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The gap effect: discontinuities of preferences around dead


  • Peep F. M. Stalmeier
  • Jan J. V. Busschbach
  • Leida M. Lamers
  • Paul F. M. Krabbe


Background: The assessment of health states considered to be worse than dead is a controversial issue. Objective: To investigate how health states are valued when they are close to dead. Differences between adjacent states are compared with the differences between the first positive/first negative state with death. Methods: A secondary analysis of the EuroQol EQ‐5D data of the measurement of valuation and health (MVH) study was made. Visual analog scale (VAS) and time trade‐off (TTO) preferences for 43 health states were obtained. Various subsets of 13 states were valued by 3395 respondents. States were rank ordered by their VAS and TTO values. Differences between adjacent states were calculated for the VAS and the positive and negative TTO values. Results: Complete data were obtained in 2997 respondents. The differences between the ordered VAS values were equally large. In contrast, significant gaps around dead were found for the positive as well as the negative TTO values. Discussion: These results are interpreted in light of a descriptive QALY model. This model was expanded to include utilities worse than dead. The VAS task does not pick up that bad states become intolerable, i.e. worse than dead, when they last too long, but the TTO task does. The current QALY model seems to lack descriptive validity for states valued worse than dead and for states with a maimal endurable time. Copyright © 2005 John Wiley & Sons, Ltd.

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  • Peep F. M. Stalmeier & Jan J. V. Busschbach & Leida M. Lamers & Paul F. M. Krabbe, 2005. "The gap effect: discontinuities of preferences around dead," Health Economics, John Wiley & Sons, Ltd., vol. 14(7), pages 679-685, July.
  • Handle: RePEc:wly:hlthec:v:14:y:2005:i:7:p:679-685
    DOI: 10.1002/hec.986

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    References listed on IDEAS

    1. Dolan, Paul & Roberts, Jennifer, 2002. "To what extent can we explain time trade-off values from other information about respondents?," Social Science & Medicine, Elsevier, vol. 54(6), pages 919-929, March.
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    4. 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.
    5. Torrance, George W., 1986. "Measurement of health state utilities for economic appraisal : A review," Journal of Health Economics, Elsevier, vol. 5(1), pages 1-30, March.
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    Cited by:

    1. Arthur E. Attema & Werner B.F. Brouwer, 2014. "Deriving Time Discounting Correction Factors For Tto Tariffs," Health Economics, John Wiley & Sons, Ltd., vol. 23(4), pages 410-425, April.
    2. Nan Luo & Minghui Li & Elly Stolk & Nancy Devlin, 2013. "The effects of lead time and visual aids in TTO valuation: a study of the EQ-VT framework," The European Journal of Health Economics, Springer;Deutsche Gesellschaft für Gesundheitsökonomie (DGGÖ), vol. 14(1), pages 15-24, July.
    3. 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.
    4. 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.
    5. Nicolas A. Menzies & Joshua A. Salomon, 2011. "Non‐monotonicity in the episodic random utility model," Health Economics, John Wiley & Sons, Ltd., vol. 20(12), pages 1523-1531, December.
    6. Anja Schwalm & You-Shan Feng & Jörn Moock & Thomas Kohlmann, 2015. "Differences in EQ-5D-3L health state valuations among patients with musculoskeletal diseases, health care professionals and healthy volunteers," The European Journal of Health Economics, Springer;Deutsche Gesellschaft für Gesundheitsökonomie (DGGÖ), vol. 16(8), pages 865-877, November.
    7. Benjamin M. Craig, 2009. "The duration effect: a link between TTO and VAS values," Health Economics, John Wiley & Sons, Ltd., vol. 18(2), pages 217-225, February.
    8. Mark Oppe & Kim Rand-Hendriksen & Koonal Shah & Juan M. Ramos‐Goñi & Nan Luo, 2016. "EuroQol Protocols for Time Trade-Off Valuation of Health Outcomes," PharmacoEconomics, Springer, vol. 34(10), pages 993-1004, October.
    9. Bansback, Nick & Hole, Arne Risa & Mulhern, Brendan & Tsuchiya, Aki, 2014. "Testing a discrete choice experiment including duration to value health states for large descriptive systems: Addressing design and sampling issues," Social Science & Medicine, Elsevier, vol. 114(C), pages 38-48.
    10. Gordon B. Hazen, 2007. "Adding Extrinsic Goals to the Quality-Adjusted Life Year Model," Decision Analysis, INFORMS, vol. 4(1), pages 3-16, March.

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