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A note on the nature of utility in time and health and implications for cost utility analysis


  • Buckingham, Ken J.
  • Devlin, Nancy Joy


Time Trade-Off (TTO) valuations of health are widely used in economic evaluation of health care. Current approaches to eliciting TTO values, and their use in economic evaluation, rest on specific assumptions about the way utility relates to time and health. Both the assumptions themselves and evidence of violations of them are discussed in the literature - yet the issues appear not to be widely appreciated by those using and applying TTO in economic evaluation. This paper adds to that literature by demonstrating both the requirements of TTO and violations of these assumptions in terms of the underlying indifference curve maps and utility functions. The advantage of this approach is that it demonstrates very clearly a number of fundamental problems for the way TTO values are currently elicited and used in cost utility analysis. In essence, it is extremely unwise to assume that the current 'tariffs' of TTO values, such as those widely used in cost utility analysis to inform health sector decisions in many countries can be applied irrespective of the duration of the health states to which they are assigned. The estimates of QALYs that result will, quite often, simply be wrong. We conclude by pointing to a number of possible solutions.

Suggested Citation

  • Buckingham, Ken J. & Devlin, Nancy Joy, 2009. "A note on the nature of utility in time and health and implications for cost utility analysis," Social Science & Medicine, Elsevier, vol. 68(2), pages 362-367, January.
  • Handle: RePEc:eee:socmed:v:68:y:2009:i:2:p:362-367

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    References listed on IDEAS

    1. Drummond, Michael F. & Sculpher, Mark J. & Torrance, George W. & O'Brien, Bernie J. & Stoddart, Greg L., 2005. "Methods for the Economic Evaluation of Health Care Programmes," OUP Catalogue, Oxford University Press, edition 3, number 9780198529453.
    2. A Mehrez & A Gafni, 1990. "Evaluating Health Related Quality-of-life: An Indifference Curve Interpretation for the Time Trade-off Technique," Centre for Health Economics and Policy Analysis Working Paper Series 13, Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Canada.
    3. Birch, Stephen & Donaldson, Cam, 2003. "Valuing the benefits and costs of health care programmes: where's the 'extra' in extra-welfarism?," Social Science & Medicine, Elsevier, vol. 56(5), pages 1121-1133, March.
    4. Brouwer, Werner B.F. & Culyer, Anthony J. & van Exel, N. Job A. & Rutten, Frans F.H., 2008. "Welfarism vs. extra-welfarism," Journal of Health Economics, Elsevier, vol. 27(2), pages 325-338, March.
    5. John M. Miyamoto & Peter P. Wakker & Han Bleichrodt & Hans J. M. Peters, 1998. "The Zero-Condition: A Simplifying Assumption in QALY Measurement and Multiattribute Utility," Management Science, INFORMS, vol. 44(6), pages 839-849, June.
    6. David Parkin & Nancy Devlin, 2006. "Is there a case for using visual analogue scale valuations in cost‐utility analysis?," Health Economics, John Wiley & Sons, Ltd., vol. 15(7), pages 653-664, July.
    7. Angela Robinson & Anne Spencer, 2006. "Exploring challenges to TTO utilities: valuing states worse than dead," Health Economics, John Wiley & Sons, Ltd., vol. 15(4), pages 393-402, April.
    8. Mehrez, Abraham & Gafni, Amiram, 1990. "Evaluating health related quality of life: An indifference curve interpretation for the time trade-off technique," Social Science & Medicine, Elsevier, vol. 31(11), pages 1281-1283, January.
    9. Ken Buckingham & Nancy Devlin, 2006. "A theoretical framework for TTO valuations of health," Health Economics, John Wiley & Sons, Ltd., vol. 15(10), pages 1149-1154, October.
    10. Dolan, Paul & Stalmeier, Peep, 2003. "The validity of time trade-off values in calculating QALYs: constant proportional time trade-off versus the proportional heuristic," Journal of Health Economics, Elsevier, vol. 22(3), pages 445-458, May.
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    Cited by:

    1. Devlin, N. & Tsuchiya, A. & Buckingham, K. & Tilling, C., 2009. "Does the value of quality of life depend on duration?," Working Papers 09/07, Department of Economics, City University London.
    2. Federico Augustovski & Lucila Rey-Ares & Vilma Irazola & Mark Oppe & Nancy Devlin, 2013. "Lead versus lag-time trade-off variants: does it make any difference?," The European Journal of Health Economics, Springer;Deutsche Gesellschaft für Gesundheitsökonomie (DGGÖ), vol. 14(1), pages 25-31, July.
    3. Nancy J. Devlin & Aki Tsuchiya & Ken Buckingham & Carl Tilling, 2011. "A uniform time trade off method for states better and worse than dead: feasibility study of the ‘lead time’ approach," Health Economics, John Wiley & Sons, Ltd., vol. 20(3), pages 348-361, March.
    4. Ariel Beresniak & Antonieta Medina-Lara & Jean Auray & Alain Wever & Jean-Claude Praet & Rosanna Tarricone & Aleksandra Torbica & Danielle Dupont & Michel Lamure & Gerard Duru, 2015. "Validation of the Underlying Assumptions of the Quality-Adjusted Life-Years Outcome: Results from the ECHOUTCOME European Project," PharmacoEconomics, Springer, vol. 33(1), pages 61-69, January.
    5. Sharma, Rajiv & Stano, Miron, 2010. "Implications of an economic model of health states worse than dead," Journal of Health Economics, Elsevier, vol. 29(4), pages 536-540, July.
    6. Papathanasopoulou, Eleni & White, Mathew P. & Hattam, Caroline & Lannin, Aisling & Harvey, Andrea & Spencer, Anne, 2016. "Valuing the health benefits of physical activities in the marine environment and their importance for marine spatial planning," Marine Policy, Elsevier, vol. 63(C), pages 144-152.


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