Background: Health state utilities (HSUs) are a key parameter in cost effectiveness analyses (CEAs), yet heterogeneity in valuation methods, patient populations, and health state descriptions makes identification of appropriate HSUs challenging. We catalogued HSUs associated with lower extremity peripheral artery disease (PAD) and examined their application in published CEAs.

Methods: We searched the Tufts CEA Registry for CEAs that included ≥1 health state in PAD: major amputation of vascular etiology, acute limb ischemia, ischemic stroke, myocardial infarction, and major bleeding. After retrieving the original valuation publications from which each HSU was sourced, we extracted information about the study population, health state description, HSU estimate and surrounding uncertainty, valuation method, and assessment timeframe (e.g., 6 months after stroke) into standardized forms.

Results: We identified 373 original HSUs (acute limb ischemia [n=153], myocardial infarction [n=90], ischemic stroke [n=74], major amputation [n=34], and major bleeding [n=22]). Valuation studies used direct elicitation methods (e.g., time tradeoff and standard gamble) less frequently than indirect instruments (e.g., EQ-5D), with variation across health states (7% of studies that evaluated myocardial infarction HSUs used direct methods vs. 33% of major bleeding studies). Substantial variation in HSU point estimates was present within health states (e.g., range 0.3 - 0.8 for major amputation), due to differences in health state definition, valuation method, and the clinical severity and geography of the source population.

CEAs which identified HSUs through secondary sources were more likely to reference other CEAs as the source of HSUs (versus an original valuation study), apply outdated HSUs (e.g., elicited >20 years ago), and use HSUs that were not empirically measured (e.g., estimated by expert opinion or author assumption).

Conclusion: Our study documented a high degree of HSU heterogeneity within PAD health states. Creation of a utility catalogue can facilitate selection of appropriate HSU estimates for economic evaluation.