Time trade-off derived EQ-5D weights for Australia

Support for Australian carers from community pharmacy: Insight into carer perspectives of a novel service

The feasibility of an individualised carer support service delivered in community pharmacies was assessed from the perspective of carer participants using a pre-post questionnaire and semistructured interviews. Eligible pharmacies were required to offer a medication management service relevant to carers and have a semiprivate space for conversations. Carers were required to self-identify as an unpaid support person for someone with a chronic condition or disability. Between September 2016 and March 2017, staff from 11 community pharmacies in South-East Queensland, Australia were trained, and provided with ongoing mentoring from a pharmacist and carer to support service implementation. Identification of carers and support to achieve a personal and care-giving goal were key features of the service. Questionnaires included the EQ-5D-3L, the Bakas Caregiving Outcomes Scale, and questions relating to goal achievement, carer roles, and responsibilities. Seven follow-up carer interviews were undertaken between March and May 2017 and analysed thematically. Pre-post questionnaires were available for 17 carers (one withdrew, two incomplete). Of the 29 goals set, 10 were achieved and 14 partially achieved. EQ-5D-3L scores were unchanged, while 7 of the 15 items comprising the Bakas score improved (p < 0.05). Carer service evaluation was generally favourable, and these two main interview themes were the impact of caring and pharmacy experience. The impact of caring, while variable, was significant. Pharmacy experiences were mostly positive and the opportunity for carers to further engage with pharmacy staff was appreciated. The service was feasible and initial reported benefits to carers may support further research potentially in terms of a larger controlled trial.

Comparison of the psychometric properties of the EQ-5D-3L and SF-6D in the general population of Chengdu city in China

The EQ-5D-3L and SF-6D are the most commonly used economic evaluation instruments. Data comparing the psychometric properties of the instruments are scarce in the Chinese population. This study compared the psychometric properties of these measures in the Chinese general population in Chengdu.From October to December 2012, 2186 respondents (age ≥18) were selected from urban and rural areas of Chengdu, China, via multistage stratified cluster sampling. Correlations, scatter plots and Bland-Altman plots were used to explore the relationships between the 2 measures. Ceiling and floor effects were used to analyze the score distribution. The known-groups method was used to evaluate discriminant validity.Among 2186 respondents, 2182 completed the questionnaire, and 2178 (18-82 years old, mean 46.09 ± 17.49) met the data quality requirement. The mean scores for the EQ-5D-3LCN, EQ-5D-3LUK, and SF-6DUK were 0.95 (Std: 0.11), 0.93 (Std: 0.15), and 0.79 (Std: 0.12), respectively. The correlations between domains ranged from 0.16 to 0.51. The correlation between the EQ-5D-3LCN and SF-6DUK and between the EQ-5D-3LUK and SF-6DUK was 0.46. The scatter plots and Bland-Altman plots demonstrated poor agreement between the EQ-5D-3L and SF-6D. The floor and ceiling effects were respectively 0.05% and 74.60% for the EQ-5D-3L and 0.05% and 2.53% for the SF-6DUK. The EQ-5D-3LCN, EQ-5D-3LUK and SF-6D have good discriminant validity in different sociodemographic and health condition groups. The SF-6D has higher level of discriminant validity in moderately healthy groups in the EQ-5D-3L full-health population.Both the EQ-5D-3L and SF-6D are valid economic evaluation instruments in the Chinese general population in Chengdu but do not seem to be interchangeable. The EQ-5D-3L has a higher ceiling effect and higher level of discriminant validity among different sociodemographic groups, and the SF-6D has a lower ceiling effect and higher level of discriminant validity in health condition groups. Users may consider the evidence in the choice of these instruments.

Modelling the impact of multiple sclerosis on life expectancy, quality-adjusted life years and total lifetime costs: Evidence from Australia

Objectives:

To quantify life expectancy (LE), quality-adjusted life years (QALYs) and total lifetime societal costs for a hypothetical cohort of Australians with multiple sclerosis (MS).

Methods:

A 4-state Markov model simulated progression from no/mild to moderate and severe disability and death for a cohort of 35-year-old women over a lifetime horizon. Death risks were calculated from Australian life tables, adjusted by disability severity. State-dependent relapse probabilities and associated disutilities were considered. Probabilities of MS progression and relapse were estimated from AusLong and TasMSL MS epidemiological databases. Annual societal (direct and indirect) costs (2017 Australian dollars) and health-state utilities for each state were derived from the Australian MS Longitudinal Study. Costs were discounted at 5% annually.

Results:

Mean (95% confidence interval (CI)) LE from age 35 years was 42.7 (41.6–43.8) years. This was 7.5 years less than the general Australian population. Undiscounted QALYs were 28.2 (26.3–30.0), a loss of 13.1 QALYs versus the Australian population. Discounted lifetime costs were $942,754 ($347,856–$2,820,219).

Conclusion:

We have developed a health economics model of the progression of MS, calculating the impact of MS on LE, QALYs and lifetime costs in Australia. It will form the basis for future cost-effectiveness analyses of interventions for MS.

Comparison of EQ-5D-5L and SPVU-5D for measuring quality of life in patients with venous leg ulcers in an Australian setting

PURPOSE

Given the importance of measuring health-related quality of life (HRQoL) for cost-utility studies, this study aimed to determine the validity and responsiveness of two preference-based HRQoL instruments, the EuroQol-five dimensions-five levels questionnaire (EQ-5D-5L) and the Sheffield Preference-based Venous Ulcer questionnaire (SPVU-5D) in patients with venous leg ulcers (VLUs) in an Australian setting.

METHODS

This study analysed de-identified data collected from 80 patients with VLUs recruited by a prospective study in Brisbane, Queensland, Australia. Patients were asked to complete EQ-5D-5L and SPVU-5D surveys at baseline, 1-month, 3-month and 6-month follow-up as part of the prospective study. Baseline data and follow-up data were pooled to test the construct validity and level of agreement of the two instruments. Follow-up data were used to test the responsiveness.

RESULTS

The ceiling effects were negligible for EQ-5D-5L and SPVU-5D utility scores. Both instruments were able to discriminate between healed VLU and unhealed VLU and showed great responsiveness when healing status changed over time. Weak to strong correlations were found between dimensions of EQ-5D-5L and SPVU-5D. The utility scores produced from EQ-5D-5L were generally lower.

CONCLUSIONS

This study found that both EQ-5D-5L and SPVU-5D were valid and responsive in detecting change of VLU healing status among a small Australian population. Both instruments may be used in economic evaluation studies that involve patients with healed or unhealed VLUs. However, given the limitations presented in this study, further research is necessary to make sound recommendations on the preferred instrument in economic evaluation of VLU-related interventions.

Update on the General Practice Optimising Structured Monitoring to Improve Clinical Outcomes in Type 2 Diabetes (GP-OSMOTIC) trial: statistical analysis plan for a multi-centre randomised controlled trial

BACKGROUND

General Practice Optimising Structured Monitoring to Improve Clinical Outcomes in Type 2 Diabetes (GP-OSMOTIC) is a multicentre, individually randomised controlled trial aiming to compare the use of intermittent retrospective continuous glucose monitoring (r-CGM) to usual care in patients with type 2 diabetes attending general practice. The study protocol was published in the British Medical Journal Open and described the principal features of the statistical methods that will be used to analyse the trial data. This paper provides greater detail on the statistical analysis plan, including background and justification for the statistical methods chosen, in accordance with SPIRIT guidelines.

OBJECTIVE

To describe in detail the data management process and statistical methods that will be used to analyse the trial data.

METHODS

An overview of the trial design and primary and secondary research questions are provided. Sample size assumptions and calculations are explained, and randomisation and data management processes are described in detail. The planned statistical analyses for primary and secondary outcomes and sub-group analyses are specified along with the intended table layouts for presentation of the results.

CONCLUSION

In accordance with best practice, all analyses outlined in the document are based on the aims of the study and have been pre-specified prior to the completion of data collection and outcome analyses.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12616001372471 . Registered on 3 August 2016.

Reducing Uncertainty in EQ-5D Value Sets: The Role of Spatial Correlation

OBJECTIVE

Scoring algorithms for the EQ-5D-3L are constructed subject to a large degree of uncertainty (a credible interval width of 0.152, which is significant in comparison to the reported minimal important differences). The purpose of this work is to explore modeling techniques that will reduce the extent of this uncertainty.

METHODS

We used the US valuation study data. A Bayesian approach was used to calculate predicted utilities and credible intervals. A spatial Gaussian correlation structure was used to model correlation among health states (HS), thus allowing directly valued HS to contribute to the predicted utility of nearby unvalued HS. Leave-one-out cross-validation was used to compare model performances.

RESULTS

The average posterior standard deviation was 0.039 for the unvalued health states and 0.011 for the valued health states. Using cross-validation, the US D1 model had 31% coverage probability. Models with independent and Gaussian correlation had coverage probabilities of 95% and 93%, respectively. Moreover, the Gaussian correlation structure resulted in a 25.6% reduction in mean squared error (SE) and 13.2% reduction in mean absolute error (AE) compared to the independent correlation structure (mean SE of 0.00131 v. 0.00176 and mean AE of 0.02818 v. 0.03248).

CONCLUSION

Uncertainty was substantially lower for the directly valued HS compared to unvalued HS, suggesting direct valuation of as many health states as possible. Incorporation of a spatial correlation significantly reduced uncertainty. Hence, we suggest incorporating this when constructing scoring algorithms.

A Web-Based Recovery Program (ICUTogether) for Intensive Care Survivors: Protocol for a Randomized Controlled Trial

Background

Those who experience a critical illness or condition requiring admission to an intensive care unit (ICU) frequently experience physical and psychological complications as a direct result of their critical illness or condition and ICU experience. Complications, if left untreated, can affect the quality of life of survivors and impact health care resources. Explorations of potential interventions to reduce the negative impact of an ICU experience have failed to establish an evidence-based intervention.

Objective

The aim of this study is to evaluate the impact of a Web-based intensive care recovery program on the mental well-being of intensive care survivors and to determine if it is a cost-effective approach.

Methods

In total, 162 patients that survived an ICU experience will be recruited and randomized into 1 of 2 groups. The intervention group will receive access to the Web-based intensive care recovery program, ICUTogether, 2 weeks after discharge (n=81), and the control group will receive usual care (n=81). Mental well-being will be measured using the Hospital Anxiety and Depression Scale, The Impact of Events Scale-Revised and the 5-level 5-dimension EuroQoL at 3 time points (2 weeks, 6 months, and 12 months post discharge). Family support will be measured using the Multidimensional Scale of Perceived Social Support at 3 time points. Analysis will be conducted on an intention-to-treat basis using regression modeling. Covariates will include baseline outcome measures, study allocation (intervention or control), age, gender, length of ICU stay, APACHE III score, level of family support, and hospital readmissions. Participants’ evaluation of the mobile website will be sought at 12 months postdischarge. A cost utility analysis conducted at 12 months from a societal perspective will consider costs incurred by individuals as well as health care providers.

Results

Participant recruitment is currently underway. Recruitment is anticipated to be completed by December 2020.

Conclusions

This study will evaluate a novel intervention in a group of ICU survivors. The findings from this study will inform a larger study and wider debate about an appropriate intervention in this population.

International Registered Report Identifier (IRRID)

PRR1-10.2196/10935

Cost-Utility Analysis of Home-Based Telerehabilitation Compared With Centre-Based Rehabilitation in Patients With Heart Failure

BACKGROUND

Whilst home-based telerehabilitation has been shown non-inferior to traditional centre-based rehabilitation in patients with chronic heart failure, its economic sustainability remains unknown. This study aimed to investigate the cost-utility of a home-based telerehabilitation program.

METHODS

A comparative, trial-based, incremental cost-utility analysis was conducted from a health care provider's perspective. We collected data as part of a multi-centre, two-arm, non-inferiority, randomised controlled trial with 6 months follow-up. There were 53 participants randomised to either a telerehabilitation program (consisting of 12 weeks of group-based exercise and education delivered into the home via online videoconferencing) or a traditional centre-based program. Health care costs (including personnel, equipment and hospital readmissions due to heart failure) were extracted from health system records, and calculated in Australian dollars using 2013 as the base year. Health utilities were measured using the EuroQol five-dimensional (EQ-5D) questionnaire. Estimates were presented as means and 95% confidence intervals (CIs) based on bootstrapping. Costs and utility differences were plotted on a cost-effectiveness plane.

RESULTS

Total health care costs per participant were significantly lower in the telerehabilitation group (-$1,590, 95% CI: -2,822, -359) during the 6 months. No significant differences in quality-adjusted life years (0, 95% CI: -0.06, 0.05) were seen between the two groups.

CONCLUSIONS

Heart failure telerehabilitation appears to be less costly and as effective for the health care provider as traditional centre-based rehabilitation.

Scoring the Child Health Utility 9D instrument: estimation of a Chinese child and adolescent-specific tariff

PURPOSE

To derive children and adolescents' preferences for health states defined by the Chinese version of Child Health Utility 9D (CHU9D-CHN) instrument in China that can be used to estimate quality-adjusted life years (QALYs) for economic evaluation.

METHODS

A profile case best-worst scaling (BWS) and a time trade-off (TTO) method were combined to derive a Chinese-specific tariff for the CHU9D-CHN. The BWS survey recruited students from primary and high schools using a multi-stage random sampling method and was administered in a classroom setting, whilst the TTO survey adopted an interviewer-administrated conventional TTO task and was administered to a convenience sample of undergraduate students. A latent class modelling framework was adopted for analysing the BWS data.

RESULTS

Two independent surveys were conducted in Nanjing, China, including a valid sample of 902 students (mean age 13 years) from the BWS survey and a valid sample of 38 students (mean age 18 years) from the TTO survey. The poolability of the best and the worst responses was rejected and the optimal result based on the best responses only. The optimal model suggests the existence of two latent classes. The BWS estimates were further re-anchored onto the QALY scale using the TTO generated health state values via a mapping approach.

CONCLUSION

This study provides further insights into the use of the BWS method to generate health state values with young people and highlights the potential different decision rules that young people may employ for determining best vs. worst choices in this context.

Health-related quality of life in people with advanced dementia: a comparison of EQ-5D-5L and QUALID instruments

BACKGROUND

Assessing health-related quality of life (HRQOL) in people with advanced dementia is challenging but important for informed decision-making. Proxy measurement of this construct is difficult and is often rated lower than self-report. Accurate proxy rating of quality of life in dementia is related to identification of concepts important to the person themselves, as well as the sensitivity of the measures used. The main aim of this study was to compare the performance of two instruments-QUALID and EQ-5D-5L-on measuring HRQOL in people with advanced dementia.

METHODS

In a sub-study nested within a cluster-RCT we collected proxy(nurse)-completed EQ-5D-5L and QUALID measures at baseline, 3, 6, 9 and 12 months' follow-up for people with advanced dementia, residing in 20 nursing homes across Australia. Spearman's rank correlations, partial correlations and linear regressions were used to assess the relationship between the HRQOL instrument scores and their changes over time.

RESULTS

The mean weight from 284 people for the EQ-5D-5L and QUALID at baseline were 0.004 (95% CI - 0.026, 0.033) and 24.98 (95% CI 24.13, 25.82), respectively. At 12 months' follow-up, 115 participants remained alive. EQ-5D-5L weights and QUALID scores at baseline and at follow-up were moderately correlated (r = - 0.437; p < 0.001 at 12 months). Changes within QUALID and EQ-5D-5L across the same follow-up periods were also correlated (r = - 0.266; p = 0.005). The regression analyses support these findings.

CONCLUSION

Whilst these quality of life instruments demonstrated moderate correlation, the EQ-5D-5L does not appear to capture all aspects of quality of life that are relevant to people with advanced dementia and we cannot recommend the use of this instrument for use within this population. The QUALID appears to be a more suitable instrument for measuring HRQOL in people with severe dementia, but is not preference-based, which limits its application in economic evaluations of dementia care.

Quality of life in older adults following a hip fracture: an empirical comparison of the ICECAP-O and the EQ-5D-3 L instruments

Background

The purpose of this study was to empirically compare the performance of two generic preference based quality of life instruments, EQ-5D-3 L (with a health and physical function focus) and ICECAP-O (with a wellbeing and capability focus), in a population of older Australians following hip fracture.

Methods

Older adults or their family member proxies (in cases of severe cognitive impairment) following surgery to repair a fractured hip were invited to take part in this cross sectional study. Inclusion criteria included an age of 60 years or older, confirmed falls-related hip fracture and those receiving current palliative care or consented to other research studies were excluded. 87 participants completed the ICECAP-O and EQ-5D-3 L instruments between one and three weeks post-surgery.

Results

For the hip fracture population, the mean ICECAP-O score was 0.639 (SD 0.206, n = 82) and the mean EQ-5D-3 L utility score was 0.545 (SD 0.251, n = 87). There was a statistically significant positive correlation between the ICECAP-O and EQ-5D-3 L scores (r = 0.529, p = < 0.001).

Conclusions

Study findings indicate significant impairments in quality of life post hip fracture. In multiple regression analyses, age and health-related QoL (measured by the EQ-5D) were significant determinants of ICECAP-O scores, while proxy respondent status, age, and capability-related QoL (measured by the ICECAP-O) were significant determinants of EQ-5D scores. Approaches to measuring and valuing quality of life in this sample, should consider the target domains of the intervention in their choice of instrument. Studies aiming to measure the impact of interventions targeting broader domains of wellbeing and QoL should consider including a broader measure of QoL in conjunction with a HRQoL measure.

The feasibility of implementing the ICHOM Standard Set for Hip and Knee Osteoarthritis: a mixed-methods evaluation in public and private hospital settings

Background

There is growing international momentum for standardising patient outcome assessment and using patient-reported outcome measures (PROMs) to capture outcomes that matter to patients. The International Consortium for Health Outcomes Measurement (ICHOM) Standard Sets were developed to capture the outcomes of care for costly conditions including osteoarthritis. This study evaluated the feasibility of implementing the ICHOM Standard Set for Hip and Knee Osteoarthritis in ‘real world’ public and private hospital settings.

Methods

A mixed-methods design was used to capture comprehensive data on patient outcomes, implementation costs, and the implementation experiences of patients, clinicians and administrative staff. The ICHOM Standard Set was implemented at two hospital sites (1 public, 1 private) in May 2016. Patients undergoing primary hip or knee replacement for osteoarthritis were recruited from pre-admission clinics and a private orthopaedic clinic. Baseline Standard Set data were collected before surgery and at pre-determined post-operative timepoints. Data on the costs of Standard Set implementation were also collected. Semi-structured interviews were conducted with key stakeholders (n = 15) to evaluate the ease of implementation, and explore barriers and enablers to implementation and sustainability.

Results

The cost of Standard Set implementation and ongoing data collection for 17 months totalled $AUD94,955. Preference data (collected prior to completing the Standard Set) revealed that most participants preferred paper-based (83%) or web-based questionnaire completion (14%), with only a small proportion preferring iPad-based completion (3%). Several PROMs within the Standard Set were responsive to change (effect size range 0.19–0.85), with significant improvements in important health outcomes identified 6 weeks after surgery. Patient interviews showed a variable understanding of why patient-reported data collection is undertaken; however, patients perceived that PROMs provided relevant information to treating clinicians, and that the burden of questionnaire completion was minimal. Staff interviews revealed that PROMs are considered valuable, dedicated personnel are required to support data collection, gaps in information technology resources must be addressed, and that the Standard Set offers benefits beyond what currently-used measures provide.

Conclusion

The Standard Set can be feasibly implemented in hospital settings, but with important caveats around staffing and technical support, consideration of patient preferences, and promotion of active clinician engagement.

Electronic supplementary material

The online version of this article (10.1186/s41687-018-0062-5) contains supplementary material, which is available to authorized users.

How Significant Are "High" Correlations Between EQ-5D Value Sets?

The calculation of quality-adjusted life years, as used for cost-utility analysis, depends on the availability of value sets representing people's preferences with respect to health-related quality of life (HRQoL). A value set consists of HRQoL index values for all health states representable by the particular descriptive system used, of which the EQ-5D (EuroQoL, 5 Dimensions) is by far the most widely used. High correlation coefficients for EQ-5D value sets derived from different samples-across countries and/or using different valuation techniques-are conventionally interpreted as evidence that the people in the respective samples have similar HRQoL preferences. However, EQ-5D value sets-for both versions of the system (EQ-5D-3L and EQ-5D-5L)-contain many inherent rankings of health state values by design. By calculating correlation coefficients for value sets created from random data, we demonstrate that "high" coefficients are artifacts of these inherent rankings, such as median Pearson's r = 0.783 for the EQ-5D-3L and 0.850 for the EQ-5D-5L instead of zero. Therefore, high correlation coefficients do not necessarily constitute evidence of meaningful associations in terms of similar HRQoL preferences. After calculating significance levels based on our simulations-available as an online resource for other researchers-we find that many high coefficients are not as significant as conventionally interpreted, whereas other coefficients are not significant. These "high" but insignificant correlations are in fact spurious.

Cost-effectiveness of the BRECONDA decision aid for women with breast cancer: Results from a randomized controlled trial

OBJECTIVE

To report on the cost-effectiveness of BRECONDA (Breast RECONstruction Decision Aid), a web-based decision aid to facilitate decisions regarding breast reconstruction surgery, with usual care for women with breast cancer.

METHODS

The economic evaluation was conducted alongside a randomized controlled trial. Women diagnosed with breast cancer or ductal carcinoma in situ and eligible for breast reconstruction following mastectomy were randomized to access BRECONDA for 6 months + usual care (n = 106) or usual care (n = 116) and were assessed at baseline preintervention, and then 1-month and 6-months post-randomization. Decisional conflict, satisfaction with information, decisional regret, and utilities were assessed by using maximum-likelihood linear mixed effects models. Costs included the fixed costs of BRECONDA, health care provider time, and health care resource use. Nonparametric bootstrapping was used to estimate incremental cost-effectiveness ratios.

RESULTS

BRECONDA resulted in significantly less decisional conflict and greater satisfaction with information over time. Quality-adjusted life years did not differ between participants who received the decision aid compared with usual care. The cost of BRECONDA was estimated to be small (AUD$10) relative to other health care interventions and resulted in decreased health care costs overall (AUD$764). Based on the point estimates, the decision aid was more effective and less costly (dominant) for all measures of effectiveness. It was estimated that the decision aid has an 87% probability of being cost-effective at $60 000 per quality-adjusted life year gained.

CONCLUSIONS

The BRECONDA web-based intervention designed to facilitate decisions regarding breast reconstruction surgery is likely to be cost-effective compared with usual care for women with breast cancer.

Assessing the Use of a Feedback Module to Model EQ-5D-5L Health States Values in Hong Kong

BACKGROUND

An international valuation protocol exists for obtaining societal values for each of the 3125 health states of the five-level EuroQol-five dimensions (EQ-5D-5L) questionnaire. A feedback module (FM) that can be related to theoretical models used in behavioral economics was recently included in this protocol.

OBJECTIVES

Our objective was to assess the impact of using an FM to estimate an EQ-5D-5L value set in Hong Kong.

METHODS

EQ-5D-5L health states were elicited using a composite time trade-off (C-TTO) and a discrete-choice (DC) experiment. Use of the FM according to participant characteristics and the impact of the FM on the number of inconsistent C-TTO responses were assessed. We employed a main-effects hybrid model that combined data from both elicitation techniques.

RESULTS

In total, 1014 individuals completed the survey. The sample was representative of the general Chinese Hong Kong population in terms of sex, educational attainment, marital status, and most age groups but not for employment status. The use of the FM reduced the number of C-TTO inconsistencies. Participant characteristics differed significantly between those who used and did not use the FM. The model without a constant resulted in logical consistent coefficients and was therefore selected as the model to produce the value set. The predicted EQ-5D-5L values ranged from -0.864 to 1.

CONCLUSIONS

The use of an FM to allow participants to exclude C-TTO responses reduced the number of inconsistent responses and improved the quality of the data when estimating an EQ-5D-5L value set in Hong Kong.

Australian Utility Weights for the EORTC QLU-C10D, a Multi-Attribute Utility Instrument Derived from the Cancer-Specific Quality of Life Questionnaire, EORTC QLQ-C30

BACKGROUND

The EORTC QLU-C10D is a new multi-attribute utility instrument derived from the widely used cancer-specific quality-of-life (QOL) questionnaire, EORTC QLQ-C30. The QLU-C10D contains ten dimensions (Physical, Role, Social and Emotional Functioning; Pain, Fatigue, Sleep, Appetite, Nausea, Bowel Problems), each with four levels. To be used in cost-utility analysis, country-specific valuation sets are required.

OBJECTIVE

The aim of this study was to provide Australian utility weights for the QLU-C10D.

METHODS

An Australian online panel was quota-sampled to ensure population representativeness by sex and age (≥ 18 years). Participants completed a discrete choice experiment (DCE) consisting of 16 choice-pairs. Each pair comprised two QLU-C10D health states plus life expectancy. Data were analysed using conditional logistic regression, parameterised to fit the quality-adjusted life-year framework. Utility weights were calculated as the ratio of each QOL dimension-level coefficient to the coefficient on life expectancy.

RESULTS

A total of 1979 panel members opted in, 1904 (96%) completed at least one choice-pair, and 1846 (93%) completed all 16 choice-pairs. Dimension weights were generally monotonic: poorer levels within each dimension were generally associated with greater utility decrements. The dimensions that impacted most on choice were, in order, Physical Functioning, Pain, Role Functioning and Emotional Functioning. Oncology-relevant dimensions with moderate impact were Nausea and Bowel Problems. Fatigue, Trouble Sleeping and Appetite had relatively small impact. The value of the worst health state was -0.096, somewhat worse than death.

CONCLUSIONS

This study provides the first country-specific value set for the QLU-C10D, which can facilitate cost-utility analyses when applied to data collected with the EORTC QLQ-C30, prospectively and retrospectively.

Economic evaluation of a nurse-led home and clinic-based secondary prevention programme to prevent progressive cardiac dysfunction in high-risk individuals: The Nurse-led Intervention for Less Chronic Heart Failure (NIL-CHF) randomized controlled study

OBJECTIVE

The objective of this study was to assess the cost-effectiveness of a long-term, nurse-led, multidisciplinary programme of home/clinic visits in preventing progressive cardiac dysfunction in patients at risk of developing de novo chronic heart failure (CHF).

METHODS

A trial-based analysis was conducted alongside a pragmatic, single-centre, open-label, randomized controlled trial of 611 patients (mean age: 66 years) with subclinical cardiovascular diseases (without CHF) discharged to home from an Australian tertiary referral hospital. A nurse-led home and clinic-based programme (NIL-CHF intervention, n = 301) was compared with standard care ( n=310) in terms of life-years, quality-adjusted life-years (QALYs) and healthcare costs. The uncertainty around the incremental cost and QALYs was quantified by bootstrap simulations and displayed on a cost-effectiveness plane.

RESULTS

During a median follow-up of 4.2 years, there were no significant between-group differences in life-years (-0.056, p=0.488) and QALYs (-0.072, p=0.399), which were lower in the NIL-CHF group. The NIL-CHF group had slightly lower all-cause hospitalization costs (AUD$2943 per person; p=0.219), cardiovascular-related hospitalization costs (AUD$1142; p=0.592) and a more pronounced reduction in emergency/unplanned hospitalization costs (AUD$4194 per person; p=0.024). When the cost of intervention was added to all-cause, cardiovascular and emergency-related readmissions, the reductions in the NIL-CHF group were AUD$2742 ( p=0.313), AUD$941 ( p=0.719) and AUD$3993 ( p=0.046), respectively. At a willingness-to-pay threshold of AUD$50,000/QALY, the probability of the NIL-CHF intervention being better-valued was 19%.

CONCLUSIONS

Compared with standard care, the NIL-CHF intervention was not a cost-effective strategy as life-years and QALYs were slightly lower in the NIL-CHF group. However, it was associated with modest reductions in emergency/unplanned readmission costs.

Thermal clothing to reduce heart failure morbidity during winter: a randomised controlled trial

OBJECTIVE

To examine whether providing thermal clothing improved the health of patients with heart failure during winter.

DESIGN

Parallel group randomised controlled trial.

SETTING

Large public hospital in Brisbane during winter 2016.

PARTICIPANTS

91 patients with systolic or diastolic heart failure who were over 50 years old.

INTERVENTION

47 patients were randomised to receive thermal clothes (socks, top and hat) and 44 received usual care. Patients could not be blinded to their randomised group. All patients' data were available for the primary outcome which was collected blind to randomised group.

MAIN OUTCOME MEASURES

The primary outcome was the mean number of days in hospital during winter. Secondary outcomes included quality of life and sleep, and blood tests were collected for cardiovascular risk factors. Participants completed clothing diaries in midwinter which were used to estimate their overall clothing insulation using the 'clo'. Monitors inside the participants' homes recorded indoor temperatures throughout winter.

RESULTS

The mean number of days in hospital during winter was 4.2 in the usual care group and 3.0 in the thermal clothing group (mean difference -1.2 days, 95% CI -4.8 to 2.5 days). Most participants (85%) in the thermal clothing group reported using the thermals. There was an increase in overall clothing insulation at night in the thermal clothing group (mean difference 0.13 clo, 95% CI 0.03 to 0.23). Most participants in both groups did not wear sufficient clothing (defined as a clo below 1) and regularly experienced indoor temperatures below 18°C during midwinter.

CONCLUSIONS

There was no clear statistical improvement in health in the thermal clothing group. Efforts to improve health during winter may need to focus on passive interventions such as home insulation rather than interventions that target behaviour change.

TRIAL REGISTRATION NUMBER

ACTRN12615001023549; Results.

Emergency department presentations in infants: Predictors from an Australian birth cohort

AIM

Infants under 12 months of age are disproportionately represented amongst emergency department (ED) presentations, and infants are more likely to be frequent ED users. This study aimed to describe and identify psychosocial predictors of ED presentation in infants.

METHODS

A prospective birth cohort from Queensland and New South Wales (Environments for Healthy Living) was used to understand infant health service use. Baseline and 12-month questionnaire data pertaining to children born between 2006 and 2011 were used to identify predictors of ED presentation, using multiple regression analysis.

RESULTS

Of the 2184 children in the cohort with available baseline and 12-month data, 579 (27%) presented at least once to an ED during their first 12 months of life. Statistically significant predictors of ED presentation in the multivariate analysis included the mother having asthma (odds ratio (OR) 1.67, 95% confidence interval (CI) 1.15-2.39) and a higher Kessler-6 score (a measure of psychological distress) of the primary carer at baseline (OR 1.04, 95% CI 1.01-1.08). Maternal education level was not associated with ED presentations of infants.

CONCLUSIONS

This study describes maternal and child factors of children who present to the ED in the first year of life. Factors related to an infant's support system were found to be predictors for an ED presentation in the first year of life. This study emphasises the need to review the maternal medical history and psychosocial situation. There may be benefits for health-care practitioners to take the opportunity (such as during routine childhood immunisation) to perform a brief screening tool (such as the Kessler-6) to understand psychological distress experienced by mothers. This may influence the likelihood of a child presenting to an ED within the first 12 months of life.

Interdisciplinary model of care (RADICALS) for early detection and management of chronic obstructive pulmonary disease (COPD) in Australian primary care: study protocol for a cluster randomised controlled trial

INTRODUCTION

Up to half of all smokers develop clinically significant chronic obstructive pulmonary disease (COPD). Gaps exist in the implementation and uptake of evidence-based guidelines for managing COPD in primary care. We describe the methodology of a cluster randomised controlled trial (cRCT) evaluating the efficacy and cost-effectiveness of an interdisciplinary model of care aimed at reducing the burden of smoking and COPD in Australian primary care settings.

METHODS AND ANALYSIS

A cRCT is being undertaken to evaluate an interdisciplinary model of care (RADICALS - Review of Airway Dysfunction and Interdisciplinary Community-based care of Adult Long-term Smokers). General practice clinics across Melbourne, Australia, are identified and randomised to the intervention group (RADICALS) or usual care. Patients who are current or ex-smokers, of at least 10 pack years, including those with an existing diagnosis of COPD, are being recruited to identify 280 participants with a spirometry-confirmed diagnosis of COPD. Handheld lung function devices are being used to facilitate case-finding. RADICALS includes individualised smoking cessation support, home-based pulmonary rehabilitation and home medicines review. Patients at control group sites receive usual care and Quitline referral, as appropriate. Follow-ups occur at 6 and 12 months from baseline to assess changes in quality of life, abstinence rates, health resource utilisation, symptom severity and lung function. The primary outcome is change in St George's Respiratory Questionnaire score of patients with COPD at 6 months from baseline.

ETHICS AND DISSEMINATION

This project has been approved by the Monash University Human Research Ethics Committee and La Trobe University Human Ethics Committee (CF14/1018 - 2014000433). Results of the study will be disseminated in peer-reviewed journals and research conferences. If the intervention is successful, the RADICALS programme could potentially be integrated into general practices across Australia and sustained over time.

TRIAL REGISTRATION NUMBER

ACTRN12614001155684; Pre-results.

Healthcare expenditure on Indigenous and non-Indigenous Australians at high risk of cardiovascular disease

BACKGROUND

In spite of bearing a heavier burden of death, disease and disability, there is mixed evidence as to whether Indigenous Australians utilise more or less healthcare services than other Australians given their elevated risk level. This study analyses the Medicare expenditure and its predictors in a cohort of Indigenous and non-Indigenous Australians at high risk of cardiovascular disease.

METHODS

The healthcare expenditure of participants of the Kanyini Guidelines Adherence with the Polypill (GAP) pragmatic randomised controlled trial was modelled using linear regression methods. 535 adult (48% Indigenous) participants at high risk of cardiovascular disease (CVD) were recruited through 33 primary healthcare services (including 12 Aboriginal Medical Services) across Australia.

RESULTS

There was no significant difference in the expenditure of Indigenous and non-Indigenous participants in non-remote areas following adjustment for individual characteristics. Indigenous individuals living in remote areas had lower MBS expenditure ($932 per year P < 0.001) than other individuals. MBS expenditure was found to increase with being aged over 65 years ($128, p = 0.013), being female ($472, p = 0.003), lower baseline reported quality of life ($102 per 0.1 decrement of utility p = 0.004) and a history of diabetes ($324, p = 0.001), gout ($631, p = 0.022), chronic obstructive pulmonary disease ($469, p = 0.019) and established CVD whether receiving guideline-recommended treatment prior to the trial ($452, p = 0.005) or not ($483, p = 0.04). When controlling for all other characteristics, morbidly obese patients had lower MBS expenditure than other individuals (-$887, p = 0.002).

CONCLUSION

The findings suggest that for the majority of participants, once individuals are engaged with a primary care provider, factors other than whether they are Indigenous determine the level of Medicare expenditure for each person.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN 126080005833347.

Home-based telerehabilitation is not inferior to a centre-based program in patients with chronic heart failure: a randomised trial

QUESTION

Is a 12-week, home-based telerehabilitation program conducted in small groups non-inferior to a traditional centre-based program in terms of the change in 6-minute walk distance? Is the telerehabilitation program also non-inferior to a centre-based program in terms of functional capacity, muscle strength, quality of life, urinary incontinence, patient satisfaction, attendance rates, and adverse events?

DESIGN

Randomised, parallel, non-inferiority trial with concealed allocation, intention-to-treat analysis and assessor blinding.

PARTICIPANTS

Patients with stable chronic heart failure (including heart failure with reduced or preserved ejection fraction) were recruited from two tertiary hospitals in Brisbane, Australia.

INTERVENTION

The experimental group received a 12-week, real-time exercise and education intervention delivered into the participant's home twice weekly, using online videoconferencing software. The control group received a traditional hospital outpatient-based program of the same duration and frequency. Both groups received similar exercise prescription.

OUTCOME MEASURES

Participants were assessed by independent assessors at baseline (Week 0), at the end of the intervention (Week 12) and at follow-up (Week 24). The primary outcome was a between-group comparison of the change in 6-minute walk distance, with a non-inferiority margin of 28m. Secondary outcomes included other functional measures, quality of life, patient satisfaction, program attendance rates and adverse events.

RESULTS

In 53 participants (mean age 67 years, 75% males), there were no significant between-group differences on 6-minute walk distance gains, with a mean difference of 15m (95% CI -28 to 59) at Week 12. The confidence intervals were within the predetermined non-inferiority range. The secondary outcomes indicated that the experimental intervention was at least as effective as traditional rehabilitation. Significantly higher attendance rates were observed in the telerehabilitation group.

CONCLUSION

Telerehabilitation was not inferior to a hospital outpatient-based rehabilitation program in patients with chronic heart failure. Telerehabilitation appears to be an appropriate alternative because it promotes greater attendance at the rehabilitation sessions.

TRIAL REGISTRATION

ACTRN12613000390785. [Hwang R, Bruning J, Morris NR, Mandrusiak A, Russell T (2017) Home-based telerehabilitation is not inferior to a centre-based program in patients with chronic heart failure: a randomised trial. Journal of Physiotherapy 63: 101-107].

Cost-effectiveness of dual-energy X-ray absorptiometry plus antiresorptive treatment in Australian women with breast cancer who receive aromatase inhibitors

Postmenopausal women with breast cancer on aromatase inhibitor (AI) treatment are at increased risk of bone mineral density loss, which may lead to minimal trauma fractures. We examined the cost-effectiveness of dual energy X-ray absorptiometry (DXA) with antiresorptive (AR) therapy compared with fracture risk assessment, lifestyle advice, and vitamin supplementation. We used a hypothetical Markov cohort model of lifetime duration for 60-year-old women with early stage breast cancer receiving AIs. The data to inform the model came from medical literature, epidemiological reports, and costing data sets. Two eligibility scenarios for AR therapy were considered: (A) osteoporosis and (B) osteopenia or osteoporosis. The main outcomes were incremental cost per quality-adjusted life years gained and cumulative fractures per 1000 women, calculated relative to the comparator. Key aspects of the model were explored in sensitivity analyses. Due to relatively low effectiveness gains, the outcomes were primarily driven by the costs. The incremental cost per quality-adjusted life year gained was A$47,556 and A$253,000 for scenarios A and B, respectively. The numbers of fractures avoided were 56 and 77 per 1000 women, respectively. The results were most sensitive to the initial probability of osteoporosis, baseline risk of fracture, and cohort starting age. Compared with risk assessment and lifestyle advice only, a DXA scan followed by an AR treatment is potentially cost-effective for women aged 60 and over undergoing AI therapy for early breast cancer. However, the number of fractures averted through this intervention is small.

Dependency and health utilities in stroke: Data to inform cost-effectiveness analyses

Introduction

Health utilities (HU) assign preference weights to specific health states and are required for cost-effectiveness analyses. Existing HU for stroke inadequately reflect the spectrum of post-stroke disability. Using international stroke trial data, we calculated HU stratified by disability to improve precision in future cost-effectiveness analyses.

Materials and methods

We used European Quality of Life Score (EQ-5D-3L) data from the Virtual International Stroke Trials Archive (VISTA) to calculate HU, stratified by modified Rankin Scale scores (mRS) at 3 months. We applied published value sets to generate HU, and validated these using ordinary least squares regression, adjusting for age and baseline National Institutes of Health Stroke Scale (NIHSS) scores.

Results

We included 3858 patients with acute ischemic stroke in our analysis (mean age: 67.5 ± 12.5, baseline NIHSS: 12 ± 5). We derived HU using value sets from 13 countries and observed significant international variation in HU distributions (Wilcoxon signed-rank test p < 0.0001, compared with UK values). For mRS = 0, mean HU ranged from 0.88 to 0.95; for mRS = 5, mean HU ranged from -0.48 to 0.22. OLS regression generated comparable HU (for mRS = 0, HU ranged from 0.9 to 0.95; for mRS = 5, HU ranged from -0.33 to 0.15). Patients' mRS scores at 3 months accounted for 65-71% of variation in the generated HU.

Conclusion

We have generated HU stratified by dependency level, using a common trial endpoint, and describing expected variability when applying diverse value sets to an international population. These will improve future cost-effectiveness analyses. However, care should be taken to select appropriate value sets.

Comparison of the HUI3 and the EQ-5D-3L in a nursing home setting

BACKGROUND

Accurately assessing changes in the quality of life of older people living permanently in nursing homes is important. The multi-attribute utility instrument most commonly used and recommended to assess health-related quality of life in the nursing home population is the three-level EuroQol EQ-5D-3L. To date, there have been no studies using the Health Utilities Index Mark III (HUI3). The purpose of this study was to compare the level of agreement and sensitivity to change of the EQ-5D-3L and HUI3 in a nursing home population.

METHODS

EQ-5D-3L and HUI3 scores were measured as part of a cluster randomised controlled trial of nurse led care coordination in a nursing home population in Perth, Western Australia at baseline and 6-month follow up.

RESULTS

Both measures were completed for 199 residents at baseline and 177 at 6-month follow-up. Mean baseline utility scores for EQ-5D-3L (0.45; 95% CI 0.41-0.49) and HUI3 (0.15; 95% CI 0.10-0.20) were significantly different (Wilcoxon signed rank test, p<0.01) and agreement was poor to moderate between absolute scores from each instrument (intra-class correlation coefficient = 0.63). The EQ-5D-3L appeared more sensitive to change over the 6-month period.

CONCLUSION

Our findings show that the EQ-5D-3L and HUI3 estimate different utility scores among nursing home residents. These differences should be taken into account, particularly when considering the implications of the cost-effectiveness of particular interventions and we conclude that the HUI3 is no better suited to measuring health-related quality of life in a nursing home population when compared to the EQ-5D-3L.

Comparison of four alternative national universal anterior cruciate ligament injury prevention programme implementation strategies to reduce secondary future medical costs

BACKGROUND/AIM

Anterior cruciate ligament (ACL) injury is a common and devastating sporting injury. With or without ACL reconstruction, the risk of knee osteoarthritis (OA) and permanent disability later in life is markedly increased. While neuromuscular training programmes can prevent 50-80% of ACL injuries, no national implementation strategies exist in Australia. The aim of this study was to compare the ability of four alternative national universal ACL injury prevention programme implementation strategies to reduce future medical costs secondary to ACL injury.

METHODS

A Markov economic decision model was constructed to estimate the value in lifetime future medical costs prevented by implementing a national ACL prevention programme among four hypothetical cohorts: high-risk sport participants (HR) aged 12-25 years; HR 18-25 years; HR 12-17 years; all youths (ALL) 12-17 years.

RESULTS

Of the four programmes examined, the HR 12-25 programme provided the greatest value, averting US$693 of direct healthcare costs per person per lifetime or US$221 870 880 in total. Without training, 9.4% of this cohort will rupture their ACL and 16.8% will develop knee OA. Training prevents 3764 lifetime ACL ruptures per 100 000 individuals, a 40% reduction in ACL injuries. 842 lifetime cases of OA per 100 000 individuals and 584 TKRs per 100 000 are subsequently averted. Numbers needed to treat ranged from 27 for the HR 12-25 to 190 for the ALL 12-17.

CONCLUSIONS

The HR 12-25 programme was the most effective implementation strategy. Estimation of the break-even cost of health expenditure savings will enable optimal future programme design, implementation and expenditure.

A Cost-Effectiveness Analysis of Nivolumab Compared with Ipilimumab for the Treatment of BRAF Wild-Type Advanced Melanoma in Australia

PURPOSE

The aim of this study was to evaluate the cost-effectiveness of nivolumab versus ipilimumab for the treatment of previously untreated patients with BRAF-advanced melanoma (BRAF-AM) from an Australian health system perspective.

METHODS

A state-transition Markov model was constructed to simulate the progress of Australian patients with BRAF-AM. The model had a 10-year time horizon with outcomes discounted at 5% annually. For the nivolumab group, risks of progression and death were based on those observed in the nivolumab arm of a phase III trial (nivolumab vs. dacarbazine). Progression-free survival and overall survival were extrapolated using parametric survival modeling with a log-logistic distribution. In the absence of head-to-head evidence, overall survival and progression-free survival for ipilimumab were estimated on the basis of an indirect comparison using published data. Costs of managing AM were estimated from a survey of Australian clinicians. The cost of ipilimumab was based on the reimbursement price in Australia. The cost of nivolumab was based on expected reimbursement prices in Australia. Quality-of-life data were obtained within the trial using the EuroQol five-dimensional questionnaire.

RESULTS

Compared with ipilimumab, nivolumab therapy over 10 years was estimated to yield 1.58 life-years and 1.30 quality-adjusted life-years per person, at a (discounted) net cost of US $39,039 per person. The incremental cost-effectiveness ratios for nivolumab compared with ipilimumab were US $25,101 per year of life saved and $30,475 per quality-adjusted life-year saved.

CONCLUSIONS

Nivolumab is a cost-effective means of preventing downstream mortality and morbidity in patients with AM compared with ipilimumab in the Australian setting.

Preventing postnatal maternal mental health problems using a psychoeducational intervention: the cost-effectiveness of What Were We Thinking

OBJECTIVES

Postnatal maternal mental health problems, including depression and anxiety, entail a significant burden globally, and finding cost-effective preventive solutions is a public policy priority. This paper presents a cost-effectiveness analysis of the intervention, What Were We Thinking (WWWT), for the prevention of postnatal maternal mental health problems.

DESIGN

The economic evaluation, including cost-effectiveness and cost-utility analyses, was conducted alongside a cluster-randomised trial.

SETTING

48 Maternal and Child Health Centres in Victoria, Australia.

PARTICIPANTS

Participants were English-speaking first-time mothers attending participating Maternal and Child Health Centres. Full data were collected for 175 participants in the control arm and 184 in the intervention arm.

INTERVENTION

WWWT is a psychoeducational intervention targeted at the partner relationship, management of infant behaviour and parental fatigue.

OUTCOME MEASURES

The evaluation considered public sector plus participant out-of-pocket costs, while outcomes were expressed in the 30-day prevalence of depression, anxiety and adjustment disorders, and quality-adjusted life years (QALYs). Incremental costs and outcomes were estimated using regression analyses to account for relevant sociodemographic, prognostic and clinical characteristics.

RESULTS

The intervention was estimated to cost $A118.16 per participant. The analysis showed no statistically significant difference between the intervention and control groups in costs or outcomes. The incremental cost-effectiveness ratios were $A36 451 per QALY gained and $A152 per percentage-point reduction in 30-day prevalence of depression, anxiety and adjustment disorders. The estimate lies under the unofficial cost-effectiveness threshold of $A55 000 per QALY; however, there was considerable uncertainty surrounding the results, with a 55% probability that WWWT would be considered cost-effective at that threshold.

CONCLUSIONS

The results suggest that, although WWWT shows promise as a preventive intervention for postnatal maternal mental health problems, further research is required to reduce the uncertainty over its cost-effectiveness as there were no statistically significant differences in costs or outcomes.

TRIAL REGISTRATION NUMBER

ACTRN12613000506796; results.

Comparison of contemporaneous responses for EQ-5D-3L and Minnesota Living with Heart Failure; a case for disease specific multiattribute utility instrument in cardiovascular conditions

BACKGROUND

The EQ-5D-3L, a generic multi-attribute utility instrument (MAUI), is widely employed to assist in economic evaluations in health care. The EQ-5D-3L lacks sensitivity when used in conditions such as cardiovascular disease (CVD). Although there are number of CVD specific quality of life instruments, currently, there are no CVD specific MAUIs. The aim of this study is to investigate the discriminative ability and responsiveness of the EQ-5D-3L and the Minnesota Living with Heart Failure Questionnaire (MLHF), a CVD specific quality of life instrument in a group of heart failure patients.

METHODS

The psychometric performance of the EQ-5D-3L and the MLHF was assessed using data from a randomised trial for a heart failure management intervention. The two instruments were compared for discrimination, responsiveness and agreement. The severity groups were defined using New York Heart Association functional classes.

RESULTS

The effect sizes for severe classes were generally similar showing good discrimination. The MLHF recorded better responsiveness between the time points than the EQ-5D-3L which was indicated by higher effect sizes and standardised response means. The change in MLHF summary scores between the time points was significant (p<0.005; paired t-test). The overall agreement between the two measures was low.

CONCLUSION

The low correlation indicates that the two classification systems cover different aspects of health space. Comparison of CVD specific instruments with other generic MAUIs such as EQ-5D-3L and AQOL-8D is recommended for further research.

Preference-based disease-specific health-related quality of life instrument for glaucoma: a mixed methods study protocol

INTRODUCTION

A primary objective of healthcare services is to improve patients' health and health-related quality of life (HRQoL). Glaucoma, which affects a substantial proportion of the world population, has a significant detrimental impact on HRQoL. Although there are a number of glaucoma-specific questionnaires to measure HRQoL, none is preference-based which prevent them from being used in health economic evaluation. The proposed study is aimed to develop a preference-based instrument that is capable of capturing important effects specific to glaucoma and treatments on HRQoL and is scored based on the patients' preferences.

METHODS

A sequential, exploratory mixed methods design will be used to guide the development and evaluation of the HRQoL instrument. The study consists of several stages to be implemented sequentially: item identification, item selection, validation and valuation. The instrument items will be identified and selected through a literature review and the conduct of a qualitative study. Validation will be conducted to establish psychometric properties of the instrument followed by a valuation exercise to derive utility scores for the health states described.

ETHICS AND DISSEMINATION

This study has been approved by the Trillium Health Partners Research Ethics Board (ID number 753). All personal information will be de-identified with the identification code kept in a secured location including the rest of the study data. Only qualified and study-related personnel will be allowed to access the data. The results of the study will be distributed widely through peer-reviewed journals, conferences and internal meetings.

RESPOND: a programme to prevent secondary falls in older people presenting to the emergency department with a fall: protocol for an economic evaluation

BACKGROUND

Falls remain common for community-dwelling older people and impose a substantial economic burden to the healthcare system. RESPOND is a novel falls prevention programme that aims to reduce secondary falls and fall injuries among older people who present to a hospital emergency department (ED) with a fall. The present protocol describes a prospective economic evaluation examining the incremental cost-effectiveness of the RESPOND programme, compared with usual care practice, from the Australian health system perspective.

METHODS AND DESIGN

This economic evaluation will recruit 528 participants from two major tertiary hospital EDs in Australia and will be undertaken alongside a multisite randomised controlled trial. Outcome and costing data will be collected for all participants over the 12-month trial. It will compare the RESPOND falls prevention programme with usual care practice (current community-based falls prevention practices) to determine its incremental cost-effectiveness according to three intermediate clinical outcomes: (1) falls prevented, (2) fall injuries prevented and (3) injurious falls prevented. In addition, utilities will be derived from a generic quality-of-life measure (EQ-5D-5L) and used to calculate the 'incremental cost per quality-adjusted life years gained'.

DISCUSSION

The results of this study will provide healthcare decision makers with evidence to assist with setting spending thresholds for preventive health programmes and inform selection of emergency and community service models of care.

TRIAL REGISTRATION NUMBER

The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000336684); Pre-results.

Examining evidence based resistance plus balance training in community-dwelling older adults with complex health care needs: Trial protocol for the Muscling Up Against Disability project

Progressive resistance plus balance training (PRBT) has been demonstrated as effective in reducing later life physical disability, falls risk and poor health, even among those with complex health care needs. However, few studies have examined the influence of PRBT on health service utilisation, cognitive wellbeing and training modality acceptance or undertaken a cost benefit analysis. This project will investigate the broad scope benefits of PRBT participation among community-dwelling older Australians receiving Government supported aged care packages for their complex health care needs. Using a modified stepped-wedge design, 248 community-dwelling adults 65 years and older with some level of government support aged care have been randomised into the study. Those randomised to exercise undertake six months of twice weekly machine-based, moderate to high intensity, supervised PRBT, followed by a six month unsupervised, unsupported follow-up. Controls spend six months undertaking usual activities, before entering the PRBT and follow-up phases. Data are collected at baseline and after each of the six month phases. Measures include level of and change in health and care needs, body composition, muscle capacity, falls, sleep, quality of life, nutritional and mental health status. In addition, acceptance and engagement is determined through telephone and focus group interviews complementing a multi-model health cost benefit evaluation. It is hypothesised this study will demonstrate the feasibility and efficacy of PRBT in improving primary and secondary health outcomes for older adults with aged care needs, and will support the value of this modality of exercise as an integral evidence-based service model of care.

The impact of multiple sclerosis severity on health state utility values: Evidence from Australia

Background:

The measurement of health state utility values (HSUVs) for a representative sample of Australian people with multiple sclerosis (MS) has not previously been performed.

Objectives:

Our main aim was to quantify the HSUVs for different levels of disease severities in Australian people with MS.

Method:

HSUVs were calculated by employing a ‘judgement-based’ method that essentially creates EQ-5D-3L profiles based on WHOQOL-100 responses and then applying utility weights to each level in each dimension. A stepwise linear regression was used to evaluate the relationship between HSUVs and disease severity, classified as mild (Expanded Disability Status Scale (EDSS) levels: 0–3.5), moderate (EDSS levels: 4–6) and severe (EDSS levels: 6.5–9.5).

Results:

Mean HSUV for all people with MS was 0.53 (95% confidence interval (CI): 0.52–0.54). Utility decreased with increasing disease severity: 0.61 (95% CI: 0.60–0.62), 0.51 (95% CI: 0.50–0.52) and 0.40 (95% CI: 0.38–0.43) for mild, moderate and severe disease, respectively. Adjusted differences in mean HSUV between the three severity groups were statistically significant.

Conclusion:

For the first time in Australia, we have quantified the impact of increasing severity of MS on health utility of people with MS. The HSUVs we have generated will be useful in further health economic analyses of interventions that slow progression of MS.

An economic evaluation alongside a randomised controlled trial on psycho-education counselling intervention offered by midwives to address women's fear of childbirth in Australia

OBJECTIVE

The rate of caesarean section continues to increase, and there is evidence that childbirth fear is a contributing factor. Insufficient evidence is available on the impact of reducing childbirth fear on health-related quality of life and health service use. We undertook an economic evaluation of a psycho-education counselling intervention offered by midwives to address women's fear of childbirth in Australia.

METHODS

Pregnant women (n = 339) with high childbirth fear were randomised to a midwife-led psycho-education intervention for childbirth fear or to usual care. This paper presents the economic evaluation of the intervention based on health-related quality of life and health service use from recruitment to six weeks postpartum (n = 184).

RESULTS

The changes in health-related quality of life after birth (EQ-5D-3L: 0.016 vs. 0.010, p = 0.833, for usual care and intervention) and total health care use cost (AUS$10,110 vs. AUS$9980, p = 0.819) were similar between groups. The intervention did not increase costs; however, in a post hoc analysis, the interventions might be cost-effective for those women with very high childbirth fear.

CONCLUSION

This brief psycho-education intervention by midwives did not improve the health-related quality of life of women, and had no impact on overall cost.

Cost-effectiveness of a pragmatic exercise intervention for women with breast cancer: results from a randomized controlled trial

OBJECTIVE

To report on the cost-effectiveness of the Exercise for Health trial, comparing an exercise intervention with usual care during and following treatment for women with breast cancer.

METHODS

Women with breast cancer were randomized to an 8-month exercise intervention (involving regular contact with an exercise physiologist over the phone, n = 67, or home delivered face to face, n = 67) or usual care (n = 60) group and were assessed pre-intervention (5 weeks post-surgery), mid-intervention (6 months post-surgery), and 10 weeks post-intervention (12 months post-surgery). The benefit measures were "number of improvers" in quality of life (FACT-B+4) and quality-adjusted life years (QALYs). Data on provider, patient, and government costs were used to consider 2 cost scenarios: (1) a service provider model and (2) a private model.

RESULTS

There were 69 improvers in the intervention group compared with 21 in the usual care group (odds ratio 2.09, 95% confidence interval 1.08, 4.01; P = .033). The incremental cost per improver was A$2282 to A$2644. Quality-adjusted life years gain for the intervention group versus the usual care group was 0.009, with incremental cost per QALY gain for models 1 and 2 being A$105 231 and A$90 842, respectively. However, sensitivity analyses indicate that incremental cost per QALY gained was volatile to EuroQol-5D-3L weights.

CONCLUSIONS

Findings suggest that a pragmatic exercise intervention yields more women with markedly improved quality of life after breast cancer than usual care and may be cost-effective. The results are less certain in terms of incremental cost per quality-adjusted life years; however, this may be an inappropriate measure for reflecting exercise benefit for women with breast cancer.

Valuing Treatments for Parkinson Disease Incorporating Process Utility: Performance of Best-Worst Scaling, Time Trade-Off, and Visual Analogue Scales

OBJECTIVE

The objective of this study was to compare treatment profiles including both health outcomes and process characteristics in Parkinson disease using best-worst scaling (BWS), time trade-off (TTO), and visual analogue scales (VAS).

METHODS

From the model comprising of seven attributes with three levels, six unique profiles were selected representing process-related factors and health outcomes in Parkinson disease. A Web-based survey (N = 613) was conducted in a general population to estimate process-related utilities using profile-based BWS (case 2), multiprofile-based BWS (case 3), TTO, and VAS. The rank order of the six profiles was compared, convergent validity among methods was assessed, and individual analysis focused on the differentiation between pairs of profiles with methods used.

RESULTS

The aggregated health-state utilities for the six treatment profiles were highly comparable for all methods and no rank reversals were identified. On the individual level, the convergent validity between all methods was strong; however, respondents differentiated less in the utility of closely related treatment profiles with a VAS or TTO than with BWS. For TTO and VAS, this resulted in nonsignificant differences in mean utilities for closely related treatment profiles.

CONCLUSIONS

This study suggests that all methods are equally able to measure process-related utility when the aim is to estimate the overall value of treatments. On an individual level, such as in shared decision making, BWS allows for better prioritization of treatment alternatives, especially if they are closely related. The decision-making problem and the need for explicit trade-off between attributes should determine the choice for a method.

Population-Based Preference Weights for the EQ-5D Health States Using the Visual Analogue Scale (VAS) in Iran

Background

Health-related quality of life (HRQoL) is used as a measure to valuate healthcare interventions and guide policy making. The EuroQol EQ-5D is a widely used generic preference-based instrument to measure Health-related quality of life.

Objectives

The objective of this study was to develop a value set of the EQ-5D health states for an Iranian population.

Patients and Methods

This study is a cross-sectional study of Iranian populations. Our sample from Iranian populations consists out of 869 participants, who were selected for this study using a stratified probability sampling method. The sample was taken from individuals living in the city of Tehran and was stratified by age and gender from July to November 2013. Respondents valued 13 health states using the visual analogue scale (VAS) of the EQ-5D. Several fixed effects regression models were tested to predict the full set of health states. We selected the final model based on the logical consistency of the estimates, the sign and magnitude of the regression coefficients, goodness of fit, and parsimony. We also compared predicted values with a value set from similar studies in the UK and other countries.

Results

Our results show that the HRQoL does not vary among socioeconomic groups. Models at the individual level resulted in an additive model with all coefficients being statistically significant, R² = 0.55, a value of 0.75 for the best health state (11112), and a value of -0.074 for the worst health state (33333). The value set obtained for the study sample remarkably differs from those elicited in developed countries.

Conclusions

This study is the first estimate for the EQ-5D value set based on the VAS in Iran. Given the importance of locally adapted value set the use of this value set can be recommended for future studies in Iran and In the EMRO regions.

QLU-C10D: a health state classification system for a multi-attribute utility measure based on the EORTC QLQ-C30

PURPOSE

To derive a health state classification system (HSCS) from the cancer-specific quality of life questionnaire, the EORTC QLQ-C30, as the basis for a multi-attribute utility instrument.

METHODS

The conceptual model for the HSCS was based on the established domain structure of the QLQ-C30. Several criteria were considered to select a subset of dimensions and items for the HSCS. Expert opinion and patient input informed a priori selection of key dimensions. Psychometric criteria were assessed via secondary analysis of a pooled dataset comprising HRQOL and clinical data from 2616 patients from eight countries and a range of primary cancer sites, disease stages, and treatments. We used confirmatory factor analysis (CFA) to assess the conceptual model's robustness and generalisability. We assessed item floor effects (>75 % observations at lowest score), disordered item response thresholds, coverage of the latent variable and differential item function using Rasch analysis. We calculated effect sizes for known group comparisons based on disease stage and responsiveness to change. Seventy-nine cancer patients assessed the relative importance of items within dimensions.

RESULTS

CFA supported the conceptual model and its generalisability across primary cancer sites. After considering all criteria, 12 items were selected representing 10 dimensions: physical functioning (mobility), role functioning, social functioning, emotional functioning, pain, fatigue, sleep, appetite, nausea, bowel problems.

CONCLUSIONS

The HSCS created from QLQ-C30 items is known as the EORTC Quality of Life Utility Measure-Core 10 dimensions (QLU-C10D). The next phase of the QLU-C10D's development involves valuation studies, currently planned or being conducted across the globe.

Video and computer-based interactive exercises are safe and improve task-specific balance in geriatric and neurological rehabilitation: a randomised trial

QUESTION

Does adding video/computer-based interactive exercises to inpatient geriatric and neurological rehabilitation improve mobility outcomes? Is it feasible and safe?

DESIGN

Randomised trial.

PARTICIPANTS

Fifty-eight rehabilitation inpatients.

INTERVENTION

Physiotherapist-prescribed, tailored, video/computer-based interactive exercises for 1 hour on weekdays, mainly involving stepping and weight-shifting exercises.

OUTCOME MEASURES

The primary outcome was the Short Physical Performance Battery (0 to 3) at 2 weeks. Secondary outcomes were: Maximal Balance Range (mm); Step Test (step count); Rivermead Mobility Index (0 to 15); activity levels; Activity Measure for Post Acute Care Basic Mobility (18 to 72) and Daily Activity (15 to 60); Falls Efficacy Scale (10 to 40), ED5D utility score (0 to 1); Reintegration to Normal Living Index (0 to 100); System Usability Scale (0 to 100) and Physical Activity Enjoyment Scale (0 to 126). Safety was determined from adverse events during intervention.

RESULTS

At 2 weeks the between-group difference in the primary outcome (0.1, 95% CI -0.2 to 0.3) was not statistically significant. The intervention group performed significantly better than usual care for Maximal Balance Range (38mm difference after baseline adjustment, 95% CI 6 to 69). Other secondary outcomes were not statistically significant. Fifty-eight (55%) of the eligible patients agreed to participate, 25/29 (86%) completed the intervention and 10 (39%) attended > 70% of sessions, with a mean of 5.6 sessions (SD 3.3) attended and overall average duration of 4.5hours (SD 3.1). Average scores were 62 (SD 21) for the System Usability Scale and 62 (SD 8) for the Physical Activity Enjoyment Scale. There were no adverse events.

CONCLUSION

The addition of video/computer-based interactive exercises to usual rehabilitation is a safe and feasible way to increase exercise dose, but is not suitable for all. Adding the exercises to usual rehabilitation resulted in task-specific improvements in balance but not overall mobility.

REGISTRATION

ACTRN12613000610730.

Cost-Effectiveness of a Home Based Intervention for Secondary Prevention of Readmission with Chronic Heart Disease

The aim of this study is to consider the cost-effectiveness of a nurse-led, home-based intervention (HBI) in cardiac patients with private health insurance compared to usual post-discharge care. A within trial analysis of the Young @ Heart multicentre, randomized controlled trial along with a micro-simulation decision analytical model was conducted to estimate the incremental costs and quality adjusted life years associated with the home based intervention compared to usual care. For the micro-simulation model, future costs, from the perspective of the funder, and effects are estimated over a twenty-year time horizon. An Incremental Cost-Effectiveness Ratio, along with Incremental Net Monetary Benefit, is evaluated using a willingness to pay threshold of $50,000 per quality adjusted life year. Sub-group analyses are conducted for men and women across three age groups separately. Costs and benefits that arise in the future are discounted at five percent per annum. Overall, home based intervention for secondary prevention in patients with chronic heart disease identified in the Australian private health care sector is not cost-effective. The estimated within trial incremental net monetary benefit is -$3,116 [95% CI: -11,145, $4,914]; indicating that the costs outweigh the benefits. However, for males and in particular males aged 75 years and above, home based intervention indicated a potential to reduce health care costs when compared to usual care (within trial: -$10,416 [95% CI: -$26,745, $5,913]; modelled analysis: -$1,980 [95% CI: -$22,843, $14,863]). This work provides a crucial impetus for future research to understand for whom disease management programs are likely to benefit most.

Health services utilization of women following a traumatic birth

This cohort study compared 262 women with high childbirth distress to 138 non-distressed women. At 12 months, high distress women had lower health-related quality of life compared to non-distressed women (EuroQol five-dimensional (EQ-5D) scale 0.90 vs. 0.93, p = 0.008), more visits to general practitioners (3.5 vs. 2.6, p = 0.002) and utilized more additional services (e.g. maternal health clinics), with no differences for infants. Childbirth distress has lasting adverse health effects for mothers and increases health-care utilization.

Between-country heterogeneity in EQ-5D-3L scoring algorithms: how much is due to differences in health state selection?

BACKGROUND

EQ-5D-3L scoring algorithms vary amongst countries, not only in the values of regression coefficients but also in the independent variables included in the regression model (hereafter referred to as model specification). It is unclear how much of this variation is due to differences in health state selection, the relative frequencies with which health states were valued, and model diagnostics, rather than to genuine differences in population preferences.

METHODS

Using aggregate data from a recent review, we noted all model specifications that were used. For each country the country's own model was re-fitted, as were all other model specifications. This was done twice: once using all valued health states for each country, and again using a common set of 17 health states for all countries. Goodness of fit was assessed using the following model diagnostics: mean absolute error (MAE), mean squared error (MSE) and rho (the Pearson correlation coefficient between predicted and observed mean utilities), both with and without leave-one-out cross-validation.

RESULTS

Thirteen countries contributed data. Even when using a common set of health states, the preferred model varied across countries. However, choice of health states did impact the preferred model specification: when using cross-validation, the preferred specification changed in five of ten countries when moving from 17 health states to all valued health states. The relative frequency with which health states were valued had little impact on the preferred model.

CONCLUSIONS

Variation in choices of health states to value is responsible for some, but not all, of the observed heterogeneity in model specification. Relative frequency of health state valuation and choice of model diagnostic has a limited impact on model preference, however, use of cross-validation has a substantial impact. The use of cross-validation, implemented through omitting health states rather than respondents, is recommended as one approach to assessing model fit.

Evaluating the effectiveness of a home-based exercise programme delivered through a tablet computer for preventing falls in older community-dwelling people over 2 years: study protocol for the Standing Tall randomised controlled trial

INTRODUCTION

In order to prevent falls, older people should exercise for at least 2 h per week for 6 months, with a strong focus on balance exercises. This article describes the design of a randomised controlled trial to evaluate the effectiveness of a home-based exercise programme delivered through a tablet computer to prevent falls in older people.

METHODS AND ANALYSIS

Participants aged 70 years or older, living in the community in Sydney will be recruited and randomly allocated to an intervention or control group. The intervention consists of a tailored, home-based balance training delivered through a tablet computer. Intervention participants will be asked to complete 2 h of exercises per week for 2 years. Both groups will receive an education programme focused on health-related information relevant to older adults, delivered through the tablet computer via weekly fact sheets. Primary outcome measures include number of fallers and falls rate recorded in weekly fall diaries at 12 months. A sample size of 500 will be necessary to see an effect on falls rate. Secondary outcome measures include concern about falling, depressive symptoms, health-related quality of life and physical activity levels (in all 500 participants); and physiological fall risk, balance, functional mobility, gait, stepping and cognitive performance (in a subsample of 200 participants). Adherence, acceptability, usability and enjoyment will be recorded in intervention group participants over 2 years. Data will be analysed using the intention-to-treat principle. Secondary analyses are planned in people with greater adherence. Economic analyses will be assessed from a health and community care provider perspective.

ETHICS AND DISSEMINATION

Ethical approval was obtained from UNSW Ethics Committee in December 2014 (ref number HC#14/266). Outcomes will be disseminated through publication in peer-reviewed journals and presentations at international conferences.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN)12615000138583.

Financial toxicity: a potential side effect of prostate cancer treatment among Australian men

The purpose of this study was to understand the extent, nature and variability of the current economic burden of prostate cancer among Australian men. An online cross‐sectional survey was developed that combined pre‐existing economic measures and new questions. With few exceptions, the online survey was viable and acceptable to participants. The main outcomes were self‐reported out‐of‐pocket costs of prostate cancer diagnosis and treatment, changes in employment status and household finances. Men were recruited from prostate cancer support groups throughout Australia. Descriptive statistical analyses were undertaken. A total of 289 men responded to the survey during April and June 2013. Our study found that men recently diagnosed (within 16 months of the survey) (n = 65) reported spending a median AU$8000 (interquartile range AU$14 000) for their cancer treatment while 75% of men spent up to AU$17 000 (2012). Twenty per cent of all men found the cost of treating their prostate cancer caused them ‘a great deal’ of distress. The findings suggest a large variability in medical costs for prostate cancer treatment with 5% of men spending $250 or less in out‐of‐pocket expenses and some men facing very high costs. On average, respondents in paid employment at diagnosis stated that they had retired 4–5 years earlier than planned.