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HOlistic Measurement
Holistic measurement is an approach to the measurement of preferences for health states or treatments in which a rater assigns values to each possible health state or treatment, where a state or treatment represents a combination of many attributes. During the assessment, the rater thus considers all the relevant attributes simultaneously.
Valuing Health States or Treatments
Basically, there are two different approaches to measuring preferences for health states, services, or treatments: the holistic and the decomposed. The decomposed approach expresses the overall value as a decomposed function of the attributes. It enables the investigator to obtain values for all health states or treatments without requiring the rater to assign values to every state or treatment; the rater is asked to value the attributes only. Holistic measurement is mostly used for health state valuation, but in some instances, it is used for the valuation of treatments or services as well, for example, in the willingness-to-pay method and the treatment trade-off method.
Holistic valuations of health states encompass valuations of the quality of life of those states, and the valuations are therefore sometimes called preference-based measures of quality of life, as distinct from descriptive measures of quality of life. Descriptive measures of quality of life generally generate quality-of-life profiles, that is, a combination of scores on different dimensions of quality of life, such as physical functioning, emotional functioning, and social functioning. A well-known example of such a descriptive instrument is the Medical Outcomes Study SF-36. These descriptive approaches to quality-of-life evaluation are not suitable for the purpose of decision making. In decision making, different attributes of treatment outcomes have to be weighed. On the one hand, different aspects of quality of life may have to be balanced against each other. Does, for example, the better pain relief from a new neuralgia medication outweigh the side effects, such as sedation and confusion? On the other hand, quality of life and length of life may have to be weighed against each other. Does the increased survival from chemotherapy outweigh the side effects, or, on the contrary, are patients willing to trade off survival for improved quality of life? For such decisional purposes, a valuation of the health outcome is needed.
Holistic Methods
Several holistic methods exist to assess preference-based measures of quality of life. The standard gamble and the time trade-off measure the utility of a health state, a cardinal measure of the strength of an individual's preference for particular outcomes when faced with uncertainty.
Standard Gamble
In the standard gamble method, a subject is offered the hypothetical choice between the sure outcome A (living his remaining life expectancy in the health state to be valued) and the gamble B. The gamble has a probability p of the best possible outcome (usually optimal health, defined as 1) and a probability (1 -p) of the worst possible outcome (usually immediate death, defined as 0). By varying p, the value at which the subject is indifferent to the choice between the sure outcome and the gamble is obtained. The utility for the sure outcome, the state to be valued, is equal to the value of p at the point of indifference (U = p × 1 + (1 −p) × 0 = p).
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