgical characteristics. The contribution (percentage) of each domain to the overall health inequalities was estimated for the EQ-5D’s and the OHS/OKS.ResultsIn TKA patients, the most compared to the least deprived group had a lower preoperative EQ-5D-3L score: -2.1 [95% confidence interval − 2.6, -1.6], p < 0.001. At 12-month follow-up, the difference was smaller: EQ-5D-3L 1.3 [-1.9, -0.7], p < 0.001. A larger difference between the most and least deprived was present in OKS (preoperatively: -4.3 [-5.3, -3.4], p < 0.001; 12-month: -1.8 [-2.5, -1.2], p < 0.001). The difference in EQ VAS was smaller (preoperatively: -0.8 [-1.5, -0.1], p = 0.024; 12-month: -0.5 [-1.2, 0.1], p = 0.108). The difference in NRS pain (in rest) was comparable to those in EQ-5D-3L and OKS (preoperatively: -4.5 [-5.4, -3.5], p < 0.001; 12-month: -2.7 [-3.5, -1.9], p < 0.001), while no difference between the most and least deprived in NRS satisfaction was observed at 12 months. For EQ-5D-3L, the domain usual activities accounted for up to 46% of the difference between SES groups, while anxiety/depression played a limited role (up to 17%). For OHS/OKS, functioning contributed most in THA (up to 61%) and pain contributed most in TKA (up to 68%). Differences in PROM scores between SES groups, and how these differences compared across PROMs, were similar in THA patients. Overall, the EQ-5D-5L produced similar patterns compared to the EQ-5D-3L.ConclusionsDeprived THA/TKA patients have poorer pre- and postoperative health, which was primarily related to worse functioning and pain; the clinical relevance of these differences remain uncertain. These differences did not translate into worse overall health (EQ VAS) or into higher dissatisfaction among deprived patients. Future research should investigate whether the EQ VAS and satisfaction measure reflected health differences between SES groups or were biased by reporting heterogeneity, where respondents interpreted the wording differently.

Low volatility has become a mainstream investment style over the past two decades, recognized for delivering high risk-adjusted returns. Many investors fail to fully capitalize on this strategy, however, due to benchmark constraints. Low-volatility stocks tend to lag during prolonged bull markets, a challenge that can be addressed using leverage. This article outlines five use cases to leverage upon the low-volatility effect, including an enhanced strategy, an alternative to the 60/40 asset allocation, and the use of long and short extensions with stocks and market futures. These approaches help investors aiming to meet objectives ranging from stable performance, consistent outperformance, market-neutral returns, or as an alternative for put options, unlocking the full potential of this underutilized factor.

This study aimed to provide normative data obtained in response to the EQ-5D-5L questionnaire in Italy and compare this with data from other countries. A sample of the Italian adult population (aged ≥18years) was recruited and interviewed online using videoconferencing software (Zoom) between November 2020 and February 2021. The distribution of answers was estimated as per the descriptive system of the EQ-5D-5L, and descriptive statistics were calculated for the EQVAS score and EQ-5D-5L index value in the whole sample and relevant subgroups. An ordinary least square (OLS) regression was performed to evaluate the impact of sociodemographic variables on EQ-5D-5L results. Lastly, a comparison was made with EQ-5D-5L population norms of other countries. Data analysis was performed using Microsoft Excel and Stata13. Overall, 1182 people representative of the Italian population (2020) in terms of sex and geographical area responded to the survey. Of the 3125 potential EQ-5D-5L health states, only 106 (3.4%) were selected, and the '11111' and '11112' states were chosen by half of the participants. In terms of EQ-5D-5L dimensions, the frequency of any problems (from slight to extreme) associated with anxiety and depression was high among the very young (18-24 years, 56.0%) and in women of all ages (49.7%). The mean index value (± standard deviation [SD]) was 0.93 (±0.11) for the entire sample and gradually decreased with age, moving from 0.95 (±0.06) in the youngest group (18-24 years) to 0.91 (±0.13) in the oldest age group (≥75 years). Similarly, the mean EQVAS score (±SD) was 81.8 (±13.5), and decreased from 87.0 (±8.9) in the 18-24 years age group to 75.1 (±16.4) among participants >75years of age. The existence of self-reported chronic conditions (e.g., cardiovascular disease), female sex, and social assistance recipiency were negatively associated with the EQ-5D index value, while the EQVAS score was significantly lower in people with chronic conditions and aged >55years. Conversely, higher income levels had a positive impact on both the EQ-5D index value and the EQVAS score. Lastly, both the EQ-5D index value and EQVAS score in Italy were, on average, higher than in most European countries. EQ-5D-5L population norms provide useful insights into the health status of the Italian population and can be used as a reference for other surveys using the same instrument.

ObjectivesTo investigate the effect of an extensive pilot phase in improving protocol compliance, face validity, reduction of interviewer effect and prediction errors in the composite time trade-off (cTTO) data elicited as part of the EQ-5D-5L valuation study in Egypt.MethodsThis study used the cTTO data and quality control (QC) reports from the Egyptian EQ-5D-5L valuation study. Three-level mixed models were estimated to test whether interviewer effects were reduced during the pilot phase and subsequent rounds of collected cTTO data. Ordinary least square (OLS) regression analysis was conducted for each interviewer separately to test whether the mean absolute error (MAE) improved as interviewers completed more interviews. Moreover, improvement in protocol compliance, face validity and reduction of prediction errors in the cTTO data were tested.Results1180 interviews were conducted by nine interviewers and included in the final analysis, of which 206 interviews were pilot and 974 interviews were actual. There was substantial improvement in the face validity and reduction of prediction errors in the cTTO data where the MAE of the actual data was 0.37, which is much lower than that of the pilot data, which was 0.44. However, there was an initial high level of protocol compliance in terms of the four indicators of the QC tool and the variance attributed to the interviewers was small throughout the whole study.ConclusionsThis study clarified the benefits of the pilot phase and the strict implementation of the QC tool in improving the face validity and the prediction accuracy of the cTTO data. However, a more extensive pilot phase may be more beneficial in EQ-5D-5L valuation studies that have issues initially with protocol compliance and interviewer effects.