Pharmacoeconomics 2009; 27 (9): 713-723

REVIEW ARTICLE 1170-7690/09/0009-0713/$49.95/0

ª 2009 Adis Data Information BV. All rights reserved.

Methods for Measuring Temporary Health

States for Cost-Utility Analyses
Davene R. Wright,1 Eve Wittenberg,1,2 J. Shannon Swan,1,3 Rebecca A. Miksad1,3,4 and
Lisa A. Prosser1,5,6
1 Preferences Working Group, Center for Health Decision Science, Harvard School of Public Health,
Boston, Massachusetts, USA
2 Schneider Institutes for Health Policy, Heller School for Social Policy and Management,
Brandeis University, Waltham, Massachusetts, USA
3 Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital,
Harvard Medical School, Boston, Massachusetts, USA
4 Beth Israel Deaconess Medical Center, Harvard Medical School, Division of Hematology and Oncology,
Boston, Massachusetts, USA
5 Center for Child Health Care Studies, Department of Ambulatory Care and Prevention, Harvard Medical
School and Harvard Pilgrim Health Care, Boston, Massachusetts, USA
6 Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan Health
System, Ann Arbor, Michigan, USA

Contents
Abstract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 713
1. Health-State Utilities, Temporary Health States and QALYs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 714
2. Assessment of Preference-Based Valuation Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 715
2.1 Search Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 715
2.2 Assessment Criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 715
3. Review of Temporary Health-State Valuation Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 716
3.1 Categories. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 716
3.2 Traditional Preference-Based Elicitation Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 716
3.2.1 Health Status Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 716
3.2.2 Time Trade-Off or Standard Gamble Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 716
3.3 Adapted Methods for Valuing Temporary Health States. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719
3.3.1 Time Trade-Off with Specified Duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719
3.3.2 Time Trade-Off with ‘Lifespan’ Modification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719
3.3.3 Waiting Trade-Off. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719
3.3.4 Chained Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719
3.3.5 Sleep Trade-Off . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 720
4. Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 720
5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 721

Abstract A variety of methods are available to measure preferences for temporary

health states for cost-utility analyses. The objectives of this review were to
summarize the available temporary health-state valuation methods, identify
advantages and disadvantages of each, and identify areas for future research.
714 Wright et al.

We describe the key aspects of each method and summarize advantages and
disadvantages of each method in terms of consistency with QALY theory,
relevance to temporary health-state-specific domains, ease of use, time pre-
ference, and performance in validation studies. Two broad categories of
methods were identified: traditional and adapted.
Traditional methods were health status instruments, time trade-off (TTO),
and the standard gamble (SG). Methods adapted specifically for temporary
health-state valuation were TTO with specified duration of the health state,
TTO with a lifespan modification, waiting trade-off, chained approaches for
TTO and SG, and sleep trade-off.
Advantages and disadvantages vary by method and no ‘gold standard’
method emerged. Selection of a method to value temporary health states will
depend on the relative importance of the following considerations: ability to
accurately capture the unique characteristics of the temporary health state, level
of respondent burden and cognition, theoretical consistency of elicited preference
values with the overall purpose of the study, and resources available for study
development and data collection. Further research should focus on evaluating
validity, reliability and feasibility of temporary health-state valuation methods.

Cost-utility analyses can facilitate policy and
clinical decision making by prioritizing health in-
terventions. Health outcomes in cost-utility ana-
lyses are valued via health-state utilities that reflect
preferences for living in various states of health for
the duration of the health state and with the quality
of life (QOL) experienced in the health state. The
standard cost-utility framework assumes that the
preference for a health state is independent of its
duration, allowing the same utility value to be
assigned to each unit of time spent in the health
state irrespective of the duration.[1-3] However,
empirical evidence suggests that preferences for
temporary health states may depend, in part, on
the duration of the health state, potentially pro-
ducing inaccurate utility values if duration is not
considered.[1-3]
In this article, we identify preference-based
methods used in the literature to value temporary
health states for cost-utility analyses. The meth-
ods fall into two categories: traditional preference
measurement methods and those adapted speci-
fically for the measurement of preferences for
temporary health states. The first class, traditional
methods, consists of techniques that assume va-
lue is independent from duration. The second
category, adapted methods, consists of ap-
proaches that allow for the duration of the health
state to affect valuation. This article describes the
key aspects of each published preference-based
valuation method, the advantages and dis-
advantages of each approach, and identifies areas
for future research. The overall objective of the
article was to provide detailed information for
each available method to assist in the selection of
appropriate methods, as well as to assist readers
in understanding and interpreting the results of
studies that have employed these methods.
1. Health-State Utilities, Temporary Health
States and QALYs
For the purposes of this article, we defined a
‘temporary’ health state as a transient health state
lasting <1 year that may impart some discomfort
or temporary reduction in QOL. Temporary
health states are common and include infections,
short-term medications and procedures, vaccina-
tions, screening tests and diagnostic procedures.
A review of the 2005 Cost-Effectiveness Analysis
Registry maintained by the Center for the Eva-
luation of Value and Risk in Health at Tufts
Medical Center (CEA Registry) revealed that ap-
proximately 20% of published cost-effectiveness
analyses to date may include measures of health
states deemed temporary by this definition.[4]

ª 2009 Adis Data Information BV. All rights reserved. Pharmacoeconomics 2009; 27 (9)
Measuring Temporary Health States for Cost-Utility Analyses
Standard preference-elicitation methods fol-
low specific axioms of economic theory in order
to obtain utility values appropriate for calculat-
ing QALYs.[5] Utility values used for generating
QALYs must satisfy three key theoretical as-
sumptions: (i) constant proportional trade-off;
(ii) risk neutrality across life-years; and (iii) in-
dependence of preferences for health regardless
of life expectancy. Constant proportional trade-
off requires that the proportion of time traded
does not depend on the remaining number of life-
years, risk neutrality requires that the utility
function over life-years be linear, and utility in-
dependence is required between life-years and
health status.[6-9] Numerous studies have dis-
cussed violations of these requirements and al-
ternative models have been proposed.[10,11]
However, conventional QALYs remain the stan-
dard metric for valuing health in cost-utility anal-
yses. Methods designed to capture the distinctive
aspects of preferences for temporary health states
may not conform to the axiom of constant pro-
portional trade-off because the duration of the
health state may affect valuation.[3]
2. Assessment of Preference-Based
Valuation Methods
This article describes the key aspects of each
published preference-based valuation method, the
advantages and disadvantages of each approach,
and identifies areas for future research. Selected
papers from the literature review were used as
examples. In contrast with a systematic literature
review, we seek to describe the advantages and
disadvantages of available preference-based ap-
proaches in order to frame the debate around
temporary health-state valuation and identify
areas for future research.
2.1 Search Methods
We identified preference-based methods used
in the literature to value temporary health states
for cost-utility analyses. Searches of an electronic
literature database and of an online health-
related QOL (HR-QOL) database were conducted
to identify all published short-term health-state
ª 2009 Adis Data Information BV. All rights reserved.
715
utilities. PubMed was searched during March
2008 using the following search terms: ‘tempo-
rary’, ‘transient’, ‘short term’, ‘health state’,
‘quality of life’, ‘health-related quality of life’,
‘utility’ and ‘preference’. In addition, 4299 unique
HR-QOL entries in the CEA Registry were re-
viewed during March 2008 (registry updated to
2005 at the time of analysis).[4] These searches
were expanded by reviewing the references of
identified articles and by discussion with experts.
In total, 34 manuscripts describing unique
temporary health states were identified.
2.2 Assessment Criteria
The preference-based valuation methods were
evaluated according to four criteria: (i) consis-
tency with QALY theory; (ii) ability to accurately
describe the health state; (iii) whether estimation
of discount rates for time preference was required;
and (iv) ease of administration.
Consistency with QALY theory has implica-
tions for how temporary health-state utilities are
interpreted and used. This issue is an important
consideration when combining or comparing
utilities elicited using different methods in a
decision-analytic model, particularly when both
temporary health-state and long-term health-
state utilities are included in the analysis. The
relative importance of theoretical consistency will
depend on characteristics of the decision being
modeled.
The accuracy of preference measurement for
the valuation of any health state of any duration
depends, in part, on how well the health state is
captured in the valuation task. The extent to
which an adapted method accurately reflects a
particular health state will depend on the health
state being valued. For example, diagnostic tests
and other experiences with very short duration
may be easier to describe using adapted methods
or more difficult to describe using traditional
methods.
Valuation methods that include trading time
from the end of a person’s life or over a long
period (e.g. 20 years) require estimation of discount
rates for time preference. Individual rates may
vary widely across individuals[12] and estimation
Pharmacoeconomics 2009; 27 (9)
716
of this factor may add uncertainty to utility esti-
mates. Time trade-off (TTO) approaches will often
overlook this effect when calculating health-state
utilities, but this has been shown to potentially
affect calculated values.[13]
The availability of resources to develop, ad-
minister and analyse a temporary health-state
valuation survey may limit the feasibility of using
some of the preference-based valuation methods.
Researchers must balance the trade-off between
cognitive burden and flexible domains. Ease of sur-
vey administration is often an important consid-
eration when designing a preference-measurement
study, but is likely to be a key factor for tempo-
rary health-state valuations given the complexity
of some of the adapted valuation methods.
3. Review of Temporary Health-State
Valuation Methods
3.1 Categories
Two categories of temporary health-state va-
luation methods were identified: (i) traditional
preference-based techniques as used for chronic
health-state valuation, such as health status in-
struments, the standard gamble (SG), or the
TTO; and (ii) adaptations of traditional methods
to specifically address the issue of the short
duration of the temporary health states.
The traditional valuation methods of the first
category assume that value is independent from
duration. Such methods generally adjust for dura-
tion through the calculation of QALYs, using the
duration of the temporary state in the same way
that duration is used for any health state.
The adapted methods of the second category
allow for the duration of the health state to affect
valuation. Adaptations of traditional methods
use a variety of approaches to specifically address
duration in the valuation task: lifespan-based
TTO, waiting trade-off (WTO), chained methods
and sleep trade-off.
Descriptions of temporary health-state valua-
tion methods along with available validation
studies are presented in table I. How each method
fits with our assessment criteria (see section 2.2),
and other considerations for choosing the most
ª 2009 Adis Data Information BV. All rights reserved.
Wright et al.
appropriate method, are presented in table II.
Selected examples for different preference-based
valuation methods were drawn from the search
using the CEA Registry, as well as examples that
were known to the authors.
3.2 Traditional Preference-Based Elicitation
Methods
3.2.1 Health Status Instruments
Health status instruments assess health states
using a specified set of attributes, and a utility value
is calculated from a mathematical model based
on community preferences.[7,39,40] The EQ-5D,
the Quality of Well Being Scale (QWB-SA), and
the Health Utilities Index Mark 2 and 3 (HUI2,
HUI3) are commonly used health status instru-
ments that yield preference-based health-state
utility weights.[39,41-47]
In order to calculate temporary health-state
values with health status instruments, the tem-
porary health state is presented to the survey re-
spondent as if it were a chronic health state. The
transient nature of the temporary health state is
accounted for in the calculation of QALYs asso-
ciated with the time spent in the temporary health
state.
The primary advantage of health status in-
struments for the measurement of temporary
health states is that utility weights are community
weights derived using TTO or SG techniques,
both of which are consistent with QALY theory.
However, the health-state utility weights may not
fully encompass the preferences associated with
the state because health status instruments may
lack attributes specifically related to the tempor-
ary health states. From a practical perspective, it
may be unrealistic to ask respondents to imagine
enduring a short-term health state (e.g. a diag-
nostic test) for a longer timeframe.
3.2.2 Time Trade-Off or Standard Gamble
Techniques
Traditional TTO or SG methods have also
been used to elicit health-state utility weights for
temporary health states.[3,19-25] The objective of
the traditional TTO is to establish the duration of
time in perfect health that the respondent regards
as equivalent to time spent in the impaired health
Pharmacoeconomics 2009; 27 (9)
Measuring Temporary Health States for Cost-Utility Analyses 717

Table I. Available methods for valuing temporary health states in cost-utility analyses
Method Description
Traditional preference-based techniques
Health status Health-state utility (assigned to
instruments a health state using indicated
levels of health domains) is
prorated by the amount of
time spent in the temporary
health state
TTO and SG Utility value from TTO or SG
prorated by amount of time
spent in temporary health state
Adapted techniques for temporary health states
TTO with specified Utility value from TTO where
duration of health time horizon is limited to the
state length of the temporary
health state
TTO with ‘lifespan’ Utility value from TTO where
modification time horizon is length of
respondent’s life expectancy
rather than duration of
health statea
Waiting trade-off Utility value from TTO of
waiting time for an ‘ideal’ test
compared with immediate
actual test
Chained methods Utility value obtained using
(TTO and SG) traditional TTO or SG methods
with an intermediary state used
as an anchor instead of death
Sleep trade-off Utility value from TTO of time
spent in non-restful sleep to
avoid time in an undesirable
state (anchors are current
health as 1.0 and sleep as 0)
a Time traded from end of life is discounted to the present value of that time.
MR = magnetic resonance; SG = standard gamble; TTO = time trade-off.
Scope of use
Used widely for chronic health states
Context, convergent and discriminant
validity, statistical strength of models, and
reliability have been verified
Not evaluated for temporary health states
Used widely for chronic health states
Validity and reliability well tested
Used often for temporary states
Not evaluated for temporary health states
Used occasionally in practice
Not formally tested for validity for
temporary health states
Used occasionally in practice
Not formally tested for validity for temporary
health states
Used occasionally
Some evidence of convergent validity for
temporary health states
Originally designed for use in states
related to diagnostic screening and
testing
Used more frequently for chronic health
states; occasionally used for temporary
states
Tested for validity and reliability
Some testing of reliability, consistency,
and concordance relative to traditional
TTO and SG
Not evaluated for temporary health states
Used minimally
Some evidence of fluctuations in validity
and reliability for temporary health states
Examples of use in temporary
health-state valuation
Influenza[14]
Pneumonia[14]
Angiography (MR and
conventional)[15,16]
Pulmonary rehabilitation[17]
Knee arthroplasty[18]
Herpes zoster (TTO)[19]
Cancer screening and diagnoses
(TTO and SG)[3,20,21]
Cancer treatment (TTO and SG)[22,23]
Cardiac rehabilitation (TTO)[24]
Kidney donation (TTO)[25]
Pertussis[26]
Pertussis[26]
Herpes zoster[19]
Otitis media, pneumonia,
meningitis[1,27,28]
Newborn screening[29]
MR angiography[15]
Conventional angiography[30]
Breast biopsy[20]
Gallstone disease treatment (TTO)[31]
Breast cancer screening, diagnosis,
and chemotherapy (TTO and SG)[32]
Deep vein thrombosis, pulmonary
embolism, bleeding (TTO)[33]
Oesophageal cancer (TTO and SG)[34]
Stroke and stroke prophylaxis[35]
Fractures, infection, peptic ulcer,
pneumonia[36]
Hormone replacement therapy,
osteoporosis prevention[37,38]

state (i.e. the amount of time the respondent is
willing to give up to avoid the impaired health
state). In the SG method, the objective is to
determine the probability of death for which the
respondent is indifferent to a particular number
of life-years in a constant impaired health state or
a gamble between perfect health and death.[40]
The researcher presents the temporary health
state as if it were a chronic health state and the
health state is valued by the respondent according
to typical TTO or SG methods. The elicited
health-state utility weight is then applied to the

ª 2009 Adis Data Information BV. All rights reserved. Pharmacoeconomics 2009; 27 (9)
718 Wright et al.

duration of the temporary health state to calcu-
late the change in QALYs associated with the
temporary health state.[48]
Traditional TTO and SG techniques are well
tested and consistent with QALY theory.[7]
However, in practice, appropriate adjustments
for time preferences (i.e. discounting) for trade-
offs made over a long period of time may be
challenging to apply.[22] These techniques may
result in a lack of sensitivity if the respondent
does not perceive the temporary health state as
sufficiently impaired to induce them to trade time
from their life or to gamble with a probability of
death. This ‘ceiling effect’ may occur despite the
presence of disutility from the impaired health
state.[33] The TTO and SG methods, and those
methods adapted from them, allow flexibility in
health-state descriptions but are relatively more

Table II. Considerations for identifying an appropriate temporary health-state utility valuation method
Method
Traditional preference-based techniques
Health status instruments
TTO and SG
Adapted techniques
TTO with specified duration
TTO with ‘lifespan’ modification
Waiting trade-off
Chained methods: TTO and SG
Sleep trade-off
SG = standard gamble; TTO = time trade-off.
Considerations
Consistent with QALY theory
Relatively easy to administer
May omit domains specific to the temporary health state(s) under evaluation
Assumes preferences are independent of health-state duration
May introduce cognitive challenges when a temporary state is presented as a chronic health state
Consistent with QALY theory
Allows flexibility in health state description
Relatively more resource intensive than health status instruments
Assumes preferences are independent of health state duration
TTO does not address time preferences when trading time from end of life
SG has high cognitive burden for respondents
Consistent with QALY theory
Allows flexibility in health state descriptions
Does not allow for states to be valued as worse than dead
Relatively more resource intensive than health status instruments
Allows flexibility in health state descriptions
Violates constant proportional trade-off assumption of QALY theory
Inclusion of life expectancy may introduce variance and bias
Does not address time preference when trading time from end of life
Relatively more resource intensive than health status instruments
Developed for screening and diagnostic tests
Allows flexibility in health state descriptions, including realistic treatment scenarios
Respondents trade current time, which eliminates discounting bias
Allows respondents to value state as worse than dead
Violates constant proportional trade-off assumption of QALY theory
Uses chain-method (see below), which may increase variance and bias
Relatively more resource intensive than health status instruments
May require estimation of pre- and post-treatment utility values
Consistent with QALY theory
Allows flexibility in health state descriptions
May provide increased sensitivity for minimally impaired states or transitory states
Choice of anchor state may affect sensitivity
Calculation of population utility somewhat unclear (mean of total utility vs mean of each link in chain)
Chaining increases variance
Relatively more resource intensive than health status instruments
Allows flexibility in health state descriptions
Respondents trade current time, which eliminates possible bias due to discounting for time preference
Consistent with QALY theory if sleep is valued as equal to dead
Relatively more resource intensive than health status instruments

ª 2009 Adis Data Information BV. All rights reserved. Pharmacoeconomics 2009; 27 (9)
Measuring Temporary Health States for Cost-Utility Analyses
resource intensive than health status instruments.
The SG, in particular, has a high cognitive bur-
den for respondents.
3.3 Adapted Methods for Valuing Temporary
Health States
3.3.1 Time Trade-Off with Specified Duration
Modifications of the TTO method attempt to
overcome limitations of traditional approaches for
temporary health-state valuation. The relatively
short time spent in the temporary health state can
be directly addressed by limiting the maximum
amount of time that can be traded (the denomi-
nator) to the duration of the temporary health
state. This modification is consistent with QALY
theory and may avoid time-preference issues.
However, the time limitation does not allow the
respondent to value the transient state as ‘worse
than dead’ because the respondent cannot trade
more time than the duration of the health state.
3.3.2 Time Trade-Off with ‘Lifespan’ Modification
In the ‘lifespan’ TTO modification, respondents
are asked to value a description that includes a
temporary health state followed by their remain-
ing life in full health.[26] The maximum amount of
time that can be traded to avoid the temporary
health state (the denominator) is the respondent’s
life expectancy, a more intuitive assessment for
some respondents. An advantage of the ‘lifespan’
TTO is that the temporary health state can be
valued as worse than death because the amount
of time that can be traded is not limited to the
duration of the temporary health state.
However, the ‘lifespan’ modification violates
the constant proportional trade-off assumption
and requires assumptions about the rate of time
preference in order to adjust (i.e. discount) the
value of time traded from the end of life. Time-
preference assumptions may lead to increased
uncertainty around utility estimates because dis-
count rates tend to vary by individual and by
situation.[2] As an additional limitation, the will-
ingness of an individual to trade time near the end
of their life may be influenced by the anticipation
that later years will have lower quality. Finally,
unless life expectancy is explicitly stated, the uti-
lities derived using the ‘lifespan’ TTO method
ª 2009 Adis Data Information BV. All rights reserved.
719
may be influenced by the respondent’s assump-
tions regarding their life expectancy.[49]
3.3.3 Waiting Trade-Off
The WTO is another variation of the TTO
specifically developed for valuing health states
associated with diagnostic screening and testing.
Respondents are presented with a choice between
having an invasive test and receiving results and
treatment immediately or waiting a specified
period of time for results from a hypothetical
‘ideal’ non-invasive test.[15,30] The QALYs asso-
ciated with the invasive test are calculated as the
product of this ‘waiting time’ and the difference
between the post-treatment and baseline health-
state utilities, which may be separately assessed
or obtained from the literature.[20,50]
In the screening and diagnostic testing setting,
the WTO may be more intuitive for some re-
spondents than other TTOs. Another advantage
is that the WTO does not require respondents
to imagine themselves in excellent health.[15] Be-
cause respondents trade off current time, dis-
counting is not a concern. However, as with other
adapted TTO methods, the WTO violates the
proportional trade-off assumption of QALY
theory. The WTO may also implicitly incorporate
a bias if respondents assume that a delay prior to
treatment may affect their prognosis. This lim-
itation may be addressed by asking the re-
spondent to assume that any delay does not affect
the disease or treatment outcome. As an addi-
tional limitation, the WTO requires estimation of
pre- and post-treatment utilities if values are not
available from the literature, which can introduce
additional uncertainty into the calculation of
QALYs, as well as increasing respondent and
investigator burden. Lastly, the use of a two-step
chained method such as the WTO may increase
variance and bias in derived utility values.
3.3.4 Chained Methods
TTO and SG chained health-state valuation
methods were developed to address ‘ceiling effect’
issues associated with mild impairment health
states. Chained health-state methods avoid the
choice between a mild health impairment and
death, which can be difficult or disturbing for
Pharmacoeconomics 2009; 27 (9)
720
respondents. The chained health-state approach
can be used with either an SG or TTO ques-
tion[23,33,40] by breaking the utility assessment
process into two distinct steps. First, a reference
health state worse than the state of interest (but not
dead) is defined and valued using traditional SG or
TTO methods. In the second step, this reference
state is used as the bottom anchor in a traditional
SG or TTO: the respondent is asked to choose
between the impaired health state of interest and a
gamble or trade-off involving life in perfect health
and the reference state valued in the previous step.
The chained approach was developed specifi-
cally for valuing mild health impairments and,
therefore, may be particularly well suited to the
valuation of temporary health states given the
mild nature of many temporary health states.
Chained methods are consistent with QALY
theory and do not force a direct comparison be-
tween death and a temporary health state.[49,51]
Disadvantages of chained approaches include
time-intensive administration and higher var-
iance in results because of the two-step pro-
cess.[40,52] The two-step nature of this approach
has lead to differences in how researchers can go
about calculating the population utility. Some
researchers may calculate the mean of the total
utility, rather than the mean of each link in the
chain, which may make the result less precise. As
an additional limitation, a ‘floor effect’ is possible
if a respondent prefers the anchor state to the
temporary health state. However, the chained
method has been validated against other pre-
ference elicitation methods for health states that
are preferred to death.[9,23]
It has performed well in a test-retest reliability
evaluation, with an agreement between the rank-
ings of health states of 0.63 using a visual analogue
scale and 0.57 using the chained TTO. Further
details on the reliability of the chained TTO can be
found in the 2004 analysis by Locadia et al.[33]
3.3.5 Sleep Trade-Off
The sleep trade-off is a variation of the TTO
method that substitutes non-restful sleep for
being dead in a traditional TTO. In this ap-
proach, the respondent is asked for the amount of
time he or she is willing to spend sleeping in a
ª 2009 Adis Data Information BV. All rights reserved.
Wright et al.
non-restful state compared with time spent in a
temporary health state.[36,37] This approach
avoids the need for discounting. As with all var-
iations of the TTO, it allows for investigator dis-
cretion in the description of the health states, and
thus domains can be customized for temporary
health states. The primary limitation is that re-
spondents must value time spent in the sleep state
as equal to zero on a utility scale in order for the
method to be consistent with QALY theory,
which may be difficult for respondents since this
implies equivalence with being dead.
4. Discussion
We identified and reviewed nine different
published methods for valuing temporary health
states for cost-utility analyses, but due to the
scarcity of validity and reliability testing, no
method emerges as a ‘gold standard’. Although
some methods have been well tested for chronic
health states, evaluation of their appropriateness
for valuing temporary health states is lacking.
Without additional validation, we will be unable
to generalize the utility values from studies that
utilize temporary health-state methods. Given
the frequency and diversity of temporary health
states, additional research is needed to rigorously
evaluate the relative performance of temporary
health-state valuation methods and to determine
whether, and to what extent, health-state duration
affects the utility value assigned to a health state.
Because of the diversity of methods, all four of
the evaluation criteria do not apply equally to all
methods. Each method has advantages and dis-
advantages, and the selection of a method for
valuing a temporary health state should reflect
the specific attributes of the condition and the
clinical or policy decision being studied, as well as
the needs and resources of the researcher. For
example, direct valuation methods (TTO, SG and
their variants) tend to be more time consuming
and complex for both the researcher and the re-
spondent, and typically require more resources
than health status instruments but allow the in-
vestigator to tailor the health-state descrip-
tion.[53] If health status instrument attributes do
not capture the salient QOL aspects of the health
Pharmacoeconomics 2009; 27 (9)
Measuring Temporary Health States for Cost-Utility Analyses
state being valued, then direct valuation using
TTO, SG, or an adapted method may be a better
choice of method. The SG, the WTO, and the
sleep trade-off methods avoid the issue of esti-
mating time preference, while time preference will
need to be considered for most TTO-based ap-
proaches.[20]
Concordance with QALY theory is a key
consideration. There is value in standardizing
utility elicitation methods to generate QALYs
that can provide a common metric for cost-utility
ratios and allow the comparison of interventions
that address very different types of health, e.g.
being able to compare the cost-utility of cancer
treatments with newborn screening programmes.
In concordance with the theoretical assumptions
of QALYs, experts recommend that QALYs
should be anchored on perfect health and death
to allow for a common base of comparison across
interventions.[5] There are consequences to vio-
lating these assumptions, as sometimes occurs in
the valuation of temporary health states. Further
research should investigate the negative impact
of violating axioms of QALY theory and how
this would or should limit the use of health-state
utilities elicited using non-traditional methods.
On the one hand, in the strictest interpretation,
methods that fail to meet the three axioms of
QALY theory could be considered invalid and
cost-utility analyses that rely on these methods
suspect. On the other hand, if the QALY loss
measured using non-traditional methods more
closely represents preferences for these states of
health than QALY loss measured using tradi-
tional methods, it could be argued that the use of
adapted methods for measuring temporary
health states may provide more accurate mea-
surement of health-state preferences. Current
cost-effectiveness analyses often combine utilities
from disparate sets of elicitation methods with
little discussion (e.g. utility weights from the EQ-
5D, HUI, and direct TTO or SG questions).
Along with the identification of appropriate
methods for valuing temporary health states,
additional research should focus on the con-
sequences of using various elicitation methods, as
well as encouraging transparency in publications
regarding sources of utility weights and potential
ª 2009 Adis Data Information BV. All rights reserved.
721
limitations of combining utilities elicited via dif-
ferent methods.
Although both the TTO and the SG have been
used to assess temporary health states, we found
a larger number of adapted methods that were
based on the TTO. It may be that the TTO is
more easily adapted to the measurement of
temporary health states as the timeframe can be
directly manipulated. Fewer approaches, such as
the chained SG, have been published for use in
temporary health-state measurement.
Generally, the advantages of the standard
valuation methods are considerable. They are
consistent with QALY theory, familiar to re-
searchers, and have been rigorously tested for
chronic health states. On the other hand, adap-
tations of standard methods developed specifi-
cally for valuing temporary health states have the
benefit of allowing the value of the health state to
vary with duration. However, these adapted
methods may require careful design, may be in-
consistent with QALY theory, and most lack
rigorous testing (table II). There is sparse litera-
ture evaluating either standard or adapted
methods and additional research is needed for
both categories of methods.
5. Conclusions
This paper summarizes available methods for
valuing temporary health states, outlines a num-
ber of key considerations for selecting a method
for a specific application, and describes the key
advantages and disadvantages of each method.
Among the currently available methods, there is
no clear ‘gold standard’ temporary health-state
valuation method. When deciding which method
to employ, we suggest that researchers consider:
(i) whether the valuation method accurately
captures the unique characteristics of the tem-
porary health state; (ii) the population from
whom values will be elicited, and the relative im-
portance of respondent burden and cognition;
(iii) the relative importance of theoretical con-
sistency of elicited preference values with the
overall purpose of the study; and (iv) resources
available for survey development, data collection
and data analysis. Given the limited evidence on
Pharmacoeconomics 2009; 27 (9)
722
performance for many of the available temporary
state valuation methods, the choice of method
should be guided by the features and constraints
of the specific situation in which preferences are
being measured.
Further research on temporary health-state
valuation methods is necessary to improve the
optimal use of existing and future methods.
Needed research includes reporting the use of
existing or new methods for valuing temporary
health states in order to expand our knowledge of
the feasibility and validity of these methods, as
well as rigorous testing of performance measures
for the various methods. Key areas for further
research include the estimation of discount rates
for both traditional and variations of TTO
methods applied to temporary health states and
valuation effects relating to the choice of anchor
state. Improvements in the methods for valuing
temporary health states would improve economic
evaluations and contribute to policy decisions
that more accurately reflect public preferences.
Acknowledgements
The authors gratefully acknowledge the assistance of
Drs Milton Weinstein and James Hammitt for their helpful
comments. Funding for this project was provided by the
Center for Health Decision Science at the Harvard School of
Public Health. We also thank two anonymous reviewers for
their very helpful comments and suggestions.
The authors have no conflicts of interest that are directly
relevant to the content of this review.
References
1. Prosser LA, Lieu TA. Comments on the Prosser et al. ap-
proach to value disease reduction in children. Pediatrics
2004 Nov; 114 (5): 1375-6
2. Dolan P, Stalmeier P. The validity of time trade-off values in
calculating QALYs: constant proportional time trade-off
versus the proportional heuristic. J Health Econ 2003 May;
22 (3): 445-58
3. Bala M, Wood L, Zarkin G, et al. Are health states ‘time-
less’? The case of the standard gamble method. J Clin
Epidemiol 1999; 52 (11): 1047-53
4. The cost-effectiveness analysis registry 2005 [online]. Avail-
able from URL: http://research.tufts-nemc.org/cear/default.
aspx [Accessed 2008 Mar 1]
5. Drummond MF, Sculpher MJ, Torrance GW, et al. Meth-
ods for the economic evaluation of health care pro-
grammes. 3rd ed. New York: Oxford University Press,
2005
ª 2009 Adis Data Information BV. All rights reserved.
Wright et al.
6. Pliskin JS, Shepard DS, Weinstein MC. Utility functions for
life years and health status. Operations Res 1980 01; 28 (1):
206-24
7. Dolan P. Output measures and valuation in health. In:
Drummond MF, McGuire A, editors. Economic evalua-
tion in health care. New York: Oxford University Press,
2001: 46-67
8. Bleichrodt H, Johannesson M. The validity of QALYs: an
experimental test of constant proportional tradeoff and
utility independence. Med Decis Making 1997 Jan-Mar;
17 (1): 21-32
9. Bleichrodt H, Wakker PP, Johannesson M. Characterizing
QALYs by risk neutrality. J Risk Uncertain 1997; 15 (2):
107-14
10. Wakker P, Stiggelbout A. Explaining distortions in utility
elicitation through the rank-dependent model for risky
choices. Med Decis Making 1995 Apr-Jun; 15 (2): 180-6
11. Bleichrodt H, Diecidue E, Quiggin J. Equity weights in the
allocation of health care: the rank-dependent QALY
model. J Health Econ 2004 Jan; 23 (1): 157-71
12. Lazaro A, Barberan R, Rubio E. Private and social time
preferences for health and money: an empirical estimation.
Health Econ 2001 Jun; 10 (4): 351-6
13. Johannesson M, Pliskin JS, Weinstein MC. A note on QA-
LYs, time tradeoff, and discounting. Med Decis Making
1994 Apr-Jun; 14 (2): 188-93
14. Turner D, Wailoo A, Nicholson K, et al. Systematic review
and economic decision modelling for the prevention and
treatment of influenza A and B. Leicester: University of
Leicester and University of Sheffield, 2002 Apr 29
15. Swan JS, Fryback DG, Lawrence WF, et al. A time-tradeoff
method for cost-effectiveness models applied to radiology.
Med Decis Making 2000 Jan-Mar; 20 (1): 79-88
16. Yin D, Baum RA, Carpenter JP, et al. Cost-effectiveness of
MR angiography in cases of limb-threatening peripheral
vascular disease. Radiology 1995 Mar; 194 (3): 757-64
17. Griffiths TL, Phillips CJ, Davies S, et al. Cost effectiveness
of an outpatient multidisciplinary pulmonary rehabilita-
tion programme. Thorax 2001 Oct; 56 (10): 779-84
18. Lavernia CJ, Guzman JF, Gachupin-Garcia A. Cost effec-
tiveness and quality of life in knee arthroplasty. Clin Or-
thop Relat Res 1997 Dec; 345: 134-9
19. Lieu TA, Ortega-Sanchez I, Ray GT, et al. Community and
patient values for preventing Herpes zoster. Pharmacoe-
conomics 2008; 26 (3): 235-49
20. Swan JS, Lawrence WF, Roy J. Process utility in breast
biopsy. Med Decis Making 2006 Jul-Aug; 26 (4): 347-59
21. Dominitz JA, Provenzale D. Patient preferences and quality
of life associated with colorectal cancer screening. Am J
Gastroenterol 1997 Dec; 92 (12): 2171-8
22. Badia X, Monserrat S, Roset M, et al. Feasibility, validity
and test-retest reliability of scaling methods for health
states: the visual analogue scale and the time trade-off.
Qual Life Res 1999 Jun; 8 (4): 303-10
23. Jansen SJ, Stiggelbout AM, Wakker PP, et al. Patients’ uti-
lities for cancer treatments: a study of the chained proce-
dure for the standard gamble and time tradeoff. Med Decis
Making 1998 Oct-Dec; 18 (4): 391-9
Pharmacoeconomics 2009; 27 (9)
Measuring Temporary Health States for Cost-Utility Analyses
24. Oldridge N, Furlong W, Feeny D, et al. Economic evalua-
tion of cardiac rehabilitation soon after acute myocardial
infarction. Am J Cardiol 1993 Jul 15; 72 (2): 154-61
25. Pace KT, Dyer SJ, Phan V, et al. Laparoscopic v open donor
nephrectomy: a cost-utility analysis of the initial experience
at a tertiary-care center. J Endourol 2002 Sep; 16 (7): 495-508
26. Lee GM, Salomon JA, LeBaron CW, et al. Health-state
valuations for pertussis: methods for valuing short-term
health states. Health Qual Life Outcomes 2005; 3: 17
27. Prosser LA, Ray GT, O’Brien M, et al. Preferences and will-
ingness to pay for health states prevented by pneumococcal
conjugate vaccine. Pediatrics 2004 Feb; 113 (2): 283-90
28. Beutels P, Viney RC. Comments on the Prosser et al. ap-
proach to value disease reduction in children [author reply].
Pediatrics 2004 Nov; 114 (5): 1375-6
29. Prosser LA, Ladapo JA, Rusinak D, et al. Parental tolerance
for false-positive newborn screening results. Arch Pediatr
Adolesc Med 2008 Sep; 162 (9): 870-6
30. Swan JS, Sainfort F, Lawrence WF, et al. Process utility for
imaging in cerebrovascular disease. Acad Radiol 2003
Mar; 10 (3): 266-74
31. Cook J, Richardson J, Street A. A cost utility analysis of
treatment options for gallstone disease: methodological
issues and results. Health Econ 1994 May-Jun; 3 (3): 157-68
32. Jansen SJ, Stiggelbout AM, Wakker PP, et al. Unstable pre-
ferences: a shift in valuation or an effect of the elicitation
procedure? Med Decis Making 2000 Jan-Mar; 20 (1): 62-71
33. Locadia M, Stalmeier PF, Oort FJ, et al. A comparison of 3
valuation methods for temporary health states in patients
treated with oral anticoagulants. Med Decis Making 2004
Nov-Dec; 24 (6): 625-33
34. McNamee P, Glendinning S, Shenfine J, et al. Chained time
trade-off and standard gamble methods: applications in
oesophageal cancer. Eur J Health Econ 2004 Feb; 5 (1): 81-6
35. Gage BF, Cardinalli AB, Owens DK. The effect of stroke
and stroke prophylaxis with aspirin or warfarin on quality
of life. Arch Intern Med 1996 Sep 9; 156 (16): 1829-36
36. Merlino LA, Bagchi I, Taylor TN, et al. Preference for
fractures and other glucocorticoid-associated adverse ef-
fects among rheumatoid arthritis patients. Med Decis
Making 2001 Mar-Apr; 21 (2): 122-32
37. Tosteson AN, Kneeland TS, Nease RF, et al. Automated
current health time-trade-off assessments in women’s
health. Value Health 2002 Mar-Apr; 5 (2): 98-105
38. Tosteson AN, Kneeland TS, Nease R. Feasibility of auto-
mated utility assessment in a phase III clinical trails:
U-Titer and a raloxifene osteoporosis prevention trial.
Med Decis Making 1995; 15: 412-36
39. Keeney R, Raiffa H. Decisions with multiple objectives:
preferences and value tradeoffs. New York: Cambridge
University Press, 1993
40. Torrance GW. Measurement of health state utilities for
economic appraisal. J Health Econ 1986; 5: 1-30
ª 2009 Adis Data Information BV. All rights reserved.
723
41. Kaplan RM, Bush JW, Berry CC. Health status: types of
validity and the index of well-being. Health Serv Res 1976
Winter; 11 (4): 478-507
42. Kaplan RM, Anderson JP, Wu AW, et al. The Quality of
Well-Being scale: applications in AIDS, cystic fibrosis, and
arthritis. Med Care 1989 Mar; 27 (3 Suppl.): S27-43
43. Anderson JP, Kaplan RM, Berry CC, et al. Interday relia-
bility of function assessment for a health status measure:
the Quality of Well-Being scale. Med Care 1989 Nov;
27 (11): 1076-83
44. Kaplan RM, Anderson JP. An integrated approach to
quality of life assessment: the general health policy model.
In: Spilker B, editor. Quality of life in clinical studies. New
York: Raven Press, 1990: 131-49
45. Torrance GW, Feeny DH, Furlong WJ, et al. Multiattribute
utility function for a comprehensive health status classifi-
cation system: Health Utilities Index Mark 2. Med Care
1996 Jul; 34 (7): 702-22
46. Shaw JW, Johnson JA, Coons SJ. US valuation of the EQ-
5D health states: development and testing of the D1 va-
luation model. Med Care 2005 Mar; 43 (3): 203-20
47. Kaplan RM, Anderson JP, Ganiants TG. The Quality of
Well-Being scale: rationale for a single quality of life index.
In: Walker SR, Rosser RM, editors. Quality of life assess-
ment: key issues in the 1990s. 2nd ed. New York: Springer-
Verlag, 1999
48. Torrance GW, Thomas WH, Sackett DL. A utility max-
imization model for evaluation of health care programs.
Health Serv Res 1972 Summer; 7 (2): 118-33
49. van Nooten F, Brouwer W. The influence of subjective ex-
pectations about length and quality of life on time trade-off
answers. Health Econ 2004 Aug; 13 (8): 819-23
50. Cullen J, Schwartz MD, Lawrence WF, et al. Short-term
impact of cancer prevention and screening activities on
quality of life. J Clin Oncol 2004 Mar 1; 22 (5): 943-52
51. Rutten-van Molken MP. Methodological issues of patient
utility measurement: experience from two clinical trials.
Med Care 1995; 33 (9): 922-37
52. O’Connor AM. Effects of framing and level of probability
on patients’ preferences for cancer chemotherapy. J Clin
Epidemiol 1989; 42 (2): 119-26
53. Bennett KJ, Torrance GW. Measuring health state prefer-
ences and utilities: rating scale, time trade-off, and standard
gamble techniques. In: Spilker B, editor. Quality of life and
pharmacoeconomics in clinical trials. Philadelphia (PA):
Lippincott-Raven, 1996: 253-65
Correspondence: Dr Lisa A. Prosser, Child Health Evalua-
tion and Research Unit, Division of General Pediatrics,
University of Michigan Health System, 300 N. Ingalls St,
Room 6E14, SPC 5456, Ann Arbor, MI 48109, USA.
E-mail: lisapros@med.umich.edu
Pharmacoeconomics 2009; 27 (9)