Framing and labelling effects in health descriptions: Quality adjusted life years for treatment of breast cancer

doi:10.1016/0895-4356(93)90011-O

Journal of Clinical Epidemiology

Volume 46, Issue 1, January 1993, Pages 77-84

https://doi.org/10.1016/0895-4356(93)90011-O Get rights and content

Abstract

At present there is a growing interest in the use of cost-utility analysis (CUA) to a point where it merits serious consideration by health care decision makers. However, there remain a number of theoretical and practical issues to be resolved including the way in which quality of life information is presented and described to subjects. Two potential sources of influence in the construction of the quality adjusted life year (QALY) values elicited for a recent Australian CUA of mammography screening have been investigated. 180 subjects were randomly allocated to nine different presentations of two breast cancer health descriptions to investigate the impact of some framing and labelling effects. No statistically significant differences were found in the valuations placed on these descriptions when framing and labelling effects were taken into account, either as separate framing and labelling factors or as interactions with one another. A significant difference was found in the particular values of descriptions that were written in the third person that differed in terms of whether the word “cancer” was used. The main contribution of these data is to the robustness of the health descriptions used in the cost-utility analysis of mammography screening.

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Vignette-Based Utilities: Usefulness, Limitations, and Methodological Recommendations
2021, Value in Health
Citation Excerpt :
Previous research has examined the effects of naming (ie, labeling) the disease in a health state. There is some evidence that naming the disease can influence utility,82 although other studies have reported that the disease label did not affect results.83,84 Some diseases such as cancer or human immunodeficiency virus may be associated with preconceptions, fear, stigma, or bias.
Health technology assessment agencies often prefer that utilities used to calculate quality-adjusted life years in cost-utility analyses (CUAs) are derived using standardized methods, such as generic preference-based measures completed by patients in clinical trials. However, there are situations when no standardized approach is feasible or appropriate for a specific medical condition or treatment that must be represented in a CUA. When this occurs, vignette-based methods are often used to estimate utilities. A vignette (sometimes called a “scenario,” “health state description,” “health state vignette,” or “health state”) is a description of a health state that is valued in a preference elicitation task to obtain a utility estimate. This method is sometimes the only feasible way to estimate utilities representing a concept that is important for a CUA. Consequently, vignette-based studies continue to be conducted and published, with the resulting utilities used in economic models to inform decision making about healthcare resource allocation. Despite the potential impact of vignette-based utilities on medical decision making, there is no published guidance or review of this methodology. This article provides recommendations for researchers, health technology assessment reviewers, and policymakers who may be deciding whether to use vignette-based methods, designing a vignette study, using vignette-based utilities in a CUA, or evaluating a CUA that includes vignette-based utilities. Recommendations are provided on: (A) when to use vignette-based utilities, (B) methods for developing vignettes, (C) valuing vignettes, (D) use of vignette-based utilities in models, and (E) limitations of vignette methods.
Valuing preferences for treating screen detected ductal carcinoma in situ
2019, European Journal of Cancer
Mammographic screening reduces breast cancer mortality but may lead to the overdiagnosis and overtreatment of low-risk breast cancers. Conservative management may reduce the potential harm of overtreatment, yet little is known about the impact upon quality of life.
To quantify women's preferences for managing low-risk screen detected ductal carcinoma in situ (DCIS), including the acceptability of active monitoring as an alternative treatment.
Utilities (cardinal measures of quality of life) were elicited from 172 women using visual analogue scales (VASs), standard gambles, and the Euro-Qol-5D-5L questionnaire for seven health states describing treatments for low-risk DCIS. Sociodemographics and breast cancer history were examined as predictors of utility.
Both patients and non-patients valued active monitoring more favourably on average than conventional treatment. Utilities were lowest for DCIS treated with mastectomy (VAS: 0.454) or breast conserving surgery (BCS) with adjuvant radiotherapy (VAS: 0.575). The utility of active monitoring was comparable to BCS alone but was rated more favourably as progression risk was reduced from 40% to 10%. Disutility for active monitoring was likely driven by anxiety around progression, whereas conventional management impacted other dimensions of quality of life. The heterogeneity between individual preferences could not be explained by sociodemographic variables, suggesting that the factors influencing women's preferences are complex.
Active monitoring of low-risk DCIS is likely to be an acceptable alternative for reducing the impact of overdiagnosis and overtreatment in terms of quality of life. Further research is required to determine subgroups more likely to opt for conservative management.
Valuing the health states associated with breast cancer screening programmes: A systematic review of economic measures
2019, Social Science and Medicine
Citation Excerpt :
No primary study explicitly considered the impact of the risk of overdiagnosis or unnecessary treatment in any of the health states described. Only Gerard (Gerard et al., 1993) and Hall (Hall et al., 1992) introduced the notion of dying of causes other than breast cancer in their vignettes, although they did not explicitly include the risk of unnecessary follow up and treatment. Kim et al. (2017) explicitly included risk in their health state descriptions of surgery and radiotherapy but only provided estimates for recurrence and survival, assuming all treatment was necessary for non-invasive disease.
Policy decisions regarding breast cancer screening and treatment programmes may be misplaced unless the decision process includes the appropriate utilities and disutilities of mammography screening and its sequelae. The objectives of this study were to critically review how economic evaluations have valued the health states associated with breast cancer screening, and appraise the primary evidence informing health state utility values (cardinal measures of quality of life). A systematic review was conducted up to September 2018 of studies that elicited or used utilities relevant to mammography screening. The methods used to elicit utilities and the quality of the reported values were tabulated and analysed narratively.
40 economic evaluations of breast cancer screening programmes and 10 primary studies measuring utilities for health states associated with mammography were reviewed in full. The economic evaluations made different assumptions about the measures used, duration applied and the sequalae included in each health state. 22 evaluations referenced utilities based on assumptions or used measures that were not methodologically appropriate. There was significant heterogeneity in the utilities generated by the 10 primary studies, including the methods and population used to derive them. No study asked women to explicitly consider the risk of overdiagnosis when valuing the health states described.
Utilities informing breast screening policy are restricted in their ability to reflect the full benefits and harms. Evaluating the true cost-effectiveness of breast cancer screening will remain problematic, unless the methodological challenges associated with valuing the disutilities of screening are adequately addressed.
Health State Utilities Associated with Glucose Monitoring Devices
2017, Value in Health
Glucose monitoring is important for patients with diabetes treated with insulin. Conventional glucose monitoring requires a blood sample, typically obtained by pricking the finger. A new sensor-based system called “flash glucose monitoring” monitors glucose levels with a sensor worn on the arm, without requiring blood samples.
To estimate the utility difference between these two glucose monitoring approaches for use in cost-utility models.
In time trade-off interviews, general population participants in the United Kingdom (London and Edinburgh) valued health states that were drafted and refined on the basis of literature, clinician input, and a pilot study. The health states had identical descriptions of diabetes and insulin treatment, differing only in glucose monitoring approach.
A total of 209 participants completed the interviews (51.7% women; mean age = 42.1 years). Mean utilities were 0.851 ± 0.140 for conventional monitoring and 0.882 ± 0.121 for flash monitoring (significant difference between the mean utilities; t = 8.3; P < 0.0001). Of the 209 participants, 78 (37.3%) had a higher utility for flash monitoring, 2 (1.0%) had a higher utility for conventional monitoring, and 129 (61.7%) had the same utility for both health states.
The flash glucose monitoring system was associated with a significantly greater utility than the conventional monitoring system. This difference may be useful in cost-utility models comparing the value of glucose monitoring devices for patients with diabetes. This study adds to the literature on treatment process utilities, suggesting that time trade-off methods may be used to quantify preferences among medical devices.
Does the process of deliberation change individuals' health state valuations? An exploratory study using the person trade-off technique
2013, Value in Health
Citation Excerpt :
However, our impression from the interview and observational data suggests that detailed discussions around health states and the implications of resource allocation decisions did take place. This detailed discussion may well have been driven by the framing of the scenarios and the inclusion of the disease label [39,40]. Results from our study suggested that valuations are more stable and less subject to change when the choice is less complex; that is, the trade is between a moderate health state (such as low back pain) and a severe health state (such as quadriplegia).
This article explores two gaps in the health state valuation literature: the effect of processes and the stability of health state valuations, and the existence of preexisting valuations. Stability in health state valuations over time depends on whether preferences are considered to be preexisting (axiom of completeness) and therefore can be gathered reliably, or are constructed during consideration and debate. Under the former, changes in revealed preferences are evidence of poor reliability; under the latter, it is a function of the deliberative process.
This study explores the effect of deliberation on health state valuations elicited by using the person trade-off technique . Quantitative analysis was used to explore whether respondents changed their responses following deliberation and the impact of change on aggregate health state values. Qualitative methods were used to explore respondents’ views on the elicitation process and the impact of deliberation on their responses.
Following discussion and deliberation, 74% of the participants changed their person trade-off valuations and this did have an impact on the aggregate valuations. The qualitative analysis lends some support to the construction of preference assumption.
The results from this exploratory study challenge the notion that individuals have preexisting health state preferences and call for further detailed research in this area. Furthermore, it raises concerns over current practices around preference elicitation exercises, which have tended to be carried out as a solitary exercise without allowing time for respondents to reflect and deliberate on their decisions.
The utility of health and wealth
2012, Journal of Health Economics
Tradeoffs between health and wealth are among the most important decisions individuals make, and are central to social and economic policy. Yet, only a few studies have investigated the utility of health and wealth empirically. This paper investigates this utility function both theoretically and empirically. We conduct detailed personal interviews with 180 cancer patients, and also obtain questionnaires from 132 diabetes patients. We find strong support for the utility function U(h, w) = h · log(w), where h denotes health and w denotes wealth.

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Original articleFraming and labelling effects in health descriptions: Quality adjusted life years for treatment of breast cancer

Abstract

Soc Sci Med

Socao-Eton Plan Sci

J Chron Dis

Soc Sci Med

J Clin Epidemiol

Lancet

Background material for the workshop on QALYs: assumptions of the QALY procedure

Soc Sci Med

Alternative methods of valuing health states: A comparative analysis based on an empirical study using the time trade-off approach in relation to health states one year after treatment for breast cancer

Cost utility analysis: The compatibility of measurement techniques and the measurement of utility through time

Describing health states: methodologic issues in obtaining values for health states

Med Care

The psychology of preference

Sci Am

Sources of bias in assessment procedures for utility functions

Manag Sci

A comparison of methods of assessing voice quality in laryngeal cancer

Original article
Framing and labelling effects in health descriptions: Quality adjusted life years for treatment of breast cancer