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In certain circumstances, the EQ-5D is insensitive to changes or differences in health status.
‘Bolt-on’ dimensions could provide additional information about certain conditions or symptoms.
Previous research has highlighted cognition and vision as good candidates for bolt-ons.
Cognition and vision bolt-ons have been used in the past, but with limited development.
No study has developed bolt-on descriptors in a programme of qualitative and quantitative research.
Marina Rodes Sanchez
●To identify the dimensions of health-
related quality of life that are important to
people with lived experience of cognitive
impairment and visual impairment.
●To develop EQ-5D-5L bolt-on descriptors
for cognition and vision, using suitable
●Recruitment of people with a range of
experiences, including carers.
●Focus groups: two for each bolt-on, 4-9
●Semi-structured interviews: three for
●Thematic analysis of transcriptions.
●Participants identified a variety of distinct cognition-specific dimensions.
●These were described using various terms, which we grouped together for coding.
●The vision group mostly described their experiences with reference to their level of vision in general.
●Specific characteristics of visual function were not framed as capturing the impact on quality of life.
●Similar generic dimensions arose in both groups, in varying degrees.
●Certain terminology used in the study, including ‘impairment’, was identified as problematic.
●The term ‘cognition’ was not recognised as useful.
●The vision group tended to use the term ‘sight’ or ‘seeing’ rather than ‘vision’.
●Some participants preferred the term ‘difficulties’ to ‘problems’.
●In general, the existing ‘severity’ terminology of the EQ-5D-5L was acceptable (e.g.
●This is the first study to report on the development of bolt-ons using focus groups.
●To develop a generic descriptor, it is necessary to recruit people with a range of different
experiences. It was very difficult to coordinate focus groups with such a group, which meant that
we needed to conduct interviews in lieu of more focus groups.
●People do not conceptualise the impact of impairment on their health-related quality of life in terms
of their functioning. Rather, people consider broader impacts on quality of life. This made the
identification of specific terminology relating to functioning a challenge.
●Without prompting, the participants identified dimensions (both specific and broad) that are not
currently captured by the EQ-5D, implying the legitimacy of the bolt-ons research.
●Cognitive impairment is made of up distinct functional impacts, implying the need for a multi-item
●The functional impact of visual impairment was described in general terms. Some people spoke
about characteristics of visual function, but these were too diverse to be useful as bolt-ons.
●Some participants disliked negative framing (e.g. “problems”) or ‘clinical’ terms (e.g. “impairment”).
●The development of bolt-on descriptors using focus groups is challenging
because of the need to recruit a heterogeneous population.
●A cognition bolt-on will probably require multiple items.
●‘Vision in general’ may be a suitable single-item bolt-on.
●The current structure of the EQ-5D-5L is amenable to bolt-ons for cognition
●Terminology is very important –certain words are not meaningful to people
with lived experience.
●It will be necessary to test a range of wordings in qualitative interviews.
●Quantitative research is needed to determine the additional information
provided by the candidate bolt-ons.
This study was commissioned by
the EuroQol Research Foundation.
Views expressed are those of the authors and do not necessarily reflect the views of the EuroQol Group
Figuring things out
Vision in general
Sight, seeing, blindness, light perception
Characteristics of visual function
Colours, depth perception, distance, visual field
Sense of self