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Multi-Attribute Utility theory
Health-related quality of life (HRQL) is a critical element in the eventual outcomes of medical care and public health. Measuring HRQL successfully involves adequate description of health states, distinguishing differences among groups, and detecting change in individuals over time. There are two major approaches to HRQL measurement: psychometric and utility. Psychometric instruments like the SF-36 measure HRQL from a descriptive point of view to capture the various dimensions and generate a health profile. Alternatively, with the utility approach, one measures people's values for health states, also called preferences or utilities. Utilities are measured on a scale where 0 = death and 1.0 = perfect or optimal health. Utilities have a basis in economic theory and decision science and so are useful for calculating the quality-adjusted life years (QALYs) used in cost-utility analysis. Because HRQL is inherently multidimensional (vision, hearing, cognition, mobility, etc.), an extension of utility theory called multi-attribute utility theory (MAUT) has been applied to HRQL in the explicit multidimensional or multi-attribute sense. This entry focuses on methods derived from MAUT. The health utilities index (HUI) is the best known example of a MAUT-based HRQL measure.
Basic health utility measurement is implicitly multidimensional. As is detailed elsewhere, direct methods like the visual analog scale (VAS), Standard Gamble (SG), and Time Trade-off (TTO) use direct queries about HRQL. With these techniques, people do all the mental processes of weighing multidimensional issues internally and respond with a summary number or point of indifference between choices. For the remainder of this essay, all direct methods are referred to as utilities or utility, though some are more accurately called preferences or values (TTO and VAS). Utilities are technically defined as measuring risk under uncertainty (SG).
MAUT allows the use of SG, TTO, or VAS utilities as a basis for modeling an individual's or a population's overall multi-attribute utility structure. Such models are called indirect since the end user may complete a simple survey from which utility is later calculated. A MAUT-based model can be used to calculate all possible health states in a comprehensive health status classification system, as defined below.
Components of MAUT-Based Models
In MAUT-based measurement, the following four steps are followed:
- Develop a health status classification system, defined as incorporating all relevant attributes of health and gradations of function or status within each attribute.
- Obtain utilities for gradations (levels) of function or status within each attribute.
- Assign relative weights to the attributes.
- Aggregate the weights of attributes and single-attribute levels of function to obtain an overall utility measure.
The perspective of the population whose utilities are being assessed for the model should be clear. The two most common perspectives are a representative sample of society and a representative sample of clinical patients experienced with certain health states. Health economists generally prefer the perspective of society.
Developing the Health Status Classification System
An example of a health status classification system (HSCS), the Health Utilities Index Mark 3 (HUI3), is shown in Figure 1. An HSCS is developed through the work of expert panels and focus groups of patients or members of society, depending on the model. The HSCS provides a basis for judging the model in terms of face validity (a simple assessment of whether the model seems sensible and appropriate), content validity (the extent to which the model represents the health attributes being measured—evaluated with statistical analysis), and construct validity (how the model statistically correlates with other measures of similar concepts or varies between known groups). Most MAUT HRQL models address overall or “generic” health. A minority focus on specific diseases or conditions.
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- Basis for Making the Decision
- Acceptability Curves and Confidence Ellipses
- Beneficence
- Bioethics
- Choice Theories
- Construction of Values
- Cost-Benefit Analysis
- Cost-Comparison Analysis
- Cost-Consequence Analysis
- Cost-Effectiveness Analysis
- Cost-Minimization Analysis
- Cost-Utility Analysis
- Decision Quality
- Distributive Justice
- Dominance
- Equity
- Evaluating Consequences
- Expected Utility Theory
- Expected Value of Perfect Information
- Extended Dominance
- Health Production Function
- League Tables for Incremental Cost-Effectivenes: Ratios
- Marginal or Incremental Analysis, Cost-Effectiveness Ratio
- Monetary Value
- Moral Choice and Public Policy
- Net Benefit Regression
- Net Monetary Benefit
- Nonexpected Utility Theories
- Pharmacoeconomics
- Protected Values
- Rank-Dependent Utility Theory
- Return on Investment
- Risk-Benefit Trade-Off
- Subjective Expected Utility Theory
- Toss-Ups and Close Calls
- Value-Based Insurance Design
- Welfare, Welfarism, and Extrawelfarism
- Biostatistics and Clinical Epidemiology
- Analysis of Covariance (ANCOVA)
- Analysis of Variance (ANOVA)
- Attributable Risk
- Basic Common Statistical Tests: Chi-Square Test, t Test, Nonparametric Test
- Bayes's Theorem
- Bayesian Analysis
- Bayesian Evidence Synthesis
- Bayesian Networks
- Bias
- Bias in Scientific Studies
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- Case Control
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- Confounding and Effect Modulation
- Cox Proportional Hazards Regression
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- Distributions: Overview
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- Experimental Designs
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- Hazard Ratio
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- Index Test
- Intraclass Correlation Coefficient
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- Meta-Analysis and Literature Review
- Mixed and Indirect Comparisons
- Multivariate Analysis of Variance (MANOVA)
- Nomograms
- Number Needed to Treat
- Odds and Odds Ratio, Risk Ratio
- Ordinary Least Squares Regression
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- Poisson and Negative Binomial Regression
- Positivity Criterion and Cutoff Values
- Prediction Rules and Modeling
- Probability
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- Randomized Clinical Trials
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- Recurrent Events
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- Sample Size and Power
- Screening Programs
- Statistical Notations
- Statistical Testing: Overview
- Subjective Probability
- Subset Analysis: Insights and Pitfalls
- Survival Analysis
- Tables, Two-by-Two and Contingency
- Variance and Covariance
- Violations of Probability Theory
- Weighted Least Squares
- Decision Analysis and Related Mathematical Models
- Applied Decision Analysis
- Boolean Algebra and Nodes
- Decision Analyses, Common Errors Made in Conducting
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- Decision Tree: Introduction
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- Decision Trees: Sensitivity Analysis, Basic and Probabilistic
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- Declining Exponential Approximation of Life Expectancy
- Deterministic Analysis
- Discrete-Event Simulation
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- Expected Value of Sample Information, Net Benefit of Sampling
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- Complications or Adverse Effects of Treatment
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- Costs, Direct Versus Indirect
- Costs, Fixed Versus Variable
- Costs, Opportunity
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- Costs, Semifixed Versus Semivariable
- Costs, Spillover
- Economics, Health Economics
- Efficacy Versus Effectiveness
- Efficient Frontier
- Health Outcomes Assessment
- Health Status Measurement Standards
- Health Status Measurement, Assessing Meaningful Change
- Health Status Measurement, Construct Validity
- Health Status Measurement, Face and Content Validity
- Health Status Measurement, Floor and Ceiling Effects
- Health Status Measurement, Generic Versus Condition-Specific Measures
- Health Status Measurement, Minimal Clinically Significant Differences, and Anchor Versus Distribution Methods
- Health Status Measurement, Reliability and Internal Consistency
- Health Status Measurement, Responsiveness and Sensitivity to Change
- Human Capital Approach
- Life Expectancy
- Morbidity
- Mortality
- Oncology Health-Related Quality of Life Assessment
- Outcomes Research
- Patient Satisfaction
- Regret
- Report Cards, Hospitals and Physicians
- Risk Adjustment of Outcomes
- SF-36 and SF-12 Health Surveys
- SF-6D
- Sickness Impact Profile
- Sunk Costs
- Impact or Weight or Utility of the Possible Outcomes
- Certainty Equivalent
- Chained Gamble
- Conjoint Analysis
- Contingent Valuation
- Cost Measurement Methods
- Decomposed Measurement
- Disability-Adjusted Life Years (DALYs)
- Discounting
- Discrete Choice
- Disutility
- EuroQol (EQ-5D)
- Health Utilities Index Mark 2 and 3 (HUI2, HUI3)
- Healthy Years Equivalents
- Holistic Measurement
- Multi-Attribute Utility Theory
- Person Trade-Off
- Quality of Well-Being Scale
- Quality-Adjusted Life Years (QALYs)
- Quality-Adjusted Time Without Symptoms or Toxicity (Q-TWiST)
- SMARTS and SMARTER
- Split Choice
- Utilities for Joint Health States
- Utility Assessment Techniques
- Willingness to Pay
- Other Techniques, Theories, and Tools
- Artificial Neural Networks
- Bayesian Networks
- Bioinformatics
- Chaos Theory
- Clinical Algorithms and Practice Guidelines
- Complexity
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- Constraint Theory
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- Error and Human Factors Analyses
- Ethnographic Methods
- Expert Systems
- Patient Decision Aids
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- Team Dynamics and Group Decision Making
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- Advance Directives and End-of-Life Decision Making
- Consumer-Directed Health Plans
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- Data Quality
- Decision Making in Advanced Disease
- Decisions Faced by Hospital Ethics Committees
- Decisions Faced by Institutional Review Boards
- Decisions Faced by Nongovernment Payers of Healthcare: Managed Care
- Decisions Faced by Patients: Primary Care
- Decisions Faced by Surrogates or Proxies for the Patient, Durable Power of Attorney
- Diagnostic Process, Making a Diagnosis
- Differential Diagnosis
- Evaluating and Integrating Research Into Clinical Practice
- Evidence Synthesis
- Evidence-Based Medicine
- Expert Opinion
- Genetic Testing
- Government Perspective, General Healthcare
- Government Perspective, Informed Policy Choice
- Government Perspective, Public Health Issues
- Health Insurance Portability and Accountability Act Privacy Rule
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- Rationing
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- Trust in Healthcare
- The Psychology Underlying Decision Making
- Accountability
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- Attention Limits
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- Bounded Rationality and Emotions
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- Coincidence
- Computational Limitations
- Confirmation Bias
- Conflicts of Interest and Evidence-Based Clinical Medicine
- Conjunction Probability Error
- Context Effects
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- Counterfactual Thinking
- Cues
- Decision Making and Affect
- Decision Modes
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- Decision Weights
- Decision-Making Competence, Aging and Mental Status
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- Developmental Theories
- Dual-Process Theory
- Dynamic Decision Making
- Editing, Segregation of Prospects
- Emotion and Choice
- Errors in Clinical Reasoning
- Experience and Evaluations
- Fear
- Frequency Estimation
- Fuzzy-Trace Theory
- Gain/Loss Framing Effects
- Gambles
- Hedonic Prediction and Relativism
- Heuristics
- Human Cognitive Systems
- Information Integration Theory
- Intuition Versus Analysis
- Irrational Persistence in Belief
- Judgment
- Judgment Modes
- Learning and Memory in Medical Training
- Lens Model
- Lottery
- Managing Variability and Uncertainty
- Memory Reconstruction
- Mental Accounting
- Minerva-DM
- Mood Effects
- Moral Factors
- Motivation
- Numeracy
- Overinclusive Thinking
- Pain
- Pattern Recognition
- Personality, Choices
- Preference Reversals
- Probability Errors
- Probability, Verbal Expressions of
- Problem Solving
- Procedural Invariance and Its Violations
- Prospect Theory
- Range-Frequency Theory
- Risk Attitude
- Risk Aversion
- Risk Communication
- Risk Perception
- Scaling
- Social Factors
- Social Judgment Theory
- Stigma Susceptibility
- Support Theory
- Uncertainty in Medical Decisions
- Unreliability of Memory
- Value Functions in Domains of Gains and Losses
- Worldviews
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