Valuing health-related quality of life in heart failure: a systematic review of methods to derive quality-adjusted life years (QALYs) in trial-based cost-utility analyses

Relationship between sitting time and health status in patients with heart failure

OBJECTIVE

To describe self-reported sitting time (ST), and determine the factors associated with health status (HS) among patients with heart failure (HF).

METHODS

A cross-sectional study design was used in this study. Outcome measures included an international physical activity questionnaire and a self-report health status questionnaire. The data assessments were examined using the Pearson correlation coefficient, t-test, one-way ANOVA, and Hierarchical multiple regression.

RESULT

180 respondents joined this study. The mean age was mean 59.92 (SD= 11.90) years old, and 60% were male. The mean score of HS was mean 9.43 (SD= 2.16). The HS had a significant correlation with age (r= .17, p< .05), Hemoglobin (r= -.46, p< .01), HF medications (r= .31, p< .01), length of diagnostic HF (r= .35, p< .01), and comorbidity (r= .25, p< .01), and the HS was associated with the NYHA Classification (F= 203.43, p< .001), and the ST (F= 73.97, p< .001). Four variables were significant predictors of HS such as comorbidity (β = .14), NYHA Class I (β= -2.22), ST 6 to 8 hours/day (β= 1.27), and ST > 8 hours/day (β= 3.03), and they were predicted 75.1% of the variance in HS.

CONCLUSION

High amounts of ST and high NYHA classifications were associated with decreased HS in patients with HF, Moreover, HS is independently associated with comorbidities status and length of diagnostic HF.

Validity and measurement equivalence of EQ-5D-5L questionnaire among heart failure patients in Malaysia: a cohort study

AIM

This study aimed to examine the validity of EQ-5D-5L among HFrEF patients in Malaysia, and to explore the measurement equivalence of three main language versions.

METHODS

We surveyed HFrEF patients from two hospitals in Malaysia, using Malay, English or Chinese versions of EQ-5D-5L. EQ-5D-5L dimensional scores were converted to utility scores using the Malaysian value set. A confirmatory factor analysis longitudinal model was constructed. The utility and visual analog scale (VAS) scores were evaluated for validity (convergent, known-group, responsiveness), and measurement equivalence of the three language versions.

RESULTS

200 HFrEF patients (mean age = 61 years), predominantly male (74%) of Malay ethnicity (55%), completed the admission and discharge EQ-5D-5L questionnaire in Malay (49%), English (26%) or Chinese (25%) languages. 173 patients (86.5%) were followed up at 1-month post-discharge (1MPD). The standardized factor loadings and average variance extracted were ≥ 0.5 while composite reliability was ≥ 0.7, suggesting convergent validity. Patients with older age and higher New York Heart Association (NYHA) class reported significantly lower utility and VAS scores. The change in utility and VAS scores between admission and discharge was large, while the change between discharge and 1MPD was minimal. The minimal clinically important difference for utility and VAS scores was ±0.19 and ±11.01, respectively. Malay and English questionnaire were equivalent while the equivalence of Malay and Chinese questionnaire was inconclusive.

LIMITATION

This study only sampled HFrEF patients from two teaching hospitals, thus limiting the generalizability of results to the entire heart failure population.

CONCLUSION

EQ-5D-5L is a valid questionnaire to measure health-related quality of life and estimate utility values among HFrEF patients in Malaysia. The Malay and English versions of EQ-5D-5L appear equivalent for clinical and economic assessments.

Willingness to pay for a quality-adjusted life year: a systematic review with meta-regression

The use of a threshold for cost-utility studies is of major importance to health authorities for making the best allocation decisions for limited resources. Regarding the increasing number of studies worldwide that seek to establish a value for a quality-adjusted life year (QALY), it is necessary to review these studies to provide a global insight into the literature. A systematic review on willingness to pay (WTP) studies focusing on QALY was conducted in eight databases up to June 26, 2020. From a total of 9991 entries, 39 studies were selected, and 511 observations were extracted for the meta-analysis using the ordinary least squares method. The results showed a predicted mean empirical value of $52,619.39 (95% CI 49,952.59; 55,286.19) per QALY in US dollars for 2018. A 1% increase in income led to an increase of 0.6% in the WTP value, while a 1-year increase in respondent age led to a decrease of 3.3% in the WTP value. Sex, education level and employment status had significant effects on WTP. Compared to face-to-face interviews, surveys conducted by the internet or telephone were more likely to have a significantly higher value of WTP per QALY, while out-of-pocket payment tended to lower the value. The prediction made for the province of Quebec, Canada, provided a QALY value of approximately USD $98,450 (CAD $127,985), which is about 2.3 times its gross domestic product (GDP) per capita in 2018. This study is consistent with the extant literature and will be useful for countries that do not yet have a preference-based survey for the value of a QALY.

Development of a preference-based heart disease-specific health state classification system using MacNew heart disease-related quality of life instrument

PURPOSE

The MacNew Heart Disease Health-Related Quality of Life Instrument (MacNew) is a validated, clinically sensitive, 27-item disease-specific questionnaire. This study aimed to develop a new heart disease-specific classification system for the MacNew amenable for use in health state valuation.

METHODS

Patients with heart disease attending outpatient clinics and inpatient wards in Brisbane, Australia, completed MacNew. The development of the new disease-specific classification system included three stages. First, a principal component analysis (PCA) established dimensionality. Second, Rasch analysis was used to select items for each dimension. Third, Rasch analysis was used to explore response-level reduction. In addition, clinician and patient judgement informed item selection.

RESULTS

Participants included 685 patients (acute coronary 6%, stable coronary 41%, chronic heart failure 20%). The PCA identified 4 dimensions (restriction, emotion, perception of others, and symptoms). The restriction dimension was divided into physical and social dimensions. One item was selected from each to be included in the classification system. Three items from the emotional dimension and two symptom items were also selected. The final classification system had seven dimensions with four severity levels in each: physical restriction; excluded from doing things with other people; worn out or low in energy; frustrated, impatient or angry; unsure and lacking in self-confidence; shortness of breath; and chest pain.

CONCLUSION

This study generated a brief heart disease-specific classification system, consisting of seven dimensions with four severity levels in each. The classification system is amenable to valuation to enable the generation of utility value sets to be developed for use in economic evaluation.

Developing an early childhood oral health impact-specific health-state classification system for a new preference-based instrument, the ECOHIS-4D

OBJECTIVES

Most of the paediatric quality-of-life instruments in oral health research are not preference-based measures, thus cannot be used in economic evaluations. The Early Childhood Oral Health Impact Scale (ECOHIS) is one such instrument which assesses oral health impact on children's quality of life among three- to five-year-olds. With increasing demands for more resource allocation in oral health care, there is a need for an outcome metric which can be used as the outcome in economic evaluations. The aim of this study was to develop a preference-based, health-state classification system from the existing ECOHIS instrument.

METHODS

The 13-item ECOHIS instrument was applied to the carers of 280 preschoolers who participated in a clinical trial in metropolitan Perth, Western Australia. Exploratory factor analysis was conducted to assess the dimensionality of the ECOHIS. Rasch analysis was used to eliminate and select items per determined dimensions and to reduce the number of response options for each item, because six levels were not amenable to valuation. The final classification system was determined through a combination of psychometric and expert advice.

RESULTS

Items loaded on to four dimensions with the factor analysis. Using Rasch analysis, three items were selected from the first dimension (child functional and psychological impact) and one item from the second dimension (child social interaction impact). None were selected from the third dimension (parental distress and family function impact) as it is not an appropriate proxy method of measuring the level of impact on a child. The final classification system has four dimensions with three levels in each, and so it has been named the ECOHIS-4D.

CONCLUSIONS

The ECOHIS-4D classification system is a new preference-based instrument derived from the existing ECOHIS instrument. Future valuation studies will develop a utility value set for the health states defined by this classification system, and this will guide economic evaluations related to oral health interventions.

β-Adrenergic receptor, an essential target in cardiovascular diseases

β-Adrenergic receptors (βARs) belong to a large family of cell surface receptors known as G protein-coupled receptors (GPCRs). They are coupled to Gs protein (Gαs) for the activation of adenylyl cyclase (AC) yielding cyclic AMP (_CAMP), and this provides valuable responses, which can affect the cardiac function such as injury. The binding of an agonist to βAR enhances conformation changes that lead to the Gαs subtype of heterotrimeric G protein which is the AC stimulatory G protein for activation of _CAMP in the cells. However, cardiovascular diseases (CVD) have been reported as having an increased rate of death and β1AR, and β2AR are a promising tool that improves the regulatory function in the cardiovascular system (CVS) via signaling. It increases the Gα level, which activates βAR kinase (βARK) that affects and enhances the progression of heart failure (HF) through the activation of cardiomyocyte βARs. We also explained that an increase in GPCR kinases (GRKs) would practically improve the HF pathogenesis and this occurs via the desensitization of βARs, which causes the loss of contractile reserve. The consistency or overstimulation of catecholamines contributes to CVD such as stroke, HF, and cardiac hypertrophy. When there is a decrease in catecholamine responsiveness, it causes aging in old people because the reduction of βAR sensitivity and density in the myocardium enhances downregulation of βARs to AC in the human heart.

Health State Utilities of Patients with Heart Failure: A Systematic Literature Review

BACKGROUND AND OBJECTIVES

New treatments and interventions are in development to address clinical needs in heart failure. To support decision making on reimbursement, cost-effectiveness analyses are frequently required. A systematic literature review was conducted to identify and summarize heart failure utility values for use in economic evaluations.

METHODS

Databases were searched for articles published until June 2019 that reported health utility values for patients with heart failure. Publications were reviewed with specific attention to study design; reported values were categorized according to the health states, 'chronic heart failure', 'hospitalized', and 'other acute heart failure'. Interquartile limits (25th percentile 'Q1', 75th percentile 'Q3') were calculated for health states and heart failure subgroups where there were sufficient data.

RESULTS

The systematic literature review identified 161 publications based on data from 142 studies. Utility values for chronic heart failure were reported by 128 publications; 39 publications published values for hospitalized and three for other acute heart failure. There was substantial heterogeneity in the specifics of the study populations, methods of elicitation, and summary statistics, which is reflected in the wide range of utility values reported. EQ-5D was the most used instrument; the interquartile limit for mean EQ-5D values for chronic heart failure was 0.64-0.72.

CONCLUSIONS

There is a wealth of published utility values for heart failure to support economic evaluations. Data are heterogenous owing to specificities of the study population and methodology of utility value elicitation and analysis. Choice of value(s) to support economic models must be carefully justified to ensure a robust economic analysis.

Evaluation of a novel strategy to implement exercise evidence into clinical practice in breast cancer care: protocol for the NEXT-BRCA randomised controlled trial

INTRODUCTION

The burden of breast cancer in Canada is steadily growing. More women are surviving breast cancer, yet, survivors live with side effects for years after treatments have ended. The benefits of exercise for women with breast cancer are well established and include improvement in treatment-related physical and emotional side effects. Despite these benefits, few survivors meet exercise guidelines. Exercise programmes are needed within the cancer institution in Canada to bridge the current knowledge to practice gap. The purpose of this study is to test the effects of a novel implementation strategy that includes institution-based exercise plus self-management (SM) or SM alone versus usual care in improving exercise level, quality of life, aerobic capacity, muscle strength and use of healthcare services over 12 months for women with breast cancer receiving chemotherapy.

METHODS AND ANALYSIS

Participants: Women with stages I-III breast cancer undergoing chemotherapy. Intervention: Group 1: institution-based exercise and SM (8 exercise sessions plus 8 SM modules); Group 2: SM alone; Group 3: usual care. Outcomes: The primary effectiveness outcome is minutes per week of moderate to vigorous physical activity. Secondary outcomes include quality of life, aerobic capacity, muscle strength, and use of healthcare services. Randomisation: Participants will be randomised (1:1:1) to one of the three groups by a blinded statistician and will be stratified based on age of participant (<40, 40-60, and >60 years). Statistical analysis: Outcomes will be measured at baseline, post-intervention, 6-month and 12-month follow-up using an analysis of covariance to test changes between groups over time adjusted for age.

ETHICS AND DISSEMINATION

This study addresses a long-standing need to help women with breast cancer undergoing chemotherapy become and stay more active by implementing novel rehabilitation strategies into real-world practice. This is vital in order for this population to minimise the lingering side effects of treatment, improve function and quality of life and prevent cancer recurrence.

TRIAL REGISTRATION NUMBER

The study protocol (v1: July 2020) has been registered on ClinicalTrials.gov (NCT04109274).

Cost-utility of venoarterial extracorporeal membrane oxygenation in cardiogenic shock and cardiac arrest

BACKGROUND

The use of venoarterial extracorporeal membrane oxygenation in cardiogenic shock keeps increasing, but its cost-utility is unknown.

METHODS

We studied retrospectively the cost-utility of venoarterial extracorporeal membrane oxygenation in a five-year cohort of consequent patients treated due to refractory cardiogenic shock or cardiac arrest in a transplant centre in 2013-2017. In our centre, venoarterial extracorporeal membrane oxygenation is considered for all cardiogenic shock patients potentially eligible for heart transplantation, and for selected postcardiotomy patients. We assessed the costs of the index hospitalization and of the one-year hospital costs, and the patients' health-related quality of life (response rate 71.7%). Based on the data and the population-based life expectancies, we calculated the amount and the costs of quality-adjusted life years gained both without discount and with an annual discount of 3.5%.

RESULTS

The cohort included 102 patients (78 cardiogenic shock; 24 cardiac arrest) of whom 67 (65.7%) survived to discharge and 66 (64.7%) to one year. The effective costs per one hospital survivor were 242,303€. Median in-hospital costs of the index hospitalization per patient were 129,967€ (interquartile range 150,340€). Mean predicted number of quality-adjusted life years gained by the treatment was 20.9 (standard deviation 9.7) without discount, and the median cost per quality-adjusted life year was 7474€ (interquartile range 10,973€). With the annual discount of 3.5%, 13.0 (standard deviation 4.8) quality-adjusted life years were gained with the cost of 12,642€ per quality-adjusted life year (interquartile range 15,059€).

CONCLUSIONS

We found the use of venoarterial extracorporeal membrane oxygenation in refractory cardiogenic shock and cardiac arrest justified from the cost-utility point of view in a transplant centre setting.