Objectives. To evaluate the impact of adding a respiratory dimension (a bolt-on dimension) to the EQ-5D-5L health state valuations. Methods. Based on extensive regression and principal component analyses, 2 respiratory bolt-on candidates were formulated: R1, limitations in physical activities due to shortness of breath, and R2, breathing problems. Valuation interviews for the selected bolt-ons were performed with a representative sample from the Dutch general public using the standardized interview protocol and software of the EuroQol group. Hybrid models based on the combined time-tradeoff (TTO) and discrete choice experiment (DCE) data were estimated to assess whether the 5 levels of the respiratory bolt-on led to significant changes in utility values. Results. For each bolt-on candidate, slightly more than 200 valuation interviews were conducted. Mean TTO values and DCE choice probabilities for health states with a level 4 or 5 for the respiratory dimension were significantly lower compared with the same health states in the Dutch EQ-5D-5L valuation study without the respiratory dimension. Results of hybrid models showed that for the bolt-on ''limitations in physical activities,'' the utility decrements were significant for level 3 (-0.055), level 4 (-0.087), and level 5 (-0.135). For ''breathing problems,'' the utility decrements for the same levels were greater (-0.086,-0.219, and-0.327, respectively). Conclusions. The addition of each of the 2 respiratory bolt-ons to the EQ-5D-5L had a significant effect on the valuation of health states with severe levels for the bolt-on. The bolt-on dimension ''breathing problems'' showed the greatest utility decrements and therefore seems the most appropriate respiratory bolt-on dimension.

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were discussed, including day of the week and day between Monday and Friday. It was agreed that 'weekdays' could be translated as 'working days', and 'weekends' as 'Saturdays and Sundays' while several languages preferred to use the English word.(3) 94% of languages struggled to find an equivalent for 'skipping'. Many English back translations showed 'hopping' or 'jumping'. The motion of skipping was discussed with translators as moving along lightly, stepping from one foot to the other with a hop or bounce. Many decided, on the absence of a similar word in their language, to replace this concept with 'skipping with a rope' which would work equally well as a 'very active' pastime. ConClusions: Similar issues often affect a number of languages. For such items, it may not be appropriate to produce literal translations and alternative solutions must be sought, taking into account linguistic features and cultural considerations, in order to achieve conceptual equivalence.

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Objectives: The Assessment of Burden of COPD (ABC) tool evaluates and visualizes the health status of patients with chronic obstructive pulmonary disease (COPD). This tool may be used during consultations to monitor the burden of COPD and to adjust treatment. The ABC tool has items in 5 dimensions: symptoms, limitations, mental status, exacerbations, and fatigue. The aim of our study was to determine the burden of each of 15 elements in the ABC questionnaire. MethOds: A discrete choice experiment (DCE) was conducted using telephone-assisted personal interviews with 279 COPD patients. They were presented 13 sets of two patients, and decided which patient was in the worst health state. In order to make the choice task feasible despite the large number of 15 attributes, we generated an efficient partial profile design, that kept attributes in some dimensions constant and all at the same level (fold in), while varying the attributes in other dimensions (fold out). This reduced the burden on respondents by having them assess some attributes combined in categories, instead of as separate attributes. Multinomial logit was used to analyze the data. Results: Patients were considered to be in worst health if they had high levels of fatigue, exacerbations, anxiety, breathlessness at rest and limitations in moderate physical activities. These factors had three to five times as much impact on the burden of disease as lower levels of these attributes and other limitations. Coefficients were very small and/or statistically insignificant for breathlessness during physical activity, limitations on strenuous activity, coughing, small numbers of exacerbations, and most mental attributes. cOnclusiOns: It is possible to administer cognitively complicated DCE questionnaires using a fold-infold-out design. COPD-patients seem to accept being unable to perform strenuous activities. Gains in well-being can primarily be achieved by focusing on patients' ability to lead a relatively normal everyday life.