How Much Better is Faster? Empirical Tests of QALY Assumptions in Health-Outcome Sequences

Objectives This study was designed to test hypotheses regarding the path dependence of health-outcome values in the form of linear additivity of health-state utilities and diminishing marginal utility of health outcomes. Methods We employed a discrete-choice experiment to quantify patient treatment preferences for major depressive disorder. In a series of choice questions, participants evaluated seven symptom-improvement sequences and out-of-pocket costs over 6-week durations. Money-equivalent values were derived from a deductive latent-class mixed-logit analysis. Results The discrete-choice experiment was completed by 751 respondents with self-reported major depressive disorder recruited from an online commercial panel. The class-membership probability was 0.83 for latent-class preferences consistent with supporting relative importance weights for all symptom-improvement sequences in the study design. First, we found strong support for diminishing marginal utility in symptom-improvement sequences. The money-equivalent value of an initial week of normal mood was $147 (95% confidence interval: $128, $166) and a second week of normal mood was $70 ($49, $91). Furthermore, for short treatment durations where conventional discounting was not a factor, equivalent changes in health status were valued more highly for an earlier onset of effect: holding subsequent symptom patterns constant, $338 (211, 454) versus $70 (49, 91) for improvements starting in week 2 versus week 3 and $147 ($128, $166) versus $29 (−$4, $64) for improvements starting in week 3 versus week 4. Conclusions Our findings imply that conventional quality-adjusted life-year calculations in which health values are assumed to be path independent can understate the value of health improvements that appear earlier in a sequence.