Measuring Family HRQOL Spillover Effects Using QALYs

Lisa A. Prosser, PhDUniversity of Michigan

CANS Special Topics ConferenceOctober 14, 2015

The authors have no conflicts to declare

Background• Guidelines for cost-effectiveness analysis

recommend inclusion of caregiver effects• Caregiver effects can include 2 components:• Time costs for informal care• Reduction in quality of life (QOL) associated with

having an ill family member

• Standard practice to include time costs but not effects on QOL (Goodrich et al., 2012)

Outline

• Brief review of spillover• Measuring spillover using QALYs• Future research topics

Household Decision Making Model

Child

Parents Grandparents

TeachersSiblings

Household Decision Making Model

Child

Parents Grandparents

TeachersSiblings

Measuring Family HRQOL Spillover Using Direct

ElicitationCo-Authors:• Eve Wittenberg, PhD, MPP, Harvard School of Public Health• Kara Lamarand, MPH, University of Michigan• Achamyeleh Gebremariam, MS, University of Michigan

Funding Source:• National Institute of Nursing Research (5R01NR011880)

Source: Prosser et al. Med Decis Making. 2015;35(1):81-93

Objectives• To measure the spillover effects on health-related

quality of life (disutility) of having a family member with a chronic illness using direct health utility assessment methods

• To assess whether spillover varies with condition or relationship type

Methods• National online survey of adults and adolescents:• Experienced sample (ill family member), n= 1389• Community sample (hypothetical scenarios), n=

1205

• Qualitative follow-up interviews, n=49• Conditions: Alzheimer’s disease, Arthritis, Cancer,

Cerebral Palsy, Depression• Ill family member: Child, Spouse, Parent• Spillover valuation approach: Direct elicitation

questions (standard gamble, rating scale)

Question Frames

YOU

Frame 1 Frame 2

YOU SPOUSE

Frame 3

YOU SPOUSE

Sample Valuation Question – Frame 2

Rating ScaleThis line represents how someone would feel (physically and emotionally) living with Cancer. Think about the bottom of the line as being the same as dead (0). Think about the top of the line as having the best health you can imagine (100).

Use the arrow to show at what point on this line you would put how YOU AND YOUR SPOUSE would feel, physically and emotionally, if your spouse was experiencing Cancer. You can move the arrow up and down until you get to the point on the line that represents how YOU AND YOUR SPOUSE would feel (physically and emotionally) if YOUR SPOUSE had Cancer.

100

90

80

70

60

50

40

30

20

10

0

Being Dead

Best Health You Can Imagine

Sample Valuation Question – Frame 2

Standard GambleThis Think about YOUR SPOUSE having Cancer. 

Think about how YOUR AND YOUR SPOUSE feel, both physically and emotionally, about YOUR SPOUSE having Cancer. Now imagine that you were offered a choice: You could take this magic pill, which will instantly get rid of YOUR SPOUSE’S Cancer, but there is sometimes a chance of dying from a severe side effect. Remembering what your spouse’s condition is like, which would you choose, to take the pill or not take the pill?

Take the pill: You take the pill, with a 50% chance of getting rid of YOUR SPOUSE’s condition, and 50% chance of a deadly side effect for YOU.

Do not take the pill: YOU AND YOUR SPOUSE live with your spouse in this condition for the rest of your lives.

Spillover Disutility

Frame 2 – Composite Disutility

Frame 3 – Spillover Disutility

Analysis Plan• Multivariate regression analyses:• Standard gamble outcomes: GEE with negative binomial• Rating scale outcomes: Linear regression

• Outcome variable: Frame 2 (Composite Disutility) • Independent variables:• Spillover Disutility (Frame 3)• Condition • Relationship• Sociodemographic characteristics• Confidence in responses

• Secondary analyses

RespondentSamples

Characteristic Communityn=1205

Experiencedn=1389

Age:13-1718-5960+

N/A69%31%

7%57%36%

Condition valued:Alzheimer’s diseaseArthritisCancerCerebral PalsyDepression

11%20%26%16%27%

6%44%12% 1%36%

Relationship:ChildSpouseParent

32%33%35%

8%56%36%

Experienced sample (n=1369)

Community sample (n=1133)

Standard Gamble Results

Arthritis Alzheimer's

Cancer Depression0.0

0.2

0.4

0.6

0.8

1.0 Spouse

Arthritis Alzheimer's

Cancer Depression0.0

0.2

0.4

0.6

0.8

1.0 Parent

Cancer Depression0

0.2

0.4

0.6

0.8

1 Child

Arthritis Alzheimer's

Cancer Depression0.0

0.2

0.4

0.6

0.8

1.0 Spouse

Arthritis Alzheimer's

Cancer Depression0.0

0.2

0.4

0.6

0.8

1.0 Parent

Cancer Depression0

0.2

0.4

0.6

0.8

1 Child

Composite

Spillover

Qualitative Interviews:Domains most affected by family spillover

Somatic Health

• General emotional health

• Sadness/depression

• Worry/fear

• General mental health

• Stress/anxiety

Psychological Health

• Caretaking

• General daily activities• Finances

• Loss of old activities w/ill person

Non-Health

• General physical health • Physical pain

Source: Wittenberg et al., The Patient, 2013.

Rating Scale Results

Source: Lavelle et al., Applied Health Econ & Health Policy, 2014

Results Summary

• Spillover disutility small but measurable • Can be assessed using direct utility

assessment techniques• Varies by condition• Relationship between QOL and relationship

type not consistently significant• Level of caregiving not significant

Discussion

• Can spillover effects can be captured by traditional preference-based measures?• Future research :• Preferred approach: composite or individual?• Aspects of conditions that identify when

spillover should be considered?

Thank youQuestions/comments:

Lisa A. Prosser, Ph.D.CHEAR Unit, Division of General PediatricsUniversity of Michiganwww.chear.orglisapros@umich.edu