Testing Nonmonotonicity in Health Preferences

Objective The main aim of this article is to test monotonicity in life duration. Previous findings suggest that, for poor health states, longer durations are preferred to shorter durations up to some threshold or maximum endurable time (MET), and shorter durations are preferred to longer ones after that threshold. Methods Monotonicity in duration is tested through 2 ordinal tasks: choices and rankings. A convenience sample ( n  = 90) was recruited in a series of experimental sessions in which participants had to rank-order health episodes and to choose between them, presented in pairs. Health episodes result from the combination of 7 EQ-5D-3L health states and 5 durations. Monotonicity is tested comparing the percentage rate of participants whose preferences were monotonic with the percentage of participants with nonmonotonic preferences for each health state. In addition, to test the existence of preference reversals, we analyze the fraction of people who switch their preference from rankings to choices. Results Monotonicity is frequently violated across the 7 EQ-5D health states. Preference patterns for individuals describe violations ranging from almost 49% with choices to about 71% with rankings. Analysis performed by separate states shows that the mean rates of violations with choices and ranking are about 22% and 34%, respectively. We also find new evidence of preference reversals and some evidence—though scarce—of transitivity violations in choices. Conclusions Our results show that there is a medium range of health states for which preferences are nonmonotonic. These findings support previous evidence on MET preferences and introduce a new “choice-ranking†preference reversal. It seems that the use of 2 tasks with a similar response scale may make preference reversals less substantial, although it remains important and systematic. Highlights Two procedures based on ordinal comparisons are used to elicit preferences: direct choices and rankings. Our study reports significant rates of nonmonotonic preferences (or maximum endurable time [MET]–type preferences) for different combinations of durations and EQ-5D health states. Analysis for separate health states shows that the mean rates of nonmonotonicity range from 22% (choices) to 34% (rankings), but within-subject analysis shows that nonmonotonicity is even higher, ranging from 49% (choices) to 71% (rankings). These violations challenge the validity of multiplicative QALY models. We find that the MET phenomenon may affect particularly those EQ-5D health states that are in the middle of the severity scale and not so much the extreme health states (i.e., very mild and very severe states). We find new evidence of preference reversals even using 2 procedures of a similar (ordinal) nature. Percentage rates of preference reversals range from 1.5% to 33%. We also find some (although scarce) evidence on violations of transitivity.