Quality of Life Research

, Volume 27, Issue 9, pp 2337–2348 | Cite as

Validity of the EQ–5D–5L and reference norms for the Spanish population

  • Gimena Hernandez
  • Olatz Garin
  • Yolanda Pardo
  • Gemma Vilagut
  • Àngels Pont
  • Mónica Suárez
  • Montse Neira
  • Luís Rajmil
  • Inigo Gorostiza
  • Yolanda Ramallo-Fariña
  • Juan Cabases
  • Jordi Alonso
  • Montse Ferrer


Background and objective

The EuroQol 5 dimensions 5 levels (EQ–5D–5L) is the new version of EQ–5D, developed to improve its discriminatory capacity. This study aims to evaluate the construct validity of the Spanish version and provide index and dimension population-based reference norms for the new EQ–5D–5L.


Data were obtained from the 2011/2012 Spanish National Health Survey, with a representative sample (n = 20,587) of non-institutionalized Spanish adults (≥ 18 years). The EQ–5D–5L index was calculated by using the Spanish value set. Construct validity was evaluated by comparing known groups with estimators obtained through regression models, adjusted by age and gender. Sampling weights were applied to restore the representativeness of the sample and to calculate the norms stratified by gender and age groups. We calculated the percentages and standard errors of dimensions, and the deciles, percentiles 5 and 95, means, and 95% confidence intervals of the health index.


All the hypotheses established a priori for known groups were confirmed (P < 0.001). The EQ–5D–5L index indicated worse health in groups with lower education level (from 0.94 to 0.87), higher number of chronic conditions (0.96–0.79), probable psychiatric disorder (0.94 vs 0.80), strong limitations (0.96–0.46), higher number of days of restriction (0.93–0.64) or confinement to bed (0.92–0.49), and hospitalized in the previous 12 months (0.92 vs 0.81).


The EQ–5D–5L is a valid instrument to measure perceived health in the Spanish-speaking population. The representative population-based norms provided here will help improve the interpretation of results obtained with the new EQ–5D–5L.


EuroQol EQ–5D–5L Health-related quality of life Health status Utilities Questionnaires Reference values Validity 



We acknowledge Aurea Martin for helping us in the English editing process and supervision of this manuscript.

Author contributions

GH analyzed and interpreted the data, drafted, and critically revised the manuscript and did the statistical analysis. OG provided supervision, conceived, and designed the study, and critically revised the manuscript. YP and GV analyzed and interpreted the data, and critically revised the manuscript. AP analyzed and interpreted the data, and did the statistical analysis. MS, MN, LR, IG, YR, and JC interpreted the data and critically revised the manuscript. JA provided supervision, conceived and designed the study, interpreted the data, and critically revised the manuscript. MF obtained funding, provided supervision, conceived and designed the study, interpreted the data, and critically revised the manuscript.


This study has been funded by grants from the Generalitat de Catalunya (2017 SGR 452 and 2014 SGR 748) and the Instituto de Salud Carlos III FEDER, (PI12/00772).

Compliance with ethical standards

Conflict of interest

All authors declare that they have no competing interests.

Ethical approval

The Spanish National Health Survey is a statistical operation included in the National Statistical Plan. The agency responsible for the survey is the Ministry of Health, Social Services and Equality and it is performed jointly with the National Statistics Institute according to the 2000 revision of the Helsinki Declaration.

Supplementary material

11136_2018_1877_MOESM1_ESM.doc (545 kb)
Supplementary material 1 (DOC 545 KB)


  1. 1.
    Mishoe, S. C., & Maclean, J. R. (2001). Assessment of health-related quality of life. Respiratory Care, 46, 1236–1257.PubMedGoogle Scholar
  2. 2.
    Vodicka, E., Kim, K., Devine, E. B., Gnanasakthy, A., Scoggins, J. F., & Patrick, D. L. (2015). Inclusion of patient-reported outcome measures in registered clinical trials: Evidence from (2007–2013). Contemporary Clinical Trials, 43, 1–9.CrossRefPubMedGoogle Scholar
  3. 3.
    Brooks, R., & The EuroQol Group (1996). EuroQol: The current state of play. Health Policy, 37, 53–72.CrossRefPubMedGoogle Scholar
  4. 4.
    Bharmal, M., & Thomas, J. III (2006). Comparing the EQ-5D and the SF-6D descriptive systems to assess their ceiling effects in the US general population. Value in Health, 9, 262–271.CrossRefPubMedGoogle Scholar
  5. 5.
    Hinz, A., Klaiberg, A., Brahler, E., & Konig, H. H. (2006). The Quality of Life Questionnaire EQ-5D: Modelling and norm values for the general population. Psychotherapie, Psychosomatik, Medizinische Psychologie, 56, 42–48.CrossRefPubMedGoogle Scholar
  6. 6.
    Xin, Y., & McIntosh, E. (2017). Assessment of the construct validity and responsiveness of preference-based quality of life measures in people with Parkinson’s: A systematic review. Quality of Life Research, 26, 1–23.CrossRefPubMedGoogle Scholar
  7. 7.
    Fransen, M., & Edmonds, J. (1999). Reliability and validity of the EuroQol in patients with osteoarthritis of the knee. Rheumatology, 38, 807–813.CrossRefPubMedGoogle Scholar
  8. 8.
    Krahn, M., Bremner, K. E., Tomlinson, G., Ritvo, P., Irvine, J., & Naglie, G. (2007). Responsiveness of disease-specific and generic utility instruments in prostate cancer patients. Quality of Life Research, 16, 509–522.CrossRefPubMedGoogle Scholar
  9. 9.
    Janssen, M. F., Birnie, E., Haagsma, J. A., & Bonsel, G. J. (2008). Comparing the standard EQ-5D three-level system with a five-level version. Value in Health, 11, 275–284.CrossRefPubMedGoogle Scholar
  10. 10.
    Feng, Y., Devlin, N., & Herdman, M. (2015). Assessing the health of the general population in England: How do the three- and five-level versions of EQ-5D compare? Health and Quality of Life Outcomes, 13, 171.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Janssen, M. F., Pickard, A. S., Golicki, D., Gudex, C., Niewada, M., Scalone, L., et al. (2013). Measurement properties of the EQ-5D-5L compared to the EQ-5D-3L across eight patient groups: A multi-country study. Quality of Life Research, 22, 1717–1727.CrossRefPubMedGoogle Scholar
  12. 12.
    Kim, S. H., Kim, H. J., Lee, S. I., & Jo, M. W. (2012). Comparing the psychometric properties of the EQ-5D-3L and EQ-5D-5L in cancer patients in Korea. Quality of Life Research, 21, 1065–1073.CrossRefPubMedGoogle Scholar
  13. 13.
    Pickard, A. S., De Leon, M. C., Kohlmann, T., Cella, D., & Rosenbloom, S. (2007). Psychometric comparison of the standard EQ-5D to a 5 level version in cancer patients. Medical Care, 45, 259–263.CrossRefPubMedGoogle Scholar
  14. 14.
    Jia, Y. X., Cui, F. Q., Li, L., Zhang, D. L., Zhang, G. M., Wang, F. Z., et al. (2014). Comparison between the EQ-5D-5L and the EQ-5D-3L in patients with hepatitis B. Quality of Life Research, 23, 2355–2363.CrossRefPubMedGoogle Scholar
  15. 15.
    Kim, T. H., Jo, M. W., Lee, S. I., Kim, S. H., & Chung, S. M. (2013). Psychometric properties of the EQ-5D-5L in the general population of South Korea. Quality of Life Research, 22, 2245–2253.CrossRefPubMedGoogle Scholar
  16. 16.
    Scalone, L., Ciampichini, R., Fagiuoli, S., Gardini, I., Fusco, F., Gaeta, L., et al. (2013). Comparing the performance of the standard EQ-5D 3L with the new version EQ-5D 5L in patients with chronic hepatic diseases. Quality of Life Research, 22, 1707–1716.CrossRefPubMedGoogle Scholar
  17. 17.
    Cunillera, O., Tresserras, R., Rajmil, L., Vilagut, G., Brugulat, P., Herdman, M., et al. (2010). Discriminative capacity of the EQ-5D, SF-6D, and SF-12 as measures of health status in population health survey. Quality of Life Research, 19, 853–864.CrossRefPubMedGoogle Scholar
  18. 18.
    Janssen, M. F., Bonsel, G. J., & Luo, N. (2018). Is EQ-5D-5L better than EQ-5D-3L? A head-to-head comparison of descriptive systems and value sets from seven countries. Pharmacoeconomics. Scholar
  19. 19.
    Aaronson, N., Alonso, J., Burnam, A., Lohr, K. N., Patrick, D. L., Perrin, E., et al. (2002). Assessing health status and quality-of-life instruments: Attributes and review criteria. Quality of Life Research, 11, 193–205.CrossRefPubMedGoogle Scholar
  20. 20.
    Alonso, J., Regidor, E., Barrio, G., Prieto, L., Rodriguez, C., & de la Fuente, L (1998). Population reference values of the Spanish version of the Health Questionnaire SF-36. Medicina Clinica, 111, 410–416.PubMedGoogle Scholar
  21. 21.
    Vilagut, G., Valderas, J. M., Ferrer, M., Garin, O., Lopez-Garcia, E., & Alonso, J. (2008). Interpretation of SF-36 and SF-12 questionnaires in Spain: Physical and mental components. Medicina Clinica, 130, 726–735.CrossRefPubMedGoogle Scholar
  22. 22.
    Ravens-Sieberer, U., Herdman, M., Devine, J., Otto, C., Bullinger, M., Rose, M., et al. (2014). The European KIDSCREEN approach to measure quality of life and well-being in children: Development, current application, and future advances. Quality of Life Research, 23, 791–803.CrossRefPubMedGoogle Scholar
  23. 23.
    Schmidt, S., & Pardo, Y. (2014). Normative data. In A. C. Michalos (Ed.), Encyclopedia of quality of life and well-being research (pp. 4375–4379). Dordrecht: Springer.CrossRefGoogle Scholar
  24. 24.
    Szende, A., Janssen, B., & Cabases, J. (2014). Self-reported population health: An international perspective based on EQ-5D. Dordrecht: SpringerOpen.CrossRefGoogle Scholar
  25. 25.
    Konig, H. H., Bernert, S., Angermeyer, M. C., Matschinger, H., Martinez, M., Vilagut, G., et al. (2009). Comparison of population health status in six european countries: Results of a representative survey using the EQ-5D questionnaire. Medical Care, 47, 255–261.CrossRefPubMedGoogle Scholar
  26. 26.
    Garcia-Gordillo, M. A., Adsuar, J. C., & Olivares, P. R. (2016). Normative values of EQ-5D-5L: In a Spanish representative population sample from Spanish Health Survey, 2011. Quality of Life Research, 25, 1313–1321.CrossRefPubMedGoogle Scholar
  27. 27.
    Ramos-Goñi, J. M., Craig, B. M., Oppe, M., Ramallo-Fariña, Y., Pinto-Prades, J. L., Luo, N., et al. (2018). Handling data quality issues to estimate the Spanish EQ-5D-5L value set using a hybrid interval regression approach. Value in Health, 21(5), 596–604.CrossRefPubMedGoogle Scholar
  28. 28.
    Martin-Fernandez, J., Ariza-Cardiel, G., Polentinos-Castro, E., Sanz-Cuesta, T., Sarria-Santamera, A., & Del Cura-Gonzalez, I. (2017). Explaining differences in perceived health-related quality of life: A study within the Spanish population. Gaceta Sanitaria. Scholar
  29. 29.
    Ministerio de Sanidad, S.S.e.I., & Instituto Nacional de Estadística (2012). Encuesta Nacional de Salud de España 2011/12.
  30. 30.
    Herdman, M., Gudex, C., Lloyd, A., Janssen, M., Kind, P., Parkin, D., et al. (2011). Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Quality of Life Research, 20, 1727–1736.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Oppe, M., Devlin, N. J., van Hout, B., Krabbe, P. F., & de Charro, F. (2014). A program of methodological research to arrive at the new international EQ-5D-5L valuation protocol. Value in Health, 17, 445–453.CrossRefPubMedGoogle Scholar
  32. 32.
    Oppe, M., Rand-Hendriksen, K., Shah, K., Ramos-Goni, J. M., & Luo, N. (2016). EuroQol protocols for time trade-off valuation of health outcomes. Pharmacoeconomics, 34, 993–1004.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Gispert, R., Rajmil, L., Schiaffino, A., & Herdman, M. (2003). Sociodemographic and health-related correlates of psychiatric distress in a general population. Social Psychiatry and Psychiatric Epidemiology, 38, 677–683.CrossRefPubMedGoogle Scholar
  34. 34.
    Goldberg, D. P., & Williams, P. (1988). A user’s guide to the General Health Questionnaire. London: Institute of Psychiatry.Google Scholar
  35. 35.
    van Oyen, H., Van der Heyden, J., Perenboom, R., & Jagger, C. (2006). Monitoring population disability: Evaluation of a new Global Activity Limitation Indicator (GALI). Sozial-Und Praventivmedizin, 51, 153–161.CrossRefPubMedGoogle Scholar
  36. 36.
    Schmidt, S., Vilagut, G., Garin, O., Cunillera, O., Tresserras, R., Brugulat, P., et al. (2012). Reference guidelines for the 12-Item Short-Form Health Survey version 2 based on the Catalan general population. Medicina Clinica, 139, 613–625.CrossRefPubMedGoogle Scholar
  37. 37.
    McClure, N. S., Sayah, F. A., Xie, F., Luo, N., & Johnson, J. A. (2017). Instrument-defined estimates of the minimally important difference for EQ-5D-5L index scores. Value in Health, 20, 644–650.CrossRefPubMedGoogle Scholar
  38. 38.
    Hopman, W. M., Towheed, T., Anastassiades, T., Tenenhouse, A., Poliquin, S., Berger, C., et al. (2000). Canadian normative data for the SF-36 health survey. Canadian Multicentre Osteoporosis Study Research Group. CMAJ, 163, 265–271.PubMedPubMedCentralGoogle Scholar
  39. 39.
    Burstrom, K., Johannesson, M., & Diderichsen, F. (2001). Swedish population health-related quality of life results using the EQ-5D. Quality of Life Research, 10, 621–635.CrossRefPubMedGoogle Scholar
  40. 40.
    Michelson, H., Bolund, C., Nilsson, B., & Brandberg, Y. (2000). Health-related quality of life measured by the EORTC QLQ-C30—Reference values from a large sample of Swedish population. Acta Oncologica, 39, 477–484.CrossRefPubMedGoogle Scholar
  41. 41.
    Power, M., Quinn, K., & Schmidt, S. (2005). Development of the WHOQOL-old module. Quality of Life Research, 14, 2197–2214.CrossRefPubMedGoogle Scholar
  42. 42.
    Hinz, A., Kohlmann, T., Stobel-Richter, Y., Zenger, M., & Brahler, E. (2014). The quality of life questionnaire EQ-5D-5L: Psychometric properties and normative values for the general German population. Quality of Life Research, 23, 443–447.CrossRefPubMedGoogle Scholar
  43. 43.
    Craig, B. M., Pickard, A. S., & Lubetkin, E. I. (2014). Health problems are more common, but less severe when measured using newer EQ-5D versions. Journal of Clinical Epidemiology, 67, 93–99.CrossRefPubMedGoogle Scholar
  44. 44.
    Golicki, D., & Niewada, M. (2017). EQ-5D-5L Polish population norms. Archives of Medical Science, 13, 191–200.CrossRefPubMedGoogle Scholar
  45. 45.
    Burstrom, K., Johannesson, M., & Rehnberg, C. (2007). Deteriorating health status in Stockholm 1998–2002: Results from repeated population surveys using the EQ-5D. Quality of Life Research, 16, 1547–1553.CrossRefPubMedGoogle Scholar
  46. 46.
    Badia, X., Schiaffino, A., Alonso, J., & Herdman, M. (1998). Using the EuroQoI 5-D in the Catalan general population: Feasibility and construct validity. Quality of Life Research, 7, 311–322.CrossRefPubMedGoogle Scholar
  47. 47.
    Puhan, M. A., Ahuja, A., Van Natta, M. L., Ackatz, L. E., & Meinert, C. (2011). Interviewer versus self-administered health-related quality of life questionnaires—Does it matter? Health and Quality of Life Outcomes, 9, 30.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Gimena Hernandez
    • 1
    • 2
    • 3
  • Olatz Garin
    • 1
    • 3
    • 4
  • Yolanda Pardo
    • 1
    • 2
    • 3
  • Gemma Vilagut
    • 1
    • 3
  • Àngels Pont
    • 1
    • 3
  • Mónica Suárez
    • 5
  • Montse Neira
    • 5
  • Luís Rajmil
    • 1
  • Inigo Gorostiza
    • 6
    • 7
  • Yolanda Ramallo-Fariña
    • 7
    • 8
  • Juan Cabases
    • 9
  • Jordi Alonso
    • 1
    • 3
    • 4
  • Montse Ferrer
    • 1
    • 2
    • 3
  1. 1.Health Services Research GroupIMIM (Hospital del Mar Medical Research Institute)BarcelonaSpain
  2. 2.Universitat Autónoma de BarcelonaBarcelonaSpain
  3. 3.Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP)MadridSpain
  4. 4.Experimental and Health Sciences DepartmentUniversitat Pompeu Fabra (UPF)BarcelonaSpain
  5. 5.Subdirección General de Información Sanitaria e InnovaciónSpanish Ministry of Health, Social Services and EqualityMadridSpain
  6. 6.Unidad de InvestigaciónHospital Universitario Basurto - OsakidetzaBilbaoSpain
  7. 7.Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC)MadridSpain
  8. 8.Fundación Canaria de Investigación Sanitaria (FUNCANIS)TenerifeSpain
  9. 9.Departamento de EconomíaUniversidad Pública de NavarraPamplonaSpain

Personalised recommendations