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Objectives To estimate capability wellbeing lost from the general adult populations in the UK, Australia and the Netherlands in the first year of the COVID-19 pandemic and the associated social restrictions, including lockdowns. Design Cross-sectional with recalled timepoints. Setting Online panels in the UK, Australia and the Netherlands conducted in February 2021 (data collected 26 January–2 March 2021). Participants Representative general adult (≥ 18 years old) population samples in the UK (n = 1,017), Australia (n = 1,011) and the Netherlands (n = 1,017) Main outcome measure Participants completed the ICECAP-A capability wellbeing measure in February 2021, and for two recalled timepoints during the initial lockdowns in April 2020 and in February 2020 (prior to COVID-19 restrictions in all three countries). ICECAP-A scores on a 0–1 no capability–full capability scale were calculated for each timepoint. Societal willingness to pay estimates for a year of full capability (YFC) was used to place a monetary value associated with change in capability per person and per country. Paired t tests were used to compare changes in ICECAP-A and YFC from pre- to post-COVID-19-related restrictions in each country. Results Mean (standard deviation) loss of capability wellbeing during the initial lockdown was 0.100 (0.17) in the UK, 0.074 (0.17) in Australia and 0.049 (0.12) in the Netherlands. In February 2021, losses compared to pre-lockdown were 0.043 (0.14) in the UK, 0.022 (0.13) in Australia and 0.006 (0.11) in the Netherlands. In monetary terms, these losses were equivalent to £14.8 billion, AUD$8.6 billion and €2.1 billion lost per month in April 2020 and £6.4 billion, A$2.6 billion and €260 million per month in February 2021 for the UK, Australia and the Netherlands, respectively. Conclusions There were substantial losses in capability wellbeing in the first year of the COVID-19 pandemic. Future research is required to understand the specific impact of particular COVID-19 restrictions on people’s capabilities.

Methods for measuring outcomes suitable for economic evaluations of health and care interventions have primarily focused on adults. The validity of such methods for children and young people is questionable in areas including the outcome domains measured and how they are measured and valued, with most existing measures narrowly focusing on health. Novel methods for assessing benefits beyond health by focusing on a person's capability have also concentrated on adults to date. This paper aims to set out the rationale for capability measures in children and young people. It argues for the need to expand the evaluative space beyond health functioning towards broader capabilities, with children and young people playing an integral role in capability measure development. Drawing from existing literature, specific challenges related to the identification, measurement, and valuation of capabilities in children and young people are also discussed. Finally, the practical implications for conducting economic evaluation when measuring and valuing capabilities at different stages across the life-course are illustrated. We develop an alternative framework based on conceiving capabilities as evolving across the life-course. This framework may also be helpful in thinking about how to model health outcomes across the life-course.

As the cross-cultural use of outcome measures grows, it is important to determine whether these instruments are: appropriate for use in other settings, translated accurately, and perform in a similar manner to their original tools. This research aimed to compare the validity of the German translation of the ICECAP-A to the original English version of the instrument, across healthy adults and seven health condition groups (arthritis, asthma, cancer, depression, diabetes, hearing loss and heart disease). Data were analysed from a cross-cultural study, which recruited participants through online panels in 2012. Data were analysed on capability wellbeing (ICECAP-A), health-related quality of life (EQ-5D-5L and SF-6D), satisfaction with life (SWLS), and a series of other condition-specific outcome measures. The ICECAP-A was assessed for internal consistency, convergent validity and construct validity. 2501 individuals were included in the analysis. The ICECAP-A demonstrated good internal consistency within Germany and the UK population, and across all seven health condition sub-groups (α = .74–.86). In both countries, ICECAP-A scores were significantly correlated with SWLS, SF-6D and EQ-5D-5L scores for healthy participants and health condition groups (r = .35–.77). Finally, experiencing one of the seven health conditions (compared to being healthy) was significantly associated with lower levels of capability wellbeing in the German and UK samples (construct validity). The German translation of the ICECAP-A yielded valid and reliable data, in both healthy respondents and the seven health condition groups. Further work could be undertaken to develop a German specific value-set for the ICECAP-A.

Background Palliative Care Day Services (PCDS) offer supportive care to people with advanced, progressive illness who may be approaching the end of life. Despite the growth of PCDS in recent years, evidence of their costs and effects is scarce. It is important to establish the value of such services so that health and care decision-makers can make evidence-based resource allocation decisions. This study examines and estimates the costs and effects of PCDS with different service configurations in three centres across the UK in England, Scotland and Northern Ireland. Methods People who had been referred to PCDS were recruited between June 2017 and September 2018. A pragmatic before-and-after descriptive cohort study design analysed data on costs and outcomes. Data on costs were collected on health and care use in the 4 weeks preceding PCDS attendance using adapted versions of the Client Service Receipt Inventory (CSRI). Outcomes, cost per attendee/day and volunteer contribution to PCDS were also estimated. Outcomes included quality of life (MQOL-E), health status (EQ-5D-5L) and capability wellbeing (ICECAP-SCM). Results Thirty-eight attendees were recruited and provided data at baseline and 4 weeks (centre 1: n = 8; centre 2: n = 8, centre 3: n = 22). The cost per attendee/day ranged from £121–£190 (excluding volunteer contribution) to £172–£264 (including volunteer contribution) across the three sites. Volunteering constituted between 28 and 38% of the total cost of PCDS provision. There was no significant mean change at 4 week follow-up from baseline for health and care costs (centre 1: £570, centre 2: -£1127, centre 3: £65), or outcomes: MQOL-E (centre 1: − 0.48, centre 2: 0.01, centre 3: 0.24); EQ-5D-5L (centre 1: 0.05, centre 2: 0.03, centre 3: − 0.03) and ICECAP-SCM (centre 1:0.00, centre 2: − 0.01, centre 3: 0.03). Centre costs variation is almost double per attendee when attendance rates are held constant in scenario analysis. Conclusions This study highlights the contribution made by volunteers to PCDS provision. There is insufficient evidence on whether outcomes improved, or costs were reduced, in the three different service configurations for PCDS. We suggest how future research may overcome some of the challenges we encountered, to better address questions of cost-effectiveness in PCDS.

BackgroundThis study aimed to provide the first assessment of construct validity of ICECAP-A in patients with cardiovascular disease, chronic obstructive pulmonary disease and diabetes, and to assess the responsiveness of the measure in this group. MethodData were provided from patients attending rehabilitation in the municipality of Aalborg, Denmark, from March 2018 to March 2019. Patients answered a questionnaire from the healthcare centre and the ICECAP-A at baseline and 12 weeks follow-up. To assess construct validity, a priori hypotheses were developed. Based on these hypotheses, associations between sociodemographic characteristics, ‘general health’, a freedom dimension, and ICECAP-A were analysed through chi-squared tests and Spearman rank correlations for categorical and ordinal variables, respectively. To investigate responsiveness, the anchor-based method was used. Patients were divided into improved, worsened or no change, based on changes between baseline and follow-up on the anchor measures (‘general health’ and ‘freedom’). To quantify responsiveness, both the weighted and un-weighted ICECAP-A scores’ effect sizes, standardised response means and t-tests were used. Findings were explored across different age groups.ResultOf all the hypothesised associations, 16 of 26 (62%) were in the expected direction. The expected relationships were found between ICECAP-A scores and general health and freedom to do things. ICECAP-A was responsive in terms of capturing the effects on general health and the freedom to do things. Differences were found across age groups, with greater responsiveness to change in those aged under 65 years. The item-by-item analysis showed that capability was mainly driven by stability and autonomy.ConclusionThis study has shown that the Danish ICECAP-A is a valid and responsive measure of the effects of an exercise and education-based rehabilitation programme.

ObjectivesTo determine the response process validity, feasibility of completion, acceptability and preferences for three patient-reported outcome measures that could be used in economic evaluation—the EQ-5D-5L, ICECAP-A and ICECAP-O—in people requiring kidney care.DesignParticipants were asked to ‘think-aloud’ while completing the EQ-5D-5L, ICECAP-A and ICECAP-O, followed by a semistructured interview. Five raters identified errors or struggles in completing the measures from the think-aloud component of the transcripts. Patient preferences for measures were extracted from the semistructured interview.SettingEligible patients were identified through a large UK secondary care renal centre.ParticipantsIn total, 30 participants were included in the study, consisting of patients attending renal outpatients for chronic kidney disease (n=18), with a functioning kidney transplant (n=6) and receiving haemodialysis (n=6).ResultsParticipants had few errors and struggles in completing the EQ-5D-5L (11% error rate, 3% struggle rate), ICECAP-A (2% error rate, 2% struggle rate) and ICECAP-O (4% error rate, 3% struggle rate). The main errors with the EQ-5D-5L were judgements that did not comply with the ‘your health today’ instruction. Comprehension errors were most prominent on ICECAP-O. Judgement errors were the only errors reported on ICECAP-A. Although the EQ-5D-5L had slightly more errors and struggles, it was the measure most preferred, with participants able to make a clearer link with EQ-5D-5L and their health condition.ConclusionsThe EQ-5D-5L, ICECAP-A and ICECAP-O are feasible for people requiring kidney care to complete and can be included in studies conducting economic evaluations of kidney care interventions. Further research is required to assess how health (eg, EQ-5D) and capability (eg, ICECAP) measures can be included in an economic evaluation simultaneously, as well as what ICECAP measure(s) to include when patient groups straddle the age ranges for ICECAP-A (18 years and older) and ICECAP-O (65 years and older).

This chapter focuses on the ethical values that underpin different types of economic evaluation. Welfarism, the standard health maximization approach to extra-welfarism, and a capability approach to extra-welfarism are all discussed in terms of the different values incorporated. Alternative decision rules around maximization and sufficiency are also examined. These theoretical discussions are then supplemented by two case studies related to mental health. The first considers the relative priority that might be given to depression treatment relative to a variety of physical health conditions, using both forms of extra-welfarism. The second explores the use of health and capability measures in interventions for drug addiction. The evidence presented indicates that interventions for mental health conditions will receive different priorities where different value judgements form the basis for the economic evaluation. This underlines the importance of these ethical decisions.

Recent years have seen increased engagement amongst health economists with the capability approach developed by Amartya Sen and others. This paper focuses on the capability approach in relation to the evaluative space used for analysis within health economics. It considers the opportunities that the capability approach offers in extending this space, but also the methodological challenges associated with moving from the theoretical concepts to practical empirical applications. The paper then examines three 'families' of measures, Oxford Capability instruments (OxCap), Adult Social Care Outcome Toolkit (ASCOT) and ICEpop CAPability (ICECAP), in terms of the methodological choices made in each case. The paper concludes by discussing some of the broader issues involved in making use of the capability approach in health economics. It also suggests that continued exploration of the impact of different methodological choices will be important in moving forward.

There is a debate in the health economics literature concerning the most appropriate way of applying Amartya Sen's capability approach in economic evaluation studies. Some suggest that quality-adjusted life years (QALYs) alone are adequate while others argue that this approach is too narrow and that direct measures of capability wellbeing provide a more extensive application of Sen's paradigm.This paper empirically explores whether QALYs provide a good proxy for individual capabilities.Data is taken from a multinational cross-sectional survey of individuals with seven health conditions (asthma, arthritis, cancer, depression, diabetes, hearing loss, heart disease) and a healthy population. Each individual completed the ICECAP-A measure of capability wellbeing for adults and six health utility instruments that are used to generate QALYs, including EQ-5D and SF-6D. Primary analysis examines how well health utility instruments can explain variation in the ICECAP-A using ordinary least squares regression.The findings show that all seven health conditions have a negative association on overall capability as measured by the ICECAP-A index. Inclusion of health utility instruments into separate regressions improves the predictive power of capability but on average, explains less than half of the variation in capability wellbeing. Individuals with arthritis appear to be less inhibited in terms of capability losses when accounting for health utility, yet those who have depression record significant reductions in capability relative to the healthy population even after accounting for the most commonly used health utility instruments.The study therefore casts doubt on the ability of QALYs to act as a reliable proxy measure of individuals' capability.

The primary aims of this review are to document capability applications in the health field and to explore the objectives and decision-rules of studies measuring capability more broadly. Relevant studies are identified using a literature search strategy known as "comprehensive pearl growing". All studies with a primary focus on health are assessed individually, whilst a summary narrative analysis of the full review examines the objectives of capability studies. Four distinct groups in the health field are identified in the review: (1) physical activity and diet; (2) patient empowerment; (3) multidimensional poverty and (4) assessments of health and social care interventions. Different approaches to applying mixed methods, selecting capability dimensions and weighting capabilities are found across studies. There is a noticeable non-reliance on health status as a sole indicator of capability in health. In terms of objectives of studies measuring capability, although there is a lack of consistency, an objective related to sufficiency of capabilities appeared most often in the studies found in this review. Even though one of the appeals of the capability perspective is its underspecified nature, this review highlights the challenge of finding a coherent alternative to more established approaches of evaluation.

Context: Statistical models employed in analysing patient-level cost and effectiveness data need to be flexible enough to adjust for any imbalanced covariates, account for correlations between key parameters, and accommodate potential skewed distributions of costs and/or effects. We compare prominent statistical models for cost-effectiveness analysis alongside randomised controlled trials (RCTs) and covariate adjustment to assess their performance and accuracy using data from a large RCT.Methods: Seemingly unrelated regressions, linear regression of net monetary benefits, and Bayesian generalized linear models with various distributional assumptions were used to analyse data from the TASMINH2 trial. Each model adjusted for covariates prognostic of costs and outcomes. Results: Cost-effectiveness results were notably sensitive to model choice. Models assuming normally distributed costs and effects provided a poor fit to the data, and potentially misleading inference. Allowing for a beta distribution captured the true incremental difference in effects and changed the decision as to which treatment is preferable. Conclusions: Our findings suggest that Bayesian generalized linear models which allow for non-normality in estimation offer an attractive tool for researchers undertaking cost-effectiveness analyses. The flexibility provided by such methods allows the researcher to analyse patient-level data which are not necessarily normally distributed, while at the same time it enables assessing the effect of various baseline covariates on cost-effectiveness results.

Amartya Sen's capability approach has been discussed widely in the health economics discipline. Although measures have been developed to assess capability in economic evaluation, there has been much less attention paid to the decision rules that might be applied alongside. Here, new methods, drawing on the multidimensional poverty and health economics literature, are developed for conducting economic evaluation within the capability approach and focusing on an objective of achieving "sufficient capability". This objective more closely reflects the concern with equity that pervades the capability approach and the method has the advantage of retaining the longitudinal aspect of estimating outcome that is associated with quality-adjusted life years (QALYs), whilst also drawing on notions of shortfall associated with assessments of poverty. Economic evaluation from this perspective is illustrated in an osteoarthritis patient group undergoing joint replacement, with capability wellbeing assessed using ICECAP-O. Recommendations for taking the sufficient capability approach forward are provided.

Background. There is a growing interest in the application of the capability approach in health economic analysis. The aim of the research reported here is to assess the feasibility of mapping from a condition-specific questionnaire (Western Ontario and McMaster Universities [WOMAC] Osteoarthritis Index) to a capability well-being questionnaire (ICEpop CAPability measure for Older people [ICECAP-O]). Methods. One hundred five osteoarthritis patients requiring joint replacement completed the 5 attributes on the ICECAP-O (attachment, security, role, enjoyment, and control) and the 3 WOMAC categories (pain, stiffness, and physical function). The prediction data set consisted of baseline scores, whereas follow-up data were used to validate the predictions. The mapping algorithms used ordinary least squares and multinomial logistic regression models to predict the relationship between WOMAC scores, categories, or items and ICECAP-O scores or the 5 ICECAP-O attributes. Results. ICECAP-O scores predicted from WOMAC category scores produced the lowest mapping error statistics (mean absolute error = 0.0832; mean squared error = 0.0142) as well as highest goodness of fit (R2 = 0.3976). Prediction of ICECAP-O attributes from WOMAC category scores was possible for the majority of capability dimensions. The “control” attribute and physical function WOMAC category exhibited the strongest relationship (R2 = 0.2143). The “attachment” attribute proved difficult to predict from any WOMAC category, which is in line with intuition given this attribute captures psychological well-being rather than pain, stiffness, or physical function. Conclusion. This is the first study to investigate the predictive ability of a condition-specific measure of health onto capability. The results presented here suggest it is feasible to map from condition-specific measures to an overall capability index, although WOMAC cannot predict individual capability in its entirety. Although the results here are encouraging for those interested in using ICECAP-O, given the small validation sample size applied, further research will be required to verify these findings.

Direct assessment of capability to function may be useful in healthcare settings, but poses many challenges. This paper reports a first investigation of the feasibility of individuals self-reporting their capabilities and the meaning of the responses. The study was conducted in 2010, using think-aloud interviews with participants in the UK. The findings of the study suggest that the majority of participants were able to comprehend questions about their capabilities, felt able to judge their own capability wellbeing and provided responses in line with this judgement. In a number of cases, for example in relation to ‘autonomy’, participants highlighted that their capability was potentially greater than their functioning. The findings also show varying interpretations of the capability concept, with some participants finding the capability concept unintuitive in relation to specific aspects of life (in particular, ‘attachment’). The findings suggest that guiding individuals in the process of identifying their capabilities may be important in generating consistent responses to capability questions., Highlights • Think-aloud interviews were used, in the UK, to study the response to capability wellbeing questions. • Most people felt able to judge their capabilities and made few obvious ‘errors’ in doing so. • The capability concept was unintuitive for some people in some aspects of their life. • Occasional divergence between capability and functioning was reported.

Background For outcome measures to be useful in health and care decision-making, they need to have certain psychometric properties. The ICECAP-Supportive Care Measure (ICECAP-SCM), a seven attribute measure (1. Choice, 2. Love and affection, 3. Physical suffering, 4. Emotional suffering, 5. Dignity, 6. Being supported, 7. Preparation) developed for use in economic evaluation of end-of-life interventions, has face validity and is feasible to use. This study aimed to assess the construct validity and responsiveness of the ICECAP-SCM in hospice inpatient and outpatient settings. Methods A secondary analysis of data collated from two studies, one focusing on palliative care day services and the other on constipation management, undertaken in the same national hospice organisation across three UK hospices, was conducted. Other quality of life and wellbeing outcome measures used were the EQ-5D-5L, McGill Quality of Life Questionnaire – Expanded (MQOL-E), Patient Health Questionnaire-2 (PHQ-2) and Palliative Outcomes Scale Symptom list (POS-S). The construct validity of the ICECAP-SCM was assessed, following hypotheses generation, by calculating correlations between: (i) its domains and the domains of other outcome measures, (ii) its summary score and the other measures’ domains, (iii) its summary score and the summary scores of the other measures. The responsiveness of the ICECAP-SCM was assessed using anchor-based methods to understand change over time. Statistical analysis consisted of Spearman and Pearson correlations for construct validity and paired t-tests for the responsiveness analysis. Results Sixty-eight participants were included in the baseline analysis. Five strong correlations were found with ICECAP-SCM attributes and items on the other measures: four with the Emotional suffering attribute (Anxiety/depression on EQ-5D-5L, Psychological and Burden on MQOL-E and Feeling down, depressed or hopeless on PHQ-2), and one with Physical suffering (Weakness or lack of energy on POS-S). ICECAP-SCM attributes and scores were most strongly associated with the MQOL-E measure (0.73 correlation coefficient between summary scores). The responsiveness analysis (n = 36) showed the ICECAP-SCM score was responsive to change when anchored to changes on the MQOL-E over time (p Conclusions This study provides initial evidence of construct validity and responsiveness of the ICECAP-SCM in hospice settings and suggests its potential for use in end-of-life care research.