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Published online by Cambridge University Press:  05 February 2014

David Tordrup
LSE Health, London School of Economics
Jean Mossman
European Brain Council
Panos Kanavos
Department of Social Policy and LSE Health, London School of Economics


Objectives: In many economic evaluations and reimbursement decisions, quality-adjusted life-years (QALYs) are used as a measure of benefit to assess effectiveness of novel therapies, often based on the EQ-5D 3-level questionnaire. As only five dimensions of physical and mental well-being are reflected in this tool, significant aspects of the patient experience may be missed. We evaluate the use of the EQ-5D as a measurement of clinical change across a wide range of disorders from dermatological (acne) to life-threatening (metastatic cancers).

Methods: We analyze published studies on the psychometric properties of the EQ-5D 3-level questionnaire, extracting information on the Visual Analogue Scale versus Index score, Standardized Response Mean, and Effect Size. These are compared with ranges generally accepted to represent good responsiveness in the psychometric literature.

Results: We find that only approximately one in five study populations report subjective health state valuation of patients within 5 percent of the score attributed by the EQ-5D index, and more than 40 percent of studies report unacceptable ceiling effects. In the majority of studies, responsiveness of the EQ-5D index was found to be poor to moderate, based on Effect Size (63 percent poor–moderate) and Standardized Response Mean (72 percent poor–moderate).

Conclusions: We conclude that the EQ-5D index does not adequately reflect patient health status across a range of conditions, and it is likely that a significant proportion of the subjective patient experience is not accounted for by the index. This has implications for economic evaluations of novel drugs based on evidence generated with the EQ-5D.

Copyright © Cambridge University Press 2014 

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1. Sorenson, C, Drummond, M, Kanavos, P. Ensuring value for money in health care: The role of health technology assessment in the European Union. London: European Observatory on European Health Systems and Policies; 2008.Google Scholar
2. Drummond, MF, Wilson, DA, Kanavos, P, et al. Assessing the economic challenges posed by orphan drugs. Int J Technol Assess Health Care. 2007;23:3642.Google Scholar
3. NICE. National institute for Health and Clinical Excellence: Appraising life-extending, end of life treatments. 2009. (accessed September 13, 2012).Google Scholar
4. Kind, P, Dolan, P, Gudex, C, Williams, A. Variations in population health status: Results from a United Kingdom national questionnaire survey. BMJ. 1998;316:736741.Google Scholar
5. Facey, K, Boivin, A, Gracia, J, et al. Patients’ perspectives in health technology assessment: A route to robust evidence and fair deliberation. Int J Technol Assess Health Care. 2010;26:334340.Google Scholar
6. INAHTA. INAHTA survey on involvement of consumers in HTA. 2005. (accessed September 20, 2011).Google Scholar
7. INAHTA. Involvement of consumers in the HTA activities of INAHTA members. 2011.—Involvement-of-consumers-in-the-HTA-activities-of-INAHTA-members-/ (accessed September 21, 2011).Google Scholar
8. Lee, A, Sinding, LS. A review of organizational and patient-related assessments in HTAs published by INAHTA members. Danish Health Technol Assess. 2007;9.Google Scholar
9. Hailey, D. Consumer involvement in health technology assessment. 2005. (accessed October 11, 2011).Google Scholar
10. Szende, A, Oppe, M, Devlin, NJ. EQ-5D value sets: Inventory, comparative review and user guide. New York: Springer; 2007.CrossRefGoogle Scholar
11. Brazier, J, Usherwood, T, Harper, R, Thomas, K. Deriving a preference-based single index from the UK SF-36 Health Survey. J Clin Epidemiol. 1998;51:11151128.CrossRefGoogle ScholarPubMed
12. Deyo, RA, Diehr, P, Patrick, DL. Reproducibility and responsiveness of health status measures statistics and strategies for evaluation. Control Clin Trials. 1991;12(Suppl):S142S158.Google Scholar
13. Dolan, P. Modeling valuations for EuroQol health states. Med Care. 1997:1095–1108.CrossRefGoogle Scholar
14. McHorney, CA, Tarlov, AR. Individual-patient monitoring in clinical practice: Are available health status surveys adequate? Qual Life Res. 1995;4:293307.Google Scholar
15. Cohen, J. Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.Google Scholar
16. Günther, OH, Roick, C, Angermeyer, MC, König, H-H. The responsiveness of EQ-5D utility scores in patients with depression: A comparison with instruments measuring quality of life, psychopathology and social functioning. J Affect Disord. 2008;105:8191.Google Scholar
17. Pickard, SA, Johnson, JA, Feeny, DH. Responsiveness of generic health-related quality of life measures in stroke. Qual Life Res. 2005;14:207219.Google Scholar
18. Burton, M, Walters, S, Saleh, M, Brazer, J. An evaluation of patient-reported outcome measures in lower limb reconstruction surgery. Qual Life Res. 2012;21:17311743.CrossRefGoogle ScholarPubMed
19. Solberg, T, Olsen, J-A, Ingebrigtsen, T, et al. Health-related quality of life assessment by the EuroQol-5D can provide cost-utility data in the field of low-back surgery. Eur Spine J. 2005;14:10001007.CrossRefGoogle ScholarPubMed
20. Krabbe, PFM, Peerenboom, L, Langenhoff, BS, Ruers, TJM. Responsiveness of the generic EQ-5D summary measure compared to the disease-specific EORTC QLQ C-30. Qual Life Res. 2004;13:12471253.Google Scholar
21. Conner-Spady, B, Cumming, C, Nabholtz, J-M, et al. Responsiveness of the EuroQol in breast cancer patients undergoing high dose chemotherapy. Qual Life Res. 2001;10:479486.Google Scholar
22. Tidermark, J, Bergström, G, Svensson, O, et al. Responsiveness of the EuroQol (EQ 5-D) and the SF-36 in elderly patients with displaced femoral neck fractures. Qual Life Res. 2003;12:10691079.Google Scholar
23. Tidermark, J, Bergström, G. Responsiveness of the EuroQol (EQ-5D) and the Nottingham Health Profile (NHP) in elderly patients with femoral neck fractures. Qual Life Res. 2007;16:321330.Google Scholar
24. Feeny, D, Spritzer, K, Hays, RD, et al. Agreement about identifying patients who change over time cautionary results in cataract and heart failure patients. Med Decis Making. 2012;32:273286.Google Scholar
25. Wu, AW, Jacobson, DL, Frick, KD, et al. Validity and responsiveness of the EuroQol as a measure of health-related quality of life in people enrolled in an AIDS clinical trial. Qual Life Res. 2002;11:273282.Google Scholar
26. van Asselt, A, Dirksen, C, Arntz, A, et al. The EQ-5D: A useful quality of life measure in borderline personality disorder? Eur Psychiatry. 2009;24:7985.Google Scholar
27. Goossens, L, Nivens, M, Sachs, P, et al. Is the EQ-5D responsive to recovery from a moderate COPD exacerbation? Respir Med. 2011;105:11951202.CrossRefGoogle ScholarPubMed
28. Mann, R, Brazier, J, Tsuchiya, A. A comparison of patient and general population weightings of EQ-5D dimensions. Health Econ. 2009;18:363372.Google Scholar
29. Stavem, K, Frøland, SS, Hellum, KB. Comparison of preference-based utilities of the 15D, EQ-5D and SF-6D in patients with HIV/AIDS. Qual Life Res. 2005;14:971980.Google Scholar
30. Maes, I, Joore, M, Cima, R, et al. Assessment of health state in patients with tinnitus: A comparison of the EQ-5D and HUI mark III. Ear Hear. 2011;32:428435.CrossRefGoogle Scholar
31. Haywood, K, Garratt, A, Lall, R, et al. EuroQol EQ-5D and condition-specific measures of health outcome in women with urinary incontinence: Reliability, validity and responsiveness. Qual Life Res. 2008;17:475483.Google Scholar
32. Grutters, J, Joore, M, van der Horst, F, et al. Choosing between measures: Comparison of EQ-5D, HUI2 and HUI3 in persons with hearing complaints. Qual Life Res. 2007;16:14391449.CrossRefGoogle ScholarPubMed
33. Kimman, M, Dirksen, C, Lambin, P, Boersma, L. Responsiveness of the EQ-5D in breast cancer patients in their first year after treatment. Health Qual Life Outcomes. 2009;7:11.Google Scholar
34. Olerud, P, Tidermark, J, Ponzer, S, et al. Responsiveness of the EQ-5D in patients with proximal humeral fractures. J Shoulder Elbow Surg. 2011;20:12001206.Google Scholar
35. Staerkle, R, Villiger, P. Simple questionnaire for assessing core outcomes in inguinal hernia repair. Br J Surg. 2011;98:148155.Google Scholar
36. Stark, R, Reitmeir, P, Leidl, R, Konig, H. Validity, reliability, and responsiveness of the EQ-5D in inflammatory bowel disease in Germany. Inflamm Bowel Dis. 2010;16:4251.Google Scholar
37. Streiner, DL. Health measurement scales: A practical guide to their development and use. Oxford: Oxford University Press; 1995.Google Scholar
38. Brazier, JE, Harper, R, Munro, J, et al. Generic and condition-specific outcome measures for people with osteoarthritis of the knee. Rheumatology (Oxford). 1999;38:870877.Google Scholar
39. Eurich, D, Johnson, J, Reid, K, Spertus, J. Assessing responsiveness of generic and specific health related quality of life measures in heart failure. Health Qual Life Outcomes. 2006;4:89.Google Scholar
40. Krahn, M, Bremner, KE, Tomlinson, G, et al. Responsiveness of disease-specific and generic utility instruments in prostate cancer patients. Qual Life Res. 2007;16:509522.Google Scholar
41. Alibhai, SMH, Naglie, G, Nam, R, et al. Do older men benefit from curative therapy of localized prostate cancer? J Clin Oncol. 2003;21:33183327.CrossRefGoogle ScholarPubMed
42. Fleming, C, Wasson, JH, Albertsen, PC, et al. A decision analysis of alternative treatment strategies for clinically localized prostate cancer. JAMA. 1993;269:26502658.CrossRefGoogle ScholarPubMed
43. Riazi, A, Cano, SJ, Cooper, JM, et al. Coordinating outcomes measurement in ataxia research: Do some widely used generic rating scales tick the boxes? Mov Disord. 2006;21:13961403.Google Scholar
44. Klassen, AF, Newton, JN, Mallon, E. Measuring quality of life in people referred for specialist care of acne: Comparing generic and disease-specific measures. J Am Acad Dermatol. 2000;43:229233.CrossRefGoogle ScholarPubMed
45. Hurst, NP, Kind, P, Ruta, D, et al. Measuring health-related quality of life in rheumatoid arthritis: Validity, responsiveness and reliability of EuroQol (EQ-5D). Rheumatology (Oxford). 1997;36:551559.Google Scholar
46. Torrance, GW. Social preferences for health states: An empirical evaluation of three measurement techniques. Socioecon Plann Sci. 1976;10:129136.Google Scholar
47. Hunger, M, Sabariego, C, Stollenwerk, B, et al. Validity, reliability and responsiveness of the EQ-5D in German stroke patients undergoing rehabilitation. Qual Life Res. 2011;21:12051216.Google Scholar
48. Fankhauser, C, Mutter, U, Aghayev, E, Mannion, A. Validity and responsiveness of the Core Outcome Measures Index (COMI) for the neck. Eur Spine J. 2012;21:101114.CrossRefGoogle ScholarPubMed
49. Nosyk, B, Sun, H, Bansback, N, et al. The concurrent validity and responsiveness of the health utilities index (HUI 3) among patients with advanced HIV/AIDS. Qual Life Res. 2009;18:815824.Google Scholar
50. Luo, N, Ng, W, Lau, P, et al. Responsiveness of the EQ-5D and 8-item Parkinson's Disease Questionnaire (PDQ-8) in a 4-year follow-up study. Qual Life Res. 2010;19:565569.Google Scholar
51. Nord, E. The validity of a visual analogue scale in determining social utility weights for health states. Int J Health Plann Manage. 1991;6:234242.Google Scholar
52. Herdman, M, Gudex, C, Lloyd, A, et al. Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res. 2011;20:17271736.Google Scholar
53. EuroQol. Status update: 5L Valuation Studies. EuroQol Group; 2013. (accessed August 6, 2013).Google Scholar
54. Stolk, EA, Busschbach, JJV. Validity and feasibility of the use of condition-specific outcome measures in economic evaluation. Qual Life Res. 2003;12:363371.CrossRefGoogle ScholarPubMed
55. Spilker, B, Molinek, FR Jr, Johnston, KA, et al. Quality of life bibliography and indexes. Med Care. 1990;28:DS1DS77.Google Scholar
56. Pickard, AS, De Leon, MC, Kohlmann, T, et al. Psychometric comparison of the standard EQ-5D to a 5 level version in cancer patients. Med Care. 2007;45:259263.Google Scholar
57. EuroQol. EQ-5D-3L health questionnaire sample. EuroQol Group; 1990. (accessed July 16, 2013).Google Scholar
58. Bushnell, DM, Martin, ML, Ricci, J-F, Bracco, A. Performance of the EQ-5D in Patients with Irritable Bowel Syndrome. Value Health. 2006;9:9097.Google Scholar
59. Frihagen, F, Grotle, M, Madsen, J, et al. Outcome after femoral neck fractures: A comparison of Harris Hip Score, Eq-5d and Barthel Index. Injury. 2008;39:11471156.Google Scholar
60. Garratt, A, Brealey, S, Robling, M, et al. Development of the Knee Quality of Life (KQoL-26) 26-item questionnaire: Data quality, reliability, validity and responsiveness. Health Qual Life Outcomes. 2008;6:48.Google Scholar
61. Gerhards, SAH, Huibers, MJH, Theunissen, KATM, et al. The responsiveness of quality of life utilities to change in depression: A comparison of instruments (SF-6D, EQ-5D, and DFD). Value Health. 2011;14:732739.Google Scholar
62. Gunther, O, Roick, C, Angermeyer, M, Konig, H. Responsiveness of EQ-5D utility indices in alcohol-dependent patients. Drug Alcohol Depend. 2008;92:291295.Google Scholar
63. Harrison, M, Davies, L, Bansback, N, et al. The comparative responsiveness of the EQ-5D and SF-6D to change in patients with inflammatory arthritis. Qual Life Res. 2009;18:11951205.CrossRefGoogle ScholarPubMed
64. Haywood, KL, Garratt, AM, Dziedzic, K, Dawes, PT. Generic measures of health-related quality of life in ankylosing spondylitis: Reliability, validity and responsiveness. Rheumatology. 2002;41:13801387.CrossRefGoogle ScholarPubMed
65. Kunz, S. Psychometric properties of the EQ-5D in a study of people with mild to moderate dementia. Qual Life Res. 2010;19:425434.Google Scholar
66. lglesias, CP, Birks, Y, Nelson, EA, et al. Quality of life of people with venous leg ulcers: A comparison of the discriminative and responsive characteristics of two generic and a disease specific instruments. Qual Life Res. 2005;14:17051718.Google Scholar
67. Marra, CA, Rashidi, AA, Guh, D, et al. Are indirect utility measures reliable and responsive in rheumatoid arthritis patients? Qual Life Res. 2005;14:13331344.Google Scholar
68. Moock, J, Kohlmann, T. Comparing preference-based quality-of-life measures: Results from rehabilitation patients with musculoskeletal, cardiovascular, or psychosomatic disorders. Qual Life Res. 2008;17:485495.Google Scholar
69. Paterson, C, Langan, CE, McKaig, GA, et al. Assessing patient outcomes in acute exacerbations of chronic bronchitis: The measure your medical outcome profile (MYMOP), medical outcomes study 6-item general health survey (MOS-6A) and EuroQol (EQ-5D). Qual Life Res. 2000;9:521527.CrossRefGoogle ScholarPubMed
70. Shikiar, R, Willian, M, Okun, M, et al. The validity and responsiveness of three quality of life measures in the assessment of psoriasis patients: Results of a phase II study. Health Qual Life Outcomes. 2006;4:71.CrossRefGoogle ScholarPubMed
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