Swedish experience-based value sets for EQ-5D health states

Early workplace dialogue in physiotherapy practice improved work ability at 1-year follow-up-WorkUp, a randomised controlled trial in primary care

Workplace involvement in rehabilitation for patients with musculoskeletal pain may improve work ability. Convergence Dialogue Meeting (CDM) is a model aimed at helping the patient, the care giver, and the employer to support work ability and return-to-work. Our aim was to study the effect on work ability when adding a workplace dialogue according to CDM in physiotherapy practice for patients with pain in ordinary primary care. We conducted a prospective pairwise cluster randomised controlled trial (ClinicalTrials.gov ID: NCT02609750) in primary care involving 20 primary care rehabilitation units with 1-year follow-up. Adult patients with acute/subacute neck and back pain, worked ≥4 weeks past year and not currently on sick leave or no more than 60 days of sick leave and considered at-risk of sick leave were included (n = 352). All patients received structured physiotherapy and the intervention was the addition of CDM, delivered by the treating physiotherapist. The main confirmatory outcome, work ability (defined as working at least 4 consecutive weeks at follow-up), was assessed by a weekly short text message question on number of sick leave days past week. Work ability was reached by significantly more patients in the intervention group (108/127, 85%) compared with the reference group (127/171, 74%) (P = 0.02). The intervention increased the odds of having work ability at 1-year follow-up, also after adjustment for baseline health-related quality of life (odds ratio 1.85, confidence interval 1.01-3.38). We conclude that an early workplace dialogue in addition to structured physiotherapy improved work ability significantly.

Real-world cost-effectiveness of targeted therapy in metastatic renal cell carcinoma in Sweden: a population-based retrospective analysis

OBJECTIVE

To explore cost-effectiveness of targeted therapies (TTs) in the treatment of metastatic renal cell carcinoma (mRCC) in a real-world context using a nationwide population-based approach.

METHODS

Data on patients diagnosed with mRCC between 2002 and 2012 were extracted from Swedish national health data registers. To facilitate comparisons of patients diagnosed before and after TT introduction to the market, three cohorts were derived: pre-TT introduction (preTT), patients diagnosed 2002-2005; early TT introduction (TTi), patients diagnosed 2006-2008; and late TT introduction (TTii), which was limited to patients diagnosed 2009-2010 to ensure availability of total health care resource utilization (HCRU) data. Patients were followed until end of 2012. The value of TTs across cohorts was estimated using mean HCRU costs per life-year (LY) gained. Data on HCRU were obtained through national health registers for dispensed medication and inpatient and outpatient care, and the associated costs were estimated using the Lin method to account for censoring. LYs gained were defined as the difference in mean survival over the study period.

RESULTS

The preTT, TTi, and TTii cohorts consisted of 1,366, 1,158, and 806 patients, respectively. Mean survival in years from mRCC diagnosis was 1.45 in the preTT cohort, 1.62 in the TTi cohort, and 1.83 in the TTii cohort. The respective mean total HCRU cost per patient over the study period was US$16,894, US$29,922, and US$30,037. The cost per LY gained per cohort was US$78,656 for TTi vs preTT, US$34,132 for TTii vs preTT, and US$523 for TTii vs TTi.

CONCLUSION

Given common willingness-to-pay per LY gained thresholds, this study in a real-world population suggests the use of TTs in the Swedish mRCC population is increasingly cost-effective over time.

Association between Disability, Cognition, Fatigue, EQ-5D-3L Domains, and Utilities Estimated with Different Western European Value Sets in Patients with Multiple Sclerosis

OBJECTIVES

To assess the association between fatigue, cognition, domains of the EuroQol five-dimensional questionnaire (EQ-5D-3L), disability, and utilities estimated with several Western European value sets in patients with multiple sclerosis (MS).

METHODS

Data from a multinational, cross-sectional, observational study of patients with MS (N = 16,808) conducted in 16 European countries were used. Health-related quality of life data were collected through the EQ-5D-3L, and fatigue and cognitive difficulties were self-assessed on a 10-point visual analogue scale. Associations were assessed using Pearson correlation and multivariate regression model.

RESULTS

Symptoms of fatigue and cognitive difficulties were present in 90% and 70% of patients at all levels of disability, respectively, and thus only weakly correlated to disability. Problems in the EQ-5D-3L domains were common even at mild disability levels. Mobility, usual activities, and pain issues were experienced by 80% to 90% of patients with moderate and high levels of disability. Mobility, usual activities, and self-care were strongly correlated to disability. Disability, MS type, fatigue, and cognition were associated with utility in regression models, although the coefficients of fatigue and cognition were small.

CONCLUSIONS

The strong relationship of disability with utility was confirmed. Despite this, fatigue and cognitive difficulties were associated with utility estimated with different European value sets.

Depression and Anxiety as Key Factors Associated With Quality of Life Among Lung Cancer Patients in Hai Phong, Vietnam

Background: Cancer is a leading cause of death. People living with cancer experience a variety of symptoms that might profoundly affect their quality of life (QoL). Objective: The study aims to identify factors associated with the QoL of patients with lung cancer at the oncology department of Viet Tiep Hospital, Hai Phong city, Vietnam in 2018. Methods: A cross-sectional study was conducted to collect data from lung cancer inpatients in Hai Phong city, Vietnam. The EQ-5D-5L and the EuroQol (EQ)-visual analogue scale (EQ VAS) were used to assess health-related quality of life (QoL). A multivariable regression analysis was performed on the EQ-5D utility score and the EQ VAS score as dependent variables, and socioeconomic, social support, and psychological factors as potential predictors. Results: A total of 125 lung cancer patients were enrolled in this study. The highest proportion of respondents reporting any problems was in anxiety/depression (92.8%), pain/discomfort (81.2%), usual activities (75.2%), and mobility (60%) dimensions, while the lowest percentage was in self-care dimension (40.8%). The multivariate analyses showed that a low QoL score was significantly associated with depression, incapacity to pay, low response to treatment, and presence of side effects. Conclusion: QoL of lung cancer patients is associated with anxiety/depression and other factors that can be modified by specific interventions. It is therefore possible to take care of psychological aspects to improve the QoL of Vietnamese people suffering from this condition.

Health Related Quality of Life in Individuals Transferred from a Needle Exchange Program and Starting Opioid Agonist Treatment

Background

Opioid agonist treatment (OAT), for the treatment of heroin dependence, has been reported to improve overall health and lower mortality. Drug use and retention in treatment have often been used as measures of treatment success. More recently, however, researchers have suggested that measurements of quality of life should be an outcome in substance use treatment evaluations. In a recent randomized controlled trial we demonstrated high rates of successful rapid referral from a needle exchange program (NEP) to OAT. The aim of this study was to see whether an improvement in health related quality of life (HRQoL) could be seen at 3-month follow-up after starting OAT and whether it was associated with any baseline characteristics. We also wanted to compare our sample to a sample from the general population with regard to HRQoL.

Methods

This was a 3-month follow-up of 71 patients who started OAT. Measurements of HRQoL with EQ-5D (an instrument developed by the EuroQol group) were made at baseline and at three months.

Results

Mean EQ-5D VAS (visual analogue scale) for the study sample at baseline was 47.3, which was lower than a Swedish reference population reporting 83.3. Individuals reporting being prescribed a drug for a psychiatric condition had significantly lower EQ-5D index values. Improvement in EQ-5D index score was significantly less for individuals reporting previous overdoses (-0.10, p=0.025). Individuals reporting previous suicide attempts had significantly lower EQ-5D VAS score at baseline. A significant increase of the EQ-5D VAS difference over time was found with a mean difference of 10.94 (p=0.008) for the total sample.

Conclusion

To our knowledge this is the first time HRQoL as an outcome is reported in a population transferred from a NEP to OAT. Our results indicate that OAT can result in increased HRQoL, even with this type of rapid low-threshold referral.

Relative importance of the EQ-5D five dimensions among patients with chronic diseases in South Korea – a comparison with the general population preference weights

Background

Who should provide the values of health states in economic evaluations of health technologies has long been the subject of debate. This study examined and compared the relative importance of the EQ-5D five dimensions, using both patient-reported values and general population tariffs, among patients with chronic diseases in South Korea and also assessed the pattern of the discrepancy between patient and general population values by type of chronic diseases.

Methods

Data were taken from the 2013 Korea Health Panel survey. This analysis focused on adult patients with chronic diseases (n = 3216). Patient-reported EQ-5D profiles and visual analogue scale (VAS) values were used to assess the relative importance of the EQ-5D five dimensions among these patients, using a linear regression model. The relative importance of the EQ-5D dimensions was then compared to the EQ-5D tariffs elicited from the general population. The relative magnitude of the discrepancies between patient and general population values was also assessed by type of chronic diseases.

Results

Anxiety/depression and pain/discomfort appeared to have the largest impact on the self-rated patient VAS, which fairly contrasted with the general population model. In addition, a further regression analysis showed that the discrepancy between patient and general population values varied with the type of chronic diseases. The greatest discrepancy between the two was found in patients with diseases of the blood and blood-forming organs, neoplasms and diseases of the digestive system.

Conclusions

These analyses revealed differences in the relative weights attached to the EQ-5D dimensions between patient groups and the general population, particularly in those ‘non-tangible’ dimensions. These differences consequently led to greater discrepancies between patient and general population values in certain patient groups, which can have significant implications for resource allocation decisions in South Korea.

Long-term quality of life after comprehensive surgical staging of high-risk endometrial cancer - results from the RASHEC trial

PURPOSE

The health-related quality of life (HRQoL) outcomes after comprehensive surgical staging including infrarenal paraaortic lymphadenectomy in women with high-risk endometrial cancer (EC) are unknown. Our aim was to investigate the long-term HRQoL between robot-assisted laparoscopic surgery (RALS) and laparotomy (LT).

PATIENTS AND METHODS

A total of 120 women with high-risk stage I-II EC were randomised to RALS or LT for hysterectomy, bilateral salpingoophorectomy, pelvic and infrarenal paraaortic lymphadenectomy in the previously reported Robot-Assisted Surgery for High-Risk Endometrial Cancer trial. The HRQoL was measured with the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC-QLQ-30) and its supplementary questionnaire module for endometrial cancer (QLQ-EN24) questionnaire. Women were assessed before and 12 months after surgery. In addition, the EuroQol Eq5D non-disease specific questionnaire was used for descriptive analysis.

RESULTS

There was no difference in the functional scales (including global health status) in the intention to treat analysis, though LT conferred a small clinically important difference (CID) over RALS in 'cognitive functioning' albeit not statistically significant -6 (95% CI-14 to 0, p = .06). LT conferred a significantly better outcome for the 'nausea and vomiting' item though it did not reach a CID, 4 (95% CI 1 to 7, p = .01). In the EORTC-QLQ/QLQ-EN24, no significant differences were observed. Eq5D-3L questionnaire demonstrated a higher proportion of women reporting any extent of mobility impairment 12 months after surgery in the LT arm (p = .03).

CONCLUSION

Overall, laparotomy and robot-assisted surgery conferred similar HRQoL 12 months after comprehensive staging for high-risk EC.

Cost-effectiveness of Pembrolizumab as Second-line Therapy for the Treatment of Locally Advanced or Metastatic Urothelial Carcinoma in Sweden

BACKGROUND

Urothelial carcinoma (UC) is the most common subtype of bladder cancer. The randomized phase 3 KEYNOTE-045 trial showed that pembrolizumab, used as second-line therapy significantly prolonged overall survival with fewer treatment-related adverse events than chemotherapy for advanced UC. Pembrolizumab has been approved by the European Medicines Agency for the treatment of locally advanced or metastatic UC in adults who have received platinum-containing chemotherapy. Many European countries use cost-effectiveness analysis to inform reimbursement decisions.

OBJECTIVE

To assess the cost-effectiveness of pembrolizumab as second-line therapy for the treatment of advanced UC from a Swedish health care perspective.

DESIGN, SETTING, AND PARTICIPANTS

We developed a partitioned-survival model to assess the costs and effectiveness of pembrolizumab compared with vinflunine (base case), paclitaxel, or docetaxel monotherapy in patients with advanced UC over a 15-yr time horizon. We obtained Kaplan-Meier estimates for survival endpoints, adverse events, and utility data from KEYNOTE-045.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We performed parametric extrapolations to estimate overall and progression-free survival beyond the clinical trial period. Swedish costs and utility weights were used to estimate total costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). We performed deterministic and probabilistic sensitivity analyses to assess the robustness of the model results.

RESULTS AND LIMITATIONS

In the base-case analysis, pembrolizumab resulted in a mean survival gain of 1.66 years (1.38 QALYs) at an incremental cost of €69852 and an ICER of €50529/QALY gained versus vinflunine monotherapy. ICERs for other chemotherapies were €81356/QALY for pembrolizumab versus paclitaxel or docetaxel monotherapy, and €71924/QALY for pembrolizumab versus paclitaxel, docetaxel, or vinflunine monotherapy. Long-term follow-up from KEYNOTE-045 and real-world data are needed to validate the extrapolations.

CONCLUSIONS

The results indicate that pembrolizumab improves survival, increases QALYs, and is cost-effective as second-line therapy at a willingness-to-pay threshold of €100000/QALY for the treatment of advanced UC.

PATIENT SUMMARY

To date, pembrolizumab is the only treatment associated with a significant overall survival benefit compared with chemotherapy in a randomized controlled trial as second-line therapy for advanced urothelial carcinoma. Our trial-based cost-effectiveness analysis suggests that pembrolizumab is a cost-effective option over chemotherapy in patients with advanced urothelial carcinoma after platinum-based therapy in Sweden.

Time Trade-Off Value Set for EQ-5D-3L Based on a Nationally Representative Chinese Population Survey

OBJECTIVES

To obtain a nationally representative Chinese three-level EuroQol five-dimensional questionnaire value set based on the time trade-off (TTO) method.

METHODS

A multistage, stratified, clustered random nationally representative Chinese sample was used. The study design followed an adapted UK Measurement and Valuation of Health protocol. Each respondent valued 11 random states plus state 33333 and "unconscious" using the TTO method in face-to-face interviews. Three types of models were explored: ordinary least squares, general least squares, and weighted least squares models.

RESULTS

In total, 5939 inhabitants aged 15 years and older were interviewed. Of these, 5503 satisfactorily interviewed participants were included in constructing models. An ordinary least squares model including 10 dummies without constant and N3 had a mean absolute error of 0.083 and a correlation coefficient of 0.899 between the predicted and mean values. Goodness-of-fit indices of two models based on split subsample were similar.

CONCLUSIONS

TTO values were higher in our study compared with those in a study carried out in urban areas, which is mirrored by the higher values in rural areas. Several other aspects, in addition to the valuation procedure, might have influenced the results, such as factors beyond demographic factors such as view on life and death and believing in an afterlife, which need further investigation. Future studies using the three-level EuroQol five-dimensional questionnaire should consider using this value set based on a nationally representative sample of the Chinese population.

Predicting EuroQoL 5 Dimensions 5 Levels (EQ-5D-5L) Utilities from Older People's Quality of Life Brief Questionnaire (OPQoL-Brief) Scores

BACKGROUND AND OBJECTIVE

Economic evaluation of healthcare treatment and services targeted at older people requires measurement of utility-based quality-of-life outcomes but it is not always possible to collect such outcome data. It may, however, be possible to estimate these outcomes using non-utility measures of quality of life where the latter have been collected. The objective of this study was to develop a regression-based algorithm to map a non-utility-based outcome, the Older People's Quality of Life brief questionnaire (OPQoL-brief), onto a utility-based outcome, the EuroQoL 5 Dimensions 5 Levels (EQ-5D-5L).

METHODS

The estimation sample comprised 330 community-based Australian older people (>65 years), while the validation sample consisted of 293 older people from a separate study. Six regression techniques were employed to estimate utilities from OPQoL-brief. The predictive accuracy of 54 regression models (six regression techniques × nine model specifications) was assessed using six criteria: mean absolute error (MAE), root mean squared error (RMSE), correlation, distribution of predicted utilities, distribution of residuals, and proportion of predictions with absolute errors <0.05.

RESULTS

The 54 regression models predicted EQ-5D-5L utilities that performed differently when assessed by the six criteria. However, best results were obtained from an ordinary least squares (OLS) model where all 13 OPQoL-brief items were included as continuous variables (OLS 4). RMSE and MAE estimates for this model (0.2201 and 0.1638, respectively) were within the range of published estimates.

CONCLUSIONS

It is possible to predict valid utilities from OPQoL-brief using regression methods. We recommend OLS model (4) for this exercise.

Experience-Based Values: A Framework for Classifying Different Types of Experience in Health Valuation Research

Whether health values should be elicited from the perspective of patients or the general public is still an open debate. The overall aim of this paper is to increase knowledge on the role of experience in health preference-based valuation research. The objectives of this paper are threefold. First, we elaborate the idea of experience-based (EB) values under the informed value or knowledge viewpoint. We think the whole scope of knowledge about the health states involved in valuation exercises is not fully integrated in the previous literature. For instance, personal knowledge based on past experiences, contemplating the health state as a likely future condition, knowing someone who is currently experiencing the state, or just receiving detailed information about the health states; all these situations capture different nuances of health-related experience which are not explicitly referred to in valuation tasks. Second, we propose a framework where the extended factor of experience is detached from other factors interwoven into the valuation exercise. Third, we examine how experience is tackled in different value sets (EB or non-EB) identified via a literature review. We identified the following elements (and items) in a value set: health state (without description, described using a multi-attribute instrument, described using other method), reference person (the respondent; other person, similar/known/hypothetical), time frame (past, present, future), raters (public, representative/convenience; vested interest, patients/other) and experience (personal experience, past/present/future; vicarious experience, affective/non-affective; no experience). Forty-nine valuation exercises were extracted from 22 reviewed papers and classified following our suggested set of elements and items. The results show that the role of experience reported in health valuation-related papers is frequently disregarded or, at most, minimised to the item of personal experience (present)-linked to self-reported health.

Mapping Quality of Life (EQ-5D) from DAPsA, Clinical DAPsA and HAQ in Psoriatic Arthritis

BACKGROUND

Clinical trials and observational studies lacking measures of health-related quality of life (QoL) are often inapplicable when conducting cost-effectiveness analyses using quality-adjusted life-years (QALYs). The only solution is to map QoL ex post from additionally collected clinical outcomes and generic QoL instruments. Nonetheless, mapping studies are absent in psoriatic arthritis (PsA).

METHODS

In this 2-year, prospective, multicentre, non-interventional study of PsA patients, EQ-5D and key clinical parameters such as Disease Activity in PsA (DAPsA), clinical DAPsA (cDAPsA; DAPsA without C-reactive protein [CRP]), and Health Assessment Questionnaire disability index (HAQ) were collected. We employed a linear mixed-effect regression model (ME) of the longitudinal dataset to explore the best predictors of QoL.

RESULTS

A total of 228 patients were followed over 873 appointments/observations. DAPsA, cDAPsA and HAQ were stable and highly significant predictors of EQ-5D utilities in both cross-sectional and longitudinal analyses. The best prediction was provided using a linear ME with HAQ and cDAPsA or DAPsA. A HAQ increase of 1 point represented a decrease in EQ-5D by -0.204 or -0.203 (p < 0.0001); a one-point increase in cDAPsA or DAPsA dropped EQ-5D equally by -0.005 (p < 0.0001). The ME revealed steeper and more accurate association compared with cross-sectional regressions or non-linear models/transformations.

CONCLUSIONS

This is the first mapping study conducted in PsA and we hope that our study will encourage further mapping studies in PsA. The results showed that in cases where CRP is absent, cDAPsA provides similar results to DAPsA in predicting QoL.

Quality of life and service use amongst parents of young children: Results from the Children and Parents in Focus trial

Aim: The aim of this study was to assess the quality of life (QoL) and service use of parents who have preschool-aged children, and whether the mental-health problems of parents and their children predict these outcomes. Methods: Cross-sectional data were gathered in 2015-2016 in Uppsala County in Sweden where 3164 parents of children aged three- to five-years-old were asked to self-report their own and their children's mental-health status and service use in the past 12 months. Data from the General Health Questionnaire were used to derive health-related quality of life (HRQoL) measures for adults. Results: Very few parents reported mental-health problems, while approximately 15% of the sample used any type of parental support and/or psychological health-care service. Families without problems used the least amount of resources. Parents' own mental-health problems predicted usage of both psychotherapy and couples' therapy, while child problems predicted the former but also the use of a parenting program. Parental HRQoL was predicted by mental-health problems, and all families with at least one individual experiencing problems rated their QoL lower than families without problems. Conclusions: Parental service use and HRQoL is associated not only with their own mental-health status but also with their children's mental-health problems.

Responsiveness of EQ-5D in Patients With a Distal Radius Fracture

BACKGROUND

The EuroQol Group 5-Dimension (EQ-5D) questionnaire is frequently used as an outcome measure of general patient-reported health-related quality of life (HRQoL). We evaluated the internal and external responsiveness of EQ-5D (specifically EQ-5D_index score) in patients with a surgically treated distal radius fracture.

METHODS

Within the context of a randomized controlled trial (RCT), 132 patients with a surgically treated distal radius fracture filled out EQ-5D and Patient-Rated Wrist Evaluation (PRWE-Swe) at baseline (preinjury state), and at 3 and 12 months. Internal responsiveness was evaluated by calculating mean change score and standardized response mean (SRM) of the EQ-5D_index scores. External responsiveness was evaluated with PRWE-Swe as the external criterion. PRWE-Swe was used to define 4 subgroups of patients with different clinical outcomes. The ability of EQ-5D_index change score to discriminate between these subgroups was analyzed with logistic regression, receiver operating characteristic (ROC) curves, and area under the ROC curves (AUROCs). Correlation analysis was made with Spearman's ρ test.

RESULTS

The mean change in EQ-5D_index score from baseline to the 3-month follow-up was -16.1 and from the 3- to the 12-month follow-up was 7.6. The corresponding SRMs were large (0.93) and small to moderate (0.47). Analysis of external responsiveness displayed odds ratios >1 and AUROCs between 0.70 and 0.76 in all 4 subgroups. The proportion of patients correctly classified into the 4 subgroups by the EQ-5D_index change scores was 78% to 94%. Spearman's ρ was 0.35.

CONCLUSION

EQ-5D displayed an overall acceptable to good responsiveness in patients with a distal radius fracture. It may thus be used as a measure of HRQoL in this patient group.

Economic evaluation of a person-centred care intervention in head and neck oncology: results from a randomized controlled trial

Purpose

Head and neck cancer and its treatment deteriorate quality of life, but symptoms improve with person-centred care. We examined the cost-effectiveness of a person-centred care intervention versus standard medical care.

Methods

In this randomized clinical trial of a person-centred intervention, patients were planned for outpatient oncology treatment in a Swedish university hospital between 2012 and 2014 and were followed during 1 year. Annual healthcare costs were identified from medical records and administrative register data. Productivity costs were calculated from reported sick leave. Health-related quality of life was collected using the EuroQol Group’s five-dimension health state questionnaire.

Results

Characteristics were similar between 53 patients in the intervention group and 39 control patients. The average total cost was Euro (EUR) 55,544 (95% confidence interval: EUR 48,474–62,614) in the intervention group and EUR 57,443 (EUR 48,607–66,279) among controls, with similar health-related quality of life.

Conclusions

This person-centred intervention did not result in increased costs and dominated the standard medical care.

Trial registration

ClinicalTrials.gov (registration number: NCT02982746).

Peer effects in health valuation: the relation between rating of contemporaries' health and own health

Background

Most health valuation studies assume that individuals’ health valuations do not depend on social comparisons. However, there is some evidence that this assumption is not satisfied in practice. This paper tests whether self-rated health by means of a Visual Analogue Scale (VAS) is related to how one perceives the health of one’s contemporaries, while accounting for one’s health as classified by the EQ-5D classification system.

Methods

In a large sample (n = 1500), representative of the general public, we use a VAS to rate respondents’ own health and their assessment of their contemporaries’ health. In addition, we directly ask them whether they perceive their health to be better, the same, or worse than their contemporaries, and we measure their own health according to the EQ-5D-5 L.

Results

We find a positive relationship between own health rating and contemporaries’ health rating, after controlling for the respondents’ own health as classified according to the EQ-5D. Furthermore, we observe a discrepancy between relative health vis-à-vis age peers as measured by an ordinal comparison and relative health as measured by a VAS. Finally, respondents, especially women, tended to overestimate the health of other people of their age.

Conclusions

We provide evidence that people’s own health rating is related to the perception of health of contemporaries. Our results indicate that knowledge about a respondent’s perception of others’ health is useful in explaining health state valuations.

Increasing return-to-work among people on sick leave due to common mental disorders: design of a cluster-randomized controlled trial of a problem-solving intervention versus care-as-usual conducted in the Swedish primary health care system (PROSA)

BACKGROUND

Common mental disorders affect about one-third of the European working-age population and are one of the leading causes of sick leave in Sweden and other OECD countries. Besides the individual suffering, the costs for society are high. This paper describes the design of a study to evaluate a work-related, problem-solving intervention provided at primary health care centers for employees on sick leave due to common mental disorders.

METHODS

The study has a two-armed cluster randomized design in which the participating rehabilitation coordinators are randomized into delivering the intervention or providing care-as-usual. Employees on sick leave due to common mental disorders will be recruited by an independent research assistant. The intervention aims to improve the employee's return-to-work process by identifying problems perceived as hindering return-to-work and finding solutions. The rehabilitation coordinator facilitates a participatory approach, in which the employee and the employer together identify obstacles and solutions in relation to the work situation. The primary outcome is total number of sick leave days during the 18-month follow-up after inclusion. A long-term follow-up at 36 months is planned. Secondary outcomes are short-term sick leave (min. 2 weeks and max. 12 weeks), psychological symptoms, work ability, presenteeism and health related quality of life assessed at baseline, 6 and 12-month follow-up. Intervention fidelity, reach, dose delivered and dose received will be examined in a process evaluation. An economic evaluation will put health-related quality of life and sick leave in relation to costs from the perspectives of society and health care services. A parallel ethical evaluation will focus on the interventions consequences for patient autonomy, privacy, equality, fairness and professional ethos and integrity.

DISCUSSION

The study is a pragmatic trial which will include analyses of the intervention's effectiveness, and a process evaluation in primary health care settings. Methodological strengths and challenges are discussed, such as the risk of selection bias, contamination and detection bias. If the intervention shows promising results for return-to-work, the prospects are good for implementing the intervention in routine primary health care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03346395 Registered January, 12 2018.

Costs and quality of life by disability among people with multiple sclerosis: a register-based study in Sweden

Background

Population-based estimates of costs of illness and health-related quality of life, by disability levels among people with multiple sclerosis, are lacking.

Objectives

To estimate the annual costs of illness and health-related quality of life, by disability levels, among multiple sclerosis patients, 21–64 years of age.

Methods

Microdata from Swedish nationwide registers were linked to estimate the prevalence-based costs of illness in 2013, including direct costs (prescription drug use and specialised healthcare) and indirect costs (calculated using sick leave and disability pension), and health-related quality of life (estimated from the EQ-5D). Disability level was measured by the Expanded Disability Status Scale (EDSS).

Results

Among 8906 multiple sclerosis patients, EDSS 0.0–3.5 and 7.0–9.5 were associated with mean indirect costs of SEK 117,609 and 461,357, respectively, whereas direct costs were similar between the categories (SEK 117,423 and 102,714, respectively). Prescription drug costs represented 40% of the costs of illness among multiple sclerosis patients with low EDSS, while among patients with high EDSS more than 80% were indirect costs. Among the 1684 individuals who had reported both EQ-5D and EDSS, the lowest health-related quality of life scores were found among those with a high EDSS.

Conclusion

Among people with multiple sclerosis, we confirmed higher costs and lower health-related quality of life in higher disability levels, in particular high indirect costs.

Estimating a constant WTP for a QALY-a mission impossible?

Economic evaluations are an important input to decision-making and priority-setting in the health care sector. Measuring preferences for health improvements, as the demand-side value (willingness to pay) of gaining a quality-adjusted life year (QALY), is one relevant component in the interpretation of the results from health economic evaluations. Our article addresses whether willingness to pay for a QALY (WTP-Q) is sensitive to the size of the health differences and the probability for improvement. We use data from a contingent valuation survey based on 1400 respondents conducted in the spring of 2014. The results show that the expectation of sensitivity to scope, or higher WTP to the larger expected quality of life improvement, is not supported. We find WTP-Q values that conform reasonably well to previous studies in Sweden.

Experience-based utility and own health state valuation for a health state classification system: why and how to do it

In the estimation of population value sets for health state classification systems such as the EuroQOL five dimensions questionnaire (EQ-5D), there is increasing interest in asking respondents to value their own health state, sometimes referred to as "experience-based utility values" or, more correctly, own rather than hypothetical health states. Own health state values differ to hypothetical health state values, and this may be attributable to many reasons. This paper critically examines whose values matter; why there is a difference between own and hypothetical values; how to measure own health state values; and why to use own health state values. Finally, the paper examines other ways that own health state values can be taken into account, such as including the use of informed general population preferences that may better take into account experience-based values.

Health-related quality of life across all stages of autosomal dominant polycystic kidney disease

Background

A limited number of studies have assessed health-related quality of life (HRQoL) in autosomal dominant polycystic kidney disease (ADPKD). Results to date have been conflicting and studies have generally focused on patients with later stages of the disease. This study aimed to assess HRQoL in ADPKD across all stages of the disease, from patients with early chronic kidney disease (CKD) to patients with end-stage renal disease.

Methods

A study involving cross-sectional patient-reported outcomes and retrospective clinical data was undertaken April-December 2014 in Denmark, Finland, Norway and Sweden. Patients were enrolled into four mutually exclusive stages of the disease: CKD stages 1-3; CKD stages 4-5; transplant recipients; and dialysis patients.

Results

Overall HRQoL was generally highest in patients with CKD stages 1-3, followed by transplant recipients, patients with CKD stages 4-5 and patients on dialysis. Progressive disease predominately had an impact on physical health, whereas mental health showed less variation between stages of the disease. A substantial loss in quality of life was observed as patients progressed to CKD stages 4-5.

Conclusions

Later stages of ADPKD are associated with reduced physical health. The value of early treatment interventions that can delay progression of the disease should be considered.

Cost-effectiveness and long-term follow-up of three forms of minimal-contact cognitive behaviour therapy for severe health anxiety: Results from a randomised controlled trial

Strategies to increase the availability of cognitive behaviour therapy (CBT) for severe health anxiety (SHA) are needed, and this study investigated the cost-effectiveness and long-term efficacy of three forms of minimal-contact CBT for SHA. We hypothesised that therapist-guided internet CBT (G-ICBT), unguided internet CBT (U-ICBT), and cognitive behavioural bibliotherapy (BIB-CBT) would all be more cost-effective than a waiting-list condition (WLC), as assessed over the main phase of the trial. We also hypothesised that improvements would remain stable up to one-year follow-up. Adults (N = 132) with principal SHA were randomised to 12 weeks of G-ICBT, U-ICBT, BIB-CBT, or WLC. The primary measure of cost-effectiveness was the incremental cost-effectiveness ratio, or the between-group difference in per capita costs divided by the between-group difference in proportion of participants in remission. The Health anxiety inventory (HAI) was the primary efficacy outcome. G-ICBT, U-ICBT, and BIB-CBT were more cost-effective than the WLC. Over the follow-up period, the G-ICBT and BIB-CBT groups made further improvements in health anxiety, whereas the U-ICBT group did not change. As expected, all three treatments were cost-effective with persistent long-term effects. CBT without therapist support appears to be a valuable alternative to G-ICBT for scaling up treatment for SHA.

Well-being among survivors of out-of-hospital cardiac arrest: a cross-sectional retrospective study in Sweden

OBJECTIVES

The psychological outcome of out-of-hospital cardiac arrest (OHCA) has been studied more extensively in recent years. Still, not much is known about the well-being among OHCA survivors. In this retrospective cross-sectional study, we aim to investigate post-OHCA well-being among patients with a good neurological outcome, 3 months after the cardiac event. To assess well-being, we analyse the frequency of anxiety, depression, post-traumatic stress disorder (PTSD) and health within this group. Further, we aim to evaluate the importance of five prognostic factors for post-OHCA well-being.

METHODS

Data collection took place between 2008 and 2012, and every OHCA survivor within one region of Sweden, with a cerebral performance category (CPC) score of ≤2 at discharge, was asked to participate. Survivors were identified through the Swedish Cardiopulmonary Resuscitation Registry, and postal questionnaires were sent out 3 months after the OHCA. The survey included Hospital Anxiety and Depression scale (HADS), PTSD Checklist Civilian version (PCL-C) and European Quality of Life 5 Dimensions 3 level (EQ-5D-3L).

RESULTS

Of 298 survivors, 150 were eligible for this study and 94 responded. The mean time from OHCA to follow-up was 88 days. There was no significant difference between respondents and non-respondents in terms of sex, age, cardiac arrest circumstances or in-hospital interventions. 48 participants reported reduced well-being, and young age was the only factor significantly correlated to this outcome (p=0.02). Women reported significantly higher scores in HADS (p=0.001) and PCL-C (p<0.001). Women also reported significantly lower EQ-5D index values (p=0.002) and EQ-visual analogue scale scores (p=0.002) compared with men.

CONCLUSION

Reduced well-being is experienced by half of OHCA survivors with a CPC score ≤2, and young age is negatively correlated to this outcome. The frequency of anxiety and PTSD is higher among women, who also report worse health.

Long-term health-related quality of life, survival and costs by different levels of functional outcome six months after stroke

INTRODUCTION

Information about the impact of functional outcome after stroke is currently missing on health-related quality of life, survival and costs. This information would be valuable for health economic evaluations and for allocation of resources in stroke health care.

PATIENTS AND METHODS

Data on 297 Swedish patients included in the Third International Stroke Trial were analysed including functional outcome at six months (measured by Oxford Handicap Scale), health-related quality of life up to 18 months (EQ-5D-3L) and survival up to 36 months. We used record linkage to collect data on costs up to 36 months, using national patient registers.

RESULTS

Patients with a better functional outcome level at six months had a significantly better health-related quality of life at 18 months (p < 0.05), better long-term survival (p < 0.05) and lower costs (p < 0.001), for all time points up to 36 months. The difference in costs was mainly due to differences in days spent in hospital (p < 0.005).

DISCUSSION

This study showed an association between functional outcome at six months and health-related quality of life up to 18 months, and costs up to 36 months.

CONCLUSION

Functional outcome six months after stroke is an important determinant of health-related quality of life, survival and costs over 36 months. Effective interventions aimed at reducing short-term disability levels are therefore also expected to reduce the overall burden of stroke.

Assessing health, quality of life and urogenital function in a sample of the Swedish general population: a cross-sectional study

OBJECTIVE

Evaluate the urinary, bowel and sexual function as well as stress symptoms and depression in a sample of the Swedish population.

DESIGN

A random sample of Swedish men and women in age groups from 30 to 89 years, a total of 3000 individuals, were contacted and after receiving informed consent, a questionnaire was sent.

MAIN OUTCOME MEASURES

Measures of urinary, bowel, sexual function and quality of life.

RESULTS

The questionnaire was sent to 2094 individuals who gave informed consent. The questionnaire was answered by 1078 individuals. Quality of life, stress symptoms and depressed mood were relatively constant across age groups for both men and women. Urinary function differed significantly across gender and age groups, but bowel function was relatively unaffected by age. Overall bowel dysfunction was slightly more prevalent among women compared with men. For both men and women, the frequency of intercourse or other sexual activities decreased with age, whereas sexually associated distress increased by age in men, but decreased among women.

CONCLUSIONS

In a general population, the urinary function varied across age and sex. Overall bowel dysfunction was slightly more prevalent among women compared with men. Sexually associated distress increased by age for men, but decreased for women.

TRIAL REGISTRATION NUMBER

NCT02392923; Results.

Effectiveness of implementing a best practice primary healthcare model for low back pain (BetterBack) compared with current routine care in the Swedish context: an internal pilot study informed protocol for an effectiveness-implementation hybrid type 2 trial

INTRODUCTION

Low back pain (LBP) is a major health problem commonly requiring healthcare. In Sweden, there is a call from healthcare practitioners (HCPs) for the development, implementation and evaluation of a best practice primary healthcare model for LBP.

AIMS

(1) To improve and understand the mechanisms underlying changes in HCP confidence, attitudes and beliefs for providing best practice coherent primary healthcare for patients with LBP; (2) to improve and understand the mechanisms underlying illness beliefs, self-care enablement, pain, disability and quality of life in patients with LBP; and (3) to evaluate a multifaceted and sustained implementation strategy and the cost-effectiveness of the BetterBack☺ model of care (MOC) for LBP from the perspective of the Swedish primary healthcare context.

METHODS

This study is an effectiveness-implementation hybrid type 2 trial testing the hypothesised superiority of the BetterBack☺ MOC compared with current routine care. The trial involves simultaneous testing of MOC effects at the HCP, patient and implementation process levels. This involves a prospective cohort study investigating implementation at the HCP level and a patient-blinded, pragmatic, cluster, randomised controlled trial with longitudinal follow-up at 3, 6 and 12 months post baseline for effectiveness at the patient level. A parallel process and economic analysis from a healthcare sector perspective will also be performed. Patients will be allocated to routine care (control group) or the BetterBack☺ MOC (intervention group) according to a stepped cluster dogleg structure with two assessments in routine care. Experimental conditions will be compared and causal mediation analysis investigated. Qualitative HCP and patient experiences of the BetterBack☺ MOC will also be investigated.

DISSEMINATION

The findings will be published in peer-reviewed journals and presented at national and international conferences. Further national dissemination and implementation in Sweden and associated national quality register data collection are potential future developments of the project.

DATE AND VERSION IDENTIFIER

13 December 2017, protocol version 3.

TRIAL REGISTRATION NUMBER

NCT03147300; Pre-results.

Association between operative technique and intrusive thoughts on health-related Quality of Life 3 years after APE/ELAPE for rectal cancer: results from a national Swedish cohort with comparison with normative Swedish data

The aim of this prospective registry‐based population study was to investigate the association between QoL 3 years after surgery for rectal cancer and intrusive thoughts and to assess the association with the type of surgery (i.e., APE or ELAPE) in a population‐based national cohort. ELAPE has been proposed as a superior surgical technique for distal rectal cancer, but long‐term effects on QoL are not known. There are also no studies on the association of negative intrusive thoughts on patients′ self‐reported Quality of Life following surgery for distal rectal cancer. Negative intrusive thoughts are regarded as a marker of incomplete cognitive processing of the psychological trauma caused by, for example, a cancer diagnosis. Intrusive thoughts have been recognized as an important factor associated Quality of Life outcome following surgery for other malignancies. All Swedish patients operated with any kind of abdominoperineal resection in the years 2007–2009 were identified through the Swedish ColoRectal Cancer Registry (SCRCR)—the APER population. All patients alive 3 years after surgery and willing to participate were included. Data were collected from three different sources: the registry, the original operative notes, and a study‐specific questionnaire regarding health‐related QoL answered by the patients. Questions on QoL from a normative reference population were also collected for comparison. Fifty‐six percent of the APER population reported a low overall Quality of Life. There was no significant difference between the sexes. Among men, there was a difference in overall QoL, with a higher level in the normative population (48%) compared with the male APER population (39%). Overall QoL was compared to a normative Swedish population. Almost half of the patients experienced negative intrusive thoughts, which was associated with a lower overall Quality of Life. The frequency and severity of negative intrusive thoughts were significantly associated with a low overall QoL. There was no difference in overall QoL after standard, compared with extralevator abdominoperineal excision. A large proportion of survivors after abdominoperineal excision for rectal cancer has a Quality of Life compared with a normative population, but many suffer from negative intrusive thoughts, a symptom of stress, which significantly decrease overall Quality of Life.

A utility valuation study assessing the impact of postprandial glucose control on quality of life of individuals with type 1 or type 2 diabetes

Background

Consideration of health-related quality of life (HRQOL) in diabetes has been associated with long-term and short-term complications such as hypoglycaemia, but not with short-term glucose control. This study aimed to collect health utilities related to different degrees of poorly controlled postprandial glucose (PPG) and its impact on HRQOL in the UK and in Sweden.

Methods

Three health state descriptions were developed based on literature reviews and interviews with people with diabetes and healthcare professionals, characterising mild, moderate and severe impact of postprandial hyperglycaemic symptoms on HRQOL. Time Trade-Off (TTO) interviews with a 10-year trade-off period were conducted with samples of the UK general public and of Swedish people with diabetes. Mean TTO-derived health state values were expressed on a scale from 0 (death) to 1 (full health).

Results

One hundred fifty participants from the general population were interviewed in the UK (57% female, mean age 35 years) and 150 participants with diabetes in Sweden (64% female, mean age 51 years, 42% type 1 and 58% type 2 diabetes). The mean TTO-derived health state values were for the UK and Swedish participants: mild impact of poorly PPG control (0.89/0.76); moderate (0.75/0.71); severe (0.56/0.58).

Conclusions

Glucose lowering treatments associated with improved control over PPG levels could have important benefits to people with type 1 and type 2 diabetes since findings suggest that increasing severity in postprandial hyperglycaemic symptoms is perceived as having significant negative impact on HRQOL of individuals with type 1 or type 2 diabetes.

People in states worse than dead according to the EQ-5D UK value set: would they rather be dead?

Purpose

Quality-adjusted life years (QALYs) measure health by combining length and quality of life. QALYs constitute the effect side of incremental cost-effectiveness ratios, describing the results of health economic evaluations. The objectives of this study were to (1) investigate the prevalence of states worse than dead (SWD) when using the EuroQol-5D UK value set, and (2) to study to what extent SWDs are reasonable with a starting point in experience-based valuations of health states.

Methods

Data from a Swedish cross-sectional population survey were used. The survey was directed to 10,000 persons 65 years and older and its primary aim was to investigate the prevalence and consequences of chronic pain. The survey included questions reflecting life situation and well-being. Some of these were used in order to characterise people in SWD.

Results

SWD were found in 1.8% of the 6611 respondents. The prevalence of SWD increased with advancing age and was more common among women than men. The control questions used indicated that most of the persons being in SWD according to the EQ-5D UK value set most probably would not judge themselves to be in a SWD.

Conclusions

Though negative QALY-weights are not very common, they constitute a non-negligible part of health states in a Swedish population 65 years and older. Prevalence of SWD is higher among women than men and increases with age. From responses to other questions on well-being and life situation, there is reason to doubt the reasonableness of experience-based negative QALY-weights in many cases.

Cost-effectiveness of supported employment adapted for people with affective disorders

OBJECTIVE

The individual enabling and support (IES) model was effective in gaining competitive employment for people with affective disorders compared with traditional vocational rehabilitation (TVR) services in a randomized controlled trial in a Swedish setting. The object of this study is to perform a cost-effectiveness analysis of IES comparing to TVR.

METHODS

We considered the costs of intervention and productivity gain due to increased competitive employment. We estimated quality of life using EuroQol 5 Dimension (EQ-5D) and Manchester Short Assessment of Quality of Life (MANSA) scale. EQ-5D was translated into quality-adjusted life-years (QALY), using the UK, Danish, and Swedish tariffs. We performed the analysis from a societal perspective with a one-year timeframe.

RESULTS

The cost of IES was €7247 lower per person per year (2014 prices) compared to TVR. There were no significant differences in QALY improvement within or between groups. However, quality of life measured by the MANSA scale significantly improved over the study period in IES.

LIMITATIONS

Besides the small sample size, details on the intervention costs for both IES and TVR group were unavailable and had to be obtained from external sources.

CONCLUSIONS

Implementation of IES for people with affective disorders is most likely cost-saving and is potentially even dominating TVR, although a larger trial is required to establish this.

Effects of brief mindfulness-based cognitive behavioural therapy on health-related quality of life and sense of coherence in atrial fibrillation patients

BACKGROUND

The aim of this study was to evaluate the effects of a brief dyadic cognitive behavioural therapy (CBT) programme on the health-related quality of life (HRQoL), as well as the sense of coherence in atrial fibrillation patients, up to 12 months post atrial fibrillation.

METHODS

A longitudinal randomised controlled trial with a pre and 12-month post-test recruitment of 163 persons and their spouses, at a county hospital in southern Sweden. In all, 111 persons were randomly assigned to either a CBT ( n=56) or a treatment as usual (TAU) group ( n=55). The primary outcome was changes in the HRQoL (Euroqol questionnaire; EQ-5D), and the secondary outcomes were changes in psychological distress (hospital anxiety and depression scale; HADS) and sense of coherence (sense of coherence scale; SOC-13).

RESULTS

At the 12-month follow-up, the CBT group experienced a higher HRQoL than the TAU group (mean changes in the CBT group 0.062 vs. mean changes in the TAU group -0.015; P=0.02). The sense of coherence improved in the CBT group after the 12-month follow-up, compared to the TAU group (mean changes in the CBT group 0.062 vs. mean changes in the TAU group -0.16; P=0.04). The association between the intervention effect and the HRQoL was totally mediated by the sense of coherence ( z=2.07, P=0.04).

CONCLUSIONS

A dyadic mindfulness-based CBT programme improved HRQoL and reduced psychological distress up to 12 months post atrial fibrillation. The sense of coherence strongly mediated the HRQoL; consequently, the sense of coherence is an important determinant to consider when designing programmes for atrial fibrillation patients.

Chronic pain, discomfort, quality of life and impact on sex life after open inguinal hernia mesh repair: an expertise-based randomized clinical trial comparing lightweight and heavyweight mesh

Purpose

There is a paucity of high-quality evidence concerning mesh choice in open inguinal hernia repair. Using an expertise-based randomized clinical trial design, we aimed to evaluate the postoperative impact of two different mesh types on pain and discomfort, quality of life and sex life.

Methods

In two regional hospitals, male patients with primary inguinal hernia were randomized to one of two groups of surgeons that performed the Lichtenstein operation. One group of surgeons used a heavyweight polypropylene mesh (90 g/m², Bard™ Flatmesh, Davol) while the second group employed a lightweight mesh (28 g/m², ULTRAPRO™, Ethicon). Follow-up data were collected by questionnaires and outpatient visits in the range of 1–3 years after surgery.

Results

Some 412 patients were randomized and 363 patients were analysed. There was no difference in pain between groups after surgery but a statistically significant difference concerning awareness of a groin lump and groin discomfort, favouring the lightweight group 1 year after surgery. No differences in quality of life between groups could be detected but both groups had a substantially better quality of life postoperatively, as compared to before surgery. In the analysis of impact on sex life, no differences between mesh groups were found.

Conclusion

The Lichtenstein operation performed for primary inguinal hernia improves quality of life for most of the male patients, independently of the type of mesh used. The lightweight mesh group experienced less awareness of a groin lump and groin discomfort 1 year postoperatively.

ClinicalTrials.gov Identifier: NCT00451893.

New methods for modelling EQ-5D-5L value sets: An application to English data

Value sets for the EQ-5D-5L are required to facilitate its use in estimating quality-adjusted life years. An international protocol has been developed to guide the collection of stated preference data for this purpose and has been used to generate EQ-5D-5L valuation data for England. The aim of this paper is report the innovative methods used for modelling those data to obtain a value set. Nine hundred and ninety-six members of the English general public completed time trade-off (TTO) and discrete choice experiment (DCE) tasks. We estimate models, with and without interactions, using DCE data only, TTO data only, and TTO/DCE data combined. TTO data are interpreted as both left and right censored. Heteroskedasticity and preference heterogeneity between individuals are accounted for. We use Bayesian methods in the econometric analysis. The final model is chosen based on the deviance information criterion (DIC). Censoring and taking account of heteroskedasticity have important effects on parameter estimation. For DCE data only, TTO data only, and DCE/TTO data combined, models with parameters for all dimensions and levels perform best, as judged by the DIC. Taking account of heterogeneity improves fit, and the multinomial model reports the lowest DIC. This paper presents approaches that suit observed characteristics of EQ-5D-5L valuation data and recognise respondents' preference heterogeneity. The methods described are potentially relevant to other value set studies.

New methods for modelling EQ-5D-5L value sets: An application to English data

Value sets for the EQ-5D-5L are required to facilitate its use in estimating quality-adjusted life years. An international protocol has been developed to guide the collection of stated preference data for this purpose and has been used to generate EQ-5D-5L valuation data for England. The aim of this paper is report the innovative methods used for modelling those data to obtain a value set. Nine hundred and ninety-six members of the English general public completed time trade-off (TTO) and discrete choice experiment (DCE) tasks. We estimate models, with and without interactions, using DCE data only, TTO data only, and TTO/DCE data combined. TTO data are interpreted as both left and right censored. Heteroskedasticity and preference heterogeneity between individuals are accounted for. We use Bayesian methods in the econometric analysis. The final model is chosen based on the deviance information criterion (DIC). Censoring and taking account of heteroskedasticity have important effects on parameter estimation. For DCE data only, TTO data only, and DCE/TTO data combined, models with parameters for all dimensions and levels perform best, as judged by the DIC. Taking account of heterogeneity improves fit, and the multinomial model reports the lowest DIC. This paper presents approaches that suit observed characteristics of EQ-5D-5L valuation data and recognise respondents' preference heterogeneity. The methods described are potentially relevant to other value set studies.

Life situation 5 years after subarachnoid haemorrhage

OBJECTIVES

Subarachnoid haemorrhage (SAH) has high mortality and morbidity among survivors. SAH mainly affects young people and may result in long-term disabilities such as decreased Health-related Quality of Life (HRQoL), mental health and cognitive function. The aim of this study was to investigate the life situation 5 years after a SAH including physical/emotional status, participation and HRQoL.

MATERIALS & METHODS

In this cross-sectional descriptive study, a mail survey was sent to all persons treated at a neurosurgery unit in Gothenburg, Sweden, for non-traumatic SAH in 2009-2010, approximately 5 years post-SAH. The survey included questions regarding HRQoL; EuroQol 5-Dimensions (EQ-5D), the impact of the SAH; Stroke Impact Scale (SIS), Occupational Gaps Questionnaire and participation in society; Impact of Participation and Autonomy (IPA).

RESULTS

Forty-two 5 year survivors were sent the survey, of whom 26 (62%) responded (59 years old, range 33-85). The participants had generally low HRQoL and scored low in the domain of anxiety and depression. Many reported problems with emotions, fatigue, memory and executive function, but few problems with physical condition. However, nearly all participants reported to have an acceptable level of participation and 64% were independent in their daily life.

CONCLUSIONS

In this 5-year follow-up after SAH, the participants reported to have a greater number of hidden disabilities compared to physical problems, whereas most had acceptable participation in society. A yearly follow-up after a SAH could be suggested aiming to improving the cognitive and mental health.

Effectiveness, costs and cost-effectiveness of chiropractic care and physiotherapy compared with information and advice in the treatment of non-specific chronic low back pain: study protocol for a randomised controlled trial

Background

Low back pain is a global public health problem and a leading cause of disability all over the world. The lifetime prevalence of low back pain is 70–80% and a significant proportion of people affected develop chronic low back pain (CLBP). Besides a severe negative impact on people’s health and health-related quality of life, CLBP is associated with substantial costs for society. Medical costs for the management of CLBP and costs for production losses due to absenteeism from work are sizeable. Pharmaceuticals, physical activity, manipulation, and multidisciplinary rehabilitation interventions are examples of widely used treatments for CLBP. However, the scientific basis to recommend the use of one treatment over another is limited and more research is needed to study the effects, costs and cost-effectiveness of treatments for CLBP in clinical practice.

The aim of the study is to evaluate the effectiveness (back pain-related functional limitation, back pain intensity, general health, health-related quality of life, and working status), costs (medical costs and costs for production losses) and cost-effectiveness of chiropractic care and physiotherapy when added to information and advice in the treatment of patients with non-specific CLBP in Sweden.

Methods/design

This is a pragmatic randomised controlled trial, where participants are recruited through six primary care rehabilitation units (PCRUs) in Stockholm County Council, Sweden. Individuals with non-specific CLBP are individually randomised to one of four treatment groups: ‘information and advice’; ‘physiotherapy, and information and advice’; ‘chiropractic care, and information and advice’; or ‘chiropractic care, physiotherapy, and information and advice’. A sample size of 600 participants will be recruited during a period of 33 months. A computer-based questionnaire is used to collect data on back pain-related functional limitation (Oswestry Disability Index), pain intensity (Numeric Rating Scale), general health (self-rated health), health-related quality of life (EQ-5D-3L), and working status (measured as percentage of full-time work). Data will be collected at baseline, and at 3, 6, and 12 months after baseline.

Discussion

The results from our study should be considered when producing evidence-based guidelines and recommendations on which treatment strategies to use for CLBP.

Trial registration

ISRCTN registry, ID: ISRCTN15830360. Registered prospectively on 2 February 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2351-3) contains supplementary material, which is available to authorized users.

International Regulations and Recommendations for Utility Data for Health Technology Assessment

Recommendations and guidelines for the collection, generation, source and usage of utility data for health technology assessment (HTA) vary across different countries, with no international consensus. Many international agencies generate their own guidelines providing details on their preferred methods for HTA submissions, and there is variability in both what they recommend and the clarity and amount of detail provided in their guidelines. This article provides an overview of international regulations and recommendations for utility data in HTA for a selection of key HTA countries: Australia, Canada, France, Germany, the Netherlands, Spain (Catalonia), Sweden and the UK (England/Wales and Scotland). International guidelines are typically clear and detailed for the selection of countries assessed regarding the source description of health states (e.g. generic preference-based measure) and who should provide preference weights for these health states (e.g. general population for own country). Many guidelines specify the use of off-the-shelf generic preference-based measures, and some further specify a measure, such as EQ-5D. However, international guidelines are either unclear or lack detailed guidance regarding the collection (e.g. patients report own health), source (e.g. clinical trial) and usage (e.g. adjusting for comorbidities) of utility values. It is argued that there is a need for transparent and detailed international guidelines on utility data recommendations to provide decision makers with the best possible evidence. Where this is not possible it is recommended that best practice should be used to inform the collection, source and usage of utility values in HTA.

Treatments for Metastatic Prostate Cancer (mPC): A Review of Costing Evidence

BACKGROUND

Prostate cancer (PC) is the most common cancer in Western countries. More than one third of PC patients develop metastatic disease, and the 5-year expected survival in distant disease is about 35%. During the last few years, new treatments have been launched for metastatic castrate-resistant prostate cancer (mCRPC).

OBJECTIVES

We aimed to review the current literature on health economic analysis on the treatment of metastatic prostate cancer (mPC), compare the studies, summarize the findings and make the results available to administrators and decision makers.

METHODS

A systematic literature search was done for economic evaluations (cost-minimization, cost-effectiveness, cost-utility, cost-of-illness, cost-of-drug, and cost-benefit analyses). We employed the PubMed^® search engine and searched for publications published between 2012 and 2016. The terms used were "prostate cancer", "metastatic" and "cost". An initial screening of all headlines was performed, selected abstracts were analysed, and finally the full papers investigated. Study characteristics, treatment and comparator, country, type of evaluation, perspective, year of value, time horizon, efficacy data, discount rate, total costs and sensitivity analysis were analysed. The quality was assessed using the Quality of Health Economic Studies (QHES) instrument.

RESULTS

A total of 227 publications were detected and screened, 58 selected for full-text assessment and 31 included in the final analyses. Despite the significant international literature on the treatment of mCRPC, there were only 15 studies focusing on cost-effectiveness analysis (CEA). Medical treatment constituted two thirds of the selected studies. Significant costs in the treatment of mCRPC were disclosed. In the pre-docetaxel setting, both abiraterone acetate (AA) and enzalutamide were concluded beyond accepted cost/quality-adjusted life year limits. In the docetaxel refractory setting, most studies concluded that enzalutamide was cost-effective and superior to AA. In most studies, cabazitaxel was not recommended, because of high cost. Looking at bone-targeting drugs, generic zoledronic acid (ZA) was recommended. External beam radiotherapy (EBRT) was analysed in three studies, and single fraction radiotherapy was concluded to be cost saving. Radium-223 was documented as beneficial, but costly. The quality of the studies was generally good, but sensitivity analyses, discounting and the measurement of health outcomes were present in less than two thirds of the selected studies.

CONCLUSIONS

The treatment of mCRPC was associated with significant cost. In the post-docetaxel setting, single fraction radiotherapy and enzalutamide were considered cost-effective in most studies. Generic ZA was the recommended bone-targeting therapy.

Patient Experience-based Value Sets: Are They Stable?

BACKGROUND

Although societal preference weights are desirable to inform resource-allocation decision-making, patient experienced health state-based value sets can be useful for clinical decision-making, but context may matter.

OBJECTIVE

To estimate EQ-5D value sets using visual analog scale (VAS) ratings for patients undergoing knee replacement surgery and compare the estimates before and after surgery.

METHODS

We used the Patient Reported Outcome Measures data collected by the UK National Health Service on patients undergoing knee replacement from 2009 to 2012. Generalized least squares regression models were used to derive value sets based on the EQ-5D-3 level using a development sample before and after surgery, and model performance was examined using a validation sample.

RESULTS

A total of 90,450 preoperative and postoperative valuations were included. For preoperative valuations, the largest decrement in VAS values was associated with the dimension of anxiety/depression, followed by self-care, mobility, usual activities, and pain/discomfort. However, pain/discomfort had a greater impact on VAS value decrement in postoperative valuations. Compared with preoperative health problems, postsurgical health problems were associated with larger value decrements, with significant differences in several levels and dimensions, including level 2 of mobility, level 2/3 of usual activities, level 3 of pain/discomfort, and level 3 of anxiety/depression. Similar results were observed across subgroups stratified by age and sex.

CONCLUSIONS

Findings suggest patient experience-based value sets are not stable (ie, context such as timing matters). However, the knowledge that lower values are assigned to health states postsurgery compared with presurgery may be useful for the patient-doctor decision-making process.

Quality of life profile of general Vietnamese population using EQ-5D-5L

BACKGROUND

Health-related quality of life (HRQOL) is a vital benchmark to assess the effects of health interventions and policies. Measuring HRQOL of the general population is essential to establish a reference for health outcomes evaluations. However, evidence on HRQOL of general populations in low and middle income countries is very limited. This study aimed to measure HRQOL of the Vietnamese population by using the EuroQol-5 dimensions-5 levels (EQ-5D-5L) instrument and determine its associated factors.

METHODS

A cross-sectional study was performed in Hanoi with 1571 residences in Hanoi, the capital city of Vietnam. EQ-5D-5L and EQ- visual analogue scale (EQ-VAS) were used to assess HRQOL. Potential covariates included socio-demographic characteristics, having acute symptoms in the last four weeks, chronic diseases in the last three months, having multiple health issues, and health service utilisation in the last twelve months. A generalized linear model was employed to identify the association between HRQOL and covariates.

RESULTS

Overall, the mean EQ-5D utility index was 0.91 (SD = 0.15), and the mean EQ-VAS score was 87.4 (SD = 14.3). The highest proportion of respondents reporting any problems was in Usual activities (24.3%), followed by Anxiety/Depression (15.2%) and Pain/Discomfort (10.0%), while the lowest percentage was in Self-care (2.5%). Lower HRQOL composite scores were related to unemployment, lower income, higher education, living in urban areas, having chronic diseases, having multiple health issues and using health service. For any health problem self-reported by respondents, the health utility reduced by 0.02 (respiratory diseases) to 0.15 (musculoskeletal diseases).

CONCLUSIONS

Health utility of the general population and reductions for self-reported health problems in this study are useful for future population health evaluations and comparisons. It also informs the development of interventions to reduce health problems of the general population.

Quality of life profile of general Vietnamese population using EQ-5D-5L

BACKGROUND

Health-related quality of life (HRQOL) is a vital benchmark to assess the effects of health interventions and policies. Measuring HRQOL of the general population is essential to establish a reference for health outcomes evaluations. However, evidence on HRQOL of general populations in low and middle income countries is very limited. This study aimed to measure HRQOL of the Vietnamese population by using the EuroQol-5 dimensions-5 levels (EQ-5D-5L) instrument and determine its associated factors.

METHODS

A cross-sectional study was performed in Hanoi with 1571 residences in Hanoi, the capital city of Vietnam. EQ-5D-5L and EQ- visual analogue scale (EQ-VAS) were used to assess HRQOL. Potential covariates included socio-demographic characteristics, having acute symptoms in the last four weeks, chronic diseases in the last three months, having multiple health issues, and health service utilisation in the last twelve months. A generalized linear model was employed to identify the association between HRQOL and covariates.

RESULTS

Overall, the mean EQ-5D utility index was 0.91 (SD = 0.15), and the mean EQ-VAS score was 87.4 (SD = 14.3). The highest proportion of respondents reporting any problems was in Usual activities (24.3%), followed by Anxiety/Depression (15.2%) and Pain/Discomfort (10.0%), while the lowest percentage was in Self-care (2.5%). Lower HRQOL composite scores were related to unemployment, lower income, higher education, living in urban areas, having chronic diseases, having multiple health issues and using health service. For any health problem self-reported by respondents, the health utility reduced by 0.02 (respiratory diseases) to 0.15 (musculoskeletal diseases).

CONCLUSIONS

Health utility of the general population and reductions for self-reported health problems in this study are useful for future population health evaluations and comparisons. It also informs the development of interventions to reduce health problems of the general population.

An Experience-Based Value Set for the EQ-5D-5L in Germany

OBJECTIVE

Valuation of health states provides a summary measure useful to health care decision makers. Results may depend on whether the currently experienced health state or a hypothetical health state is being evaluated. This study derives a value set for the EuroQoL Five-Dimensional Five-Level Questionnaire (EQ-5D-5L) by focusing on the individual's current experience.

DATA AND METHODS

Data include four pooled population surveys of the general German population in 2012-2015 (N = 8114). For valuation, a visual analogue scale (VAS) was used. Six specifications of a generalized linear model with binomial error distribution and constraint parameter estimation were analyzed. In each 1000 simulation runs, models were cross-validated after splitting the sample into an estimation part and a validation part. Predictive accuracy was measured by mean absolute error and sum of squared errors.

RESULTS

The models rendered a consistent set of parameters. With regard to predictive accuracy, the model considering all problem levels within the five dimensions and the highest problem level reached performed best overall.

DISCUSSION

Estimation proved to be feasible. Predictive accuracy exceeded that of a similar, experience-based value set for the EQ-5D-3L. Compared with a Dutch value set for the EQ-5D-5L derived for hypothetical health states, experienced values tended to be slightly lower for mild health states and substantially higher for severe health states. Clinical relevance and usefulness of the value set remain to be determined in future studies.

CONCLUSIONS

For decision makers who prioritize patient-relevant benefit, the experience-based value set provides a novel option to summarize health states, reflecting how health states experienced are valued in a population.

Health-related quality of life in the Brazilian Amazon: a population-based cross-sectional study

BACKGROUND

To analyze perceptions of health-related quality of life and associated factors in populations from the Manaus Metropolitan Region.

METHODS

We conducted a population-based cross-sectional study from May to August 2015. Adults aged 18 years and older were selected using probabilistic three-phase cluster sampling and stratified by sex and age, based on official estimates. Quality of life data were collected using the European Quality of Life 5-Dimensions 3-Levels (EQ-5D-3L) along with socioeconomic, demographic, and health perception data. Utility scores were calculated using the Brazilian version of the EQ-5D-3L. Descriptive statistics were derived, and a multivariate Tobit regression model with correction for complex sampling was performed to identify the variables that influence utility levels.

RESULTS

A total of 4001 participants were included. The average utility score was 0.886 (95% confidence interval [CI]: 0.881-0.890) with significant differences according to living area (the capital (0.882 ± 0.144) or inner cities (0.908 ± 0.122; p < 0.001)). The dimension for which the highest proportion of people reported moderate to severe problems was pain/discomfort (39%), followed by anxiety/depression (18%). Men had a higher quality of life than women (β = 0.041, p < 0.001). Not working was a factor that increased quality of life compared with being formally employed (β = 0.031, p = 0.037). The poorest people had a lower quality of life than the richest people (β = -0.118, p < 0.001). Better health perceptions increased utility scores (p < 0.001), while being separated decreased the scores (β = -0.052, p = 0.001).

CONCLUSION

Health-related quality of life in the Manaus Metropolitan Region was high, as expected for the general population, and was higher among individuals who lived in the inner cities, men and those in higher social classes. Gender discrepancies and differences in quality of life between the capital and inner cities should be further investigated.

An exploration of differences between Japan and two European countries in the self-reporting and valuation of pain and discomfort on the EQ-5D

PURPOSE

To investigate the systematic differences in the self-reporting and valuation of overall health and, in particular, pain/discomfort between three countries (England/UK, Japan, and Spain) on the EQ-5D.

METHODS

Existing datasets were used to explore differences in responses on the EQ-5D descriptive system between Japan (3L and 5L), the UK (3L), England (5L), and Spain (5L), particularly on the dimension of pain/discomfort. The role of different EQ dimensions in determining self-reported overall health scores for the EuroQol visual analog scale (EQ-VAS) was investigated using ordinary least squares regression. Time trade-off (TTO) results from Japanese and UK respondents for the EQ-5D-3L as well as Japanese and English respondents for the EQ-5D-5L were compared using t tests.

RESULTS

For the EQ-5D-3L, a higher percentage of respondents in Japan than in the UK reported 'no pain/discomfort' (81.6 vs 67.0%, respectively); for the EQ-5D-5L, the proportions were 79.2% in Spain, 73.2% in Japan, and 63-64% in England, after adjusting for age differences in samples. The 'pain/discomfort' dimension had the largest impact on respondents' self-reported EQ-VAS only for EQ-5D-3L in Japan. Using the EQ-5D-3L, Japanese respondents were considerably less willing to trade off time to avoid pain/discomfort than the UK respondents; for example, moving from health state, 11121 (some problems with pain/discomfort) to 11131 (extreme pain/discomfort) represented a decrement of 0.65 on the observed TTO value in the UK compared with 0.15 in Japan. Using the EQ-5D-5L, Japanese respondents were also less willing to trade off time to avoid pain/discomfort than respondents in England; however, the difference in values was much smaller than that observed using EQ-5D-3L data.

CONCLUSIONS

This study provides evidence of between-country differences in the self-reporting and valuation of health, including pain/discomfort, when using EQ-5D in general population samples. The results suggest a need for caution when comparing or aggregating EQ-5D self-reported data in multi-country studies.

How is disease severity associated with quality of life in psoriasis patients? Evidence from a longitudinal population-based study in Sweden

BACKGROUND

Assessing the impact of disease severity on generic quality of life (QOL) is a critical step in outcomes research and in the development of decision-analytic models structured around health states defined by clinical measures. While data from routine clinical practice found in healthcare registers are increasingly used for research, more attention should be paid to understanding the relationship between clinical measures of disease severity and QOL. The purpose of this work was therefore to investigate this relationship in psoriasis using a population-based dataset.

METHODS

Severity was measured by the Psoriasis Area and Severity Index (PASI), which combines severity of erythema, induration, and desquamation into a single value ranging from 0 to 72. The generic EQ-5D-3L utility instrument, under the UK tariff, was used to measure QOL. The association between PASI and EQ-5D-3L was estimated using a population-based dataset of 2674 patients with moderate to severe psoriasis enrolled over ten years in the Swedish psoriasis register (PsoReg). Given the repeated measurement of patients in the register data, a longitudinal fixed-effects model was employed to control for unobserved patient-level heterogeneity.

RESULTS

Marginal changes in PASI are associated with a non-linear response in EQ-5D-3L: Moving from PASI 10 to 9 (1 to 0) is associated with an increase of 0.0135 (0.0174) in EQ-5D-3L. Furthermore, unobserved patient-level heterogeneity appears to be an important source of confounding when estimating the relationship between QOL and PASI.

CONCLUSIONS

Using register data to estimate the impact of disease severity on QOL while controlling for unobserved patient-level heterogeneity shows that PASI appears to have a larger impact on QOL than previously estimated. Routine collection of generic QOL data in registers should be encouraged to enable similar applications in other disease areas.

TRIAL REGISTRATION

Not applicable.

Quality of life during early radiotherapy in patients with head and neck cancer and pain

BACKGROUND

Patients with head and neck cancer (HNC) have a potentially severe diagnosis and often suffer from tumor-related pain as well as from adverse side effects of treatment such as radiotherapy (RT). Knowledge about quality of life (QoL) during early RT in this group is limited and should be assessed in relation to diagnosis and treatment.

PURPOSE

The purpose of this cross-sectional study was to identify potential factors that may influence QoL in patients with HNC during the early stages of RT (no later than two weeks of ongoing RT). We hypothesized that pain intensity, pain interference, catastrophizing, and mood disturbances are associated with QoL during early RT.

PATIENTS AND METHODS

In this study, 54 patients (53% of eligible patients) diagnosed with HNC were consecutively recruited from the regular flow to the Pain and Rehabilitation Center at Linköping University. The patients completed self-reported questionnaires on sociodemographics, pain intensity, pain interference, anxiety, depression, pain catastrophizing, and QoL.

RESULTS

The patients in this study scored high for QoL, low for pain intensity, and low for pain interference. The patients reported minor depressive symptoms and anxiety symptoms. Regression analyses showed that pain intensity and depressive symptoms negatively influenced QoL.

CONCLUSION

No later than two weeks of RT, pain intensity and depression negatively influenced QoL in patients with HNC. Early screening for pain and depression in a targeted preventive strategy might maintain QoL during the course of the RT for patients with HNC. This assumption needs to be further investigated.

International comparison of experience-based health state values at the population level

BACKGROUND

Decision makers need to know whether health state values, an important component of summary measures of health, are valid for their target population. A key outcome is the individuals' valuation of their current health. This experience-based perspective is increasingly used to derive health state values. This study is the first to compare such experience-based valuations at the population level across countries.

METHODS

We examined the relationship between respondents' self-rated health as measured by the EQ-VAS, and the different dimensions and levels of the EQ-5D-3 L. The dataset included almost 32,000 survey respondents from 15 countries. We estimated generalized linear models with logit link function, including country-specific models and pooled-data models with country effects.

RESULTS

The results showed significant and meaningful differences in the valuation of health states and individual health dimensions between countries, even though similarities were present too. Between countries, coefficients correlated positively for the values of mobility, self-care and usual activities, but not for the values of pain and anxiety, thus underlining structural differences.

CONCLUSIONS

The findings indicate that, ideally, population-specific experience-based value sets are developed and used for the calculation of health outcomes. Otherwise, sensitivity analyses are needed. Furthermore, transferring the results of foreign studies into the national context should be performed with caution. We recommend future studies to investigate the causes of differences in experience-based health state values through a single international study possibly complemented with qualitative research on the determinants of valuation.

Establishing benchmark EQ-5D-3L population health state utilities and identifying their correlates in Gansu Province, China

PURPOSES

Despite a flurry of cost utility analyses conducted in the Chinese population in recent years, a standard set of health state utilities (HSUs) for the Chinese population is lacking. The aims of this study were to (1) determine benchmark age- and sex-specific HSUs for a Chinese population, and (2) assess key correlates of HSUs in this population.

METHODS

Quality-of-life was evaluated using the validated EQ-5D-3L questionnaire. HSUs were calculated using data collected from Gansu Province (n = 9833). Overall differences in HSUs were analysed using linear regression and a two-tailed p value <0.05 was determined to be statistically significant. The minimal difference in weighted index was set at 0.074.

RESULTS

HSUs decreased with age in both males and females. Living in the non-capital areas, being separated/divorced/widowed or never married, being never educated, diagnosed with chronic disease, and no regular physical activity were associated with lower HSUs. HSUs for women were lower than for men in univariate regression analysis; however, no differences were found after adjusting for other covariates. In addition, the difference in HSU reached the level of minimal difference in weighted index for participants with chronic disease. HSUs for those who were diagnosed with chronic disease were 0.098 (0.092-0.104) lower than those without chronic disease.

CONCLUSIONS

This study reports HSUs for a Chinese population in Gansu and investigates the key correlates of HSUs in this population. In addition, the use of EQ-5D-3L in assessing population health is limited given the high ceiling effect and skewed HSUs.