Order Description<\/p>\n

Write a critical summary of the paper, including the key points, such as its motivation, its hypothesis, the data used, the methods used to analyse those data, and the outcome\/result of this analysis.<\/p>\n

Also state its relevant policy implications and discuss its limitations.<\/p>\n

HEALTH ECONOMICS; Health Econ.<\/p>\n

THINKING ABOUT IT: THOUGHTS ABOUT HEALTH<\/p>\n

AND VALUING QALYs<\/p>\n

PAUL DOLAN<\/p>\n

Department of Social Policy, London School of Economics and Political Science, London, UK<\/p>\n

SUMMARY<\/p>\n

When valuing health states (e.g. for use in the assessment of health technologies), health economists often ask<\/p>\n

respondents how many years of life in poor health they would be willing to trade-off in order to live in full health.<\/p>\n

Problems with preferences of this kind have led to calls for the use of more direct measures of the utility associated<\/p>\n

with experiencing a health state. The fact remains, however, that individuals are often willing to make large<\/p>\n

sacrifices in life expectancy to alleviate conditions for which there appears to be a considerable degree of hedonic<\/p>\n

adaptation. The purpose of this study is to investigate this important discrepancy in more detail. Data from 1173<\/p>\n

internet and telephone surveys in the United States suggest that time trade-off responses are related to the frequency<\/p>\n

and intensity of negative thoughts about health in ways that may not be very well captured by any of the proposed<\/p>\n

valuation methods. Copyright<\/p>\n

r<\/p>\n

2010 John Wiley & Sons, Ltd.<\/p>\n

Received 18 August 2009; Revised 19 June 2010; Accepted 24 August 2010<\/p>\n

KEY WORDS:<\/p>\n

quality-adjusted life years; time trade-off; experienced utility<\/p>\n

1. INTRODUCTION<\/p>\n

Decisions about who gets what treatment should be informed by the value of the benefits that health<\/p>\n

services generate. The question is how to judge the value of those benefits. Until about 100 years ago,<\/p>\n

economists would have thought about benefits in terms of people\u2019s experiences \u2013 the greater the gains in<\/p>\n

an individual\u2019s enjoyment of an outcome, the greater the benefit (Edgeworth, 1881). More recently, they<\/p>\n

have thought about benefits in terms of preferences \u2013 the stronger an individual\u2019s preference for that<\/p>\n

outcome, the greater the benefit (Fisher, 1918). The two definitions amount to the same thing if people<\/p>\n

want most what they will eventually enjoy best and this is a common, albeit often implicitly made,<\/p>\n

assumption in economics. It is also descriptively flawed (Dolan and Kahneman, 2008). Since we value<\/p>\n

health using preference-based methods and since we may wish to know what effect health interventions<\/p>\n

have on people\u2019s experiences, we need further enquiry into the difference between strength of preference<\/p>\n

and intensity of experience.<\/p>\n

Methods have been developed for valuing states of health that are based on preferences and which<\/p>\n

allow for the calculation of quality-adjusted life years (QALYs). The QALY approach assigns a weight<\/p>\n

between 0 (for death) and 1 (for full health) to each state of health and then multiplies that value by how<\/p>\n

long the state lasts. QALYs are increasingly being used by health technology assessment agencies to<\/p>\n

help determine the relative cost-effectiveness of different interventions e.g. they are used by the National<\/p>\n

Institute for Health and Clinical Excellence (NICE) in the UK. There are three main questions that need<\/p>\n

*Correspondence to: Department of Social Policy, London School of Economics and Political Science, Houghton Street, London<\/p>\n

WC2A 2AE, UK. E-mail: p.h.dolan@lse.ac.uk<\/p>\n

Copyright<\/p>\n

r<\/p>\n

2010 John Wiley & Sons, Ltd.<\/p>\n

to be aIDressed to calculate the \u2018quality adjustment\u2019 part of the QALY:<\/p>\n

what<\/p>\n

is to be valued;<\/p>\n

how<\/p>\n

is it to<\/p>\n

be valued; and<\/p>\n

who<\/p>\n

is to value it (Dolan, 2000)?<\/p>\n

The choice of<\/p>\n

what<\/p>\n

refers to the dimensions of health or well-being being considered. Most health<\/p>\n

economists would recommend using an established generic measure of health that is designed<\/p>\n

specifically for generating QALYs. One such descriptive system is the EQ-5D, which describes health in<\/p>\n

terms of three levels (broadly, no problems, some problems and extreme problems) for each of five<\/p>\n

dimensions (mobility, self-care, usual activities, pain\/discomfort and anxiety\/depression). The choice of<\/p>\n

how<\/p>\n

refers to the ways in which the health states are valued so that they lie on a 0\u20131 scale. One of the<\/p>\n

most widely used preference-based methods is the time trade-off (TTO), which requires respondents to<\/p>\n

consider how many years in full health are equivalent to a longer period of time in a poor health state.<\/p>\n

The choice of<\/p>\n

who<\/p>\n

refers to the source of health state values, such as \u2018patients\u2019 experiencing a particular<\/p>\n

state or the \u2018public\u2019 asked to imagine it.<\/p>\n

A set of valuations for the EQ-5D have been estimated from the responses to hypothetical TTO<\/p>\n

questions of a representative sample of over 3000 members of the UK general population (Dolan, 1997).<\/p>\n

NICE recommends that patients describe their own health using the EQ-5D and that the population<\/p>\n

valuation set be used to determine the number of QALYs associated with any change in health state as a<\/p>\n

result of intervention. These recommendations are also being followed in other countries (e.g. Australia<\/p>\n

and Canada), and are broadly consistent with the current emphasis in economics on an account of well-<\/p>\n

being that is based on the satisfaction of preferences.<\/p>\n

It is increasingly recognised that a person\u2019s preferences at time 0 are often a poor guide to that<\/p>\n

person\u2019s preferences at time 1 (see Loewenstein and Angner, 2003 for a good review). Although very few<\/p>\n

longitudinal studies exist, we do find in the health state valuation literature that members of the general<\/p>\n

public (analogous with an assessment at<\/p>\n

t<\/p>\n

5<\/p>\n

0 before circumstances change) generally consider most<\/p>\n

adverse health states to be more severe than do those in the states (an assessment at<\/p>\n

t<\/p>\n

5<\/p>\n

1) (de Wit<\/p>\n

et al<\/p>\n

.,<\/p>\n

2000). Beyond this, there is also good evidence to suggest that the strength of preference is often a poor<\/p>\n

guide to the intensity of experience (Schkade and Kahneman, 1998; Wilson and Gilbert, 2003). This is<\/p>\n

partly because we exaggerate the extent to which we will attend to the state being valued (Dolan and<\/p>\n

Kahneman, 2008) and we are all (\u2018public\u2019 and \u2018patients\u2019) susceptible to exaggeration.<\/p>\n

Imagine being asked to value walking with a cane. It is almost impossible to avoid imagining that as<\/p>\n

you walk you will be thinking about the cane much of the time when, in fact, the cane will rarely be the<\/p>\n

focus of your attention, especially as time passes. Focussing effects are an issue for any preference<\/p>\n

elicitation question for any population, including those with experience of the condition, since what we<\/p>\n

focus on in the question may not be focussed on the same extent in the experience of our lives. A person<\/p>\n

who walks with a cane who is asked to imagine having their walking restrictions alleviated will<\/p>\n

inevitably imagine actively enjoying the freedom of normal walking, which they may quickly take for<\/p>\n

granted.<\/p>\n

This is not to say that walking with a cane will not have any effect on utility but, rather, that its effect<\/p>\n

is likely to be considerably less than we think about it being. As Adam Smith noted over 250 years ago:<\/p>\n

\u2018The great source of both the misery and disorders of human life seems to arise from over-rating the<\/p>\n

difference between one permanent situation and another\u2019 (Smith, 1759). This may generally be true but<\/p>\n

some things, like the effects of prolonged and unexplained pain (Peters<\/p>\n

et al<\/p>\n

., 2000), may perhaps turn<\/p>\n

out to be worse than we imagine them to be. The important general point is that the focus of attention<\/p>\n

that drives our strength of our preferences is different from the focus of attention that explains the<\/p>\n

intensity of our experiences.<\/p>\n

Partly in response to such problems, increasing interest is being shown in the direct assessment of<\/p>\n

experienced utility, as approximated by the flow of feelings during the day (Dolan and Kahneman,<\/p>\n

2008). The day reconstruction method (DRM), for example, has been specifically designed to measure<\/p>\n

experienced utility in this way (Kahneman<\/p>\n

et al<\/p>\n

., 2004). The DRM asks respondents to divide the<\/p>\n

previous day into a number of episodes and then to rate different feelings during those activities. Any<\/p>\n

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