A vision ‘bolt-on’ increases the responsiveness of EQ-5D: preliminary evidence from a study of cataract surgery

  • Mihir Gandhi
  • Marcus Ang
  • Kelvin Teo
  • Chee Wai Wong
  • Yvonne Chung-Hsi Wei
  • Rachel Lee-Yin Tan
  • Mathieu F. Janssen
  • Nan LuoEmail author
Original Paper



(1) To evaluate the effect of adding a vision dimension (‘bolt-on’) to the 5-level EQ-5D (EQ-5D-5L) and 3-level EQ-5D (EQ-5D-3L) on their responsiveness, and (2) to compare the responsiveness of a vision ‘bolt-on’ EQ-5D-3L (EQ-5D-3L + V) with SF-6D and Health Utilities Index Mark 3 (HUI3) to the benefit of cataract surgery.


Sixty-three patients were assessed before and after their cataract surgery using the EQ-5D-3L, EQ-5D-5L, SF-6D, HUI3, as well as a 3-level and a 5-level vision dimension. Preference-based indices were calculated using available value sets for EQ-5D-3L, EQ-5D-3L + V, EQ-5D-5L, SF-6D, and HUI3, and non-preference-based indices were calculated using the sum-score method for EQ-5D-5L and EQ-5D-5L + V (vision bolt-on EQ-5D-5L). Responsiveness was assessed using the standardized response mean (SRM) and F-statistic.


Among preference-based indices, mean changes from pre to post-surgery in EQ-5D-3L + V and EQ-5D-3L indices were 0.031 and 0.018, respectively. The mean changes for EQ-5D-5L, SF-6D and HUI3 indices were 0.020, 0.012 and 0.105, respectively. The SRM (F-statistic) for EQ-5D-3L + V and EQ-5D-3L indices were 0.458 (13.2) and 0.098 (0.6), respectively. The responsiveness of EQ-5D-3L + V was better than EQ-5D-5L, SF-6D; the responsiveness of HUI3 was better than all other measures. Using non-preference-based indices, mean change for EQ-5D-5L + V and EQ-5D-5L were 0.067 and 0.017, respectively. The corresponding SRM (F-statistic) were 0.709 (31.7) and 0.295 (5.4).


Preliminary evidence from our study suggests that a vision ‘bolt-on’ may increase the responsiveness of EQ-5D-3L and EQ-5D-5L to change in health outcomes experienced by patients undergoing cataract surgery. In absence of the preference-based vision bolt-on EQ-5D-5L index, HUI3 was the most responsive measure.


EQ-5D Responsiveness Vision Bolt-on Cataract 

JEL Classification




We thank the EuroQol Research Foundation for funding this study and all patients of this study for their participation.

Author contributions

MA, MFJ, and NL jointly conceived the study. KT, CWW, and YCHW contributed in the study design and patient recruitment. RLYT contributed in the data collection form design, patient recruitment and data management. MG analyzed the data and drafted the first version of the manuscript. All authors reviewed and approved the manuscript.

Compliance with ethical standards

Conflict of interest

The study had financial support from the EuroQol Research Foundation (EQ Project 2016310), The Netherlands; MFJ is a member of the scientific team of the EuroQol Business Office and both MFJ and NL are members of the EuroQol Group. The EuroQol Research Foundation has had no other involvement in the running of the study or the writing of the manuscript. The views expressed by the authors in this paper do not necessarily reflect the views of the EuroQol Group. No other relationship or activities that could appear to have influenced the submitted work. Other authors declare that they have no conflict of interest.

Research involving human participants and/or animals

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed consent

The study was approved by the SingHealth Centralized Institutional Review Board (CIRB Ref: 2016/2649). Informed consent was obtained from all individual participants included in the study.

Supplementary material

10198_2019_1156_MOESM1_ESM.docx (59 kb)
Supplementary material 1 (DOCX 59 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Authors and Affiliations

  1. 1.Department of BiostatisticsSingapore Clinical Research InstituteSingaporeSingapore
  2. 2.Centre for Quantitative Medicine, Duke-NUS Medical SchoolSingaporeSingapore
  3. 3.Tampere Center for Child Health Research, Tampere UniversityTampereFinland
  4. 4.Department of OphthalmologySingapore National Eye CentreSingaporeSingapore
  5. 5.Ophthalmology and Visual Sciences DepartmentDuke-NUS Medical SchoolSingaporeSingapore
  6. 6.Saw Swee Hock School of Public HealthNational University of SingaporeSingaporeSingapore
  7. 7.Section Medical Psychology and Psychotherapy, Department of PsychiatryErasmus MCRotterdamThe Netherlands

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