Skip to main content


Log in

Differences in EQ-5D-3L health state valuations among patients with musculoskeletal diseases, health care professionals and healthy volunteers

  • Original Paper
  • Published:
The European Journal of Health Economics Aims and scope Submit manuscript



Results from existing studies indicate that different respondent groups’ health state valuations in cost-utility analyses are not equivalent.


The objectives in our study were to analyse differences in health state valuations among three respondent groups in the context of medical rehabilitation in Germany.


Using the time trade-off (TTO) technique, valuations of EQ-5D-3L health states were obtained from patients with musculoskeletal diseases, healthy volunteers and health care professionals. We used linear mixed models to predict TTO utilities and specified and tested interaction effects.


We identified statistically significant (p < 0.05) differences among the three groups in six out of 42 health states. On average, patients’ TTO values were somewhat higher compared with other respondent groups. Most of these differences occurred in severe health states. Mean differences and mean absolute differences were 0.02 and 0.14 for patients vs healthy volunteers and 0.06 and 0.14 for patients vs health care professionals. Furthermore, significant effects among respondents were observed for seven of the 22 possible interactions describing differences between respondent groups. Coefficients associated with significant interaction effects ranged from 0.08 to 0.18 (absolute values).


The results of our study suggest that TTO valuations of health states differ depending on the specific respondent group from which valuations are obtained. On average, these differences were small. However, researchers and decision makers should remain aware of these differences when interpreting incremental cost-utility assessments.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others


  1. Each respondent valued the “33333” and “completely paralyzed” health states, 2 from 5 very mild states (11112, 11121, 11211, 12111, 21111), 3 from 12 mild states (11122, 11131, 11113, 21133, 21222, 21312, 12211, 11133, 22121, 12121, 22112, 11312), 3 from 12 moderate states (13212, 32331, 13311, 22122, 12222, 21323, 32211, 12223, 22331, 21232, 32313, 22222), and 3 from 12 severe states (33232, 23232, 23321, 13332, 22233, 22323, 32223, 32232, 33321, 33323, 23313, 33212).

  2. Although the “completely paralyzed” health state is not included in the EQ-5D and cannot be used for modelling purposes, the health state was chosen as a reference point. From the subsequent regression analysis, this health state was excluded.

  3. MO2/MO3, mobility level 2/level3; SC2/SC3, self-care level 2/level 3; UA2/UA3, usual activities level 2/level 3; PD2/PD3, pain-discomfort level 2/level3; AD2/AD3, anxiety-depression level 2/level 3; N3, at least one dimension on level 3.


  1. Drummond, M., Sculpher, M., Torrance, G., O Brien, B., Stoddart, G.: Methods for the economic evaluation of health care programmes, 3rd edn. Oxford Univeristy Press, Oxford (2006)

  2. Gold, M.R., Siegel, J.E., Russel, L.B., Weinstein, M.C.: Cost-effectiveness in health and medicine. Oxford University Press, Oxford (1996)

    Google Scholar 

  3. Brazier, J., Ratcliffe, J., Tsuchixa, A., Salomon, J.: Measuring and valuing health benefits for economic evaluation. Oxford University Press, Oxford (2007)

    Google Scholar 

  4. McGregor, M., Caro, J.J.: QALYs: are they helpful to decision makers? Pharmacoeconomics 24(10), 947–952 (2006)

    Article  PubMed  Google Scholar 

  5. Nord, E., Daniels, N., Kamlet, M.: QALYs: some challenges. Value Health 12(Suppl 1), S10–S15 (2009)

    Article  PubMed  Google Scholar 

  6. Ethikrat, D.: Nutzen und Kosten im Gesundheitswesen—Zur normativen Funktion ihrer Bewertung. Stellungnahme. (2011). Accessed 22 November 2013

  7. Torrance, G.W.: Preferences for health outcomes and cost-utility analysis. Am. J. Manag. Care. 3(Suppl), S8–S20 (1997)

    PubMed  Google Scholar 

  8. Gandjour, A.: Theoretical foundation of patient v. population preferences in calculating QALYs. Med. Decis. Mak. 30(4), E57–E63 (2010)

    Article  Google Scholar 

  9. Ubel, P.A., Loewenstein, G., Jepson, C.: Whose quality of life? A commentary exploring discrepancies between health state evaluations of patients and the general public. Qual. Life. Res. 12(6), 599–607 (2003)

    Article  PubMed  Google Scholar 

  10. Weinstein, M.C., Torrance, G., McGuire, A.: QALYs: the basics. Value Health 12(Suppl 1), S5–S9 (2009)

    Article  PubMed  Google Scholar 

  11. Brazier, J., Akehurst, R., Brennan, A., Dolan, P., Claxton, K., McCabe, C., Sculpher, M., Tsuchyia, A.: Should patients have a greater role in valuing health states? Appl. Health Econ. Health. Policy. 4(4), 201–208 (2005)

    Article  PubMed  Google Scholar 

  12. Dolan, P.: Whose preferences count? Med. Decis. Mak. 19(4), 482–486 (1999)

    Article  CAS  Google Scholar 

  13. Nord, E.: Towards cost-value analysis in health care? Health Care. Anal. 7(2), 167–175 (1999)

    Article  CAS  PubMed  Google Scholar 

  14. Dolders, M.G., Zeegers, M.P., Groot, W., Ament, A.: A meta-analysis demonstrates no significant differences between patient and population preferences. J. Clin. Epidemiol. 59(7), 653–664 (2006)

    Article  PubMed  Google Scholar 

  15. Peeters, Y., Stiggelbout, A.M.: Health state valuations of patients and the general public analytically compared: a meta-analytical comparison of patient and population health state utilities. Value Health 13(2), 306–309 (2010)

    Article  PubMed  Google Scholar 

  16. Kahneman, D., Tversky, A.: Prospect theory: an analysis of decision under risk. Econometrica 47(2), 263–291 (1979)

    Article  Google Scholar 

  17. Lenert, L.A., Treadwell, J.R., Schwartz, C.E.: Associations between health status and utilities implications for policy. Med. Care 37(5), 479–489 (1999)

    Article  CAS  PubMed  Google Scholar 

  18. Mann, R., Brazier, J., Tsuchiya, A.: A comparison of patient and general population weightings of EQ-5D dimensions. Health Econ. 18(3), 363–372 (2009)

    Article  PubMed  Google Scholar 

  19. Happich, M., von Lengerke, T.: Valuing the health state ‘tinnitus’: differences between patients and the general public. Hear. Res. 207(1–2), 50–58 (2005)

    Article  PubMed  Google Scholar 

  20. Oemar, M., Oppe, M.: EQ-5D-3L User Guide. Basic information on how to use the EQ-5D-3L instrument. (2013). Accessed 2 July 2014

  21. Rentenversicherung., D.: Reha-Bericht 2013. (2013). Accessed 8 July 2014

  22. Dolan, P., Gudex, C., Kind, P., Williams, A.: The time trade-off method: results from a general population study. Health Econ. 5(2), 141–154 (1996)

    Article  CAS  PubMed  Google Scholar 

  23. Greiner, W., Claes, C., Busschbach, J.J.V.: Graf von der Schulenburg, J.M.: Validating the EQ-5D with time trade-off for the German population. Eur. J. Health Econ. 6(2), 124–130 (2005)

    Article  CAS  PubMed  Google Scholar 

  24. Walters, S.J., Brazier, J.E.: Comparison of the minimally important difference for two health state utility measures: EQ-5D and SF-6D. Qual. Life Res. 14(6), 1523–1532 (2005)

    Article  PubMed  Google Scholar 

  25. Brosius, F.: SPSS 19. mitp, Heidelberg (2011)

    Google Scholar 

  26. Dolan, P., Roberts, J.: To what extent can we explain time trade-off values from other information about respondents? Soc. Sci. Med. 54(6), 919–929 (2002)

    Article  PubMed  Google Scholar 

  27. Gabriel, S., Kneeland, T., Melton 3rd, L., Moncur, M., Ettinger, B., Tosteson, A.: Health-related quality of life in economic evaluations for osteoporosis: whose values should we use? Med. Decis. Mak. 19(2), 141–148 (1999)

    Article  CAS  Google Scholar 

  28. Suarez-Almazor, M.E., Conner-Spady, B.: Rating of arthritis health states by patients, physicians, and the general public. Implications for cost-utility analyses. J. Rheumatol. 28(3), 648–656 (2001)

    CAS  PubMed  Google Scholar 

  29. Souchek, J., Byrne, M.M., Kelly, P.A., O, M.K., Richardson, M., Pak, C., Nelson, H., Suarez-Almazor, M.E.: Valuation of arthritis health states across ethnic groups and between patients and community members. Med. Care 43(9), 921–928 (2005)

    Article  PubMed  Google Scholar 

  30. Stalmeier, P.F., Busschbach, J.J., Lamers, L.M., Krabbe, P.F.: The gap effect: discontinuities of preferences around dead. Health Econ. 14(7), 679–685 (2005)

    Article  PubMed  Google Scholar 

  31. Devlin, N., Buckingham, K., Shah, K., Tsuchiya, A., Tilling, C., Wilkinson, G., van Hout, B.: A comparison of alternative variants of the lead and lag time TTO. Health Econ. 22(5), 517–532 (2013)

    Article  PubMed  Google Scholar 

  32. Ramos-Goni, J.M., Rivero-Arias, O., Errea, M., Stolk, E.A., Herdman, M., Cabases, J.M.: Dealing with the health state ‘dead’ when using discrete choice experiments to obtain values for EQ-5D-5L heath states. Eur. J. Health Econ. 14(Suppl 1), S33–S42 (2013)

    Article  PubMed  Google Scholar 

  33. Brazier, J., Deverill, M., Green, C., Harper, R., Booth, A.: A review of the use of health status measures in economic evaluation. (1999). Accessed 9 March 2014

  34. Herdman, M., Gudex, C., Lloyd, A., Janssen, M., 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)

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  35. 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)

    Article  PubMed  Google Scholar 

  36. Leidl, R., Reitmeir, P.: A value set for the EQ-5D based on experienced health states: development and testing for the German population. Pharmacoeconomics 29(6), 521–534 (2011)

    Article  PubMed  Google Scholar 

  37. Insinga, R.P., Fryback, D.G.: Understanding differences between self-ratings and population ratings for health in the EuroQOL. Qual. Life Res. 12(6), 611–619 (2003)

    Article  PubMed  Google Scholar 

  38. Drummond, M., Brixner, D., Gold, M., Kind, P., McGuire, A., Nord, E.: Toward a consensus on the QALY. Value Health 12(Suppl 1), S31–S35 (2009)

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Anja Schwalm.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Schwalm, A., Feng, YS., Moock, J. et al. Differences in EQ-5D-3L health state valuations among patients with musculoskeletal diseases, health care professionals and healthy volunteers. Eur J Health Econ 16, 865–877 (2015).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


JEL Classification