A Cross-sectional Assessment of Health-related Quality of Life among Patients with Chronic Obstructive Pulmonary Disease

Abstract

Background
Chronic obstructive pulmonary disease (COPD) is a major cause of mortality characterized by progressive airflow obstruction and inflammation in the airways, which has an impact on health-related quality of life. The EQ-5D-5L is one of the most used preference-based, health-related quality of life questionnaire. The objective of this study was to provide normative values of EQ-5D-5L for Spanish people suffering from COPD.

Methods
Data were extracted from the Spanish National Health Survey (2011/2012). Overall, 1130 people with COPD participated in this survey. The utility index of EQ-5D-5L and the Visual Analog Scale (VAS) score were defined by gender, region, and age.

Results
Mean (SD) EQ-5D-5L utility index and VAS score for Spanish people with COPD were 0.742 (0.309) and 60.466 (21.934) respectively. In general, men reported better health status than women. Ceiling effect of the whole sample was 30.35%.

Conclusion
The current study provides normative values of EQ-5D-5L for Spanish people affected by COPD. Ceiling effect was high and better results were observed in men compared with women.

Full text

Iran J Public Health, Vol. 46, No.8, Aug 2017, pp.1046-1053 Original Article
1046 Available at: http://ijph.tums.ac.ir
A Cross-sectional Assessment of Health-related Quality of Life
among Patients with Chronic Obstructive Pulmonary Disease
*Miguel Ángel GARCIA-GORDILLO 1,2 , Daniel COLLADO-MATEO
3, Pedro Rufino
OLIVARES
4,5 , José Carmelo ADSUAR
2,3 , Eugenio MERELLANO-NAVARRO
4
1. Dept. of Economics, Faculty of Economics and Business Sciences, University of Extremadura, Badajoz, Spain
2. Dept. of Applied Economics, Faculty of Economics and Business, University of Murcia, Murcia, Spain
3. Faculty of Sport Sciences, University of Extremadura, Cáceres, Spain
4. Instituto de Actividad Fisica y Salud, Universidad Autonoma de Chile, Talca, Chile
5. Higher Institute of Physical Education, University of the Republic, Montevideo, Uruguay
*Corresponding Author: Email: miguelgarciagordillo@gmail.com
(Received 24 Aug 2016; accepted 11 Dec 2016)
Introduction
Chronic obstructive pulmonary disease (COPD)
is a major cause of morbidity and mortality
worldwide, characterized by progressive airflow
obstruction and inflammation in the airways (1).
According to the World Health Organization, it
is not one single disease but an umbrella term,
which includes chronic lung diseases that affect
the airflow. In this regard, chronic bronchitis and
emphysema are now included within the COPD
diagnosis.
The estimated prevalence of COPD in Spanish
adults aged 40-80 years is 10.2% and is higher in
men (15.6%) than in women (5.6%). This preva-
lence is increased with age and with cigarette
smoking (2). COPD is associated with reduced
health-related quality of life (HRQoL) but the
reduction is stronger on the physical than on the
mental component of HRQoL. The impact of
severe COPD on HRQoL is higher than the re-
ported impact of other diseases such as diabetes
or self-reported cardiovascular diseases (3).
Comorbidities in COPD are also associated with
worse HRQoL and excess in costs, especially,
cardiovascular diseases, depression, anxiety and
diabetes (4, 5). COPD imposes a substantial bur-
den. According to the study in Spain, the total
Abstract
Background: Chronic obstructive pulmonary disease (COPD) is a major cause of mortality characterized by progres-
sive airflow obstruction and inflammation in the airways, which has an impact on health-related quality of life. The
EQ-5D-5L is one of the most used preference-based, health-related quality of life questionnaire. The objective of this
study was to provide normative values of EQ-5D-5L for Spanish people suffering from COPD.
Methods:
Data were extracted from the Spanish National Health Survey (2011/2012). Overall, 1130 people with
COPD participated in this survey. The utility index of EQ-5D-5L and the Visual Analog Scale (VAS) score were de-
fined by gender, region, and age.
Results:
Mean (SD) EQ-5D-5L utility index and VAS score for Spanish people with COPD were 0.742 (0.309) and
60.466 (21.934) respectively. In general, men reported better health status than women. Ceiling effect of the whole
sample was 30.35%.
Conclusion:
The current study provides normative values of EQ-5D-5L for Spanish people affected by COPD.
Ceiling effect was high and better results were observed in men compared with women.
Keywords:
EQ-5D, Quality of life, COPD, Pulmonary disease, Normative values

Garcia-Gordillo et al.: A Cross-sectional Assessment of Health-related Quality of Life …
Available at: http://ijph.tums.ac.ir 1047
cost per patient per year was €1922.60 (6). Of
that amount, hospitalization costs were the high-
est with €788.72; followed by cost of drugs,
€492.87; and emergencies, €134.32.
The EQ-5D-5L (7) is one of the most used tools
to evaluate HRQoL. It was developed from the
previous version of EQ-5D, which only included
3 levels of problem (8). The questionnaire also
includes a Visual Analogue Scale (VAS), on
which the best imaginable health state is marked
100 and the worst is marked 0.
There are few studies using EQ-5D-5L in pa-
tients with COPD. A multi-country (Denmark,
England, Italy, Netherlands, Poland, and Scot-
land) study compared the properties of EQ-5D-
3L and EQ-5D-5L across 8 patient groups, in-
cluding respiratory disease (COPD or asthma)
(9). In that study, absolute discriminatory power
had remarkably improved with EQ-5D-5L.
Normative values for a specific region and condi-
tion are often useful in the interpretation of re-
sults by other researchers, taking into account
deviations according to age, gender or other va-
riables. In this regard, there is a lack of normative
values for Spanish people suffering from COPD.
Therefore, the main objective of the current
study is to provide the normative values of EQ-
5D-5L from a representative Spanish sample with
COPD.
Methods
The current cross-sectional study used data from
the Spanish National Health Survey. This survey
is periodically conducted by the Spanish Ministry
of Health, Social Services, and Equality. Acquisi-
tion of data was performed between Jul 2011 and
Jun 2012. The method utilized to collect data was
computer-assisted personal interviews (CAPI).
The mentioned survey included the EQ-5D-5L in
the health status block for the first time since it is
performed.
The sample of the Spanish National Health Sur-
vey is representative for the Spanish population
and for the 17 autonomous regions and the 2
autonomous cities. Totally, 21007 participants
completed the survey. Of these, 1130 (15-102 yr)
were diagnosed with EPOC (including emphy-
sema and chronic bronchitis).
Statistical analysis
The current study presents descriptive statistics
(mean, SD, median, interquartile range –IQR-
and ceiling effect) of EQ-5D-5L utility index and
VAS. The whole sample was stratified by gender,
age groups, and 19 regions. Potential influence of
marital status, smoking status, net monthly in-
come of household, and educational level were
also considered.
The 5-digit EQ-5D-5L health status and the VAS
were obtained from the Spanish National Health
Survey. The health status 11111 would be the
perfect health state, whereas 55555 would mean
the worst imaginable health state. EQ-5D-5L
utility was calculated from the 5-digit health sta-
tus score by using the algorithm available at the
website of the EuroQol Group (http://
http://www.euroqol.org/). In Spanish population,
this algorithm to calculate EQ-5D-5L utility is the
result of a “crosswalk” from the version with 3
levels. The EQ-5D-5L utility index for Spanish
population can range from -0.654 (worst imagina-
ble health status) to 1 (perfect health status).
Therefore, ceiling effect can be calculated as the
frequency of the health status 11111, whereas the
floor effect would be the opposite, i.e. the fre-
quency of the health status 55555. Given that the
floor effect is not reported in the EQ-5D-5L, the
current study only evaluates the frequency (total
number and percentage) of the perfect health
state in order to calculate the ceiling effect.
Mann-Whitney U and Kruskal-Wallis H non-
parametric tests were used in the analysis of the
subgroups. A p-value 0.05 was set for all the tests
in order to indicate statistical significance. The
answers "do not know" and "no answer" were
considered as missing data.
Results
The mean and SD of EQ-5D-5L utility and the
VAS score can be seen in Table 1.

Iran J Public Health, Vol. 46, No.8, Aug 2017, pp. 1046-1053
1048 Available at: http://ijph.tums.ac.ir
Table 1: Study sample characteristics EQ-5D-5L population norms
EQ-5D-5L Index
EQ-5D-VAS
Ceiling effect
P-
value
n (%)
Mean (SD)
Median (IQR)
Mean (SD)
Median (IQR)
n (%)
Overall
1,130 (-)
0.74 (0.31)
0.85 (0.38)
60.47 (21.93)
61 (29)
343 (30.35)
Gender
<0.001a
Male
550 (48.67)
0.8 (0.28)
0.91 (0.3)
61.87 (21.66)
65 (29)
206 (37.45)
Female
580 (51.33)
0.69 (0.33)
0.8 (0.39)
59.16 (22.13)
60 (30)
137 (23.62)
Age group
<0.001b
15-39
129 (11.42)
0.94 (0.10)
1 (0.09)
76.64 (19.22)
81 (21)
87 (67.44)
40-65
397 (35.13)
0.80 (0.25)
0.90 (0.26)
62.8 (20.81)
64 (29)
135 (34.01)
66-102
604 (53.45)
0.66 (0.34)
0.74 (0.40)
55.3 (21.23)
55 (29.5)
121 (20.03)
Region
0.09b
Andalusia
123 (10.88)
0.68 (0.35)
0.83 (0.39)
55.94 (21.75)
55 (32)
25 (20.33)
Aragon
42 (3.72)
0.73 (0.32)
0.84 (0.37)
59.26 (17.88)
55 (20.25)
14 (33.33)
Principality of Asturias
64 (5.66)
0.7 (0.33)
0.78 (0.41)
59.16 (19.86)
60 (26.5)
19 (29.69)
Balearic Island
31 (2.74)
0.78 (0.25)
0.89 (0.4)
65.35 (25.81)
74 (41)
12 (38.71)
Canarias
74 (6.55)
0.69 (0.3)
0.78 (0.39)
59.3 (21.13)
60 (26)
14 (18.92)
Cantabria
29 (2.57)
0.63 (0.43)
0.89 (0.7)
49.9 (19.04)
50 (23)
9 (31.03)
Castile and Leon
73 (6.46)
0.82 (0.18)
0.84 (0.3)
58.9 (21.12)
60 (37)
22 (30.14)
Castile -La Mancha
69 (6.11)
0.66 (0.4)
0.85 (0.63)
57.41 (24.78)
60 (41)
24 (34.78)
Catalonia
149 (13.19)
0.77 (0.26)
0.86 (0.4)
64.13 (21.89)
69 (30)
42 (28.19)
Community of Valencia
83 (7.35)
0.73 (0.33)
0.83 (0.33)
60.92 (20.04)
61 (26)
28 (33.73)
Extremadura
56 (4.96)
0.82 (0.2)
0.88 (0.29)
55.4 (23.59)
59 (31)
18 (32.14)
Galicia
72 (6.37)
0.72 (0.33)
0.86 (0.43)
61.1 7(20.1)
64 (24)
20 (27.78)
Community of Madrid
78 (6.9)
0.76 (0.29)
0.89 (0.32)
64.5 (23.71)
69 (35)
24 (30.77)
Murcia Region
51 (4.51)
0.81 (0.22)
0.88 (0.34)
62.71 (22.73)
64 (31)
19 (37.25)
Community of Navarre
47 (4.16)
0.81 (0.23)
0.86 (0.27)
61.51 (18.01)
66 (22)
12 (25.53)
Basque Country
56 (4.96)
0.72 (0.39)
0.89 (0.36)
65.14 (22.66)
70 (32.25)
24 (42.86)
La Rioja
19 (1.68)
0.88 (0.24)
1 (0.14)
77.16 (18.21)
84 (20)
12 (63.16)
Ceuta
9 (0.8)
0.85 (0.17)
0.91 (0.31)
60.11 (29.27)
71 (43.5)
3 (33.33)
Melilla
5 (0.44)
0.82 (0.22)
0.93 (0.42)
49.8 (28.65)
41 (44)
2 (40)
Marital status
<0.001b
Single
226 (20)
0.84 (0.23)
0.91 (0.21)
65.75 (23.01)
70 (32.5)
101 (44.69)
Married
572 (50.62)
0.77 (0.3)
0.89 (0.35)
60.74 (21.44)
62 (28)
192 (33.57)
Divorced/separated
75 (6.64)
0.78 (0.27)
0.67 (0.47)
60.13 (21.65)
54 (30)
18 (24)
Widowed
255 (22.57)
0.59 (0.34)
0.86 (0.21)
55.16 (21.11)
63 (26)
31 (12.16)
Smoking status
<0.001a
Yes
282 (24.96)
0.83 (0.25)
0.91 (0.23)
64.97 (20.95)
70 (29)
108 (38.3)
No
847 (74.96)
0.71 (0.32)
0.82 (0.43)
58.93 (22.07)
60 (31)
235 (27.74)
Net monthly income household
<0.001b
Less than 550 €
106 (9.38)
0.69 (0.31)
0.77 (0.36)
57.82 (20.66)
55.5 (26.3)
19 (17.92)
551-1,300 €
523 (46.28)
0.71 (0.31)
0.82 (0.42)
58.38 (21.85)
60 (31)
130 (24.86)
1,301-2,250 €
186 (16.46)
0.78 (0.31)
0.89 (0.3)
61.9 (22.93)
65 (31)
70 (37.63)
2,251-3,450 €
72 (6.37)
0.81 (0.31)
0.93 (0.26)
66.01 (22.93)
72.5 (33.3)
35 (48.61)
3,451 + €
19 (1.68)
0.92 (0.14)
1 (0.11)
71.63 (14.37)
70 (21)
12 (63.16)
Educational level
<0.001b
Low
552 (48.85)
0.67 (0.33)
0.76 (0.38)
55.59 (21.61)
56 (30)
114 (20.65)
Medium
463 (40.97)
0.79 (0.28)
0.89 (0.29)
63.45 (21.71)
66 (31)
165 (35.64)
High
115 (10.18)
0.88 (0.21)
1 (0.14)
70.87 (18.43)
74 (21)
64 (55.65)
a, Mann-Whitney U. b, Kruskal Wallis H.
Educational level: According to the International Standard Classification of Education (ISCED); Low educational level (Early childhood edu-
cation and Primary education), Medium educational level (Lower secondary education, Upper secondary education and Post-secondary non-
tertiary education) and High educational level (tertiary education).
A total of 1130 COPD patients participated in
the survey. Of these, 550 (48.67%) were males
and 580 (51.33%) were females. Mean (SD) EQ-
5D-5L utility for the whole sample was 0.74
(0.30). In general terms, men reported higher
scores in this utility [0.79 (0.27)] than women
[0.69 (0.32)]. The VAS score was slightly higher
in men compared with women, 61.86 (21.65) and
59.16 (22.12), respectively.
Age had a relevant effect in the utility index and
VAS score. In this regard, older age groups re-
ported much lower scores on both measures than
younger groups. Results varied by region; higher
scores in the utility were observed in La Rioja
and the autonomous city of Ceuta, 0.88 (0.23)
and 0.85 (0.16) respectively. On the other hand,
worst results were observed in Cantabria and
Castile-La Mancha, where the utility of the EQ-

Garcia-Gordillo et al.: A Cross-sectional Assessment of Health-related Quality of Life …
Available at: http://ijph.tums.ac.ir 1049
5D-5L was 0.63 (0.43) and 0.65 (0.39) respective-
ly.
Twenty-five percent (25%) of the sample were
regular smokers. This group reported higher
scores in the utility index of EQ-5D-5L and the
VAS score compared with the non-smoker
group. As expected, the two HRQoL measures
were higher as the monthly incomes and educa-
tional level were higher. Besides, means of the
EQ-5D-5L utilities showed significant differences
(P<0.01) among the different sub-groups of de-
mographic variables, except with the region varia-
ble (0.09). Results by sex are shown in Table 2.
The score in the utility index of EQ-5D-5L re-
ported by males was higher than the reported by
females in the 9 age groups and in all the regions.
These differences were detected regardless marit-
al and smoking status. However, this tendency
was not observed in the group with higher
monthly incomes and higher educational level,
where women reported better HRQoL. In the
VAS score, the results did not entirely follow the
tendency of the utility: men reported higher
scores in 6 of the 9 age groups, and in 14 of the
19 regions. When educational level was low or
medium, men reported higher VAS scores than
women, but women reported better health status
than men when educational level was high.
Table 3 shows the distribution of EQ-5D-5L
dimensions by gender and age groups. The fre-
quency of the level of problem 5 was always
higher in the female group.
Distribution of the health status in Spanish
COPD patients can be observed in Fig. 1. The
most frequent health status was 11111. More
than 30% of the sample reported this health sta-
tus. The second and third most frequent health
states were 11121 and 11112 respectively.
Ceiling effect can be observed in Table 1 and 2,
and Fig. 1. Of 1130 participants, 343 reported
perfect health status, which means 30.35% of the
total sample. Ceiling effect was higher among
males (37.45%) than among females (23.62%). It
was reduced as the age was increased, and was
increased, as the monthly incomes and educa-
tional level were higher.
Fig. 1: Spanish distribution of EQ-5D-5L Health Status (n=1130)
Discussion
To our knowledge, this is the first article that
aims to provide normative values of EQ-5D-5L
for Spanish people affected by COPD. Spanish
men affected by COPD reported better health
status than women. These results are consistent
with previous studies that reported worse
HRQoL in women with COPD compared with
men (10, 11). This gender difference was higher

Iran J Public Health, Vol. 46, No.8, Aug 2017, pp. 1046-1053
1050 Available at: http://ijph.tums.ac.ir
in the EQ-5D-5L utility index (14%) and lower in
the VAS score (4%). Results in previous studies
also showed the same discrepancy between males
and females in other diseases, such as cancer (12)
or diabetes (13). Women and men might under-
stand or interpret differently their own health
status and there could be another important vari-
able not assessed in EQ-5D-5L that could
strongly influence their self-reported health sta-
tus.
Gender differences were reduced, as the net
monthly incomes and educational level were
higher. In this regard, bigger sex differences were
observed in those patients with less than 550€
per month and in those with low educational
level. These results support the notion of an as-
sociation between knowledge about the own dis-
ease and the ability to handle the disease better
(14) and are consistent with previous studies that
reported a positive association between educa-
tional level and knowledge about the own disease
(15, 16). Therefore, the current study supports
the relevance of health education as a tool for the
management of disease.
One of the most unexpected findings of the cur-
rent study was that smokers reported higher
scores in the utility index and the VAS compared
with non-smokers. However, one limitation of
the current study is that there was no differentia-
tion between patients that never smoked and
those that quit smoking. In this regard, the ob-
served results could be due to a high percent of
ex-smokers in the non-smokers group.
In the current study, 343 participants (30.35% of
the COPD sample) reported perfect health status.
This result is higher respect to other studies. A
multi-country study reported a ceiling effect of
only 7% in the EQ-5D-5L and 8.5% in the EQ-
5D-3L (9). However, those ceiling effects are
much lower than the observed in the EQ-5D-3L
for Spanish people with COPD (17), which was
22% (moderate COPD 29.6%, severe COPD
20%, and very severe COPD 10.6%). According
to dimensions, the greatest ceiling effect (77.8%)
was observed in the dimension “self-care”, whe-
reas the lowest was found in the dimension
“pain/discomfort” (42.9%).
Studies providing normative values of HRQoL in
special populations contribute allowing compari-
sons between specific pathologic or not-
pathologic populations and general population,
helping the development and planning of health
policy (18, 19). Normative values allow research-
ers to estimate the clinical relevance of a treat-
ment, training or intervention (20, 21) and may
be a useful tool in interpreting patient-reported
outcome results (22).
The current study has several limitations. The
most relevant limitation is the lack of another
measure that could classify patients according to
the severity of the disease. The second limitation
is the lack of an algorithm specifically designed
for EQ-5D-5L in Spanish populations, so the
Spanish utility index of the 5 level version of EQ-
5D is the result of a “crosswalk” from the pre-
vious 3 level version. In spite of these 2 limita-
tions, this study meets the main mentioned ob-
jective, which is the setting of normative values
for the Spanish population affected by COPD.
Conclusion
The current study provides normative values of
EQ-5D-5L for Spanish patients suffering from
COPD. Mean (SD) EQ-5D-5L utility and VAS
score were 0.74 (0.30) and 60.46 (21.93) respec-
tively. Men reported better health status than
women. As educational level and monthly in-
comes were higher, gender differences were low-
er and HRQoL was better.
Ethical considerations
Ethical issues (Including plagiarism, informed
consent, misconduct, data fabrication and/or
falsification, double publication and/or submis-
sion, redundancy, etc.) have been completely
observed by the authors.
Acknowledgements
The author DCM was supported by a grant from
the Spanish Ministry of Education, Culture and
Sport (FPU14/01283).

Garcia-Gordillo et al.: A Cross-sectional Assessment of Health-related Quality of Life …
Available at: http://ijph.tums.ac.ir 1051
Conflict of Interests
The authors declare that there is no conflict of
interests.
References
1. Decramer M, Janssens W, Miravitlles M (2012).
Chronic obstructive pulmonary disease.
Lancet, 379:1341-51.
2. Miravitlles M, Soriano JB, Garcia-Rio F, et al
(2009). Prevalence of COPD in Spain: impact
of undiagnosed COPD on quality of life and
daily life activities. Thorax, 64:863-8.
3. Janson C, Marks G, Buist S, et al (2013). The
impact of COPD on health status: findings
from the BOLD study. Eur Respir J, 42:1472-
83.
4. Huber MB, Wacker ME, Vogelmeier CF, Leidl
R (2015). Comorbid Influences on Generic
Health-Related Quality of Life in COPD: A
Systematic Review. PLoS One, 10:e0132670.
5. Huber MB, Wacker ME, Vogelmeier CF, Leidl
R (2015). Excess costs of comorbidities in
chronic obstructive pulmonary disease: a
systematic review. PLoS One, 10:e0123292.
6. de Miguel Diez J, Carrasco Garrido P, Garcia
Carballo M, et al (2008). Determinants and
predictors of the cost of COPD in primary
care: a Spanish perspective. Int J Chron Obstruct
Pulmon Dis, 3:701-12.
7. Herdman M, Gudex C, Lloyd A, et al (2011).
Development and preliminary testing of the
new five-level version of EQ-5D (EQ-5D-
5L). Qual Life Res, 20:1727-36.
8. Rabin R, de Charro F (2001). EQ-5D: a measure
of health status from the EuroQol Group.
Ann Med, 33:337-43.
9. Janssen MF, Pickard AS, Golicki D, et al (2013).
Measurement properties of the EQ-5D-5L
compared to the EQ-5D-3L across eight
patient groups: a multi-country study. Qual
Life Res, 22:1717-27.
10. Miravitlles M, Huerta A, Valle M, et al (2015).
Clinical variables impacting on the estimation
of utilities in chronic obstructive pulmonary
disease. Int J Chron Obstruct Pulmon Dis, 10:367-
77.
11. Carrasco Garrido P, de Miguel Diez J, Rejas
Gutierrez J, et al (2006). Negative impact of
chronic obstructive pulmonary disease on the
health-related quality of life of patients.
Results of the EPIDEPOC study. Health Qual
Life Outcomes, 4:31.
12. Areia M, Alves S, Brito D, Cadime AT, et al
(2014). Health-related quality of life and
utilities in gastric premalignant conditions and
malignant lesions: a multicentre study in a
high prevalence country. J Gastrointestin Liver
Dis, 23:371-8.
13. Collado Mateo D, Garcia Gordillo MA, et al
(2015). Normative Values of Eq-5d-5l for
Diabetes Patients from Spain. Nutr Hosp,
32:1595-602.
14. Kim S, Love F, Quistberg DA, Shea JA (2004).
Association of health literacy with self-
management behavior in patients with
diabetes. Diabetes Care, 27:2980-2.
15. Rani PK, Raman R, Subramani S, et al (2008).
Knowledge of diabetes and diabetic
retinopathy among rural populations in India,
and the influence of knowledge of diabetic
retinopathy on attitude and practice. Rural
Remote Health, 8:838.
16. Lemes Dos Santos PF, Dos Santos PR, Ferrari
GS, et al (2014). Knowledge of diabetes
mellitus: does gender make a difference?
Osong Public Health Res Perspect, 5:199-203.
17. Miravitlles M, Huerta A, Fernandez-Villar JA, et
al (2014). Generic utilities in chronic
obstructive pulmonary disease patients
stratified according to different staging
systems. Health Qual Life Outcomes, 12:120.
18. Berg B (2012). Sf‐6d Population Norms. Health
Econ, 21:1508-12.
19. Hawthorne G, Osborne R (2005). Population
norms and meaningful differences for the
Assessment of Quality of Life (AQoL)
measure. Aust N Z J Public Health, 29:136-42.
20. Kendall PC, Marrs-Garcia A, Nath SR, Sheldrick
RC (1999). Normative comparisons for the
evaluation of clinical significance. J Consult
Clin Psychol, 67:285-99.
21. Kendall PC, Grove WM (1988). Normative
comparisons in therapy outcome. Behav
Assess, 10: 147-158.
22. Snyder CF, Aaronson NK, Choucair AK, et al
(2012). Implementing patient-reported
outcomes assessment in clinical practice: a
review of the options and considerations.
Qual Life Res, 21:1305-14.

Iran J Public Health, Vol. 46, No.8, Aug 2017, pp. 1046-1053
1052 Available at: http://ijph.tums.ac.ir
Table 2: Study sample characteristics, EQ-5D-5L male and female population norms
n = 1130
EQ-5D-5L Index
EQ-5D-5L VAS
Ceiling Effect
Male
Female
Male
Female
Male
Female
Male
Female
n
n
Mean (SD)
Median (IQR)
Mean (SD)
Median (IQR)
Mean (SD)
Median (IQR)
Mean (SD)
Median (IQR)
%
%
Age group
15-17
9
6
1 (0)
1 (0)
0.97 (0.04)
1 (0.08)
84.67 (15.48)
82 (20)
91.83 (4.62)
91.5 (6.5)
100.00
66.67
18-29
20
23
0.97 (0.08)
1 (0)
0.97 (0.08)
1 (0)
85.5 (9.56)
84.5 (13.5)
81.83 (19.07)
87 (15)
85.00
78.26
30-39
28
43
0.96 (0.11)
1 (0.07)
0.89 (0.13)
0.93 (0.17)
76.25 (14.43)
76 (18.75)
66.21 (22.42)
71 (35)
75.00
41.86
40-49
45
59
0.87 (0.2)
0.91 (0.18)
0.84 (0.26)
0.93 (0.23)
60.21 (22.23)
61 (25)
69.54 (18.6)
74 (23)
42.22
45.76
50-59
76
82
0.84 (0.2)
0.91 (0.23)
0.73 (0.31)
0.83 (0.34)
59.05 (22.6)
60 (39.75)
60.99 (21.19)
60.5 (27.5)
31.58
23.17
60-69
129
116
0.85 (0.21)
0.91 (0.22)
0.73 (0.27)
0.82 (0.37)
63.9 (18.66)
68.5 (28)
58.97 (19.99)
57 (25)
39.53
21.55
70-79
123
142
0.77 (0.3)
0.89 (0.34)
0.64 (0.32)
0.7 (0.37)
59.97 (19.62)
62 (25.75)
52.99 (20.68)
55 (29.25)
34.15
12.68
80-89
106
96
0.64 (0.37)
0.76 (0.42)
0.47 (0.38)
0.57 (0.55)
54.93 (23.35)
59 (37)
51.43 (21.75)
50 (32.5)
19.81
8.33
90 +
14
13
0.58 (0.3)
0.63 (0.53)
0.31 (0.32)
0.29 (0.46)
51.31 (27.27)
50 (38)
43.33 (21.19)
42.5 (28.5)
14.29
0.00
Region
Andalusia
60
63
0.77 (0.29)
0.87 (0.33)
0.6 (0.39)
0.72 (0.59)
58.45 (21.97)
61 (36)
53.56 (21.44)
50 (35)
26.67
14.29
Aragon
19
23
0.77 (0.31)
0.89 (0.27)
0.71 (0.33)
0.84 (0.4)
64.89 (19.55)
65 (51)
54.61 (15.27)
35 (15)
42.11
26.09
Principality of Asturias
28
36
0.73 (0.35)
0.83 (0.35)
0.68 (0.32)
0.76 (0.4)
61.93 (21.42)
62.5 (29)
57 (18.57)
60 (20.75)
35.71
25.00
Balearic Islands
20
11
0.81 (0.24)
0.97 (0.4)
0.73 (0.28)
0.89 (0.5)
65.2 (26.84)
75.5 (45.75)
65.64 (25.09)
71 (40)
50.00
18.18
Canarias
27
47
0.72 (0.35)
0.85 (0.4)
0.67 (0.28)
0.75 (0.35)
58.11 (21.28)
61 (22)
59.98 (21.24)
57 (29)
29.63
12.77
Cantabria
9
20
0.81 (0.29)
0.91 (0.26)
0.55 (0.47)
0.69 (0.94)
52.56 (16.85)
50 (22)
48.7 (20.24)
48 (25.75)
33.33
30.00
Castile and Leon
39
34
0.85 (0.16)
0.89 (0.3)
0.79 (0.2)
0.82 (0.25)
55.97 (20.37)
52 (35)
62.26 (21.76)
60.5 (38)
35.90
23.53
Castile-La Mancha
31
38
0.8 (0.34)
0.91 (0.15)
0.54 (0.41)
0.56 (0.63)
62.26 (25.03)
65 (44)
53.45 (24.19)
56 (39.75)
48.39
23.68
Catalonia
77
72
0.79 (0.25)
0.86 (0.32)
0.74 (0.27)
0.83 (0.42)
65.88 (21.16)
70 (29)
62.49 (22.6)
62 (32)
28.57
27.78
Community of Valencia
42
41
0.79 (0.36)
0.97 (0.23)
0.68 (0.3)
0.74 (0.3)
63.19 (20.05)
67.5 (25.75)
58.59 (20.01)
60 (21.5)
50.00
17.07
Extremadura
35
21
0.84 (0.17)
0.89 (0.24)
0.78 (0.248)
0.84 (0.36)
56.62 (21.37)
60.5 (25.75)
53.43 (27.25)
51 (41.5)
34.29
28.57
Galicia
33
39
0.73 (0.37)
0.91 (0.4)
0.72 (0.284)
0.8 (0.47)
57.18 (19.66)
61 (26.5)
64.54 (20.1)
66 (25)
30.30
25.64
Community of Madrid
37
41
0.81 (0.23)
0.89 (0.29)
0.71 (0.34)
0.84 (0.43)
66.11 (20.98)
69 (33.5)
63.05 (26.11)
69 (37)
37.84
24.39
Murcia Region
27
24
0.85 (0.21)
0.97 (0.24)
0.77 (0.22)
0.81 (0.43)
64.59 (22.65)
70 (29)
60.58 (23.12)
54.5 (31.5)
44.44
29.17
Community of Navarre
25
22
0.81 (0.27)
0.91 (0.29)
0.8 (0.186)
0.85 (0.2)
60.6 (19.78)
66 (28.5)
62.55 (16.16)
69 (22)
36.00
13.64
Basque Country
22
34
0.82 (0.26)
0.9 (0.28)
0.66 (0.45)
0.86 (0.62)
66.18 (21.17)
64.5 (33.75)
64.47 (23.87)
70 (31)
45.45
41.18
La Rioja
10
9
0.97 (0.74)
1 (0.04)
0.78 (0.318)
0.92 (0.45)
83.8 (11.13)
85 (14.25)
69.78 (22.15)
82 (44.5)
80.00
44.44
Ceuta
6
3
0.91 (0.14)
0.96 (0.16)
0.73 (0.186)
0.74 (0.37)
66.17 (28.99)
77.5 (33.5)
48 (31.58)
61 (59)
50.00
0.00
Melilla
3
2
0.84 (0.22)
0.93 (-)
0.79 (0.3)
0.79 (-)
56.67 (37.07)
41 (-)
39.5 (13.44)
39.5 (-)
33.33
50.00
Marital status
Single
122
104
0.87 (0.2)
0.91 (0.18)
0.81 (0.27)
0.91 (0.27)
65.5 (23.59)
73 (31)
66.03 (22.45)
69 (35)
48.36
40.38
Married
335
237
0.78 (0.3)
0.91 (0.32)
0.74 (0.3)
0.84 (0.41)
60.8 (21.21)
64 (27)
60.66 (21.79)
61 (30)
37.91
27.43
Divorced/separated
60
195
0.71 (0.28)
0.88 (0.23)
0.55 (0.35)
0.83 (0.26)
59.76 (20.33)
68.5 (28.75)
53.75 (21.2)
60 (30)
16.67
10.77
Widowed
32
43
0.82 (0.24)
0.78 (0.35)
0.75 (0.29)
0.64 (0.53)
63.13 (20.75)
64.5 (27.75)
57.91 (22.27)
51 (29)
31.25
18.60
Smoking status
Yes
157
125
0.85 (0.21)
0.91 (0.2)
0.79 (0.28)
0.89 (0.28)
64.59 (19.71)
70 (27)
65.45 (22.49)
70 (30)
42.04
33.60
No
393
454
0.77 (0.3)
0.89 (0.33)
0.66 (0.33)
0.76 (0.4)
60.74 (22.34)
63 (30.75)
57.4 (21.74)
58 (29)
35.62
20.93
Net Monthly income household
Less than 550 €
39
67
0.87 (0.14)
0.91 (0.23)
0.59 (0.34)
0.67 (0.34)
67.08 (20.48)
71 (30)
52.43 (18.9)
51 (19)
35.90
7.46
551-1,300 €
250
273
0.76 (0.29)
0.86 (0.35)
0.67 (0.32)
0.76 (0.38)
57.85 (22.22)
61.5 (33.5)
58.84 (21.54)
59 (30)
29.60
20.51
1,301-2,250 €
100
86
0.84 (0.25)
0.91 (0.22)
0.72 (0.37)
0.89 (0.35)
64.78 (21.09)
70 (27)
58.51 (24.62)
60 (40)
45.00
29.07
2,251-3,450 €
39
33
0.83 (0.31)
1 (0.18)
0.79 (0.31)
0.91 (0.28)
68.87 (19.83)
72 (25)
62.64 (26.02)
73 (43)
53.85
42.42
3,451 + €
9
10
0.89 (0.19)
1 (0.25)
0.95 (0.07)
1 (0.1)
68.56 (15.99)
69 (24)
74.4 (12.96)
78.5 (17.75)
66.67
60.00
Educational level
Low
272
280
0.75 (0.31)
0.86 (0.35)
0.59 (0.33)
0.68 (0.44)
58.13 (21.6)
60 (31.75)
53.18 (21.37)
53 (29)
29.41
12.14
Medium
222
241
0.84 (0.24)
0.91 (0.23)
0.75 (0.31)
0.86 (0.35)
64.3 (21.85)
69 (31)
62.68 (21.59)
62 (31)
41.89
29.88
High
56
59
0.87 (0.24)
1 (0.18)
0.9 (0.19)
1 (0.14)
69.46 (17.8)
72.5 (19)
72.22 (19.07)
77 (26)
58.93
52.54
Educational level: According to the International Standard Classification of Education (ISCED); Low educational level (Early childhood education and Primary education), Medium educational level (Lower
secondary education, Upper secondary education and Post-secondary non-tertiary education) and High educational level (tertiary education).

Garcia-Gordillo et al.: A Cross-sectional Assessment of Health-related Quality of Life …
Available at: http://ijph.tums.ac.ir 1053
Table 3: Percentage frequency distributions of EQ-5D-5L dimensions by gender and age group
Level
Mobility
Self-care
Usual activities
Pain/discomfort
Anxiety/depression
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
All
1
54.6
60.0
49.5
77.8
81.5
74.3
62.5
68.8
56.6
42.9
52.7
33.6
65.1
73.3
57.2
2
17.1
16.5
17.6
8.9
9.1
8.8
15.2
12.9
17.4
22.8
22.8
22.7
15.7
13.4
17.9
3
14.6
12.4
16.7
6.5
4.4
8.4
11.3
8.9
13.6
21.1
16.1
25.8
11.9
8.3
15.3
4
11.0
8.9
12.9
3.2
1.6
4.7
5.5
4.4
6.6
11.7
6.9
16.2
5.2
2.7
7.6
5
2.7
2.2
3.3
3.6
3.5
3.8
5.3
4.7
5.9
1.1
0.7
1.4
1.1
0.9
1.4
15-17
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
1
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
86.7
100.0
66.7
2
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
6.7
0.0
16.7
3
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
6.7
0.0
16.7
4
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
5
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
18-29
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
1
100.0
100.0
100.0
100.0
100.0
100.0
97.7
95.0
100.0
83.7
85.0
82.6
90.7
95.0
87.0
2
0.0
0.0
0.0
0.0
0.0
0.0
2.3
5.0
0.0
11.6
15.0
8.7
4.7
0.0
8.7
3
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
2.3
0.0
4.3
2.3
0.0
4.3
4
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
2.3
0.0
4.3
2.3
5.0
0.0
5
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
30-39
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
1
94.4
96.4
93.0
98.6
96.4
100.0
87.3
92.9
83.7
64.8
82.1
53.5
76.1
89.3
67.4
2
0.0
0.0
0.0
1.4
3.6
0.0
8.5
0.0
14.0
15.5
10.7
18.6
14.1
7.1
18.6
3
5.6
3.6
7.0
0.0
0.0
0.0
4.2
7.1
2.3
16.9
7.1
23.3
4.2
0.0
7.0
4
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
2.8
0.0
4.7
5.6
3.6
7.0
5
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
40-49
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
1
78.8
80.0
78.0
93.3
95.6
91.5
81.7
88.9
76.3
59.6
64.4
55.9
63.5
60.0
66.1
2
11.5
13.3
10.2
3.8
2.2
5.1
9.6
6.7
11.9
26.9
28.9
25.4
19.2
20.0
18.6
3
3.8
2.2
5.1
1.0
2.2
0.0
2.9
0.0
5.1
8.7
4.4
11.9
9.6
11.1
8.5
4
4.8
4.4
5.1
1.9
0.0
3.4
3.8
2.2
5.1
2.9
2.2
3.4
4.8
4.4
5.1
5
1.0
0.0
1.7
0.0
0.0
0.0
1.9
2.2
1.7
1.9
0.0
3.4
2.9
4.4
1.7
50-59
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
1
62.7
68.4
57.3
86.7
88.2
85.4
67.3
70.1
64.6
44.3
56.6
32.9
60.8
64.5
57.3
2
15.2
15.8
14.6
4.4
5.3
3.7
13.2
10.4
15.9
20.3
21.1
19.5
17.1
21.1
13.4
3
13.3
10.5
15.9
5.7
3.9
7.3
12.6
13.0
12.2
24.1
15.8
31.7
14.6
14.5
14.6
4
7.6
5.3
9.8
0.6
1.3
0.0
2.5
1.3
3.7
10.8
6.6
14.6
6.3
0.0
12.2
5
1.3
0.0
2.4
2.5
1.3
3.7
3.1
2.6
3.7
0.6
0.0
1.2
1.3
0.0
2.4
60-69
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
1
58.4
66.7
49.1
86.5
90.7
81.9
71.0
75.2
66.4
44.1
60.0
37.9
63.3
77.5
47.4
2
18.8
13.2
25.0
6.9
4.7
9.5
13.1
11.6
14.7
22.0
25.2
24.3
17.1
13.2
21.6
3
15.5
14.7
16.4
4.5
3.1
6.0
10.6
8.5
12.9
20.4
10.4
25.2
13.1
7.8
19.0
4
6.9
5.4
8.6
1.6
0.8
2.6
4.5
3.9
5.2
12.7
4.3
11.7
4.9
1.6
8.6
5
0.4
0.0
0.9
0.4
0.8
0.0
0.8
0.8
0.9
0.8
0.0
1.0
1.6
0.0
3.4
70-79
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
1
42.6
52.0
34.5
72.8
79.7
66.9
53.6
66.7
42.3
33.5
48.4
20.4
65.0
72.6
58.5
2
25.7
25.2
26.1
14.3
13.8
14.8
21.9
18.7
24.6
27.8
25.0
30.3
14.3
12.1
16.2
3
15.8
11.4
19.7
6.4
2.4
9.9
14.7
7.3
21.1
22.6
16.1
28.2
13.9
7.3
19.7
4
11.7
7.3
15.5
3.0
0.0
5.6
4.2
2.4
5.6
14.3
8.1
19.7
5.6
5.6
5.6
5
4.2
4.1
4.2
3.4
4.1
2.8
5.7
4.9
6.3
1.1
0.8
1.4
0.4
0.8
0.0
80-89
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
1
25.7
31.1
19.8
52.5
58.5
45.8
37.6
46.2
28.1
25.7
34.0
16.7
61.8
71.3
51.0
2
20.3
22.6
17.7
15.3
17.9
12.5
21.3
18.9
24.0
23.3
25.5
20.8
17.6
13.9
21.9
3
22.3
17.9
27.1
14.4
9.4
19.8
15.3
13.2
17.7
30.2
27.4
33.3
11.8
8.3
15.6
4
25.2
22.6
28.1
7.4
4.7
10.4
10.9
7.5
14.6
18.8
10.4
28.1
5.4
0.9
10.4
5
6.4
5.7
7.3
10.4
9.4
11.5
14.9
14.2
15.6
2.0
2.8
1.0
1.5
1.9
1.0
90 or more
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
1
11.1
21.4
0.0
22.2
35.7
7.7
14.8
21.4
7.7
27.6
33.3
21.4
56.7
66.7
46.7
2
7.4
7.1
7.7
11.1
14.3
7.7
3.7
7.1
0.0
24.1
26.7
21.4
6.7
0.0
13.3
3
40.7
42.9
38.5
22.2
21.4
23.1
22.2
21.4
23.1
27.6
26.7
28.6
13.3
13.3
13.3
4
29.6
21.4
38.5
22.2
14.3
30.8
37.0
42.9
30.8
6.9
0.0
14.3
3.3
6.7
0.0
5
11.1
7.1
15.4
22.2
14.3
30.8
22.2
7.1
38.5
0.0
0.0
0.0
0.0
0.0
0.0