The European Journal of Health Economics

, Volume 18, Issue 4, pp 519–531 | Cite as

Validation and comparison of the psychometric properties of the EQ-5D-3L and EQ-5D-5L instruments in Greece

  • John N. YfantopoulosEmail author
  • Athanasios E. Chantzaras
Original Paper



To validate and compare the psychometric properties of the EQ-5D-3L with the EQ-5D-5L classification systems in Greece.


Participants (n = 2279) over 40 years old, sampled from the greater area of Athens using a multistage stratified quota sampling method, completed both EQ-5D versions, while information was also collected on socio-demographics and health-related characteristics. The EQ-5D-5L and EQ-5D-3L were evaluated in terms of agreement, ceiling effects, redistribution and inconsistency, informativity, and convergent and known-groups validity.


The agreement between the EQ-5D-3L and EQ-5D-5L was high (ICC = 0.85). Ceiling effects decreased significantly in the EQ-5D-5L in all domains (P < 0.001), with “usual activities” (−21.4 %) and “self-care” (−20.1 %) showing the highest absolute and “anxiety/depression” the highest relative reduction (−32.46 %). Inconsistency was low (5.7 %). The increase in prevalence of problems was larger than the decrease in their severity, resulting in a lower mean health utility for the EQ-5D-5L. Overall absolute and relative informativity improved by 70.5 % and 16.4 %, respectively, in the EQ-5D-5L. Both instruments exhibited good convergent and known-groups validity, with evidence of a considerably better convergent performance and discriminatory ability of the EQ-5D-5L.


Both EQ-5D versions demonstrated good construct validity and had consistent redistribution. The EQ-5D-5L system may be preferable to the EQ-5D-3L, as it exhibited superior performance in terms of lower ceiling effects, higher absolute and relative informativity, and improved convergent and known-groups validity efficiency.


EQ-5D Health-related quality of life Psychometrics Validity Greece 

JEL Classification

I10 I19 



We would like to express our sincere appreciation to Dr. Dion Balourdos, Research Director at the National Centre for Social Research (EKKE) for his collaboration with the data source.

Compliance with ethical standards

Conflict of interest

The authors have no conflicts to declare.

Supplementary material

10198_2016_807_MOESM1_ESM.doc (48 kb)
Supplementary material 1 (DOC 48 kb)


  1. 1.
    EuroQol: EuroQol-a new facility for the measurement of health-related quality of life. Health Policy 16(3), 199–208 (1990)Google Scholar
  2. 2.
    Rabin, R., Oemar, M., Oppe, M.: EQ-5D-3L User Guide, Version 4.0. Rotterdam, The Netherlands: EuroQoL Group (2011)Google Scholar
  3. 3.
    Rabin, R., Oemar, M., Oppe, M., Janssen, B., Herdman, M.: EQ-5D-5L user guide: basic information on how to use the EQ-5D-5L instrument. Version 1.0. In. EuroQol Group, (2011)Google Scholar
  4. 4.
    Craig, B.M., Pickard, A.S., Lubetkin, E.I.: Health problems are more common, but less severe when measured using newer EQ-5D versions. J. Clin. Epidemiol. 67(1), 93–99 (2014). doi: 10.1016/j.jclinepi.2013.07.011 CrossRefPubMedGoogle Scholar
  5. 5.
    Brussoni, M., Kruse, S., Walker, K.: Validity and reliability of the EQ-5D-3L™ among a paediatric injury population. Health Qual. Life Outcomes 11(1), (2013)Google Scholar
  6. 6.
    Lang, H.C., Chuang, L., Shun, S.C., Hsieh, C.L., Lan, C.F.: Validation of EQ-5D in patients with cervical cancer in Taiwan. Support Care Cancer 18(10), 1279–1286 (2010)CrossRefPubMedGoogle Scholar
  7. 7.
    Janssen, M.F., Lubetkin, E.I., Sekhobo, J.P., Pickard, A.S.: The use of the EQ-5D preference-based health status measure in adults with Type 2 diabetes mellitus. Diabet. Med. 28(4), 395–413 (2011)CrossRefPubMedGoogle Scholar
  8. 8.
    Aburuz, S., Bulatova, N., Twalbeh, M., Gazawi, M.: The validity and reliability of the Arabic version of the EQ-5D: a study from Jordan. Ann. Saudi Med. 29(4), 304–308 (2009)CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Kontodimopoulos, N., Pappa, E., Niakas, D., Yfantopoulos, J., Dimitrakaki, C., Tountas, Y.: Validity of the EuroQoL (EQ-5D) instrument in a Greek general population. Value Health 11(7), 1162–1169 (2008)CrossRefPubMedGoogle Scholar
  10. 10.
    Van De Willige, G., Wiersma, D., Nienhuis, F.J., Jenner, J.A.: Changes in quality of life in chronic psychiatric patients: a comparison between EuroQol (EQ-5D) and WHOQoL. Qual. Life Res. 14(2), 441–451 (2005). doi: 10.1007/s11136-004-0689-y CrossRefPubMedGoogle Scholar
  11. 11.
    Petrou, S., Hockley, C.: An investigation into the empirical validity of the EQ-5D and SF-6D based on hypothetical preferences in a general population. Health Econ. 14(11), 1169–1189 (2005)CrossRefPubMedGoogle Scholar
  12. 12.
    Petrou, S., Morrell, J., Spiby, H.: Assessing the empirical validity of alternative multi-attribute utility measures in the maternity context. Health Qual. Life Outcomes 7(1), 40 (2009)CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Bharmal, M., Thomas 3rd, J.: Comparing the EQ-5D and the SF-6D descriptive systems to assess their ceiling effects in the US general population. Value health J. Int. Soc. Pharmacoeconomics Outcomes Res. 9(4), 262–271 (2006). doi: 10.1111/j.1524-4733.2006.00108.x CrossRefGoogle Scholar
  14. 14.
    Brazier, J., Roberts, J., Tsuchiya, A., Busschbach, J.: A comparison of the EQ-5D and SF-6D across seven patient groups. Health Econ. 13(9), 873–884 (2004). doi: 10.1002/hec.866 CrossRefPubMedGoogle Scholar
  15. 15.
    Janssen, M.F., Birnie, E., Haagsma, J.A., Bonsel, G.J.: Comparing the Standard EQ-5D three-level system with a five-level version. Value Health 11(2), 275–284 (2008)CrossRefPubMedGoogle Scholar
  16. 16.
    Kim, S.H., Kim, H.J., Lee, S.I., Jo, M.W.: Comparing the psychometric properties of the EQ-5D-3L and EQ-5D-5L in cancer patients in Korea. Qual. Life Res. 21(6), 1065–1073 (2012)CrossRefPubMedGoogle Scholar
  17. 17.
    Janssen, M.F., Pickard, A.S., Golicki, D., Gudex, C., Niewada, M., Scalone, L., Swinburn, P., Busschbach, J.: Measurement properties of the EQ-5D-5L compared to the EQ-5D-3L across eight patient groups: a multi-country study. Qual. Life Res. 22(7), 1717–1727 (2013). doi: 10.1007/s11136-012-0322-4 CrossRefPubMedGoogle Scholar
  18. 18.
    Pickard, A.S., Kohlmann, T., Janssen, M.F., Bonsel, G., Rosenbloom, S., Cella, D.: Evaluating equivalency between response systems: application of the Rasch model to a 3-level and 5-level EQ-5D. Med. Care. 45(9), 812–819 (2007)CrossRefPubMedGoogle Scholar
  19. 19.
    Janssen, M.F., Birnie, E., Bonsel, G.J.: Quantification of the level descriptors for the standard EQ-5D three-level system and a five-level version according to two methods. Qual life Res.Int. J. Qual. Life Asp. Treat. care Rehabil. 17(3), 463–473 (2008). doi: 10.1007/s11136-008-9318-5 CrossRefGoogle Scholar
  20. 20.
    Luo, N., Li, M., Chevalier, J., Lloyd, A., Herdman, M.: A comparison of the scaling properties of the English, Spanish, French, and Chinese EQ-5D descriptive systems. Qual Life Res., 1–7 (2012). doi: 10.1007/s11136-012-0342-0
  21. 21.
    Kim, T.H., Jo, M.W., Lee, S.i., Kim, S.H., Chung, S.M.: Psychometric properties of the EQ-5D-5L in the general population of South Korea. Qual Life Res., 22(8):2245–2253 (2013)Google Scholar
  22. 22.
    Pickard, A.S., De Leon, M.C., Kohlmann, T., Cella, D., Rosenbloom, S.: Psychometric comparison of the standard EQ-5D to a 5 level version in cancer patients. Med. Care 45(3), 259–263 (2007)CrossRefPubMedGoogle Scholar
  23. 23.
    Scalone, L., Ciampichini, R., Fagiuoli, S., Gardini, I., Fusco, F., Gaeta, L., Del Prete, A., Cesana, G., Mantovani, L.G.: Comparing the performance of the standard EQ-5D 3L with the new version EQ-5D 5L in patients with chronic hepatic diseases. Qual. Life Res. 22(7), 1707–1716 (2013)CrossRefPubMedGoogle Scholar
  24. 24.
    Errea, M.: Comparing the psychometric properties of the EQ-5D-5L between mental and somatic chronic patients populations. In: Departamento de Economía-Universidad Pública de Navarra, (2013)Google Scholar
  25. 25.
    Herdman, M., Gudex, C., Lloyd, A., Janssen, M.F., Kind, P., Parkin, D., Bonsel, G., Badia, X.: Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual. Life Res. 20(10), 1727–1736 (2011). doi: 10.1007/s11136-011-9903-x CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Tadros, A., Vergou, T., Stratigos, A.J., Tzavara, C., Hletsos, M., Katsambas, A., Antoniou, C.: Psoriasis: is it the tip of the iceberg for the quality of life of patients and their families? J. Eur. Acad. Dermatol. Venereol. 25(11), 1282–1287 (2011)CrossRefPubMedGoogle Scholar
  27. 27.
    Rabin, R., de Charro, F.: EQ-5D: a measure of health status from the EuroQol Group. Ann. Med. 33(5), 337–343 (2001)CrossRefPubMedGoogle Scholar
  28. 28.
    Bhosle, M.J., Kulkarni, A., Feldman, S.R., Balkrishnan, R.: Quality of life in patients with psoriasis. Health Qual. Life Outcomes 4, 35 (2006). doi: 10.1186/1477-7525-4-35 CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Dolan, P., Gudex, C., Kind, P., Williams, A.: A social tariff for EuroQol: results from a UK general population survey. Cent. Health Econ., (1995)Google Scholar
  30. 30.
    Brooks, R.: The EuroQol group after 25 years. Springer, Dordrecht (2012)Google Scholar
  31. 31.
    EuroQol: EQ-5D-5L index value calculator. version 1.0. (2013). Accessed 10 Μαίου 2013
  32. 32.
    Van Hout, B., Janssen, M.F., Feng, Y.S., Kohlmann, T., Busschbach, J., Golicki, D., Lloyd, A., Scalone, L., Kind, P., Pickard, A.S.: Interim scoring for the EQ-5D-5L: mapping the EQ-5D-5L to EQ-5D-3L value sets. Value Health 15(5), 708–715 (2012). doi: 10.1016/j.jval.2012.02.008 CrossRefPubMedGoogle Scholar
  33. 33.
    Brooks, R., EuroQol Group: EuroQol: the current state of play. Health Policy 37(1), 53–72 (1996)CrossRefGoogle Scholar
  34. 34.
    Brooks, R.G.: 28 Years of the EuroQol Group: an overview. EuroQol Working Paper Series. (2015)Google Scholar
  35. 35.
    Yfantopoulos, J.: The Greek version of the EuroQol (EQ-5D) instrument. Arch. Hell. Med. 18(2), 180–191 (2001)Google Scholar
  36. 36.
    Terwee, C.B., Bot, S.D., de Boer, M.R., van der Windt, D.A., Knol, D.L., Dekker, J., Bouter, L.M., de Vet, H.C.: Quality criteria were proposed for measurement properties of health status questionnaires. J. Clin. Epidemiol. 60(1), 34–42 (2007)CrossRefPubMedGoogle Scholar
  37. 37.
    Bland, Martin: J., Altman, D.: statistical methods for assessing agreement between two methods of clinical measurement. Lancet 327(8476), 307–310 (1986)CrossRefGoogle Scholar
  38. 38.
    Whitehurst, D.G.T., Bryan, S., Lewis, M.: Systematic review and empirical comparison of contemporaneous EQ-5D and SF-6D group mean scores. Med. Decis. Mak. 31(6), E34–E44 (2011). doi: 10.1177/0272989X11421529 CrossRefGoogle Scholar
  39. 39.
    Janssen, M.F.B., Birnie, E., Bonsel, G.J.: Evaluating the discriminatory power of EQ-5D, HUI2 and HUI3 in a US general population survey using Shannon’s indices. Qual. Life Res. 16(5), 895–904 (2007)CrossRefPubMedCentralGoogle Scholar
  40. 40.
    Lloyd, M., Ghelardi, R.J.: A table for calculating theEquitability’Component of species diversity. J. Anim. Ecol., 217–225 (1964)Google Scholar
  41. 41.
    Heip, C.H., Herman, P.M., Soetaert, K.: Indices of diversity and evenness. Oceanis 24(4), 61–88 (1998)Google Scholar
  42. 42.
    Barton, G.R., Sach, T.H., Avery, A.J., Jenkinson, C., Doherty, M., Whynes, D.K., Muir, K.R.: A comparison of the performance of the EQ-5D and SF-6D for individuals aged ≥ 45 years. Health Econ. 17(7), 815–832 (2008). doi: 10.1002/hec.1298 CrossRefPubMedGoogle Scholar
  43. 43.
    Deng, N., Allison, J.J., Fang, H.J., Ash, A.S., Ware Jr, J.E.: Using the bootstrap to establish statistical significance for relative validity comparisons among patient-reported outcome measures. Health Qual. Life Outcomes 11, 89 (2013). doi: 10.1186/1477-7525-11-89 CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Pickard, A.S., Ray, S., Ganguli, A., Cella, D.: Comparison of FACT- and EQ-5D-based utility scores in cancer. Value Health 15(2), 305–311 (2012). doi: 10.1016/j.jval.2011.11.029 CrossRefPubMedGoogle Scholar
  45. 45.
    Wilke, C.T., Pickard, A.S., Walton, S.M., Moock, J., Kohlmann, T., Lee, T.A.: Statistical implications of utility weighted and equally weighted HRQL measures: an empirical study. Health Econ. 19(1), 101–110 (2010)PubMedGoogle Scholar
  46. 46.
    Hays, R., Anderson, R., Revicki, D.: Psychometric considerations in evaluating health-related quality of life measures. Qual. Life Res. 2(6), 441–449 (1993)CrossRefPubMedGoogle Scholar
  47. 47.
    Luo, N., Johnson, J.A., Shaw, J.W., Coons, S.J.: Relative efficiency of the EQ-5D, HUI2, and HUI3 index scores in measuring health burden of chronic medical conditions in a population health survey in the USA. Med. Care 47(1), 53–60 (2009). doi: 10.1097/MLR.0b013e31817d92f8 CrossRefPubMedGoogle Scholar
  48. 48.
    Huang, I.C., Willke, R.J., Atkinson, M.J., Lenderking, W.R., Frangakis, C., Wu, A.W.: US and UK versions of the EQ-5D preference weights: does choice of preference weights make a difference? Qual. Life Res. 16(6), 1065–1072 (2007)CrossRefPubMedGoogle Scholar
  49. 49.
    Cunillera, O., Tresserras, R., Rajmil, L., Vilagut, G., Brugulat, P., Herdman, M., Mompart, A., Medina, A., Pardo, Y., Alonso, J.: Discriminative capacity of the EQ-5D, SF-6D, and SF-12 as measures of health status in population health survey. Qual. Life Res. 19(6), 853–864 (2010)CrossRefPubMedGoogle Scholar
  50. 50.
    Nosyk, B., Sun, H., Guh, D.P., Oviedo-Joekes, E., Marsh, D.C., Brissette, S., Schechter, M.T., Anis, A.H.: The quality of eight health status measures were compared for chronic opioid dependence. J. Clin. Epidemiol. 63(10), 1132–1144 (2010)CrossRefPubMedGoogle Scholar
  51. 51.
    Zhao, F.L., Yue, M., Yang, H., Wang, T., Wu, J.H., Li, S.C.: Validation and comparison of euroqol and short form 6D in chronic prostatitis patients. Value Health 13(5), 649–656 (2010)CrossRefPubMedGoogle Scholar
  52. 52.
    García-Gordillo, M.A., del Pozo-Cruz, B., Adsuar, J.C., Sánchez-Martínez, F.I., Abellán-Perpiñán, J.M.: Validation and comparison of 15-D and EQ-5D-5L instruments in a Spanish Parkinson’s disease population sample. Qual. Life Res., 1–12 (2013). doi: 10.1007/s11136-013-0569-4
  53. 53.
    DeLong, E.R., DeLong, D.M., Clarke-Pearson, D.L.: Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 44(3), 837–845 (1988)CrossRefPubMedGoogle Scholar
  54. 54.
    Pan, C.W., Sun, H.P., Wang, X., Ma, Q., Xu, Y., Luo, N., Wang, P.: The EQ-5D-5L index score is more discriminative than the EQ-5D-3L index score in diabetes patients. Quality of life research: an international journal of quality of life aspects of treatment, care and rehabilitation 24(7), 1767–1774 (2015). doi: 10.1007/s11136-014-0902-6 CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • John N. Yfantopoulos
    • 1
    Email author
  • Athanasios E. Chantzaras
    • 1
  1. 1.School of Economics and Political SciencesUniversity of AthensAthensGreece

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