Ken Buckingham - Academia.edu (original) (raw)

Papers by Ken Buckingham

Community Care, Secondary Health Care and Care Management

Journal of Primary Health Care

INTRODUCTION: Pacific people suffer disproportionately poorer health and reduced life expectancy ... more INTRODUCTION: Pacific people suffer disproportionately poorer health and reduced life expectancy at birth compared to the total New Zealand population. AIM: To assess causes of excess morbidity in the Pacific population, and identify lesser known or previously unknown causes which require further investigation. METHODS: We obtained public hospital discharge data from July 2000 to December 2002. The population data were from the 2001 Census. Standardised discharge ratios were calculated to compare Pacific peoples with the total New Zealand population. RESULTS: Pacific peoples were six times more likely to have a diagnosis of cardiomyopathy and gout, and four to five times of rheumatic fever, gastric ulcer, systemic lupus erythematosus (SLE), and diabetes. Respiratory diseases, skin abscesses, heart failure, cataracts, cerebral infarction and chronic renal failure were also significant causes of excess morbidity. Unexpected causes of excess morbidity included candidiasis, excess vomit...

Discussion Papers 17th Plenary Meeting of the Euroqol Group 2001 Isbn 84 95075 57 1 Pags 137 152, 2001

The aims of this study are to investigate the feasibility of eliciting Time Trade Off (TTO) valua... more The aims of this study are to investigate the feasibility of eliciting Time Trade Off (TTO) valuations using short durations; to determine the effect of contrasting durations on individuals’ responses to the TTO; to examine variations within and between respondents’ values with respect to duration; and to consider the insights provided by participants’ comments and explanations regarding their reaction to duration in the valuation task. 27 participants provided TTO values using short and long durations for three EQ-5D states. Feedback was sought using a series of open ended questions. Of the 81 opportunities to observe it, strict constant proportionality was satisfied twice. 11 participants had no systematic relationship between duration and value; 11 provided consistently lower valuations in long durations, while 5 had higher valuations in long durations. Comments provided by participants were consistent with the values they provided. Mean TTO values did not differ markedly between alternative durations. We conclude that it is feasible to elicit TTO values for short durations. There is considerable heterogeneity in individuals’ responses to the time frames used to elicit values. Further research is required to ensure that the values used in cost effectiveness analysis adequately represent preferences about quality and length of life.Keywords: EQ-5D; PROMs, health outcomes; performance indicators

British Journal of Community Health Nursing, 1997

The New Zealand medical journal, Jan 8, 2004

To describe the occupational implications and impact of low back pain (LBP) in a birth cohort now... more To describe the occupational implications and impact of low back pain (LBP) in a birth cohort now aged 26. The LBP data were collected by an interviewer-administered questionnaire. Study members were asked about the prevalence and frequency of LBP and, for the worst episode, details were sought on occupation, time off work or job limitation, the severity of the discomfort, and disability. The cohort comprised 980 individuals, and 969 individuals answered the questionnaire. Of these 969 individuals, 524 (54%) experienced LBP in the previous 12 months, with a modal frequency of three or more times a year. For the 448 individuals with a current occupation, there was no difference in the distribution of LBP between those with professional, clerical, and technical jobs and those with production or trades jobs. Fifty-six individuals had to have time off work (the majority for less than 7 days), and 13 individuals could not look after themselves because of pain. Based on data gathered on 2...

Medical decision making : an international journal of the Society for Medical Decision Making

Social Science & Medicine, 2009

Medical Decision Making, 2010

Background. The time tradeoff (TTO) method of preference elicitation allows respondents to value ... more Background. The time tradeoff (TTO) method of preference elicitation allows respondents to value a state as worse than dead, generally either through the Torrance protocol or the Measurement and Valuation of Health (MVH) protocol. Both of these protocols have significant weaknesses: Valuations for states worse than dead (SWD) are elicited through procedures different from those for states better than dead (SBD), and negative values can be extremely negative. Purpose. To provide an account of the different TTO designs for SWD, to identify any alternatives to the MVH and Torrance approaches, and to consider the merits of the approaches identified. Methods. Medline was searched to identify all health state valuation studies employing TTO. The ways in which SWD were handled were recorded. Furthermore, to ensure that there are no unpublished but feasible TTO variants, the authors developed a theoretical framework for identifying all potential variants. Results. The search produced 593 hi...

Journal of Health Economics, 1993

This note presents a simplified description of the Healthy Years Equivalent (HYE) health outcome ... more This note presents a simplified description of the Healthy Years Equivalent (HYE) health outcome measure. I examine the claims made for the HYE and discuss their theoretical validity. The HYE is shown to be conceptually flawed because of confusions between the measures of value and the things being valued. Under close inspection the unnecessarily complicated multiple stage valuation used to determine the HYE is seen to be no more than an indirect way of asking the Time Trade-Off. For this reason the claimed superiority of the method over the Quality Adjusted Life Year (QALY) is rejected.

Journal of Health Economics, 1995

Two related points still require consideration by Gafni et al. following their reply to my articl... more Two related points still require consideration by Gafni et al. following their reply to my article in volume 12. ' Firstly they should be more clear about what they mean by 'choice problems under uncertainty'. They use the term to describe two quite distinct processes; the valuation of uncertain states of the world and valuation using risk as in the standard gamble. Loosely speaking, they fail to distinguish valuation of uncertainty from valuation by uncertainty. Secondly they should be more clear about what they regard as the contribution of the intermediate stage in their valuation procedure. A simple model embracing the key variables used by Gafni and Birch might help identify the issues. Assume that the utility (17) we anticipate achieving is some function of our health (Z-Z); length of life (L), the probability of immediate death (P), wealth (W) and other items (X,1, too numerous to list. (The wealth term has been included to emphasise that willingness to pay shares a common genealogy with the standard gamble and the time tradeoff.

Journal of Epidemiology & Community Health, 2007

To assess the short term health effects of improving housing. Design: Randomised to waiting list.... more To assess the short term health effects of improving housing. Design: Randomised to waiting list. Setting: 119 council owned houses in south Devon, UK. Participants: About 480 residents of these houses. Intervention: Upgrading houses (including central heating, ventilation, rewiring, insulation, and re-roofing) in two phases a year apart. Main outcome measures: All residents completed an annual health questionnaire: SF36 and GHQ12 (adults). Residents reporting respiratory illness or arthritis were interviewed using condition-specific questionnaires, the former also completing peak flow and symptom diaries (children) or spirometry (adults). Data on health service use and time lost from school were collected. Results: Interventions improved energy efficiency. For those living in intervention houses, non-asthma-related chest problems (Mann-Whitney test, p = 0.005) and the combined asthma symptom score for adults (Mann-Whitney test, z = 2.7, p = 0.007) diminished significantly compared with control houses. No difference between intervention and control houses was seen for SF36 or GHQ12. Conclusions: Rigorous study designs for the evaluation of complex public health and community based interventions are possible. Quantitatively measured health benefits are small, but as health benefits were measured over a short time scale, there may have been insufficient time for measurable improvements in general and disease-specific health to become apparent.

International Journal of Technology Assessment in Health Care, 1994

We describe the effects on costs, working patterns, and clinical behavior of installing a DAX “di... more We describe the effects on costs, working patterns, and clinical behavior of installing a DAX “discretionary” biochemistry analyzer. Use of the new analyzer encouraged doctors to be more specific in requesting biochemical tests, which substantially reduced the number of tests requested and slightly reduced overall costs. Doctors preferred being able to order tests in this more specific way.

Family Practice, 2004

Six month outcomes after emergency admission of elderly patients to a community or a district gen... more Six month outcomes after emergency admission of elderly patients to a community or a district general hospital. Family Practice 2004; 21: 173-179. Background. Emergency admissions account for 40% of National Health Service bed usage. Recent policy is to increase the role of intermediate care, which includes the use of community hospitals (CHs). However, the proposed expansion presumes that CH care is as effective as acute hospital care. No direct comparison of outcomes between CHs and district general hospitals (DGHs) has been undertaken. Objectives. The aim of this study was to compare patient-based outcomes at 6 months following emergency admission to a DGH or CH. Methods. We designed a prospective cohort study, with strict eligibility criteria. The study was set in one DGH and five CHs in Devon, UK. Study participants were people aged Ͼ70 years with an acute illness requiring hospital admission, but whose condition could have been treated in either hospital setting. A cohort of people admitted to each setting was identified and followedup for 6 months. The primary outcome measure was change in quality of life 6 months after admission, as measured by SF-36 and EuroQol. Secondary outcome measures were death, readmission and place of residence at 6 months. The use of drugs and investigations during the hospital stay were also measured. Results. A total of 376 patients were recruited and completed baseline measures, 254 of whom were followed-up at the 6-month stage (136 CH, 118 DGH). There were no differences in outcome between settings, with a small increase in quality of life scores at 6 months in both cohorts: the mean change in EuroQol 5D in CH was 6.6 points (95% confidence interval, 2.8-10.4) and in DGH was 6.5 (2.4-10.7); P = 0.97. Mortality and place of residence at 6 months were similar in the two groups. The numbers of investigations (median CH four investigations, DGH 22; P Ͻ 0.001) and of prescribed medications during the hospital stay (median CH eight drugs, DGH 11; P Ͻ 0.001) were significantly higher in the DGH. Conclusions. The quality of life and mortality in the CH cohort was similar to those in the DGH cohort. CH care can be used as an alternative to DGH care for a wide range of conditions requiring emergency admission.

BMJ, 1997

To examine whether the sociodemographic and morbidity characteristics of populations influence th... more To examine whether the sociodemographic and morbidity characteristics of populations influence their use of the following community heath services: district nursing, health visiting, chiropody, community maternity, community mental illness, and the professions allied to medicine. Observational study. Nationally representative sample of provider trusts in England. Activity levels for each service calculated for enumeration districts within the catchment areas of the sample of trusts and standardised to allow for differences in age structure. Regression analysis to determine whether the standardised activity rates for each service could be predicted by a range of socio-demographic and morbidity proxies. Morbidity or deprivation, or both, seemed to influence the use of services in each of the care programmes examined. The allocation of funds for community health services should allow for differences in the health and socio-demographic characteristics of health authorities.

BMJ, 1993

popular over recent years and have an important role, they must be continually updated to take ac... more popular over recent years and have an important role, they must be continually updated to take account of changes in medical knowledge and practice.2 At the same time, guidelines must honestly reflect the many uncertainties in management and not attempt to simplify healthy variation in practice.3 In two separate studies in South East Thames region looking at a total of 1600 patients with head injury attending accident and emergency departments, 16 skull fractures would have been missed if the criteria for ordering skull radiography had been adhered to. To avoid "laundry lists" or "cookbook medicine,"4 criteria should be restricted to elements that are essential or critical to management; that surely must include the mechanism of injury in patients presenting with the common diagnosis of mild head injury. If the criteria are to be effective they need to be considered in all cases of head injury by doctors in accident and emergency departments. Handwritten notes from local departments suggest that this is not the case. With use of a specially designed form for head injury the quality of documentation and hence consideration of the criteria have been considerably improved. Such a method of documentation has been used in nine accident and emergency departments in South East Thames region and is being evaluated. The doctors in Manchester seem to support the view that guidelines are not intended to replace clinical judgment' and have shown that practising medicine in the 1990s remains an art.

Background: The estimation of Quality Adjusted Life Years gained from treatment requires length o... more Background: The estimation of Quality Adjusted Life Years gained from treatment requires length of life to be quality adjusted by the weight ('value') attached to the quality of life in each health state. These weights are anchored on a scale of 1 for full health and 0 for dead, with health states considered to be so bad that they are worse than being dead, having negative values. A widely used method for obtaining these values is the 'Time Trade Off' (TTO). The National Institute for Health and Clinical Excellence (NICE), for example, recommend the use of TTO values in evidence submitted to it on the cost effectiveness of new technologies. However, there are some important problems with TTO. These problems centre on the inability of the method adequately to handle very poor states of health, which people may consider to be worse than dead. Where that arises, the TTO has to switch to a different questioning process, with corresponding problems for the comparability and interpretation of values in the negative range. In previous research, we tested a new TTO approach, the 'Lead Time TTO', which is capable of producing weights both for states better and worse than dead in a uniform manner. Aims: The aims of this research are (i) to investigate the values generated from Lead Time TTO (LT-TTO) using different combinations of the duration of the health state and the time in full health which participants are asked to consider; as well as varying the order in which these appear (Lag Time TTO); (ii) to gauge if values generated from these methods concur with participants' views as to whether the states are better or worse than dead (iii) to explore a range of methods for handling the preferences of those whose distaste for very poor health states is such that they 'use up' all their lead time. Methods: A sample of 200 members of the general public valued five health states, using two of four variants of the LT-TTO: a lead time of 10 years with a health state duration of 20 years; a lead time of 5 years and a health state duration of 1 year; a lead time of 5 years and a duration of 10 years; and a duration of 5 years with a lag time of 10 years. Participants also responded to a range of supplementary tasks and other questions. Results: Values are influenced by the length of the lead time relative to the health state duration. Longer lead times enable somewhat more preferences to be captured, but appear to exert a framing effect on values. Lag time TTO results in less non-trading for mild states, and to participants trading off less time for severe states. Of those who valued the worst health state as negative, 70% also expressed the view that this state was worse than dead. Conclusions: LT-TTO confers an important advantage over the traditional TTO by providing a single method capable of generating positive and negative values that seem broadly in keeping with participants' stated views about those states being better or worse than dead. However, values are sensitive to the length of time in full health relative to the duration of the state to be valued, and to the order in which these appear (lead vs. lag time). For those who use up their lead time, we show that additional ways of eliciting these preferences (via additional questioning) are feasible, as is modelling those values (via survival analysis). However, a small (<5%) group of participants remain whose preferences are so 'extreme' they cannot be captured by any approach.

British Journal of Community Health Nursing, 1997

Community Care, Secondary Health Care and Care Management

Journal of Primary Health Care

INTRODUCTION: Pacific people suffer disproportionately poorer health and reduced life expectancy ... more INTRODUCTION: Pacific people suffer disproportionately poorer health and reduced life expectancy at birth compared to the total New Zealand population. AIM: To assess causes of excess morbidity in the Pacific population, and identify lesser known or previously unknown causes which require further investigation. METHODS: We obtained public hospital discharge data from July 2000 to December 2002. The population data were from the 2001 Census. Standardised discharge ratios were calculated to compare Pacific peoples with the total New Zealand population. RESULTS: Pacific peoples were six times more likely to have a diagnosis of cardiomyopathy and gout, and four to five times of rheumatic fever, gastric ulcer, systemic lupus erythematosus (SLE), and diabetes. Respiratory diseases, skin abscesses, heart failure, cataracts, cerebral infarction and chronic renal failure were also significant causes of excess morbidity. Unexpected causes of excess morbidity included candidiasis, excess vomit...

Discussion Papers 17th Plenary Meeting of the Euroqol Group 2001 Isbn 84 95075 57 1 Pags 137 152, 2001

The aims of this study are to investigate the feasibility of eliciting Time Trade Off (TTO) valua... more The aims of this study are to investigate the feasibility of eliciting Time Trade Off (TTO) valuations using short durations; to determine the effect of contrasting durations on individuals’ responses to the TTO; to examine variations within and between respondents’ values with respect to duration; and to consider the insights provided by participants’ comments and explanations regarding their reaction to duration in the valuation task. 27 participants provided TTO values using short and long durations for three EQ-5D states. Feedback was sought using a series of open ended questions. Of the 81 opportunities to observe it, strict constant proportionality was satisfied twice. 11 participants had no systematic relationship between duration and value; 11 provided consistently lower valuations in long durations, while 5 had higher valuations in long durations. Comments provided by participants were consistent with the values they provided. Mean TTO values did not differ markedly between alternative durations. We conclude that it is feasible to elicit TTO values for short durations. There is considerable heterogeneity in individuals’ responses to the time frames used to elicit values. Further research is required to ensure that the values used in cost effectiveness analysis adequately represent preferences about quality and length of life.Keywords: EQ-5D; PROMs, health outcomes; performance indicators

British Journal of Community Health Nursing, 1997

The New Zealand medical journal, Jan 8, 2004

To describe the occupational implications and impact of low back pain (LBP) in a birth cohort now... more To describe the occupational implications and impact of low back pain (LBP) in a birth cohort now aged 26. The LBP data were collected by an interviewer-administered questionnaire. Study members were asked about the prevalence and frequency of LBP and, for the worst episode, details were sought on occupation, time off work or job limitation, the severity of the discomfort, and disability. The cohort comprised 980 individuals, and 969 individuals answered the questionnaire. Of these 969 individuals, 524 (54%) experienced LBP in the previous 12 months, with a modal frequency of three or more times a year. For the 448 individuals with a current occupation, there was no difference in the distribution of LBP between those with professional, clerical, and technical jobs and those with production or trades jobs. Fifty-six individuals had to have time off work (the majority for less than 7 days), and 13 individuals could not look after themselves because of pain. Based on data gathered on 2...

Medical decision making : an international journal of the Society for Medical Decision Making

Social Science & Medicine, 2009

Medical Decision Making, 2010

Background. The time tradeoff (TTO) method of preference elicitation allows respondents to value ... more Background. The time tradeoff (TTO) method of preference elicitation allows respondents to value a state as worse than dead, generally either through the Torrance protocol or the Measurement and Valuation of Health (MVH) protocol. Both of these protocols have significant weaknesses: Valuations for states worse than dead (SWD) are elicited through procedures different from those for states better than dead (SBD), and negative values can be extremely negative. Purpose. To provide an account of the different TTO designs for SWD, to identify any alternatives to the MVH and Torrance approaches, and to consider the merits of the approaches identified. Methods. Medline was searched to identify all health state valuation studies employing TTO. The ways in which SWD were handled were recorded. Furthermore, to ensure that there are no unpublished but feasible TTO variants, the authors developed a theoretical framework for identifying all potential variants. Results. The search produced 593 hi...

Journal of Health Economics, 1993

This note presents a simplified description of the Healthy Years Equivalent (HYE) health outcome ... more This note presents a simplified description of the Healthy Years Equivalent (HYE) health outcome measure. I examine the claims made for the HYE and discuss their theoretical validity. The HYE is shown to be conceptually flawed because of confusions between the measures of value and the things being valued. Under close inspection the unnecessarily complicated multiple stage valuation used to determine the HYE is seen to be no more than an indirect way of asking the Time Trade-Off. For this reason the claimed superiority of the method over the Quality Adjusted Life Year (QALY) is rejected.

Journal of Health Economics, 1995

Two related points still require consideration by Gafni et al. following their reply to my articl... more Two related points still require consideration by Gafni et al. following their reply to my article in volume 12. ' Firstly they should be more clear about what they mean by 'choice problems under uncertainty'. They use the term to describe two quite distinct processes; the valuation of uncertain states of the world and valuation using risk as in the standard gamble. Loosely speaking, they fail to distinguish valuation of uncertainty from valuation by uncertainty. Secondly they should be more clear about what they regard as the contribution of the intermediate stage in their valuation procedure. A simple model embracing the key variables used by Gafni and Birch might help identify the issues. Assume that the utility (17) we anticipate achieving is some function of our health (Z-Z); length of life (L), the probability of immediate death (P), wealth (W) and other items (X,1, too numerous to list. (The wealth term has been included to emphasise that willingness to pay shares a common genealogy with the standard gamble and the time tradeoff.

Journal of Epidemiology & Community Health, 2007

To assess the short term health effects of improving housing. Design: Randomised to waiting list.... more To assess the short term health effects of improving housing. Design: Randomised to waiting list. Setting: 119 council owned houses in south Devon, UK. Participants: About 480 residents of these houses. Intervention: Upgrading houses (including central heating, ventilation, rewiring, insulation, and re-roofing) in two phases a year apart. Main outcome measures: All residents completed an annual health questionnaire: SF36 and GHQ12 (adults). Residents reporting respiratory illness or arthritis were interviewed using condition-specific questionnaires, the former also completing peak flow and symptom diaries (children) or spirometry (adults). Data on health service use and time lost from school were collected. Results: Interventions improved energy efficiency. For those living in intervention houses, non-asthma-related chest problems (Mann-Whitney test, p = 0.005) and the combined asthma symptom score for adults (Mann-Whitney test, z = 2.7, p = 0.007) diminished significantly compared with control houses. No difference between intervention and control houses was seen for SF36 or GHQ12. Conclusions: Rigorous study designs for the evaluation of complex public health and community based interventions are possible. Quantitatively measured health benefits are small, but as health benefits were measured over a short time scale, there may have been insufficient time for measurable improvements in general and disease-specific health to become apparent.

International Journal of Technology Assessment in Health Care, 1994

We describe the effects on costs, working patterns, and clinical behavior of installing a DAX “di... more We describe the effects on costs, working patterns, and clinical behavior of installing a DAX “discretionary” biochemistry analyzer. Use of the new analyzer encouraged doctors to be more specific in requesting biochemical tests, which substantially reduced the number of tests requested and slightly reduced overall costs. Doctors preferred being able to order tests in this more specific way.

Family Practice, 2004

Six month outcomes after emergency admission of elderly patients to a community or a district gen... more Six month outcomes after emergency admission of elderly patients to a community or a district general hospital. Family Practice 2004; 21: 173-179. Background. Emergency admissions account for 40% of National Health Service bed usage. Recent policy is to increase the role of intermediate care, which includes the use of community hospitals (CHs). However, the proposed expansion presumes that CH care is as effective as acute hospital care. No direct comparison of outcomes between CHs and district general hospitals (DGHs) has been undertaken. Objectives. The aim of this study was to compare patient-based outcomes at 6 months following emergency admission to a DGH or CH. Methods. We designed a prospective cohort study, with strict eligibility criteria. The study was set in one DGH and five CHs in Devon, UK. Study participants were people aged Ͼ70 years with an acute illness requiring hospital admission, but whose condition could have been treated in either hospital setting. A cohort of people admitted to each setting was identified and followedup for 6 months. The primary outcome measure was change in quality of life 6 months after admission, as measured by SF-36 and EuroQol. Secondary outcome measures were death, readmission and place of residence at 6 months. The use of drugs and investigations during the hospital stay were also measured. Results. A total of 376 patients were recruited and completed baseline measures, 254 of whom were followed-up at the 6-month stage (136 CH, 118 DGH). There were no differences in outcome between settings, with a small increase in quality of life scores at 6 months in both cohorts: the mean change in EuroQol 5D in CH was 6.6 points (95% confidence interval, 2.8-10.4) and in DGH was 6.5 (2.4-10.7); P = 0.97. Mortality and place of residence at 6 months were similar in the two groups. The numbers of investigations (median CH four investigations, DGH 22; P Ͻ 0.001) and of prescribed medications during the hospital stay (median CH eight drugs, DGH 11; P Ͻ 0.001) were significantly higher in the DGH. Conclusions. The quality of life and mortality in the CH cohort was similar to those in the DGH cohort. CH care can be used as an alternative to DGH care for a wide range of conditions requiring emergency admission.

BMJ, 1997

To examine whether the sociodemographic and morbidity characteristics of populations influence th... more To examine whether the sociodemographic and morbidity characteristics of populations influence their use of the following community heath services: district nursing, health visiting, chiropody, community maternity, community mental illness, and the professions allied to medicine. Observational study. Nationally representative sample of provider trusts in England. Activity levels for each service calculated for enumeration districts within the catchment areas of the sample of trusts and standardised to allow for differences in age structure. Regression analysis to determine whether the standardised activity rates for each service could be predicted by a range of socio-demographic and morbidity proxies. Morbidity or deprivation, or both, seemed to influence the use of services in each of the care programmes examined. The allocation of funds for community health services should allow for differences in the health and socio-demographic characteristics of health authorities.

BMJ, 1993

popular over recent years and have an important role, they must be continually updated to take ac... more popular over recent years and have an important role, they must be continually updated to take account of changes in medical knowledge and practice.2 At the same time, guidelines must honestly reflect the many uncertainties in management and not attempt to simplify healthy variation in practice.3 In two separate studies in South East Thames region looking at a total of 1600 patients with head injury attending accident and emergency departments, 16 skull fractures would have been missed if the criteria for ordering skull radiography had been adhered to. To avoid "laundry lists" or "cookbook medicine,"4 criteria should be restricted to elements that are essential or critical to management; that surely must include the mechanism of injury in patients presenting with the common diagnosis of mild head injury. If the criteria are to be effective they need to be considered in all cases of head injury by doctors in accident and emergency departments. Handwritten notes from local departments suggest that this is not the case. With use of a specially designed form for head injury the quality of documentation and hence consideration of the criteria have been considerably improved. Such a method of documentation has been used in nine accident and emergency departments in South East Thames region and is being evaluated. The doctors in Manchester seem to support the view that guidelines are not intended to replace clinical judgment' and have shown that practising medicine in the 1990s remains an art.

Background: The estimation of Quality Adjusted Life Years gained from treatment requires length o... more Background: The estimation of Quality Adjusted Life Years gained from treatment requires length of life to be quality adjusted by the weight ('value') attached to the quality of life in each health state. These weights are anchored on a scale of 1 for full health and 0 for dead, with health states considered to be so bad that they are worse than being dead, having negative values. A widely used method for obtaining these values is the 'Time Trade Off' (TTO). The National Institute for Health and Clinical Excellence (NICE), for example, recommend the use of TTO values in evidence submitted to it on the cost effectiveness of new technologies. However, there are some important problems with TTO. These problems centre on the inability of the method adequately to handle very poor states of health, which people may consider to be worse than dead. Where that arises, the TTO has to switch to a different questioning process, with corresponding problems for the comparability and interpretation of values in the negative range. In previous research, we tested a new TTO approach, the 'Lead Time TTO', which is capable of producing weights both for states better and worse than dead in a uniform manner. Aims: The aims of this research are (i) to investigate the values generated from Lead Time TTO (LT-TTO) using different combinations of the duration of the health state and the time in full health which participants are asked to consider; as well as varying the order in which these appear (Lag Time TTO); (ii) to gauge if values generated from these methods concur with participants' views as to whether the states are better or worse than dead (iii) to explore a range of methods for handling the preferences of those whose distaste for very poor health states is such that they 'use up' all their lead time. Methods: A sample of 200 members of the general public valued five health states, using two of four variants of the LT-TTO: a lead time of 10 years with a health state duration of 20 years; a lead time of 5 years and a health state duration of 1 year; a lead time of 5 years and a duration of 10 years; and a duration of 5 years with a lag time of 10 years. Participants also responded to a range of supplementary tasks and other questions. Results: Values are influenced by the length of the lead time relative to the health state duration. Longer lead times enable somewhat more preferences to be captured, but appear to exert a framing effect on values. Lag time TTO results in less non-trading for mild states, and to participants trading off less time for severe states. Of those who valued the worst health state as negative, 70% also expressed the view that this state was worse than dead. Conclusions: LT-TTO confers an important advantage over the traditional TTO by providing a single method capable of generating positive and negative values that seem broadly in keeping with participants' stated views about those states being better or worse than dead. However, values are sensitive to the length of time in full health relative to the duration of the state to be valued, and to the order in which these appear (lead vs. lag time). For those who use up their lead time, we show that additional ways of eliciting these preferences (via additional questioning) are feasible, as is modelling those values (via survival analysis). However, a small (<5%) group of participants remain whose preferences are so 'extreme' they cannot be captured by any approach.

British Journal of Community Health Nursing, 1997