Original Article
The standard gamble showed better construct validity than the time trade-off

https://doi.org/10.1016/j.jclinepi.2007.03.001Get rights and content

Abstract

Background and objective

There is little evidence for the relative cross-sectional validity of the standard gamble (SG) and time trade-off (TTO). We compared these preference-based instruments in patients with Irritable Bowel Syndrome (IBS).

Methods

Patients rated their own health on the SG and TTO and completed the disease-specific IBS questionnaire, the Brief Pain Inventory, the SF-36, the Sickness Impact Profile, and a global rating of disease severity.

Results

Mean scores of the 96 enrolled patients (mean age 39.5 years, 84.4% women) were 0.84 (standard deviation 0.16) for the SG and 0.76 (0.22) for the TTO. The correlation of the SG with the TTO was 0.36. For the SG, correlation coefficients with the IBS questionnaire domain scores ranged from 0.36 to 0.47, whereas those of the TTO were substantially lower (0.15–0.42). The SG also had higher correlations than the TTO with generic questionnaires (0.18–0.34 versus 0.13–0.26), Brief Pain Inventory (0.27 versus 0.11), global rating of disease severity (0.22 versus 0.10) as well as with SF-36-derived patient preferences (0.31–0.43 versus 0.27–0.31).

Conclusions

The higher correlations of the SG with validation measures indicate that the SG better reflects health-related quality of life and patient preferences compared to the TTO.

Introduction

Preference-based instruments such as the standard gamble (SG), time trade-off (TTO), and rating scales are uniquely valuable for obtaining people's values for health states, and thus facilitating economic evaluation of health care interventions [1], [2]. Preference scores express the desirability that individuals exhibit for a specific health state and allow integration of impaired quality and quantity of life. In addition, preference-based instruments are increasingly used as global measures of health-related quality of life (HRQL), but evidence about their construct validity is still scarce [3], [4], [5].

There is a debate about the most appropriate choice of preference instrument. Because the SG meets theoretical econometric assumptions, including that of choice under uncertainty, some health economists favor it as the gold standard for measuring preferences [2]. Other investigators argue that the TTO is more consistent with individual preferences than the SG, less prone to bias [6], [7] and easier for patients to understand [8], [9], [10].

Current evidence suggests that the results of preference ratings from the SG are not interchangeable with the TTO. The SG yields systematically higher scores than the TTO [7]. Several studies showed that correlations between the SG and TTO are too low to allow for corrections or equations that would transform one score into another [8], [9], [11], [12], [13], [14], [15], [16].

To decide between instruments, investigators should have support for the validity of the instruments they use (i.e., the results represent what they intend to measure). Only a few studies compared the relative construct validity (i.e., correlation of preference scores with scores of other measures) of the SG and TTO [11], [13]. The aim of this study was to compare the cross-sectional construct validity of the SG and TTO in patients with Irritable Bowel Syndrome (IBS). IBS represents the most common disorder in gastroenterology practice [17] affecting over 15% of the general population [18], [19] and leading to substantial impairment in HRQL [20].

Section snippets

Study design and patients

For this analysis, we used data from a study that aimed at developing a disease-specific HRQL instrument for patients with IBS [21]. In brief, this was a cross-sectional study with one comprehensive assessment at either McMaster Health Sciences Centre, Hamilton, Canada or the patient's home. We identified patients through medical records of the gastroenterology clinic at McMaster Health Sciences Centre and through 10 local gastroenterologists.

We included patients between 18 and 75 years of age

Results

We enrolled 100 patients with IBS, of whom 96 completed all HRQL instruments. Table 1 shows their characteristics and the baseline scores of the utility and HRQL instruments. Most of the study participants were women around 40 years of age; almost 25% finished 8th grade or less. The SG scores were higher, with a smaller SD, compared to the TTO. Patients demonstrated widely varying scores on the validation measures indicating that the study population represented a broad sample of IBS patients.

Discussion

This comparison of the cross-sectional construct validity of the SG and TTO demonstrated higher correlations with generic and specific HRQL questionnaires as well as SF-36 derived preferences for the SG. The results suggest that in patients with IBS, the SG better reflects HRQL and patient preferences compared to the TTO.

Strengths of this study include the standardized administration of the utility instruments by a trained research assistant and the large number of validation measures. The

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