Whose quality of life? A commentary exploring discrepancies between health state evaluations of patients and the general public

"Naming and Framing": The Impact of Labeling on Health State Values for Multiple Sclerosis

INTRODUCTION

Health state valuation is a key input in many economic evaluations that inform resource allocation across competing healthcare interventions. Empirical evidence has shown that, in preference elicitation surveys, respondents may value a health state differently if they are aware of the condition causing it ('labeling effects'). This study investigates the impact of including a multiple sclerosis (MS) label for valuation of MS health states.

METHODS

Health state values for MS were elicited using two internet-based surveys in representative samples of the UK population ( n = 1702; n = 1788). In one survey respondents were not informed that health states were caused by MS. The second survey included a condition label for MS. Surveys were identical in all other ways. Health states were described using a MS-specific eight-dimensional classification system (MSIS-8D), and the time trade-off valuation technique was used. Differences between values for labeled and unlabeled states were assessed using descriptive statistics and multivariate regression methods.

RESULTS

Adding a MS condition label had a statistically significant effect on mean health state values, resulting in lower values for labeled MS states v. unlabeled states. The data suggest that the MS label had a more significant effect on values for less severe states, and no significant effect on values for the most severe states. The inclusion of the MS label had a differential impact across the dimensions of the MSIS-8D. Across the MSIS-8D, predicted values ranged from 0.079 to 0.883 for unlabeled states, and 0.066 to 0.861 for labeled states.

CONCLUSION

Differences reported in health state values, using labeled and unlabeled states, demonstrate that condition labels affect the results of valuation studies, and can have important implications in decision-analytic modelling and in economic evaluations.

Are preferences over health states informed?

Background

The use of preference-elicitation tasks for valuing health states is well established, but little is known about whether these preferences are informed. Preferences may not be informed because individuals with little experience of ill health are asked to value health states. The use of uninformed preferences in cost-effectiveness can result in sub-optimal resource allocation. The aim of this study was to pilot a novel method to assess whether members of the public are informed about health states they value in preference-elicitation tasks.

Methods

The general public was said to be informed if the expectations of the public about the effect of ill health on people’s lives were in agreement with the experience of patients. Sixty-two members of the public provided their expectations of the consequences of ill health on five life domains (activities, enjoyment, independence, relationships, and avoiding being a burden). A secondary dataset was used to measure patient experience on those five consequences.

Results

There were differences between the expectations of the public and the experience of patients. For example, for all five life consequences the public underestimated the effects of problems in usual activities compared to problems in mobility. They also underestimated the effect of ‘anxiety or depression’ compared to physical problems on enjoyment of life and on the quality of personal relationships.

Conclusions

This proof-of-concept study showed that it is possible to test whether preferences are informed. This study should be replicated using a larger sample. The findings suggest that preferences over health states in this sample are not fully informed because the participants do not have accurate expectations about the consequences of ill health. These uninformed preferences may not be adequate for allocation of public resources, and research is needed into methods to make them better informed.

Pregnancy context and women's health-related quality of life

OBJECTIVE

The objective was to quantify the association of pregnancy context and health-related quality of life (HRQoL).

STUDY DESIGN

English- or Spanish-speaking women, aged 16-44, with pregnancies <24 weeks' gestation were enrolled in this cross-sectional study between June 2014 and June 2015. Participants completed self-assessments of pregnancy "context," including timing, intention, wantedness, desirability, happiness, and planning (measured with the London Measure of Unplanned Pregnancy). HRQoL was measured using the Patient Reported Outcomes Measurement Information System Global Short Form. Associations between measures of pregnancy context and HRQoL scores in the lowest tertile were examined using multivariable logistic regression to adjust for potential confounding variables.

RESULTS

We enrolled 161 participants (mean age=27.2±6.6 years). Only 14% self-identified as White, non-Hispanic; 42% Hispanic; 37% Black, non-Hispanic; and 7% multiracial. Most (79%) participants were unmarried, and 75% were parenting. Mean gestational age was 9±4.6 weeks. In unadjusted models, women reporting mixed feelings about wanting to have a baby, an undesired pregnancy or feeling unhappy about learning of their pregnancy more frequently had low mental and physical HRQoL compared to women reporting wanted, desired, happy pregnancies. Women with an unplanned pregnancy or pregnancy occurring at the wrong time also had lower physical HRQoL than women reporting pregnancies that were planned or happened at the right time. However, after multivariate adjustment, including history of depression, pregnancy contexts were not associated with low mental or physical HRQoL.

CONCLUSIONS

After adjusting for multiple confounders, pregnancy context is not significantly associated with HRQoL.

IMPLICATIONS

The focus on pregnancy intention in public health programs may not sufficiently assess multidimensional aspects of pregnancy context and may not align with patient-centered outcomes such as HRQoL.

Psychological morbidity and health-related quality of life after injury: multicentre cohort study

PURPOSE

To demonstrate the impact of psychological morbidity 1 month post-injury on subsequent post-injury quality of life (HRQoL) in a general injury population in the UK to inform development of trauma care and rehabilitation services.

METHODS

Multicentre cohort study of 16-70-year-olds admitted to 4 UK hospitals following injury. Psychological morbidity and HRQoL (EQ-5D-3L) were measured at recruitment and 1, 2, 4 and 12 months post-injury. A reduction in EQ-5D compared to retrospectively assessed pre-injury levels of at least 0.074 was taken as the minimal important difference (MID). Multilevel logistic regression explored relationships between psychological morbidity 1 month post-injury and MID in HRQoL over the 12 months after injury.

RESULTS

A total of 668 adults participated. Follow-up rates were 77% (1 month) and 63% (12 months). Substantial reductions in HRQoL were seen; 93% reported a MID at 1 month and 58% at 12 months. Problems with pain, mobility and usual activities were commonly reported at each time point. Depression and anxiety scores 1 month post-injury were independently associated with subsequent MID in HRQoL. The relationship between depression and HRQoL was partly explained by anxiety and to a lesser extent by pain and social functioning. The relationship between anxiety and HRQoL was not explained by factors measured in our study.

CONCLUSIONS

Hospitalised injuries result in substantial reductions in HRQoL up to 12 months later. Depression and anxiety early in the recovery period are independently associated with lower HRQoL. Identifying and managing these problems, ensuring adequate pain control and facilitating social functioning are key elements in improving HRQoL post-injury.

Questioning the differences between general public vs. patient based preferences towards EQ-5D-5L defined hypothetical health states

The purpose of this article is to explore whether any differences exist between the general population and patient based preferences towards EQ-5D-5L defined hypothetical health states. The article discusses the role of adaptation and self-interest in valuing health states and it also contributes rigorous empirical evidence to the scientific debate on the differences between the patient and general population preferences towards hypothetical health states. Patient preferences were elicited in 2015 with the EQ-5D-5L questionnaire using time trade-off and discrete choice experiment design and compared to the Spanish general population preferences, which were elicited using identical methods. Patients were chosen on a voluntary basis according to their willingness to participate in the survey. They were recruited from patient organisations and a hospital in Madrid, Spain. 282 metastatic breast cancer patients and 333 rheumatoid arthritis patients were included in the sample. The analysis revealed differences in preferences between the general population and patient groups. Based on the results of our analysis, it is suggested that the differences in preferences stem from patients being more able to accurately imagine "non-tangible" dimensions of health states (anxiety or depression, and pain or discomfort) than the general population with less experience in various health states. However, this does not mean that general public values should not be reflected in utilities derived for coverage decision making.

Emotional distress impacts quality of life evaluation: a report from the Childhood Cancer Survivor Study

PURPOSE

We compared health-related quality of life (HRQOL) between adult survivors of childhood cancer and siblings by investigating the mediating role of emotional distress on HRQOL assessment, and examining the extent to which emotional distress affected the item responses of HRQOL measures given the same underlying HRQOL (i.e., measurement non-invariance).

METHODS

Cancer survivors (7103) and siblings (390) enrolled in Childhood Cancer Survivor Study who completed the SF-36 measuring HRQOL and the Brief Symptom Inventory-18 measuring anxiety, depression, and somatization were analyzed. Multiple Indicators & Multiple Causes modeling was performed to identify measurement non-invariance related to emotional distress on the responses to HRQOL items. Mediation analysis was performed to test the effects of cancer experience on HRQOL accounting for the mediating role of emotional distress.

RESULTS

Twenty-nine percent, 40%, and 34% of the SF-36 items were identified with measurement non-invariance related to anxiety, depression, and somatization, respectively. Survivors reported poorer HRQOL than siblings in all domains (ps < 0.05), except for pain. Other than physical functioning and general health perceptions, poorer HRQOL was explained by the mediating role of emotional distress (ps < 0.05).

CONCLUSIONS

Differences in HRQOL between survivors and siblings appear due, in part, to the mediating effect of emotional distress through which cancer experience influences the responses to HRQOL measures.

IMPLICATIONS OF CANCER SURVIVORS

Interventions to treat emotional distress may improve cancer survivors' HRQOL.

Health State Preference Weights for the Glasgow Outcome Scale Following Traumatic Brain Injury: A Systematic Review and Mapping Study

BACKGROUND

Valid and relevant estimates of health state preference weights (HSPWs) for Glasgow Outcome Scale (GOS) categories are a key input of economic models evaluating treatments for traumatic brain injury (TBI).

OBJECTIVES

To characterize existing HSPW estimates, and model the EuroQol five-dimensional questionnaire (EQ-5D) from the GOS, to inform parameterization of future economic models.

METHODS

A systematic review of HSPWs for GOS categories following TBI was conducted using a highly sensitive search strategy implemented in an extensive range of information sources between 1975 and 2016. A cross-sectional mapping study of GOS health states onto the three-level EQ-5D UK tariff index values was also performed in patients with significant TBI (head region Abbreviated Injury Scale score ≥3) from the Victoria State Trauma Registry. A limited dependent variable mixture model was used to estimate the 12-month EQ-5D UK value set as a function of GOS category, age, and other explanatory variables.

RESULTS

Six unique HSPWs from five eligible studies were identified. All studies were at high risk of bias with limited applicability. The magnitude of HSPWs differed significantly between studies. Three class mixture models demonstrated excellent goodness of fit to the observed Victoria State Trauma Registry data. GOS category, age at injury, sex, comorbidity, and major extracranial injury all had significant independent effects on mean EQ-5D utility values.

CONCLUSIONS

The few available HSPWs for GOS categories are challenged by potential biases and restricted generalizability. Mixture models are presented to provide HSPWs for GOS categories consistent with the National Institute for Health and Care Excellence reference case.

Does the EQ-5D capture the effects of physical and mental health status on life satisfaction among older people? A path analysis approach

PURPOSE

To examine the extent to which EQ-5D utility scores capture the effect of mental and physical health status on life satisfaction (LS) in older adults.

METHODS

Retrospective cohort study of 884 patients aged ≥70 years from 15 general practices in Ireland, including medical records, pharmacy claims, and self-completion questionnaire. Path analysis was used to evaluate the direct and indirect effects of: (1) chronic disease burden (based on medications data); (2) activity limitation (basic and instrumental activities of daily living); (3) anxiety symptoms and; (4) depressive symptoms (Hospital Anxiety and Depression Scale) on LS (Life Satisfaction Index Z), via a utility score based on responses to the EQ-5D scale. Utility scores were calculated using UK time trade-off utility weights. Covariates included age and socioeconomic status.

RESULTS

The final path model fitted the data well (goodness of fit χ² = 7.5, df (7), p = 0.37). The direct effects of chronic disease burden and disability on LS were not statistically significant and were excluded from the final model, indicating that EQ-5D score mediated 100% of the total effect on LS. The direct and indirect effects of anxiety and depression on LS were statistically significant, but the size of the indirect effect was small (4% of the total effect for anxiety and 6% of the total effect for depression).

CONCLUSION

The EQ-5D does not adequately capture the effects of anxiety and depression on LS among older adults, suggesting that it may lead to inaccurate assessments of the effectiveness of interventions in this cohort.

The meaning of vaguely quantified frequency response options on a quality of life scale depends on respondents' medical status and age

PURPOSE

Self-report items in quality of life (QoL) scales commonly use vague quantifiers like "sometimes" or "often" to measure the frequency of health-related experiences. This study examined whether the meaning of such vaguely quantified response options differs depending on people's medical status and age, which may undermine the validity of QoL group comparisons.

METHODS

Respondents (n = 600) rated the frequency of positive and negative QoL experiences using vague quantifiers (never, rarely, sometimes, often, always) and provided open-ended numeric frequency counts for the same items. Negative binomial regression analyses examined whether the numeric frequencies associated with each vague quantifier differed between medical status (no vs. one or more medical conditions) and age (18-40 vs. 60+ years) groups.

RESULTS

Compared to respondents without a chronic condition, those with a medical condition assigned a higher numeric frequency to the same vague quantifiers for negative QoL experiences; this effect was not evident for positive QoL experiences. Older respondents' numeric frequencies were more extreme (i.e., lower at the low end and somewhat higher at the high end of the response range) than those of younger respondents. After adjusting for these effects, differences in QoL became somewhat more pronounced between medical status groups, but not between age groups.

CONCLUSIONS

The results suggest that people with different medical backgrounds and age do not interpret vague frequency quantifiers on a QoL scale in the same way. Open-ended numeric frequency reports may be useful to detect and potentially correct for differences in the meaning of vague quantifiers.

Debiasing affective forecasting errors with targeted, but not representative, experience narratives

OBJECTIVE

To determine whether representative experience narratives (describing a range of possible experiences) or targeted experience narratives (targeting the direction of forecasting bias) can reduce affective forecasting errors, or errors in predictions of experiences.

METHODS

In Study 1, participants (N=366) were surveyed about their experiences with 10 common medical events. Those who had never experienced the event provided ratings of predicted discomfort and those who had experienced the event provided ratings of actual discomfort. Participants making predictions were randomly assigned to either the representative experience narrative condition or the control condition in which they made predictions without reading narratives. In Study 2, participants (N=196) were again surveyed about their experiences with these 10 medical events, but participants making predictions were randomly assigned to either the targeted experience narrative condition or the control condition.

RESULTS

Affective forecasting errors were observed in both studies. These forecasting errors were reduced with the use of targeted experience narratives (Study 2) but not representative experience narratives (Study 1).

CONCLUSION

Targeted, but not representative, narratives improved the accuracy of predicted discomfort.

PRACTICE IMPLICATIONS

Public collections of patient experiences should favor stories that target affective forecasting biases over stories representing the range of possible experiences.

Do Risk Attitudes Differ across Domains and Respondent Types?

Objective . To evaluate differences in risk attitude across the domains of health and money for 2 types of respondents, patients and community members. Methods . Two groups of respondents, patients with multiple sclerosis (n = 56) and members of the general community (n = 57), completed a survey that collected information on risk attitudes and socioeconomic and clinical variables (e.g., disability level). Risk attitude was measured using 2 standard-gamble questions on money and 1 standard-gamble question on health outcomes. Multivariate regression was used to evaluate the relationship between risk attitude and respondent type (patient v. community), adjusting for covariates that could affect risk attitude. Results . The median certainty equivalents for money gambles were significantly different from and less than the expected value of the gamble for both types of respondents. Median certainty equivalents for the health gamble were not significantly different from the expected value for either group of respondents. For all 3 gambles, there was no difference in median certainty equivalents between the 2 types of respondents in both unadjusted and adjusted analyses. Conclusions . Risk attitude varied across domains but not by respondent type. Patients and community members were predominantly risk neutral with respect to health outcomes and risk averse with respect to money. Research on risk preferences on money outcomes may not be an appropriate proxy for risk preferences regarding health outcomes. Risk preferences may depend more on characteristics of the choice than on respondent type.

ТЕХНОЛОГІЯ ОТРИМАННЯ ЗАЛІЗОВМІСНОГО КОМПЛЕКСУ НА ОСНОВІ ПОЛІСАХАРИДІВ ПЕЧЕРИЦІ ДВОСПОРОВОЇ

Розроблено технологію отримання залізовмісного комплексу на основі полісахаридів печериці дво-спорової, яка складається з двох стадій: вилучення полісахаридів та формування залізовмісного комплексу. Встанов-лено, що одержувати полісахариди з сировини доцільно екстракцією 3 % розчином натрій гідроксиду протягом 4 год зподальшою очисткою від речовин невуглеводної природи. У складі полісахаридів домінує галактоглюкан. Раціональ-ними умовами отримання залізовмісного комплексу на основі полісахаридів грибів є суміщення розчинів ферум (III)хлориду та полісахаридів; концентрації реагуючих речовин становлять: Fe3+ – 0,075 %, полісахаридів – 0,113 %, масо-ве співвідношення залізо : полісахариди 1,0 : 1,5, рН середовища – 11,5. Комплекс стійкий до дії агресивних середо-вищ травного тракту, є мікробіологічно безпечним та залишається доброякісним протягом 12 місяців зберігання. Він єефективним протианемічним засобом.

Patient and general public preferences for health states: A call to reconsider current guidelines

In economic evaluations of health care interventions, benefits are often expressed in terms of Quality-Adjusted Life-Years (QALYs). The QALY comprises length and quality of life into one measure which allows cross-disease comparability. The quality adjustment of the QALY is based on preferences for health states. An important normative choice is the question whose preferences for states of health we wish to capture. The answer to this question is directly related to the normative question regarding the appropriate maximand in health care decisions. Currently, preferences are commonly derived from the general public, rather than from actual patients. This choice, which can have large consequences on final outcomes of economic evaluations, has always been a topic of debate. This paper clarifies and furthers the discussion regarding the appropriate source of preferences for health state valuations, acknowledges the plurality of different perspectives, and argues that health economic guidelines could require analysis of benefit in terms of QALYs based on both patient and general public preferences.

Liver Transplant Recipients' First Year of Posttransplant Recovery: A Longitudinal Study

A longitudinal study of 20 liver transplant recipients was conducted to investigate their posttransplant recovery experience. Data were collected using semistructured interviews at 6 weeks, 6 months, and 1 year after transplantation. Qualitative analysis of data revealed physical, psychological, social, economic, and spiritual dimensions of recovery. Findings reflect ongoing improvement of physical health and functionality for most recipients. Those with continuing health problems often suffered from preexisting health conditions. Psychological adjustment was uneven, with intermittent periods of fear, anxiety, and depression. Some recipients reported short-lived split identities and personality changes. Social support of family was critical in the hospital and at home. Economic issues became primary by the 1-year interview, with all recipients questioning whether they could afford ongoing healthcare and medicines. Spiritual needs were met in secular and nonsecular activities. Findings suggest that healthcare personnel should attend to the lived experience of liver transplant recipients.

Cross-cultural variation in preference for replantation or revision amputation: Societal and surgeon views

Treatment decisions after an injury like finger amputation are made based on injury and patient factors. However, decisions can also be influenced by provider and patient preferences. We compared hand surgeon and societal preferences and attitudes regarding finger amputation treatment in Japan and the US. We performed a cross-sectional survey with subjects derived from large tertiary care academic institutions in the US and Japan. We secured 100% participation of American hand surgeon members of the Finger Replantation and Amputation Multicenter Study and presenting hand surgeons at the 32nd Annual meeting of the Central Japanese Society for Surgery of the Hand. Societal preferences were gathered from volunteers at the 2 universities in the US and Japan. There were no significant differences in estimations of function, sensation, or appearance after replantation; American and Japanese societal participants preferred replantation compared to surgeons, although this was more pronounced in Japan. The Japanese society displayed more negative attitudes toward finger amputees than did Japanese surgeons. American respondents anticipated more public stigmatisation of amputees than did American surgeons. Societal preference for replantation was not caused by inflated expectations of outcomes after replantation. Japanese societal preference was likely driven by negative views of finger amputees. American society noted no decrease in physical health after amputation, but did note a quality of life decrease attributed to public stigmatisation. Japanese society and surgeons had a stronger preference for replantation than American society and surgeons, possibly attributed to cultural differences.

Prospective, multicenter, controlled study of quality of life, psychological adjustment process and medical outcomes of patients receiving a preemptive kidney transplant compared to a similar population of recipients after a dialysis period of less than three years--The PreKit-QoL study protocol

BACKGROUND

Treatment of end stage renal disease has an impact on patients' physical and psychological health, including quality of life (QoL). Nowadays, it is known that reducing the dialysis period has many advantages regarding QoL and medical outcomes. Although preemptive transplantation is the preferred strategy to prevent patients undergoing dialysis, its psychological impact is unknown. Moreover, transplantation can be experienced in a completely different manner among patients who were on dialysis and those who still had a functioning kidney at the time of surgery. Longitudinal data are often collected to allow analyzing the evolution of patients' QoL over time using questionnaires. Such data are often difficult to interpret due to the patients' changing standards, values, or conceptualization of what the questionnaire is intended to measure (e.g. QoL). This phenomenon is referred to as response shift and is often linked to the way the patients might adapt or cope with their disease experience. Whether response shift is experienced in a different way among patients who were on dialysis and those who still had a functioning kidney at time of surgery is unknown and will be studied in the PreKit-QoL study (trial registration number: NCT02154815). Understanding the psychological impact of pre-emptive transplantation is an important issue since it can be associated with long-term patient and graft survival.

METHODS/DESIGN

Adult patients with a pre-emptive transplantation (n = 130) will be prospectively included along with a control group of patients with a pre-transplant dialysis period < 36 months (n = 260). Only first and single kidney transplantation will be considered. Endpoints include: comparison of change between groups in QoL, anxiety and depressive disorders, perceived stress, taking into account response shift. These criteria will be evaluated every 6 months prior to surgery, at hospital discharge, at three and six months, one and two years after transplantation.

DISCUSSION

The PreKit-QoL study assesses and compares the evolution of QoL and other psychological criteria in preemptive and dialyzed patients taking patients' adaptation into account through response shift analyses. Our study might help to conceive specific, adapted educational programs and psychological support to prevent a possible premature loss of the kidney as a consequence of non-compliance in patients that may be insufficiently prepared for transplantation.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT02154815 , registered on May 28, 2014.

Towards a 'patient-centred' operationalisation of the new dynamic concept of health: a mixed methods study

OBJECTIVE

To evaluate among stakeholders the support for the new, dynamic concept of health, as published in 2011: 'Health as the ability to adapt and to self-manage', and to elaborate perceived indicators of health in order to make the concept measurable.

DESIGN

A mixed methods study: a qualitative first step with interviews and focus groups, followed by a quantitative survey.

PARTICIPANTS

Representatives of seven healthcare stakeholder domains, for example, healthcare providers, patients with a chronic condition and policymakers. The qualitative study involved 140 stakeholders; the survey 1938 participants.

RESULTS

The new concept was appreciated, as it addresses people as more than their illness and focuses on strengths rather than weaknesses. Caution is needed as the concept requires substantial personal input of which not everyone is capable. The qualitative study identified 556 health indicators, categorised into six dimensions: bodily functions, mental functions and perception, spiritual/existential dimension, quality of life, social and societal participation, and daily functioning, with 32 underlying aspects. The quantitative study showed all stakeholder groups considering bodily functions to represent health, whereas for other dimensions there were significant differences between groups. Patients considered all six dimensions almost equally important, thus preferring a broad concept of health, whereas physicians assessed health more narrowly and biomedically. In the qualitative study, 78% of respondents considered their health indicators to represent the concept.

CONCLUSIONS

To prevent confusion with health as 'absence of disease', we propose the use of the term 'positive health' for the broad perception of health with six dimensions, as preferred by patients. This broad perception deserves attention by healthcare providers as it may support shared decision-making in medical practice. For policymakers, the broad perception of 'positive health' is valuable as it bridges the gap between healthcare and the social domain, and by that it may demedicalise societal problems.

A Value-Based Approach to Treatment of HER2-Positive Breast Cancer: Examining the Evidence

Over the past decade, treatment of HER2-positive breast cancer has been revolutionized with the introduction of targeted therapies. Survival in both early and advanced HER2-positive breast cancer has improved significantly. With evidence for major clinical benefit, it is imperative that health systems evaluate new treatments to maximize the value of health expenditures. Physicians, funding agencies, and policy makers are tasked with analyzing available evidence to ensure that each individual patient receives the optimal treatment in a resource-challenged environment.

Determinants of time trade-off valuations for EQ-5D-5L health states: data from the Canadian EQ-5D-5L valuation study

BACKGROUND

Previous studies suggest that population subgroups have different perceptions of health, as well as different preferences for hypothetical health states.

OBJECTIVE

To identify determinants of health states preferences elicited using time trade-off (TTO) for the 5-level EQ-5D questionnaire (EQ-5D-5L) in Canada.

METHODS

Data were from the Canadian EQ-5D-5L Valuation Study, which took place in Edmonton, Hamilton, Montreal, and Vancouver. Each respondent valued 10 of 86 hypothetical health states during an in-person interview using a computer-based TTO exercise. The TTO scores were the dependent variable and explanatory variables including age, sex, marital status, education, employment, annual household income, ethnicity, country of birth, dwelling, study site, health literacy, number of chronic conditions, previous experience with illness, and self-rated health.

RESULTS

Average [standard deviation (SD)] age of respondents (N = 1209) was 48 (17) years, and 45 % were male. In multivariable linear regression models with random effects, adjusted for severity of health states and inconsistencies in valuations, older age [unstandardized regression coefficient (β) = -0.077], male sex (β = 0.042), being married (β = 0.069), and urban dwelling (β = -0.055) were significantly associated with health states scores. Additionally, participants from Edmonton (β = -0.124) and Vancouver (β = -0.156), but not those from Hamilton, had significantly lower TTO scores than those from Montreal.

CONCLUSIONS

Socio-demographic characteristics were the main determinants of preferences for EQ-5D-5L health states in this study. Interestingly, preferences were significantly lower in western Canadian cities compared to eastern ones, bringing into question whether a single preference algorithm is suitable for use in all parts of Canada.

Differences in EQ-5D-3L health state valuations among patients with musculoskeletal diseases, health care professionals and healthy volunteers

BACKGROUND

Results from existing studies indicate that different respondent groups' health state valuations in cost-utility analyses are not equivalent.

OBJECTIVES

The objectives in our study were to analyse differences in health state valuations among three respondent groups in the context of medical rehabilitation in Germany.

METHODS

Using the time trade-off (TTO) technique, valuations of EQ-5D-3L health states were obtained from patients with musculoskeletal diseases, healthy volunteers and health care professionals. We used linear mixed models to predict TTO utilities and specified and tested interaction effects.

RESULTS

We identified statistically significant (p < 0.05) differences among the three groups in six out of 42 health states. On average, patients' TTO values were somewhat higher compared with other respondent groups. Most of these differences occurred in severe health states. Mean differences and mean absolute differences were 0.02 and 0.14 for patients vs healthy volunteers and 0.06 and 0.14 for patients vs health care professionals. Furthermore, significant effects among respondents were observed for seven of the 22 possible interactions describing differences between respondent groups. Coefficients associated with significant interaction effects ranged from 0.08 to 0.18 (absolute values).

CONCLUSION

The results of our study suggest that TTO valuations of health states differ depending on the specific respondent group from which valuations are obtained. On average, these differences were small. However, researchers and decision makers should remain aware of these differences when interpreting incremental cost-utility assessments.

Outcome Preferences in Patients With Noninfectious Uveitis: Results of a Best-Worst Scaling Study

PURPOSE

To estimate patient preferences regarding potential adverse outcomes of local versus systemic corticosteroid therapies for noninfectious uveitis by using a best-worst scaling (BWS) approach.

METHODS

Local and systemic therapies are alternatives for noninfectious uveitis that have different potential adverse outcomes. Patients participating in the Multicenter Uveitis Steroid Treatment Trial Follow-up Study (MUST FS) and additional patients with a history of noninfectious uveitis treated at two academic medical centers (Johns Hopkins University and University of Pennsylvania) were surveyed about their preferences regarding six adverse outcomes deemed important to patients. Using "case 1" BWS, patients were asked to repeatedly select the most and least worrying from a list of outcomes (in the survey three outcomes per task).

RESULTS

Eighty-two patients in the MUST FS and 100 patients treated at the academic medical centers completed the survey. According to BWS, patients were more likely to select vision not meeting the requirement for driving (individual BWS score: median = 3, interquartile range, 0-5), development of glaucoma (2, 1-4), and needing eye surgery (1, 0-3) as the most worrying outcomes as compared to needing medicine for high blood pressure/cholesterol (-2, -4 to 0), development of cataracts (-2, -3 to -1), or infection (sinusitis) (-3, -5 to 0). Larger BWS scores indicated the outcomes were more worrying to patients.

CONCLUSIONS

Patients with noninfectious uveitis considered impaired vision, development of glaucoma, and need for eye surgery worrying adverse outcomes, which suggests that it is especially desirable to avoid these outcomes if possible. (ClinicalTrials.gov number, NCT00132691.)

Does the choice of EQ-5D tariff matter? A comparison of the Swedish EQ-5D-3L index score with UK, US, Germany and Denmark among type 2 diabetes patients

Objective

To compare the performance of the recently developed Swedish experience-based time trade-off (TTO) valuation of the EuroQol-5D-3L (EQ-5D-3L) against the hypothetical-based TTO valuations from UK, US, Germany and Denmark.

Methods

Type 2 diabetes patients from the Swedish National Diabetes Register (N = 1 757) responded to EQ-5D-3L questionnaire in 2008. Health utilities were compared using a range of parametric and nonparametric tests. Absolute agreement and consistency were investigated using intra-class correlations coefficients (ICCs) and Bland-Altman plots. Differences in health utilities between known-groups were evaluated. Transition scores for pairs of observed EQ-5D-3L health states were calculated and compared.

Results

The Swedish tariff (SWT) resulted in substantially higher health utilities and differences were more profound for more severe health problems. ICC ranged 0.6 to 0.8 and Bland-Altman plots showed wide limits of agreement. While all tariffs discriminate between known-groups, the effect sizes were generally small. The SWT had higher (lower) known-group validity for macrovascular (microvascular) complications. The SWT and UK tariff were associated with the lowest and the highest mean absolute transition scores, respectively, for 2775 observed pairs of the EQ-5D-3L health states.

Conclusion

There were systematic differences between the SWT and tariffs from other countries meaning that the choice of tariff might have substantial impact on funding decisions. The Swedish experienced-based TTO valuation will give higher priority to life-extending interventions than those which improve quality of life. We suggest that economic evaluations in Sweden include both Swedish experience-based and non-Swedish hypothetical-based valuations through a sensitivity analysis.

Calculating Preference Weights for the Labor and Delivery Index: A Discrete Choice Experiment on Women's Birth Experiences

OBJECTIVE

The aim of this study was to calculate preference weights for the Labor and Delivery Index (LADY-X) to make it suitable as a utility measure for perinatal care studies.

METHODS

In an online discrete choice experiment, 18 pairs of hypothetical scenarios were presented to respondents, from which they had to choose a preferred option. The scenarios describe the birth experience in terms of the seven LADY-X attributes. A D-efficient discrete choice experiment design with priors based on a small sample (N = 110) was applied. Two samples were gathered, women who had recently given birth and subjects from the general population. Both samples were analyzed separately using a panel mixed logit (MMNL) model. Using the panel mixed multinomial logit (MMNL) model results and accounting for preference heterogeneity, we calculated the average preference weights for LADY-X attribute levels. These were transformed to represent a utility score between 0 and 1, with 0 representing the worst and 1 representing the best birth experience.

RESULTS

In total, 1097 women who had recently given birth and 367 subjects from the general population participated. Greater value was placed on differences between bottom and middle attribute levels than on differences between middle and top levels. The attributes that resulted in larger utility increases than the other attributes were "feeling of safety" in the sample of women who had recently given birth and "feeling of safety" and "availability of professionals" in the general population sample.

CONCLUSIONS

By using the derived preference weights, LADY-X has the potential to be used as a utility measure for perinatal (cost-) effectiveness studies.

Differences between hypothetical and experience-based value sets for EQ-5D used in Sweden: Implications for decision makers

Aims: A number of value sets are available today for converting EQ-5D questionnaire responses to quality-adjusted life year-weights used in health economic evaluations. The aim of this study is to analyse the differences between the commonly used hypothetical UK value set and the newly introduced Swedish experience-based value set and to evaluate health economic implications of such differences on policy decisions. Methods: Differences between the two value sets were studied using two methods: a comparison of health states and improvements as well as an empirical comparison. In the comparison of health states and improvements, the valuations of all EQ-5D states and all pure improvements were compared. In the empirical study, a database of 23,925 individuals was used to identify patient groups that could be affected by the implementation of the Swedish experience-based value set. Results: The comparison of health states and possible improvements showed that only three health states were assigned a lower quality-adjusted life year-weight and most improvements were given smaller absolute values if the experience-based value set was used. The empirical comparison showed that severe conditions were assigned higher values when using the experience-based value set. Conclusions: The Swedish experience-based value set seems to render a higher estimated level of health-related quality of life in virtually all health conditions compared to the hypothetical UK value set. In extension, health-related quality of life enhancing interventions are likely to be given higher priority in decision-making situations where hypothetical values are used to construct quality-adjusted life year-weights. In situations where experience-based quality-adjusted life year-weights are used, life-prolonging interventions would be prioritised.

Do individuals with and without depression value depression differently? And if so, why?

Purpose

Health state valuations, used to evaluate the effectiveness of healthcare interventions, can be obtained either by the patients or by the general population. The general population seems to value somatic conditions more negatively than patients, but little is known about valuations of psychological conditions. This study examined whether individuals with and without depression differ in their valuations of depression and whether perceptions regarding depression (empathy, perceived susceptibility, stigma, illness perceptions) and individual characteristics (mastery, self-compassion, dysfunctional attitudes) bias valuations of either individuals with or without depression.

Methods

In an online study, a general population sample used a time-trade-off task to value 30 vignettes describing depression states (four per participant) and completed questionnaires on perceptions regarding depression and individual characteristics. Participants were assigned to depression groups (with or without depression), based on the PHQ-9. A generalized linear mixed model was used to assess discrepancies in valuations and identify their determinants.

Results

The sample (N = 1268) was representative of the Dutch population on age, gender, education and residence. We found that for mild depression states, individuals with depression (N = 200) valued depression more negatively than individuals without depression (N = 1068) (p = .007). Variables related to perceptions of depression and individual characteristics were not found to affect valuations of either individuals with or individuals without depression.

Conclusion

Since the general population values depression less negatively, using their perspective might result in less effectiveness for interventions for mild depression. Perceptions of depression or to individual characteristics did not seem to differentially affect valuations made by either individuals with or without depression.

A systematic review of utilities in hand surgery literature

PURPOSE

To systematically review the literature to determine if utilities (a quantitative way to express patient preferences for health outcomes) have been measured in hand surgery studies.

METHODS

A literature search was conducted using Cochrane, EMBASE, HealthSTAR, MEDLINE, and CINAHL electronic databases (1966-2013). This search was supplemented by cited and manual reference searches and expert consultation to retrieve all relevant studies. Studies were selected by 2 independent reviewers if they pertained to hand or wrist surgery, were published in English, and measured utilities as an outcome. Descriptive data were extracted, including the hand surgery procedure investigated, study design, value of utilities, and methodology of utilities measurement.

RESULTS

Eleven studies were included after reviewing 989 studies. Most hand conditions were associated with utilities less than 0.8. Utilities in the reviewed studies were measured using different methods and from different subjects. Three studies paradoxically mapped greater utilities for poorer heath states.

CONCLUSIONS

Hand conditions cause impairment, as evidenced by their utilities. Measurement of utilities remains uncommon in hand surgery literature. Future studies should not only measure utilities but also do so with consistent and appropriate methodology to ensure that mapped values are valid and comparable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/decision analysis III.

Evaluation of the cost-effectiveness of buprenorphine in treatment of chronic pain using competing EQ-5D weights

Background and aims

Chronic pain is a life altering condition and common among elderly persons. The 7-day buprenorphine patch could be a suitable treatment for managing chronic pain of moderate severity in elderly patients in Sweden.

The objective of this analysis was to investigate the cost-effectiveness of the 7-day buprenorphine patch, versus no treatment, in patients >50 years old who suffer from moderate pain in a health economic perspective. An additional aim was to evaluate how the cost-effectiveness is affected by the choice of EQ-5D weights.

Methods

The annual treatment cost and the potential gains in health-related quality of life (HRQoL) of buprenorphine, compared to no treatment, were evaluated. Original EQ-5D data were collected from four clinical reference studies at baseline and at the final visit. Treatment effects on HRQoL were then assessed using both UK and Swedish EQ-5D weights. Annual treatment costs were calculated based on costs of physician visits and pharmaceuticals.

The optimal treatment dose was 10-15 μg/h and the analysis was hence performed on both a 10- and a 15 μg/h buprenorphine patch.

Results

The analysis of buprenorphine treatment resulted in improved HRQoL in all reference studies, irrespective of choice of EQ-5D weight set. The change in quality adjusted life years (QALYs) varied with a gain of 0.042-0.118 using the UK weights and 0.020-0.051 with the Swedish weights. The average annual treatment cost was SEK14454 for the 10μg/h patch and SEK17 017 for the 15 μg/h patch, while cost for the no-treatment alternative was SEK 9 960. The base case incremental cost-effectiveness ratios (ICER) with the UK weights were SEK 40000-SEK 170000 and SEK 90000-SEK 350000 when applying the Swedish weights. The corresponding ICER-span in the sensitivity analysis was SEK 15 000-SEK 400 000 when applying the UK weights and SEK 30 000-SEK 840 000 with the Swedish weights (SEK 100 is about €11).

Conclusions

The results imply that the 7-day buprenorphine patch may be a cost-effective treatment of moderate chronic pain in patients over 50 years of age. The UK and the Swedish EQ-5D weights generated vastly different HRQoL estimates but buprenorphine remains cost-effective regardless choice of weight set.

Assessing Health-Related Quality of Life in the Greek Home Health Care Setting

The study’s aim was to evaluate the agreement between patients’ and nurses’ ratings of patients’ health-related quality of life (HRQoL) and to identify factors that affect their level of agreement. A total of 150 home health care cancer patients from Greece and all nurses ( N = 5) who worked in the home health care units completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire–Core 30 (EORTC QLQ-C30). Intraclass correlation coefficients varied between .45 and .87, indicating a moderate to excellent agreement. Median absolute difference on QLQ-C30 scores ranged from 0.00 to 16.66 points on the 0 to 100 scale. Cohen’s d varied between −0.15 and 0.59. Nurses’ higher educational level was associated with greater agreement ( p = .05). Nurses assessed lower the QoL of patients who were completely disabled than the patients themselves did ( p = .005). Our findings suggest that Greek home health care nurses estimate patients’ QoL in a reliable and valid way.

Spinal cord stimulation and pain relief in painful diabetic peripheral neuropathy: a prospective two-center randomized controlled trial

OBJECTIVE

Painful diabetic peripheral neuropathy (PDPN) is a common complication of diabetes mellitus. Unfortunately, pharmacological treatment is often partially effective or accompanied by unacceptable side effects, and new treatments are urgently needed. Small observational studies suggested that spinal cord stimulation (SCS) may have positive effects.

RESEARCH DESIGN AND METHODS

We performed a multicenter randomized clinical trial in 36 PDPN patients with severe lower limb pain not responding to conventional therapy. Twenty-two patients were randomly assigned to SCS in combination with the best medical treatment (BMT) (SCS group) and 14 to BMT only (BMT group). The SCS system was implanted only if trial stimulation was successful. Treatment success was defined as ≥50% pain relief during daytime or nighttime or "(very) much improved" for pain and sleep on the patient global impression of change (PGIC) scale at 6 months.

RESULTS

Trial stimulation was successful in 77% of the SCS patients. Treatment success was observed in 59% of the SCS and in 7% of the BMT patients (P < 0.01). Pain relief during daytime and during nighttime was reported by 41 and 36% in the SCS group and 0 and 7% in the BMT group, respectively (P < 0.05). Pain and sleep were "(very) much improved" in 55 and 36% in the SCS group, whereas no changes were seen in the BMT group, respectively (P < 0.001 and P < 0.05). One SCS patient died because of a subdural hematoma.

CONCLUSIONS

Treatment success was shown in 59% of patients with PDPN who were treated with SCS over a 6-month period, although this treatment is not without risks.

Does diabetes have an impact on health-state utility? a study of Asians in Singapore

OBJECTIVE

Our objective was to compare the time trade-off (TTO) values of EQ-5D-3L health states elicited from Singaporeans with and without type 2 diabetes mellitus (T2DM) and T2DM patients with and without complications.

METHODS

The TTO values of ten EQ-5D-3L health states were elicited from a consecutive sample of T2DM patients and a general Singaporean population sample using similar valuation protocols. In face-to-face interviews, T2DM patients and members of the general population were asked to value five and ten health states, respectively. The difference in TTO values between the two samples and between T2DM patients with and without complications was examined using multiple linear regression models.

RESULTS

A total of 109 T2DM patients and 46 individuals without T2DM provided data. All ten health states considered, the mean TTO value was -0.02 for the general population sample and -0.04 for T2DM patients, with the unadjusted and adjusted difference being -0.06 (95 % confidence interval [CI] -0.16, 0.03) and 0.02 (95 % CI -0.12, 0.15). The general population sample had systematically lower TTO values for mild health states, with the adjusted difference being -0.13 (95 % CI -0.25, -0.02); while the two samples had similar TTO values for severe health states, with the adjusted difference being 0.02 (95 % CI -0.16, 0.19). T2DM patients without complications had systematically lower TTO values than those with complications, with the adjusted difference being -0.10 (95 % CI -0.23, 0.03).

CONCLUSIONS

It appears that diabetes and its complications affect patients' valuation of health states. Hence, the EQ-5D-3L health-state values based on the general population may underestimate the utility of health interventions for T2DM.

Experience-based VAS values for EQ-5D-3L health states in a national general population health survey in China

Purpose

To investigate the feasibility of deriving experience-based visual analogue scale (VAS) values for EQ-5D-3L health states using national general population health survey data in China.

Methods

The EQ-5D-3L was included in the National Health Services Survey (n = 120,709, aged 15–103 years) to measure health-related quality of life. The respondents reported their current health status on a VAS and completed the EQ-5D-3L questionnaire, enabling modelling of the association between the experience-based VAS values and self-reported problems on EQ-5D dimensions and severity levels.

Results

VAS values were generally negatively associated with problems reported on the EQ-5D dimensions, and the anxiety/depression dimension had the greatest impact on VAS values. A previously obtained value for dead allowed the values for all 243 EQ-5D-3L health states to be transformed to the 0–1 scale (0 = dead, 1 = full health).

Conclusions

This study presents the feasibility of deriving an experience-based VAS values for EQ-5D-3L health states in China. The analysis of these VAS data raises more fundamental issues concerning the universal nature of the classification system and the extent to which Chinese respondents utilise the same concepts of health as defined by this classification system.

Electronic supplementary material

The online version of this article (doi:10.1007/s11136-014-0793-6) contains supplementary material, which is available to authorized users.

Higher quality of life and lower depression for people on ART in Uganda as compared to a community control group

Provision of antiretroviral treatment (ART) to people living with HIV (PLWH) has increased globally. Research measuring whether ART restores subjective well-being to "normal" levels is lacking, particularly in resource limited settings. The study objectives are to compare quality of life and depression symptoms for PLWH on ART to a general community population and to explore factors to explain these differences, including socio-economic status and the impact of urban or rural residence. PLWH on ART (n = 263) were recruited from ART delivery sites and participants not on ART (n = 160) were recruited from communities in Wakiso District, Uganda. Participants were interviewed using the translated World Health Organisation Quality of Life brief measure, the Hopkins Symptom Checklist depression section, and questions about socio-economic status, residence as urban or rural and, for PLWH on ART, self-reported adherence and use of HIV counselling. Compared to the community sample and controlling for location of residence, PLWH on ART had significantly higher quality of life (QOL) for physical, psychological and environment domains, but not the social domain. These differences were not due to socio-economic status alone. Depression scores were significantly lower for PLWH on ART. Both comparisons controlled for the effect of location of residence. People on ART self-reported high adherence and the majority had used HIV counselling services. Our findings show better QOL amongst PLWH on ART compared to a general community sample, which cannot be explained solely by differences in socio-economic status nor location of residence. The general community sample results point towards the challenges of life in this setting. Access to health services may underpin this difference and further research should explore this finding, in addition to identification of psychological mechanisms that relate to better QOL. ART provision infrastructure has clear benefits. Further work should consider sustainability and replication for other health conditions.

Validity of standard gamble estimated quality of life in acute venous thrombosis

INTRODUCTION

The standard gamble is considered the 'gold standard' technique for measuring quality of life. We recently used the standard gamble to estimate quality of life in acute venous thrombosis, and found unexpected variability in the responses. The current study aimed to explore the reasons for variability by comparing the standard gamble technique in patients with acute venous thrombosis to other quality of life measurement tools.

MATERIALS AND METHODS

Thrombosis clinic patients treated for venous thrombosis were eligible to participate. Patients evaluated their current health state by performing a standard gamble interview, reporting on a visual analogue scale, completing the SF-36 and disease specific questionnaires (PEmb-Qol and VEINES-QOL/Sym). Validity was assessed by correlating the standard gamble utilities with the other methods. Test-retest reliability, responsiveness and acceptability were also assessed.

RESULTS

Forty-four patients were interviewed, with 16 attending for a repeat interview. The median standard gamble utility was 0.97 (0.84-1.0), SF-6D 0.64 (0.59 - 0.80) and visual analogue score 70 (60 - 80). Participants with pulmonary embolism had lower standard gamble estimates than those with deep vein thrombosis. There was good discriminant validity in that the standard gamble estimates were not associated with risk taking behavior, negative outlook, sex or education. Test-retest reliability with the standard gamble was moderate and there was evidence of a ceiling effect.

CONCLUSIONS

Standard gamble utilities are higher than other methods of measuring quality of life in venous thrombosis. The choice of utility values adopted in studies will impact on future economic studies.

The cost-effectiveness analysis of video capsule endoscopy compared to other strategies to manage acute upper gastrointestinal hemorrhage in the ED

STUDY OBJECTIVE

Acute upper gastrointestinal (GI) hemorrhage is a common presentation in hospital-based emergency departments (EDs). A novel diagnostic approach is to use video capsule endoscopy to directly visualize the upper GI tract and identify bleeding. Our objective was to evaluate and compare the relative costs and benefits of video capsule endoscopy compared to other strategies in low- to moderate-risk ED patients with acute upper GI hemorrhage.

METHODS

We constructed a model using standard decision analysis software to examine the cost-effectiveness of 4 available strategies for a base-case patient who presents to the ED with either mild- or moderate-risk scenarios (by Glasgow-Blatchford Score) for requiring invasive hemostatic intervention (ie, endoscopic, surgical, etc) The 4 available diagnostic strategies were (1) direct imaging with video capsule endoscopy performed in the ED; (2) risk stratification using the Glasgow-Blatchford score; (3) nasogastric tube placement; and, finally, (4) an admit-all strategy.

RESULTS

In the low-risk scenario, video capsule endoscopy was the preferred strategy (cost $5691, 14.69 quality-adjusted life years [QALYs]) and was more cost-effective than the remaining strategies including nasogastric tube strategy (cost $8159, 14.69 QALYs), risk stratification strategy (cost $10,695, 14.69 QALYs), and admit-all strategy (cost $22,766, 14.68 QALYs). In the moderate-risk scenario, video capsule endoscopy continued to be the preferred strategy (cost $9190, 14.56 QALYs) compared to nasogastric tube (cost $9487, 14.58 QALYs, incremental cost-effectiveness ratio $15,891) and more cost effective than admit-all strategy (cost, $22,584, 14.54 QALYs.)

CONCLUSION

Video capsule endoscopy may be cost-effective for low- and moderate-risk patients presenting to the ED with acute upper GI hemorrhage.

The impact of differences between patient and general population EQ-5D-3L values on the mean tariff scores of different patient groups

BACKGROUND

Health states can be valued by those who currently experience a health state (experienced health states [EHS]) or by the general public, who value a set of given health states (GHS) described to them. There has been debate over which method is more appropriate when making resource allocation decisions.

OBJECTIVE

This article informs this debate by assessing whether differences between these methods have an effect on the mean EQ-5D-3L tariff scores of different patient groups.

METHODS

The European tariff based on GHS valuations was compared with a German EHS tariff. Comparison was made in the context of EQ-5D-3L health states describing a number of diagnosed chronic diseases (stroke, diabetes, myocardial infarction, and cancer) taken from the Cooperative Health Research in the Augsburg Region population surveys. Comparison was made of both the difference in weighting of the dimensions of the EQ-5D-3L and differences in mean tariff scores for patient groups.

RESULTS

Weighting of the dimensions of the EQ-5D-3L were found to be systematically different. The EHS tariff gave significantly lower mean scores for most, but not all, patient groups despite tariff scores being lower for 213 of 243 EQ-5D-3L health states using the GHS tariff. Differences were found to vary between groups, with the largest change in difference being 5.45 in the multiple stoke group.

CONCLUSIONS

The two tariffs have systematic differences that in certain patient groups could drive the results of an economic evaluation. Therefore, the choice as to which is used may be critical when making resource allocation decisions.

Health utilities of type 2 diabetes-related complications: a cross-sectional study in Sweden

This study estimates health utilities (HU) in Sweden for a range of type 2 diabetes-related complications using EQ-5D and two alternative tariffs (UK and Swedish) from 1757 patients with type 2 diabetes from the Swedish National Diabetes Register (NDR). Ordinary least squares were used for statistical analysis. Lower HU was found for female gender, younger age at diagnosis, higher BMI, and history of complications. Microvascular and macrovascular complications had the most negative effect on HU among women and men, respectively. The greatest decline in HU was associated with kidney disorders (−0.114) using the UK tariff and stroke (−0.059) using the Swedish tariff. Multiple stroke and non-acute ischaemic heart disease had higher negative effect than a single event. With the UK tariff, each year elapsed since the last microvascular/macrovascular complication was associated with 0.013 and 0.007 units higher HU, respectively. We found important heterogeneities in effects of complications on HU in terms of gender, multiple event, and time. The Swedish tariff gave smaller estimates and so may result in less cost-effective interventions than the UK tariff. These results suggest that incorporating subgroup-specific HU in cost-utility analyses might provide more insight for informed decision-making.

How illness affects family members: a qualitative interview survey

OBJECTIVE

Spillover effects of illness on family members can be substantial. The objective of this study was to identify the domains of family members' health and well-being that are affected when a relative has a chronic health condition.

METHODS

Semi-structured telephone interviews were conducted in February 2012 with 49 individuals whose relatives had any of five chronic health conditions (arthritis, cancer, Alzheimer's disease/dementia, cerebral palsy, and depression), purposively sampled to include different relationships with the ill relative (parent, child, spouse). Subjects were queried on whether and how having an ill relative affected their health and well-being; they were also asked about their caregiving responsibilities and the relative's health. Interview data were analyzed using thematic analysis.

RESULTS

Family members in our sample reported experiencing psychological and non-health effects from having an ill relative, and secondarily somatic effects. Effects on emotional health were most commonly reported as psychological spillover; non-health effects frequently included changes in daily activities and provision of caregiving. Spouses of patients reported the broadest range of spillover domains affected and adolescents of ill parents the fewest. Family members reported experiencing effects that were perceived as both positive and negative.

CONCLUSIONS

Spillover of illness onto family members encompasses a wide range of domains of health and well-being, extending beyond those included in many existing health-related quality of life measures. Outcomes measurement efforts should be expanded to adequately capture these health and well-being outcomes for analysis, to ensure that the benefits of interventions are accurately estimated and conclusions are valid.

Assessment of Preference for Hormonal Treatment-Related Health States among Patients with Breast Cancer

OBJECTIVES

1) To obtain preference scores from patients with breast cancer in Singapore for different stages of breast cancer and hormonal therapy-related adverse effects, and 2) to determine the association of patients' demographic and clinical characteristics with those preference scores.

METHODS

A total of 22 health states were used to elicit preference values from 64 patients with breast cancer. At each interview, 14 health states were randomly selected and rated by the patient using the visual analogue scale and standard gamble methods to derive health state preference scores, which were recalibrated to the scale of 0 (death) and 1 (perfect health).

RESULTS

Mean adjusted visual analogue scale scores ranged from 0.25 (no recurrence with ischemic cerebrovascular events) to 0.82 (no recurrence with no adverse effects). Mean adjusted standard gamble scores ranged from 0.31 (distant recurrence with chemotherapy-related adverse effects) to 0.80 (no recurrence with no adverse effects). Adverse effects ischemic cerebrovascular events and spine fracture resulted in the greatest decline in health state preference scores. Age, ethnicity, education level, and prior chemotherapy were associated with preference scores. Having children was not found to be associated with the preference scores.

CONCLUSIONS

Taking into account disease progression and hormonal therapy-related adverse effects as well as their impact on health-related quality of life, this study quantifies patients' preference for various breast cancer-related health states. The findings offer valuable information for future cost-utility analysis of breast cancer treatments.

Utility values in health technology assessments: a statistician's perspective

This paper provides an introduction to utilities for statisticians working mainly in clinical research who have not had experience of health technology assessment work. Utility is the numeric valuation applied to a health state based on the preference of being in that state relative to perfect health. Utilities are often combined with survival data in health economic modelling to obtain quality-adjusted life years. There are several methods available for deriving the preference weights and the health states to which they are applied, and combining them to estimate utilities, and the clinical statistician has valuable skills that can be applied in ensuring the robustness of the trial design, data collection and analyses to obtain and handle this data. In addition to raising awareness of the subject and providing source references, the paper outlines the concepts and approaches around utilities using examples, discusses some of the key issues, and proposes areas where statisticians can collaborate with health economic colleagues to improve the quality of this important element of health technology assessment.

A comparison of injured patient and general population valuations of EQ-5D health states for New Zealand

Background

A near-universal finding internationally is that patient valuations of their own health, represented using the EQ-5D system, are mostly higher than general population valuations of the same EQ-5D states. This paper investigates whether this result also applies to New Zealand. Despite the EQ-5D’s widespread use for cost-utility analysis in New Zealand, in particular by the Pharmaceutical Management Agency (PHARMAC) for health technology assessments, no previous studies comparing patient and general population valuations have included data for New Zealand.

Methods

Valuations of 13 EQ-5D health states from a 1999 survey of the New Zealand general population (n = 396) are compared with injured New Zealanders’ (n = 2099) valuations of their own health (also represented on the EQ-5D) collected between 2007 and 2009 in the Prospective Outcomes of Injury Study. Which EQ-5D dimensions are most strongly associated with the population valuations is also investigated.

Results

Injured population valuations are higher (better-rated health) than general population valuations for all 13 health states considered except 11111 (no problems on any EQ-5D dimension). This difference, which tends to be larger the ‘worse’ the state, is statistically significant at the 10% level for most of the states. State 11111 is rated significantly lower by the injured population than the general population. Pain/discomfort is more important in determining valuations for the general population than for injured people, whereas problems with self-care are more important for the injured population; anxiety/depression is important in both general and injured population valuations.

Conclusions

Consistent with the international literature, injured people’s valuations of their own health are mostly higher than the general population’s hypothetical valuations of the same EQ-5D states for New Zealand. These differences are practically significant in the sense that they are larger than minimally important differences for the EQ-5D from the literature, and they appear capable of significantly affecting CUA results.

Health state utilities associated with adult attention-deficit/hyperactivity disorder

OBJECTIVES

With growing awareness of the importance of adult attention-deficit/hyperactivity disorder (ADHD) treatment, cost-effectiveness analyses, including utilities, are needed to compare the value of treatment options. Although utilities have been reported for childhood ADHD, little is known about utilities representing adult ADHD. Therefore, the purpose of this study was to estimate utilities associated with adult ADHD.

METHODS

Health-state descriptions of adult ADHD were drafted based on literature review, interviews with four clinicians, and clinical trial data. Health states were revised based on a pilot study with 26 participants. Final health states were rated in time trade-off interviews with general population respondents in London and Edinburgh, UK.

RESULTS

A total of 158 participants completed interviews (mean age =47.0 years; 49.4% female; Edinburgh =80 participants). Mean (standard deviation [SD]) utilities were 0.82 (0.17), 0.68 (0.28), and 0.67 (0.28) for health states describing treatment responders (health state A), nonresponders (health state B), and untreated patients (health state C), respectively. Most participants rated health state A as preferable to B (n=92; 58.2%) and C (n=97; 61.4%). The majority rated B and C as equal (n=125; 79.1%). Paired Student's t-tests found that A had a significantly greater mean utility than B (t=10.0; P<0.0001) and C (t=10.2; P<0.0001).

CONCLUSION

The current study provides utilities that may be used in cost-utility models of treatment for adult ADHD. Results reflected clear differences between health states representing treatment responders and nonresponders/untreated patients. Current utilities were comparable to those previously reported for childhood ADHD.

Using existing data to identify candidate items for a health state classification system in multiple sclerosis

PURPOSE

In multiple sclerosis (MS), the use of preference-based measures is limited to generic measures such as Health Utilities Index Mark 2 and 3, the EQ-5D and the SF-6D. However, the challenge of using such generic preference-based measures in people with MS is that they may not capture all domains of health relevant to the disease. Therefore, the main aim of this paper is to describe the development of a health state classification system for MS patients. The specific objectives are: (1) to identify items best reflecting the domains of quality of life important to people with MS and (2) to provide evidence for the discriminative capacity of the response options by cross-walking onto a visual analog scale of health rating.

METHODS

The data come from an epidemiologically sampled population of people with MS diagnosed post-1994. The dataset consisted of 206 items relating to impairments, activity limitations, participation restrictions, health perception and quality of life. Important domains were identified from the responses to the Patient Generated Index, an individualized measure of quality of life. The extent to which the items formed a uni-dimensional, linear construct was estimated using Rasch analysis, and the best item was selected using the threshold map.

RESULTS

The sample was young (mean age 43) and predominantly female (n = 140/189; 74%). The P-PBMSI classification system consisted of five items, with three response levels per item, producing a total of 243 possible health states. Regression coefficient values consistently decreased between response levels and the linear test for trend were statistically significant for all items. The linear test for trend indicated that for each item the response options provided the same discriminative ability within the magnitude of their capacity. A scoring algorithm was estimated using a simple additive formula. The classification system demonstrated convergent validity against other measures of similar constructs and known-groups validity between different clinical subgroups.

CONCLUSION

This study produced a health state classifier system based on items impacted upon by MS, and demonstrated the potential to discriminate the health impact of the disease.