健康效用值测量研究
摘要
健康是人类追求的永恒目标,如何以有限资源最好地满足人们的健康需求是每个国家面临的重大问题,而这一问题在人均资源更加有限的我国显得愈发迫在眉睫。对不同的卫生干预方案进行经济性评估为资源的合理配置提供了切实的指导和依据,决策者可以比较不同方案的投入与结果产出进行最优的选择。结果指标可以是以货币来计量的效益、以临床终点等来表示的效果或用质量调整生命年等来反映的效用,根据这些指标的不同分为成本-效益、成本-效果及成本-效用分析等不同的评价方法。质量调整生命年具有一定的通用属性,同时充分考虑了健康改善的客观实际以及受访者的主观感受,这些特点使得成本-效用分析在对卫生干预项目进行经济性评价时具有重要的作用,并广泛地被各国推荐使用。
健康效用值是指人们对某种特定健康状态的偏好程度,是生命质量的量化指标,可以用来计算质量调整生命年,具体反映的是其中的生命质量权重。该指标可以采用视觉模拟标尺法、时间权衡法或标准博弈法等直接测量得到,也可以采用建立了效用值积分体系的生命质量量表间接测量得到,积分体系的构建是间接测量的关键所在。由于健康效用值代表人们的偏好,其测量结果会受到不同文化体系、价值观念、经济发展水平的影响,因此,采用基于本国或本地区人群偏好测量的健康效用值进行成本-效用分析对于当地的卫生决策才具有重要的指导和参考意义。
本文通过系统的文献分析发现,我国有关健康效用值测量的研究数量很少且范围较窄,主要集中在对一些直接测量方法的介绍、探讨,以及采用这些方法在小样本或特定人群中进行的实证研究方面,缺乏有关健康效用值测量更加深入的研究使得成本-效用分析在我国的发展应用受到很大的限制。鉴于准确、方便、有效测量健康效用值具有现实的迫切需求以及其指导实践的重要现实意义,本文对主要的测量方法及效用值积分体系构建进行了全面的介绍和分析,在总结国内外学者研究经验的基础上建立了基于我国人群偏好的欧洲五维健康量表效用值积分体系,并分析了效用值评价的影响因素。
直接测量方法在实际操作中繁琐耗时,对受访者的理解和配合程度要求较高,其在小样本下开展的研究较为常用,但当需要测量的受访者人数较多时,通过已建立了以偏好为基础的效用值积分体系生命质量量表进行间接测量更加方便有效。效用值积分体系的构建思路是选取一定数量有代表性的人群直接测量量表中少数健康状态的效用值,再根据多维效用函数或计量经济学方法建立合适的模型以预测所有健康状态的效用值。由于国内对健康效用值测量尤其是在效用值积分体系构建方面的研究较少,因此,本文首先对主要的直接测量方法以及如何构建效用值积分体系进行了全面的介绍和分析。
在构建效用值积分体系时也涉及到直接测量方法的应用,且该体系是健康效用值间接测量的关键内容,因此分析已有研究在建立该体系时的成功经验并构建基于我国人群偏好的量表效用值积分体系是本文的研究重点。本研究对效用值积分体系构建相对成熟并取得公认的健康效用指数量表第二版、六维健康调查短表以及具有代表性的两个特异性量表积分体系构建实例进行了深入的分析,结合对欧洲五维健康量表在英国、美国、日本等国积分体系构建实践的比较研究,总结可供借鉴的经验启示,并探讨了在积分体系构建中需要关注的问题。
理论与实践相连,本文在以上研究的基础上,以在国际上有广泛应用的欧洲五维健康量表为研究对象,配额选取1222名一般人群对量表中97个健康状态的效用值进行了时间权衡法直接测量,采用计量经济学方法建立模型来预测量表中所有健康状态的效用值。结果表明,基于均值水平数据,采用普通最小二乘法估计的N3模型预测效果最好,其平均绝对误差为0.020,绝对误差大于0.05的状态数为7个,没有绝对误差大于0.1的状态,拟合优度R2为0.988。另外,本文还研究了年龄、性别等受访者的个人特征对其在评价健康状态效用值时的影响,结果显示年龄、是否参加锻炼等是显著的影响因素,但从总体来看影响的程度较小。本文成功构建了欧洲五维健康量表的效用值积分体系,但其中的不足之处也有待于进一步完善。
Health is a permanent goal pursued by the people. How to take advantage of limited resources to meet the health demands confronting every country, and is a more serious problem for China where more population and less per capita resources. Economic evaluation for different health interventions provides the guideline and reference for allocating resources reasonably. The decision makers could make the optimal choice through comparing the inputs and the outputs among variety interventions. The monetary indicator (benefit), clinical end-point (effectiveness) or quality adjusted life years (utility) are the three types of outcome indicators to refer to the outputs, which standing for cost-benefit analysis (CBA), cost-effectiveness analysis (CEA), and cost-utility analysis (CUA), respectively. QALYs is a general comparable indicator, which combines the actual improvements of health and the subjective perception, so CUA is the most important approach and recommended to be used by many countries.
Health utility refers to the preference for a particular health state, which is a quantitative index for quality of life to calculate the QALYs. Direct and indirect measurement can be used to obtain this index. The first method including visual analogue scale (VAS), time trade-off (TTO), and standard gamble (SG), etc. Establishing the value set for a health-related quality of life instrument is critical to indirect measurement method. Because health utility refers to the preferences, people from different countries with different culture systems and outlooks of value and economic development levels would have different preferences to the same health state. Therefore, the value set based on the local population preferences should be used in making health decisions.
Through systematic literature review, this paper finds that there are few studies about health utility measurement and the research scope is narrow relatively. Most of the existing studies focus on theoretical introduction and discussion on some direct measurements and empirical study on small or specific population. Thus, the application of CUA is restricted in China due to the lack of deeply research on health utility measurement. In view of imperious demands as well as the important practical significance of obtaining health utility in an accurate, convenient and effective way, this paper gives a comprehensive introduction and analysis to the main measurement methods and how to develop the value set. Then, the Chinese tariff for EQ-5D is developed based on the experiences of previous studies. This article also investigates the influencing factors affected valuations.
Direct measurement method is overloaded and time expended. Respondents with high capacity of understanding and cooperation are required in practice when direct method used. However, indirect measurement method is more feasible than direct measurement method if there are large respondents in study. The basic thinking of value set development is to obtain valuations for some health states from a representative sample, and then construct model to predict valuations for all the health states. Because of lacking studies about health utility measurement, especially about how to obtain the value set, the comprehensive introduction and analysis to the main measurement methods and how to develop the value set are gave at the beginning of this article.
Applications of direct measurements including in developing the value set, and how to obtain the value set is critical to indirect measurement, so the research focus of this paper is to analysis the experiences of previous studies and establish the local value set. HUI mark2, SF-6D, EQ-5D and two disease-specific instruments are the objects of this paper. The details about the steps of value set construction and the results are introduced, which would provide the important references for the following empirical study in this research. The problems about establishing value set are also discussed.
Theory must not be divorced from practice. This paper chooses the EQ-5D as the object of empirical study. Utility values for a subset of97health states defined by the EQ-5D descriptive system are directly elicited by applying TTO technique. Econometric model is used to predict utility values of all health states. The total sample is1222general population selected by quota sampling. The results demonstrate that the N3model based on OLS regression at the aggregate level yielded the best predictive ability, with an adjusted R2of0.988, a mean absolute error (MAE) of0.020,7and0prediction errors greater than0.05and0.1respectively in absolute magnitude. In addition, the respondent's characteristics including age, gender, etc. whether affecting the evaluations of health utility values or not are also investigated in this paper. The results show that the habits of physical exercise and age etc. are the influencing factors. But on the whole, the degree of influences is small. This study successfully develops Chinese utility weights for EQ-5D by applying TTO technique, base on representative population sample in China, and which is the first attempt ever to derive social value set for HRQoL instrument in China. But the limitations need to be further improved.
健康效用值是指人们对某种特定健康状态的偏好程度,是生命质量的量化指标,可以用来计算质量调整生命年,具体反映的是其中的生命质量权重。该指标可以采用视觉模拟标尺法、时间权衡法或标准博弈法等直接测量得到,也可以采用建立了效用值积分体系的生命质量量表间接测量得到,积分体系的构建是间接测量的关键所在。由于健康效用值代表人们的偏好,其测量结果会受到不同文化体系、价值观念、经济发展水平的影响,因此,采用基于本国或本地区人群偏好测量的健康效用值进行成本-效用分析对于当地的卫生决策才具有重要的指导和参考意义。
本文通过系统的文献分析发现,我国有关健康效用值测量的研究数量很少且范围较窄,主要集中在对一些直接测量方法的介绍、探讨,以及采用这些方法在小样本或特定人群中进行的实证研究方面,缺乏有关健康效用值测量更加深入的研究使得成本-效用分析在我国的发展应用受到很大的限制。鉴于准确、方便、有效测量健康效用值具有现实的迫切需求以及其指导实践的重要现实意义,本文对主要的测量方法及效用值积分体系构建进行了全面的介绍和分析,在总结国内外学者研究经验的基础上建立了基于我国人群偏好的欧洲五维健康量表效用值积分体系,并分析了效用值评价的影响因素。
直接测量方法在实际操作中繁琐耗时,对受访者的理解和配合程度要求较高,其在小样本下开展的研究较为常用,但当需要测量的受访者人数较多时,通过已建立了以偏好为基础的效用值积分体系生命质量量表进行间接测量更加方便有效。效用值积分体系的构建思路是选取一定数量有代表性的人群直接测量量表中少数健康状态的效用值,再根据多维效用函数或计量经济学方法建立合适的模型以预测所有健康状态的效用值。由于国内对健康效用值测量尤其是在效用值积分体系构建方面的研究较少,因此,本文首先对主要的直接测量方法以及如何构建效用值积分体系进行了全面的介绍和分析。
在构建效用值积分体系时也涉及到直接测量方法的应用,且该体系是健康效用值间接测量的关键内容,因此分析已有研究在建立该体系时的成功经验并构建基于我国人群偏好的量表效用值积分体系是本文的研究重点。本研究对效用值积分体系构建相对成熟并取得公认的健康效用指数量表第二版、六维健康调查短表以及具有代表性的两个特异性量表积分体系构建实例进行了深入的分析,结合对欧洲五维健康量表在英国、美国、日本等国积分体系构建实践的比较研究,总结可供借鉴的经验启示,并探讨了在积分体系构建中需要关注的问题。
理论与实践相连,本文在以上研究的基础上,以在国际上有广泛应用的欧洲五维健康量表为研究对象,配额选取1222名一般人群对量表中97个健康状态的效用值进行了时间权衡法直接测量,采用计量经济学方法建立模型来预测量表中所有健康状态的效用值。结果表明,基于均值水平数据,采用普通最小二乘法估计的N3模型预测效果最好,其平均绝对误差为0.020,绝对误差大于0.05的状态数为7个,没有绝对误差大于0.1的状态,拟合优度R2为0.988。另外,本文还研究了年龄、性别等受访者的个人特征对其在评价健康状态效用值时的影响,结果显示年龄、是否参加锻炼等是显著的影响因素,但从总体来看影响的程度较小。本文成功构建了欧洲五维健康量表的效用值积分体系,但其中的不足之处也有待于进一步完善。
Health is a permanent goal pursued by the people. How to take advantage of limited resources to meet the health demands confronting every country, and is a more serious problem for China where more population and less per capita resources. Economic evaluation for different health interventions provides the guideline and reference for allocating resources reasonably. The decision makers could make the optimal choice through comparing the inputs and the outputs among variety interventions. The monetary indicator (benefit), clinical end-point (effectiveness) or quality adjusted life years (utility) are the three types of outcome indicators to refer to the outputs, which standing for cost-benefit analysis (CBA), cost-effectiveness analysis (CEA), and cost-utility analysis (CUA), respectively. QALYs is a general comparable indicator, which combines the actual improvements of health and the subjective perception, so CUA is the most important approach and recommended to be used by many countries.
Health utility refers to the preference for a particular health state, which is a quantitative index for quality of life to calculate the QALYs. Direct and indirect measurement can be used to obtain this index. The first method including visual analogue scale (VAS), time trade-off (TTO), and standard gamble (SG), etc. Establishing the value set for a health-related quality of life instrument is critical to indirect measurement method. Because health utility refers to the preferences, people from different countries with different culture systems and outlooks of value and economic development levels would have different preferences to the same health state. Therefore, the value set based on the local population preferences should be used in making health decisions.
Through systematic literature review, this paper finds that there are few studies about health utility measurement and the research scope is narrow relatively. Most of the existing studies focus on theoretical introduction and discussion on some direct measurements and empirical study on small or specific population. Thus, the application of CUA is restricted in China due to the lack of deeply research on health utility measurement. In view of imperious demands as well as the important practical significance of obtaining health utility in an accurate, convenient and effective way, this paper gives a comprehensive introduction and analysis to the main measurement methods and how to develop the value set. Then, the Chinese tariff for EQ-5D is developed based on the experiences of previous studies. This article also investigates the influencing factors affected valuations.
Direct measurement method is overloaded and time expended. Respondents with high capacity of understanding and cooperation are required in practice when direct method used. However, indirect measurement method is more feasible than direct measurement method if there are large respondents in study. The basic thinking of value set development is to obtain valuations for some health states from a representative sample, and then construct model to predict valuations for all the health states. Because of lacking studies about health utility measurement, especially about how to obtain the value set, the comprehensive introduction and analysis to the main measurement methods and how to develop the value set are gave at the beginning of this article.
Applications of direct measurements including in developing the value set, and how to obtain the value set is critical to indirect measurement, so the research focus of this paper is to analysis the experiences of previous studies and establish the local value set. HUI mark2, SF-6D, EQ-5D and two disease-specific instruments are the objects of this paper. The details about the steps of value set construction and the results are introduced, which would provide the important references for the following empirical study in this research. The problems about establishing value set are also discussed.
Theory must not be divorced from practice. This paper chooses the EQ-5D as the object of empirical study. Utility values for a subset of97health states defined by the EQ-5D descriptive system are directly elicited by applying TTO technique. Econometric model is used to predict utility values of all health states. The total sample is1222general population selected by quota sampling. The results demonstrate that the N3model based on OLS regression at the aggregate level yielded the best predictive ability, with an adjusted R2of0.988, a mean absolute error (MAE) of0.020,7and0prediction errors greater than0.05and0.1respectively in absolute magnitude. In addition, the respondent's characteristics including age, gender, etc. whether affecting the evaluations of health utility values or not are also investigated in this paper. The results show that the habits of physical exercise and age etc. are the influencing factors. But on the whole, the degree of influences is small. This study successfully develops Chinese utility weights for EQ-5D by applying TTO technique, base on representative population sample in China, and which is the first attempt ever to derive social value set for HRQoL instrument in China. But the limitations need to be further improved.
引文
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