HEALTH ECONOMICS OUTCOME VALUATION

Health Econ. 12: 655–668 (2003)

Published online 3 December 2002 in Wiley InterScience (www.interscience.wiley.com). DOI:10.1002/hec.768

The TTO method and procedural invariance

Anne Spencer*
Department of Economics, Queen Mary, University of London, UK

Summary
In a pilot study we investigate whether the inferences we draw about people’s preferences towards health care
treatments are altered if we vary the procedure that is used to elicit these preferences. In a conventional time trade-
off (TTO) question, respondents express their preferences towards treatment by comparing a period of ill-health with
a shorter period in a higher quality of life. In our less conventional TTO question, we vary the procedure by asking
respondents their preferences towards treatment by comparing a period of ill-health with a longer period in a lower
quality of life. The quantitative data are equivocal about whether preferences for treatment differ between the
conventional and unconventional questions. The qualitative data support the notion of contrasting issues in the
questions that involve prolonging time in a lower quality of life and appear to account for a failure to find
quantitative differences in all of the questions. Copyright # 2002 John Wiley & Sons, Ltd.

JEL classification: 131

Keywords time trade-off; procedural invariance

[2,3]. This set of assumptions allows for a unified

Introduction
In health economics, survey methods have been
developed over the last thirty years to elicit
people’s preferences for undergoing different
health care treatments. One of these methods is
the time trade-off (TTO) method [1]. The TTO
method applies the principle of opportunity cost to
different types of treatment by asking respondents
to consider a trade-off between time and quality of
life. In the conventional TTO method, respondents
express their preferences towards treatment by
comparing a period of ill-health with a shorter
period in a higher quality of life.
The assumptions required for the TTO method
to be a valid measure of preferences under
expected utility theory, a theory of decision
making under risk, are outlined by Pliskin et al.
concept of utility to represent preferences in both
riskless and risky health care decisions [4,5]. A key
feature of this utility is that procedural invariance
holds and that preferences will be equivalent if the
method used to elicit them is changed slightly, for
instance, to one of prolonging life in a lower
quality of life [6].
Concern over whether procedural invariance
holds in practice has already been expressed for
preference elicitation methods that involve a trade-
off between quality or longevity of life on the one
hand and either risk or money on the other [7]. In
the standard gamble (SG) method that involves
risk, it has been shown that procedural invariance
systematically breaks down if the question is asked
in terms of a treatment’s risk or longevity of life
[8]. In the contingent valuation (CV) method that
involves money, the difference between asking the

*Correspondence to: Department of Economics, Queen Mary, University of London, Mile End Road, London, E1 4NS. UK.
E-mail: a.e.spencer@qmul.ac.uk

Received 3 July 2001

Copyright # 2002 John Wiley & Sons, Ltd. Accepted 23 July 2002
656
question in terms of a person’s willingness-to-pay
or willingness-to-accept money is well documented
[9,10]. In the SG and CV methods this has led to
the development and application of alternatives to
expected utility theory to explain the systematic
failures of procedural invariance. We add to this
debate by exploring whether procedural invariance
holds in the TTO method.
The aim of this paper is to test the equivalence
of preferences elicited under the TTO method. A
secondary aim of the paper is to consider the issues
that respondents may be using to make their
decisions. We ask a conventional TTO question
and a less conventional TTO question. In our less
conventional TTO question, respondents express
these preferences by comparing a period of ill-
health with a longer period in a lower quality of
life. Procedural invariance states that if errors are
small, preferences elicited from TTO questions
that offer a longer period in a lower quality of life
should be equivalent to preferences elicited from
TTO questions that offer a shorter period in a
higher quality of life. This is interesting for two
reasons. Firstly, the possibility of prolonging time
in a lower quality of life already occurs in the
treatment for certain cancers. Jansen et al. [11] are
interested in using such questions in applied work
but as far as we are aware such questions have not
been used. Secondly, if this method elicits quite
different preferences, it raises concerns over the
assumptions typically made in the conventional
TTO method.
The paper uses a combined qualitative and
quantitative approach to reveal the issues con-
sidered by respondents in their answers. There
appears to be renewed interest in linking qualita-
tive and quantitative approaches in the field of
value elicitation to help understand the issues
driving respondents’ answers. However, there have
been relatively few joint qualitative and quantita-
tive studies of value elicitation procedures [12–15].
A qualitative and quantitative approach is parti-
cularly applicable in this paper given the pilot
nature of this work.
Throughout, conventional values refer to values
implied by the conventional TTO question and
unconventional values, refer to values implied by
our question. The remainder of the paper is set out
as follows. The Methods section overviews the
questionnaire used in our paper and our test. In
Theoretical predictions, we consider other recent
explanations that have been offered to explain
differences in the TTO values. Data collection and
Copyright # 2002 John Wiley & Sons, Ltd.
A. Spencer
analysis describes the qualitative and quantitative
data and Results overviews our findings. Finally,
Discussion considers the implications of our test
for the TTO method.
Methods
The questionnaire
The study used the EuroQol classification system,
which describes states of health along five dimen-
sions: mobility, self-care, usual activities, pain and
anxiety. Each dimension had three levels of
severity: no problems, some problems and severe
problems, denoted by 1, 2 and 3, respectively, and
colour-coded black, blue and red in the study.
Level 3 pain was described as moderate pain or
discomfort with periods of severe pain or dis-
comfort rather than extreme pain or discomfort
used in the EuroQol work. The description of level
3 pain was changed to ensure that worse than
death states were not included in the study.
Respondents were asked to tick one statement
from each dimension that best described their
current state of health. This helped to familiarise
respondents with the EuroQol dimensions. Re-
spondents were then presented with six cards: five
EuroQol states (11111, 12221, 21211, 21222 and
22232) and immediate death [16,17]. Each state
was colour-coded: 11111 was given the colour
white, 12221 the colour grey, 21211 the colour
yellow, 21222 the colour green, 22232 the colour
pink and death the colour black (following the
example of Carthy et al. [18]). These are referred to
here by letters: 11111 is referred to as N, 12221 as
W , 21211 as X , 21222 as Y , 22232 as Z and death
as D. The state 12221 was used in a practice
question to allow respondents to become familiar
with the methods but the actual values were not
used in the study.
The respondents were asked to imagine that
each state lasted for ten years without change, to
be followed immediately by death. They were
asked to rank the cards from the best state to the
worst and then to place the cards on a visual
analogue scale, putting the best state at 100 and
the worst state at 0. This was followed by twelve
TTO questions, then seven SG questions. The
research question posed in this paper involves the
TTO questions only and the SG questions are
reported elsewhere [19]. To elicit the preferences
Health Econ. 12: 655–668 (2003)
The TTO Method and Procedural Invariance
we used the TTO boards and interview protocol
developed by the measurement and valuation of
health (MVH) study [14]. These boards and
interview protocols were modified slightly to
include the colours depicting each health state
and to allow for the new types of TTO questions
presented here. The respondents were asked four
conventional TTO questions that valued health
states against normal health and death (questions
1 to 4). They were then asked eight more TTO
questions. We concentrate here on the two TTO
questions that involved prolonging time in a lower
quality of life (questions 9 to 10). The remainder of
the TTO questions tested whether the TTO value
would be affected by comparing the health state
against normal health and a more-severe state (but
not death) and are reported elsewhere [19].
TTO questions
The conventional TTO questions are illustrated
using question 4 in Figure 1. A respondent was
asked to imagine living in health state Z for ten
years or undergoing a combination of t4 years in
normal health (N) but dying (D) 10
t4 , years
earlier (where the subscript on the time, t, indicates
the question number). In effect, they were asked to
consider a shorter period in a higher quality of life.
The time in normal health t4 was varied until the
respondent was indifferent between the two alter-
natives. At this point the two alternatives should
be equivalent. The majority of applied work using
the TTO method then assumes that respondents
do not have preferences towards the timing of ill-
health (or a zero rate of time preference) [5]. It is
therefore possible to express this equivalence by
the following equality where V ð:Þ represents the
TTO value assigned to the health state:
10  V ðZÞ ¼ t4  V ðNÞ þ ð10
t4 Þ  V ðDÞ ð1Þ
Figure 1. An example of a conventional TTO question,
question 4
Copyright # 2002 John Wiley & Sons, Ltd.
657
If the value for V ðNÞ ¼ 1 and V ðDÞ ¼ 0 this
expression can be rearranged to give
V ðZÞ ¼ t4 =10 ð2Þ
Question 4 is summarised in row 4 of Table 1,
where ten years in health state Z (column 1) is
compared against normal health and death (col-
umn 2), and is used to derive a conventional value
for Z (column 3).
We considered two different types of unconven-
tional question for this study. The first type
involved asking a respondent to imagine living in
normal health for t4 years or undergoing a
treatment that involved prolonging time in health
state Z. Procedural invariance holds if the value
derived from this unconventional question equal-
led the value derived from the conventional
question in question 4. Early piloting of the
questionnaire suggested that respondents found
this type of unconventional question unrealistic.
Respondents argued that if they were in normal
health, they would not want to consider an
alternative that offered a lower quality of life.
Hence, it was very hard to get respondents to
engage in the notion of a trade-off of time, an
essential feature of the TTO method. The second
type of unconventional question that was used in
our study overcame this problem by asking a
respondent to imagine living in health state X or
Y , rather than normal health.
The two unconventional TTO questions used in
our study are questions 9 and 10. In these
questions, respondents were asked to imagine
living in a given health state for two years followed
by death, or prolonging life in a lower quality of
life. The time in the initial health state was set at
two years, since it was anticipated that the
responses to these questions would lie within the
ten year period based on conventional TTO
questions. Setting time at two years required us
to impose an additional assumption, commonly
applied to the TTO method, that utility is linear in
duration. If utility is linear, the value of a health
state is not affected by the duration in that health
state [5]. Together with procedural invariance, this
assumption suggests that if errors are small,
the conventional value equals the unconven-
tional value. Questions 9 and 10 are illustrated
in Figure 2.
For example, in question 9, the question begins
by comparing two years in health state Y and two
years in health state Z and respondents are asked
which they prefer. When the time is the same, all
Health Econ. 12: 655–668 (2003)
658
Table 1. Questions used to test procedural invariance
(1)
Question Health state Comparison health states
1 10 W
2 10 X
3 10 Y
4 10 Z
9 2Y þ 8D
10 2X þ 8D
Figure 2. Questions 9 and 10
respondents prefer to spend time in the higher
quality of life, Y . The time in the lower quality of
life, t9 is then increased until the respondent is
indifferent between the two alternatives (the
questionnaire and protocol are available upon
request from the author). At this point of
indifference between the two alternatives the
following equality holds, assuming that respon-
dents have a zero rate of time preference:
2  V ðY Þ ¼ t9  V ðZÞ ð3Þ
If V ðY Þ is say, V ðY Þ ¼ t3 =10 (from question 3) this
leads to:
2  t3
V ðZÞ ¼ ð4Þ
10  t9
Question 9 is summarised in row 5 in Table 1,
where two years in health state Y (column 1) is
compared against a longer period in Z (column 2),
and is used to derive an unconventional value for
Z (column 3). The null hypotheses to be tested in
our paper is that the conventional value equals the
unconventional value, and so in Table 1 the
conventional V(Z)=unconventional V ðZÞ and
conventional V(Y)=unconventional V ðY Þ.
Copyright # 2002 John Wiley & Sons, Ltd.
A. Spencer
(2) (3)
Abbreviation
N þD Conventional V ðW Þ
N þD Conventional V ðX Þ
N þD Conventional V ðY Þ
N þD Conventional V ðZÞ
ZþD Unconventional V ðZÞ
Y þD Unconventional VðY Þ
Table 2. Summary of predicted impacts
Predicted impacts
Maximal endurable time +
Strong preference for longevity of life +
Loss aversion

Time preference

Theoretical predictions
Recent research has suggested that a respondent’s
preferences are influenced by issues that are not
typically reflected in the assumptions made in the
TTO method. These issues are of interest to the
study since they have the potential to create
differences between the conventional and uncon-
ventional TTO values. In this section, we review
the impact these issues have on the conventional
and unconventional values.
Table 2 summarises four issues that are pre-
dicted to create differences between the conven-
tional and unconventional TTO responses: (1)
maximal endurable time, (2) strong preference for
longevity of life, (3) loss aversion and (4) time
preference. In the following discussion we outline
the links between these four issues and the
conventional and unconventional values. We find
that the first two issues would serve to increase the
unconventional value whilst the last two would
serve to decrease the unconventional value. Table 2
summarises the extent to which these issues result
in an unconventional value that is: ‘+’ higher
than, ‘=’ equal to or ‘
’ lower than the conven-
tional value. If the four issues in Table 2 cancel one
another out in our study, then the conventional
value will equal the unconventional value.
A respondent may learn to cope and adapt to
a new health state [20], termed positive adaptation
by Ross and Simonson [21], or they may be-
come increasingly disgruntled, termed negative
Health Econ. 12: 655–668 (2003)
The TTO Method and Procedural Invariance
adaptation. Dolan [22] speculated that healthy
members of the public dwell more on the negative
adaptation, whilst patients dwell more on the
positive adaptation. As respondents were recruited
from the general public and mature students it is
likely, therefore, that negative adaptation will be
more pronounced in the present study. If the
health state is particularly severe a respondent may
doubt their ability to cope with continuing ill-
health, termed maximal endurable time by Suther-
land et al. [23]. Sutherland et al. suggested that
concerns over endurance might be particularly
important if the health state is followed by death
rather than normal health. Question 9 involved
prolonging time in a more severe state Z, whilst
question 10 involved prolonging time in a less
severe state Y . We would, therefore, expect the
maximal endurance to arise more in question 9
than question 10. To illustrate the impact this has
upon the conventional and unconventional values,
consider the conventional and unconventional
values in questions 4 and 9, respectively. Let te4
and te9 denote the responses unaffected by the
issues in Table 2 and tme 9 and tme
9 denote the
responses under maximal endurance. For the
unconventional value, a respondent’s fear that
they cannot endure a severe health state may
discourage them from increasing time in the worse
state and then tme e
9 5t9 and the unconventional
value will increase. However for the conventional
value, the same respondent’s concern for the severe
health state will encourage them to sacrifice more
time to return to normal health and then tme e
4 5t4 ,
and the conventional value will decrease. Overall
then, maximal endurable time leads to an un-
conventional value that is higher than the conven-
tional value.
Anomalies between the conventional and un-
conventional values may arise if respondents give
strong weight to quality or longevity of life. A
respondent’s concerns over the quality or long-
evity of life can become more important if the
treatment is assessed against a scale that includes
quality or longevity of life, termed scale compat-
ibility [24]. Bleichrodt [25] used scale compatibility
to argue that respondents may give strong weight
to the longevity of life in the TTO method, since
the method varies time to elicit preferences. For
instance, in questions that involve prolonging life,
they may seek to increase the longevity of life even
if this puts them in a more severe health state.
They would, therefore, be willing to take any
treatment which offered a marginal increase in
Copyright # 2002 John Wiley & Sons, Ltd.
659
time. Let tl4 and tl9 denote the responses under scale
compatibility in questions 4 and 9, respectively. If
a respondent prefers any treatment which extends
life then tl9 5te9 . However, the same respondent
may be unwilling to give up time in the elicitation
of the conventional value, tl4 4te4 . The conventional
and unconventional values in this case, therefore,
will both increase. It is likely that this effect will be
greater for the unconventional value, given that
the unconventional value has two instances where
time has been set by a respondent (in Equation (4),
t3 and t9 ) and so this could amplify the scale
compatibility effect. A strong preference for the
longevity of life can be linked to the Robinson et al.
[15] idea that there exists a threshold of tolerance
below which health must decline before a respon-
dent considers sacrificing time. If a respondent is
unwilling to sacrifice time, the conventional and
unconventional values both equal 1. Overall then,
a strong preference towards the longevity of life,
arising from scale compatibility or a threshold of
tolerance, leads to an unconventional value that is
equal to or higher than the conventional value.
Bleichrodt [25] and Spencer [19,26] consider the
impact on the conventional TTO value if a
respondent evaluates the question as gains and
losses relative to a reference point. Central to these
explanations is the assumption that a respondent is
more sensitive to losses than to gains, termed loss
aversion [27]. In addition, both Bleichrodt and
Spencer assume that the reference point is the
initial health state that is considered in each
question. In the conventional value derived in
question 4, the reference point is Z, and in the
unconventional value derived in 9, is Y . Let tloss 4
and tloss
9 denote the responses under loss aversion
in questions 4 and 9, respectively. In the conven-
tional value, the gains in health status are valued
less than the loss in longevity of life and so a
respondent compensates by demanding a longer
time in normal health, tloss4 > te4 . The conventional
value will increase. Whilst in the unconventional
value, the loss in health state is valued more than
the gain in health, and so they demand a longer
time in Z to compensate, tloss 9 > te9 , and the
unconventional value will decrease. As a result of
these two issues, the unconventional value is lower
than the conventional value.
Finally, the TTO responses may be affected by a
respondent’s attitude towards time. Like the
majority of TTO applications, the present study
assumes that a respondent does not have prefer-
ences towards the timing of ill-health [5]. It is as
Health Econ. 12: 655–668 (2003)
660
though a respondent gives equal weight to all time
periods. If a respondent instead prefers to con-
sume health in the short-term rather than in the
long-term they will assign a higher weight to the
short-term. A value that correctly adjusts for a
respondent’s time preference hereafter is termed a
discounted value. The paper by Dolan and Jones-
Lee [28] can be used to show that the unconven-
tional value is lower than the conventional value,
given that the unconventional value includes two
instances where the values underestimate the
impact of discounting (see appendix).
In the conventional TTO value, Bleichrodt [25]
noted that the assumption that there is no
preference towards the timing of ill-health might
cancel out the impacts of scale compatibility and
loss aversion. Maximal endurable time also has the
same ability to cancel out the impacts of scale
compatibility and loss aversion in the conventional
TTO value. This issue is predicted to gain
importance in our study for questions that involve
severe states or cases where there is prolonged
exposure to ill-health.
Data collection and analysis
Respondents were recruited from members of the
general public and from mature students begin-
ning a course in the Department of Health
Sciences at the University of York. Respondents
were invited to take part in a 90-min interview in
the Department of Economics at York University
for a payment of £15. All interviews were tape-
recorded. In total, 30 respondents were inter-
viewed, 12 males and 18 females (see Table 3).
In the quantitative data, the Wilcoxon signed
ranks test was used [29]. The test calculates the
extent to which the conventional and unconven-
tional values differ for each respondent. It then
ranks the absolute value of these differences for all
respondents (i.e. considering only the size and not
direction of difference) from smallest to largest and
calculates the sum of the ranks for all positive
differences and all negative differences. The null
hypothesis is that the median of these differences is
zero and that the conventional and unconven-
tional values are the same. The alternative
hypothesis is that there is a systematic difference
between the responses. If the alternative hypoth-
esis was to hold, there would be a clustering of the
positive and negative differences in the ranking.
Copyright # 2002 John Wiley & Sons, Ltd.
A. Spencer
Table 3. The sample
(1) (2) (3)
21–39 40–59 Total
Male 9 3 12
Female 8 10 18
Total 17 13 30
In the qualitative data the respondent was
encouraged to think aloud using a verbal protocol
analysis approach developed by Ericsson and
Simons [30].
Early piloting of the questionnaire suggested
that the questions might not have been well suited
to such concurrent data collection. In particular,
the questions were broken down into a number of
repetitive stages before the final answer was
reached and the natural reaction of respondents
was to give a conventional answer without
elaboration.
To overcome the problem, it was felt necessary
to ask respondents an additional question at the
end of the task:
What types of things were you thinking about when
you answered this question?
We avoided ‘why’ questions because Patton [31]
argues these can be answered on many different
levels. Patton classifies four broad types of probes:
detail orientated, elaboration, clarification and
contrast probes. The study used elaboration
probes, which encourage the respondent to con-
tinue talking using body language by a gentle
nodding of the head or verbal ‘uh-huh’ as well as
questions which asked a respondent to say a little
more about a particular issue. The study also made
use of clarification probes to check that the
interviewer had understood the respondent [31].
The interviewer verbalised a respondent’s non-
verbal cues, such as eye or hand movements which
were used to emphasise a point. The interviews
were transcribed and analysed using the software
package HyperResearch# that aids the manage-
ment and analysis of non-numerical data. This
analysis began by summarising excerpts using the
respondents own terminology and key phrases.
These were categorised as specific codes. This was
followed by an attempt to link the specific codes to
form general codes which help to characterise
particular themes. Finally, themes that seemed to
contradict the TTO assumptions were identified.
The qualitative analysis seemed best applied to
Health Econ. 12: 655–668 (2003)
The TTO Method and Procedural Invariance
hypothesis generation rather than hypothesis
testing as it challenged existing concepts and
helped to understand the material more fully. At
the beginning of the analysis, there was no pre-
defined coding schedule but only a series of
questions that the researcher intended to address.
In the process of transcribing a coding system was
developed. Specific codes recorded the question
number and any additional interview probes.
Some respondents wanted to engage in debate
with the interviewer and it was felt necessary to
challenge a respondent’s answer if they were not
interating towards their point of indifference. This
occurred particularly in the TTO question that
involved prolonging time in the lower quality of
life as some respondents began to answer the
question by stating their maximum endurance in
that state, or suggested the point at which one
treatment would be strictly preferred.
Results
Quantitative results
The median conventional values for health states
X , Y and Z are 0.9, 0.65 and 0.45 (see Table 4) and
the Wilcoxon signed ranks test showed that
respondents found the states statistically different
(P ¼ 0:0002 or less). We can compare the conven-
tional TTO values derived here against those
estimated from a larger study to check the extent
to which our results are consistent with earlier
studies. The MVH study asked 3395 members of
the general public to value a subset of EuroQol
states using the TTO method and this subset of
states were used to infer the values for the full
range of EuroQol states [30]. For health states X ,
Table 4. The summary statistics
(1)
Question Abbreviation
1 Conventional V ðW Þ
2 Conventional V ðX Þ
3 Conventional V ðY Þ
4 Conventional V ðZÞ
9 Unconventional VðZÞ
10 Unconventional V ðY Þ
a
Respondents were excluded from the analysis it they felt that the health states were worse than death. Two respondents felt that
health state Z was worse than death and one respondent felt that health state Y was worse than death.
Copyright # 2002 John Wiley & Sons, Ltd.
661
Y and Z the estimated mean values in the MVH
study were 0.81, 0.62 and
0.02 and the estimated
median values were 0.94, 0.65 and 0.028. These
values are very similar to those derived in this
study and that are shown in Table 4 except for
Health state Z. Health state Z is valued higher in
the present study since level 3 pain was described
as moderate pain or discomfort with periods of
severe pain or discomfort rather than extreme pain
or discomfort used in the EuroQol work. For
equivalent health state descriptions, therefore, the
conventional TTO method used in our study is
consistent with earlier TTO studies.
The median unconventional value for health
state Z is 0.4 and for health state Y is 0.425 (see
Table 4). The Wilcoxon signed ranks test showed
the unconventional values for Y were significantly
lower than the conventional values (in question 10)
whilst the differences between the unconventional
and conventional values for Z were not statisti-
cally different, and responses were evenly spread
between higher and lower unconventional values
(in question 9, column 1 rows 1 and 2 in Table 5).
In summary, the quantitative results were mixed:
the unconventional values for Y were significantly
lower in question 10 than conventional values, but
the unconventional values for Z in question 9 were
not statistically different to the conventional
values. The null hypotheses, that the conventional
values equal the unconventional values, are there-
fore rejected in only one of the two tests.
Qualitative results
In the qualitative analysis responses appeared to
fall into five themes listed in Table 6 for questions
9 and 10, respectively. The first column of Table 6
(2) (3) (4) (5)
na Mean Median Standard deviation
30 0.802 0.950 0.248
30 0.856 0.900 0.163
29 0.635 0.650 0.217
28 0.457 0.450 0.207
28 0.479 0.400 0.228
29 0.502 0.425 0.257
Health Econ. 12: 655–668 (2003)
662
Table 5. The Wilcoxon signed ranks test
(1)
Question 9
unconventional V ðZÞ
versus conventional V ðZÞ
No. of cases where unconventional value5
conventional value
No. of cases where unconventional value>
conventional value
No. of cases where unconventional value=
conventional value
Total
Wilcoxon Z
2-tailed P
refers to the number of respondents in questions 9
and 10 who were willing to trade quality of life
(based on specific codes Q9 trade-off and Q10
trade-off). For example, in question 9 that asked
respondents to consider prolonging time in the
more severe health state (health state Z), 13 of the
28 respondents expressed a willingness to trade
quality for longevity of life. This willingness to
trade rose to 21 respondents in question 10 that
considered prolonging time in the more moderate
health state (health state Y ). An example of this
kind of response is as follows:
Respondent: For several reasons, in pink (Z) you are
in a greater degree of ill-health so you’re not able to
do the things as you would be able to do if you were
in a lesser degree of ill-health, i.e. in green (Y). So
therefore, you may need that small duration of time
to achieve the same things as you would be able to
achieve in a lesser state of ill-health, i.e. being in
green (Y). Are you with me? What you can actually
do here, you may be able to do in a lesser time than
you could do there. [Interview 22, Q9 trade-off.]
The main reasons for their willingness to trade
quality of life for longevity of life related to the
impression that two years was too short (specific
codes: Q9 time is short, Q10 time is short, Q9 that
or death, Q9 yes alive, Q10 want extra life, Q10 still
alive) and that they would need more time to
achieve the same life goals (specific codes: Q9
something to achieve, Q10 a bit more). Respondents
that were willing to trade accounted for the
majority of the cases where the unconventional
Copyright # 2002 John Wiley & Sons, Ltd.
A. Spencer
(2)
Question 10
unconventional V ðY Þ versus
conventional V ðY Þ
14 20
13 7
1 2
28 29

0.745
2.499
0.456 0.010
Accept Reject
values for a health state were lower than the
conventional values.
Of those respondents who were willing to
trade quality of life for longevity of life,
some respondents felt that they would need more
time in Z to compensate (specific codes: Q9
increase by a lot, Q9 need longer Z). This supports
the notion that respondents sought longer periods
of time to compensate for the reduction in the
quality of life and is consistent with loss aversion.
In addition, they felt that they might accommo-
date to the health state (specific code: Q10
accommodate) or could cope with the state (specific
code: Q10 cope) which is consistent with positive
adaptation to the health state. Other respondents
felt that they wanted longer to live but disliked the
more severe health state Z (specific codes: Q9 try
hold on, Q9 only just cope, Q9 hang on, Q9 knock
deaths door, Q10 adding poor quality, Q10 not
stand depression, Q10 plod, Q10 max endurance Y ).
One respondent in question 9 and 10 demanded
more time in the lower quality of life, but it is not
clear that this was perceived as a form of
compensation and so this is reported separately
in column 5, Table 6.
The second most popular response related to
an unwillingness to prolong time in a lower quality
of life (based on specific codes: Q9 not prolong
and Q10 not prolong). In the case of ques-
tions that involved prolonging time in the more
severe health state Z, 11 of the 28 respondents
were unwilling to prolong time in Z (column 2,
Table 6). An example of the unwillingness
Health Econ. 12: 655–668 (2003)
 Table 6. The conventional and unconventional values for health states
(1) (2) (3) (4) (5)
Loss aversion: Maximal endurable time: Strong preference
The TTO Method and Procedural Invariance

for longevity

Copyright # 2002 John Wiley & Sons, Ltd.

of life:
Willing to Unwilling to Increase Health Demanding
trade-off quality prolong time in a longevity of life states perceived to be more time in
for longevity lower quality irrespective of quality the same lower quality of life
of life of life and of life
Question 9
Unconventional5conventional 13 0 0 n/a 1
Unconventional>conventional 0 10 3 n/a 0
Unconventional=conventional 0 1 0 n/a 0
n ¼ 28 13 11 3 n/a 1

Question 10
Unconventional5conventional
Unconventional>conventional
Unconventional=conventional
n ¼ 29
n/a=not applicable.
20 0 0 0 0
1 3 1 1 1
0 0 2 0 0
21 3 3 1 1

Health Econ. 12: 655–668 (2003)

663
664
to prolong in a lower quality in Z is given as
follows:
Respondent: I wouldn’t really want it, it’s a . . .
because its only two years anyway, but my sort of
personal feeling looking at it right now is, that’s it
would be two years in pink (Z) or 20 years in pink (Z)
there’s not a great deal that’s going to be accom-
plished, if I’m able to I’ll see the kids grow up and
that, so a definite choice that I would want to live,
but I think that my own state of mind that I would go
crazy in the end, so I’ll stick with choice B. [Interview
12, Q9 not prolong.]
The main reasons for respondents’ unwillingness
to prolong time in a lower quality of life centred
around the impression that this state represented a
very severe state of health (specific codes: Q9
absolute writhing, Q9 go crazy, Q9 suffer, Q9 seen
people suffer, Q10 two major categories, Q10 can
take so much, Q10 prolong pain). However, all
these respondents had considered health state Z to
be better than death in the conventional TTO
questions. Some respondents saw immediate death
as an option to a lingering death in a lower quality
of life (specific codes: Q9 believe in euthanasia and
Q9 go quickly) whilst others just stated that they
would receive no benefit from increasing time in a
lower quality of life (specific codes: Q9 no point
and Q9 not worth living). These explanations are
consistent with maximal endurable time.
There was an indication that more of the
respondents would have been unwilling to prolong
the time in the lower quality of life if the
alternative with which they were initially presented
was for longer than two years (two respondents,
specific codes: Q9 time is short and Q10 time is
short). An example of this kind of response is as
follows:
Respondent: Two years isn’t long, but I’m not too
bad am I, I don’t know because it’s a hard
comparison to make because I don’t want to be in
pink (Z) at all, so the thought of being in pink (Z) for
any length of time, fills me with dread but the
thought of being in green (Y ) for two years is equally
as bad because it’s only two years, so the instinct is to
favour pink (Z) because it’s for longer. . .. [Interview
14, Q9 time is short.]
Some respondents were willing to increase the
longevity of life irrespective of quality of life
(based on specific codes: Q9 prolong because like
life and Q10 prolong because like life). In the case
of questions that involved prolonging time in
health state Z, three of the 28 respondents were
Copyright # 2002 John Wiley & Sons, Ltd.
A. Spencer
willing to prolong time irrespective of the quality
of life (column 3, Table 6). An example of this kind
of response is as follows:
Respondent: No, I would always go for choice A,
length of life rather than quality of life. [Interview 8,
Q9 prolong life because like life.]
The main reasons for increasing longevity of life
irrespective of quality of life seemed to relate to the
desire for longer lives (Q10 time is short, but can
envisage this). It is possible that scale compatiblity
encouraged these responses to give more weight to
the longevity of life than quality of life. In question
9, this led to an unconventional value that was
higher than the conventional value. There is also
evidence of a threshold of tolerance, below which a
health state had to fall before they were willing to
sacrifice longevity of life. Two respondents were
unwilling to trade longevity for improvements in
quality of life for health states X and Y and the
conventional and unconventional values equalled l
for these states.
These two types of responses, an unwillingness
to prolong time in a lower quality of life (linked to
maximal endurable time) and a willingness to
increase longevity irrespective of quality of life,
account for the majority of cases where the
unconventional values were higher than the con-
ventional values. For example, in question 9, 10 of
the 11 respondents who were unwilling to prolong
time in the lower quality of life gave an unconven-
tional value that was higher than the conventional.
This effect is greater for health state Z in question
9 than health state Y in question 10 and is likely to
account for our failure to find statistical differences
between the conventional and unconventional
values for Z. Finally, in question 10, one of the
respondents felt that the two states were very
similar (column 4, Table 6).
Discussion
In this section, we consider the issues raised by the
qualitative results, and the extent to which they
explain the quantitative results. We also outline
the weakness of our test design and suggest where
further research is needed. Finally we look at the
implications that this study has the for the TTO
method.
We are unable to conclusively reject procedural
invariance, with only one of the two tests detecting
a statistical difference. The qualitative data help to
Health Econ. 12: 655–668 (2003)
The TTO Method and Procedural Invariance
shed light on the issues that people consider in
their responses and suggest three main issues can
account for the quantitative results.
* Firstly, a willingness to trade-off quality for
longevity of life led to an unconventional value
that was lower than the conventional value. The
driving force for such responses appeared to be
related to loss aversion, where respondents
demanded a larger increase in the time spent
in the more severe state to compensate for the
decrease in the quality of life. It is also possible
that people’s preferences for the timing of ill-
health led to an unconventional value that was
lower than the conventional. We are unable to
test for these effects separately here but in a
later section of the discussion we argue that
discounting is unlikely to be the main driving
force in this study.
* Secondly, an unwillingness to prolong time in a
lower quality of life led to an unconventional
value that was higher than the conventional
value. The main driving force for such re-
sponses appeared to be related to maximal
endurance and was stronger when respondents
were asked to prolong time in the more severe
state Z. More than a third of the sample were
unwilling to prolong time in a more severe
health state Z in question 9 compared to only a
tenth for prolonging time in health state Y in
question 10. The concern over the severity of Z,
therefore, appears to have undermined our
ability to detect statistically significant differ-
ences in one of the two tests. Hence, the
quantitative results found lower unconventional
values in only one of the two tests considered.
* Thirdly, a willingness to increase longevity of
life irrespective of quality of life led to an
unconventional value that was equal to or
higher than the conventional value. The main
driving force for such responses appeared to be
related to scale compatibility and threshold of
tolerance.
There are two reasons to question whether time
preferences alone are able to explain our findings.
Firstly, Dolan and Jones-Lee [28] show that the
distortions related to time preferences are larger
for health states that are valued around 0.5. The
health states that are involved in question 9 are
Copyright # 2002 John Wiley & Sons, Ltd.
665
valued closer to 0.5 than those in question 10, and
so we would anticipate more of an impact in the
former than the latter questions. The contrary
result is found in our study. It is of course possible
that in question 9 the concerns over the maximal
endurance undermined the impact of time prefer-
ences. Secondly, there is a general conclusion that
although summary measures suggest people have
no preference over the timing of ill-health, there is
larger variation in preferences between people
[33,34]. It is therefore, quite possible that incor-
porating people’s preferences towards time will
lead to both higher and lower unconventional
values compared to the conventional values, and
so may fail to explain our findings. Nevertheless, it
is an important variable to consider in future
studies to determine whether time preferences lead
to differences between the conventional and
unconventional values.
The study also allows us to consider the extent
to which the different issues cancel one another
out. Both a strong preference for longevity of
life and maximal endurable time have the
potential to cancel out the impact of loss aversion.
However, maximal endurable time appears to play
a greater role in the one test that resulted
in equivalent conventional and unconventional
values.
A design weakness of the test is that a
respondent’s willingness to trade quality and
longevity of life may have been affected by the
short duration of the states in the TTO questions
involving two years followed by death. Short time
periods have been shown to affect people’s will-
ingness to trade in conventional TTO questions.
McNeil [35] found that, for states lasting under
five years, patients with laryngeal cancer were
unwilling to trade longevity for quality of life.
However, unlike the questions here, the conven-
tional TTO questions used by McNeil involved a
reduction in the longevity of life. The qualitative
data allow us to reflect upon whether the short
duration affected those questions that increase
longevity. Some respondents explicitly stated that
they would be more unwilling to prolong the time
in the lower quality of life if the alternative
treatment was for longer than two years. This
unwillingness to trade is likely to be related to
concerns over the maximal endurable time and so
this issue could begin to dominate in longer time
spans, leading to an unconventional value that
is higher than the conventional value. We recom-
mend further work to replicate the questions
Health Econ. 12: 655–668 (2003)
666 A. Spencer

for different time periods and health states, to see conventional and unconventional values are af-
the extent to which concerns over maximal fected by discounting.
endurable time cancel out concerns over loss Question 9 compares 2 years in Y and death or
aversion. t9 years in Z and death. Question 9 therefore
What are the implications of this study for compares 2 years in Y and dying (t9
2) years
the TTO method? Firstly, the study brings into earlier or t9 years in health state Z. Let a
question the assumptions that are typically made. respondent’s rate of time preference be represented
To improve the method’s descriptive ability, by a discount weight, r, and let 05r51. The
we recommend that it is expanded to incorporate discounted value for Z is then calculated from
respondents’ loss of quality of life and concern question 9 by equation (1).
over maximal endurance or longevity of life.
X
1 X
t9
1
For example, the TTO method could apply rt  V ðY Þ ¼ rt  V ðZÞ ðA1Þ
non-expected utility theories that model the impact 0 0
of loss aversion. In addition, the impact of
maximal endurable time and preference for long- where t9 52. The geometric progression formula is
evity of life could be considered in the interpreta- given as
tion of results. Secondly, the study raises concerns X
n
1
a  ð1
rn Þ
over how best to aggregate individual responses. a  rt ¼
The equivocal quantitative results appear to mask 0
1
r
a variety of individual responses associated with using this in Equation (A1) gives:
loss aversion, maximal endurable time and a
strong preference for longevity of life. The fact 1
r2 1
rt 9
 V ðY Þ ¼  V ðZÞ
that these issues can cancel out at an aggregate 1
r 1
r
level suggests that, in some instances, the summary
statistics may fail to closely approximate indivi- Rearranging it follows that the discounted value
dual values [5]. There is a trend towards subgroup for Z is:
analyses of preferences within populations [36]. If 1
r2
policy makers want to reflect more broadly the V ðZÞ ¼  V ðY Þ ðA2Þ
1
r t9
preferences of individual members, future work
should consider more carefully the implications of The unconventional value for Z assumes no
subgroup analyses and how these views should be discounting and is given as
aggregated. 2
V ðZÞ ¼  V ðY Þ ðA3Þ
t9
Acknowledgements To compare the unconventional value in Equation
(A3) against the discounted value in Equation (A2)
The author would like to thank Graham Loomes, Karl it is important to note that since 05r51 it follows
Claxton, Judith Covey, Nick Pidgeon, Björn Lindgren, immediately that
Carl Hampus Lyttkens and two referees for their
valuable comments. In addition, the author is grateful
1
r2 2
> ðA4Þ
to the Swedish Medical Research Council and the 1
r t9 t 9
Swedish Social Research Council for funding a visiting
research fellowship to pilot the approach, via research
Therefore, the unconventional value for Z,
grants to Björn Lindgren, Lund University. The author V ðZÞ ¼ ð2=t9 Þ  V ðY Þ, is lower than the dis-
is also grateful to the ESRC award R00023 4987 for counted value for Z, V ðZÞ ¼ ½ð1
r2 Þ=ð1
rt9 Þ 
financial support for the UK study. Any errors are the V ðY Þ
responsibility of the author alone. The extent to which the unconventional value is
lower than the discounted value is reinforced by
any underestimation of the conventional value Y
Appendix A which forms part of the unconventional formula
for Z in Equation (A3) [28]. Overall then, this
Dolan and Jones-Lee [28] showed that the reinforcement results in an unconventional value
conventional value is lower than the discounted for Z that is lower than the conventional value
value. We use their approach to compare how the for Z.

Copyright # 2002 John Wiley & Sons, Ltd. Health Econ. 12: 655–668 (2003)
The TTO Method and Procedural Invariance
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