Intended for healthcare professionals


Comparison of direct and indirect methods of estimating health state utilities for resource allocation: review and empirical analysis

BMJ 2009; 339 doi: (Published 22 July 2009) Cite this as: BMJ 2009;339:b2688
  1. David Arnold, medical student1,
  2. Alan Girling, senior research fellow2,
  3. Andrew Stevens, professor of public health2,
  4. Richard Lilford, professor of clinical epidemiology2
  1. 1Cardiff University Medical School, Cardiff
  2. 2School of Health and Population Sciences, University of Birmingham, Birmingham B15 2TT
  1. Correspondence to: R Lilford r.j.lilford{at}
  • Accepted 18 February 2009


Background and objective Utilities (values representing preferences) for healthcare priority setting are typically obtained indirectly by asking patients to fill in a quality of life questionnaire and then converting the results to a utility using population values. We compared such utilities with those obtained directly from patients or the public.

Design Review of studies providing both a direct and indirect utility estimate.

Selection criteria Papers reporting comparisons of utilities obtained directly (standard gamble or time trade off) or indirectly (European quality of life 5D [EQ-5D], short form 6D [SF-6D], or health utilities index [HUI]) from the same patient.

Data sources PubMed and Tufts database of utilities.

Statistical methods Sign test for paired comparisons between direct and indirect utilities; least squares regression to describe average relations between the different methods.

Main outcome measures Mean utility scores (or median if means unavailable) for each method, and differences in mean (median) scores between direct and indirect methods.

Results We found 32 studies yielding 83 instances where direct and indirect methods could be compared for health states experienced by adults. The direct methods used were standard gamble in 57 cases and time trade off in 60 (34 used both); the indirect methods were EQ-5D (67 cases), SF-6D (13), HUI-2 (5), and HUI-3 (37). Mean utility values were 0.81 (standard gamble) and 0.77 (time trade off) for the direct methods; for the indirect methods: 0.59 (EQ-5D), 0.63 (SF-6D), 0.75 (HUI-2) and 0.68 (HUI-3).

Discussion Direct methods of estimating utilities tend to result in higher health ratings than the more widely used indirect methods, and the difference can be substantial. Use of indirect methods could have important implications for decisions about resource allocation: for example, non-lifesaving treatments are relatively more favoured in comparison with lifesaving interventions than when using direct methods.


  • We thank Stirling Bryan and Tracey Roberts for helpful discussion. We also thank the referees Steven McPhail and Cindy Lam for their detailed and perceptive comments.

  • Contributors: RJL conceived the idea for the paper, DA performed the literature reviews and data extraction, and AG repeated the data extraction and carried out statistical analyses. All authors prepared the manuscript and RL is guarantor.

  • Funding: This work was supported through the MATCH programme (EPSRC Grant GR/S29874/01) although the views expressed are entirely the authors’ own.

  • Competing interests: None declared.

  • Ethical approval: Not required.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

View Full Text