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

Health-related quality of life in patients with palmoplantar pustulosis - a Swedish register study

BACKGROUND

Real-world data on health-related quality of life (HRQoL) in palmoplantar pustulosis (PPP) are scarce and few studies have analysed the generic HRQoL.

OBJECTIVES

To assess HRQoL using the generic EQ-5D instrument and the Dermatology Life Quality Index (DLQI) instrument in PPP compared to plaque psoriasis.

METHODS

Cross-sectional data from PsoReg, the Swedish National Registry for Systemic Treatment of Psoriasis (2006-2021), were examined. The study included 306 patients with PPP, out of which 22% had concomitant plaque psoriasis (n = 68), and 7041 patients with plaque psoriasis only. EQ-5D and DLQI were compared between patients with PPP and patients with plaque psoriasis, overall and stratified by sex. A subgroup analysis compared outcomes for patients with PPP vs. patients with severe plaque psoriasis (Psoriasis Area and Severity Index ≥10). Multiple regression analyses were performed to control for potential confounders (age, sex, comorbidities, lifestyle factors).

RESULTS

Patients with PPP were to a larger extent female (79% vs. 37%, p < .01) and older (mean [SD] age 59.9 [11.9] vs. 50.7 [16.0] years, p < .01) than patients with plaque psoriasis. EQ-5D values were significantly lower (worse) in patients with PPP (mean [SD] 0.622 [0.309]) compared to patients with plaque psoriasis (mean [SD] 0.715 [0.274]). No significant difference was observed compared to patients with severe plaque psoriasis (p = .237). DLQI was comparable in PPP and plaque psoriasis patients (p = .117). In the regression analyses, PPP only and PPP with plaque psoriasis were associated with lower EQ-5D values of 0.065 (p < .01) and 0.061 points (p < .10) compared to plaque psoriasis patients.

CONCLUSIONS

PPP had a substantial negative impact on patients' generic and dermatology-specific HRQoL. Patients with PPP were worse off in terms of generic HRQoL compared with patients with plaque psoriasis when controlling for the impact of potential confounders.

Health-related quality of life in patients with generalized pustular psoriasis - a Swedish register study

BACKGROUND

Real-world data on health-related quality of life (HRQoL) in generalized pustular psoriasis (GPP) are scarce and studies have been restricted in terms of instruments used for assessments.

OBJECTIVE

To assess generic and dermatology-specific HRQoL of patients with GPP compared with patients with plaque psoriasis using real-world data from the Swedish National Register for Systemic Treatment of Psoriasis.

METHODS

Cross-sectional data from 2006 to 2021 including 7041 individuals with plaque psoriasis without GPP and 80 patients with GPP, of which 19% also had plaque psoriasis. Total scores for the EuroQol-5 Dimensions (EQ-5D) and Dermatology Life Quality Index (DLQI), as well as degree of severity within the instruments' dimensions/questions, were compared between patient groups.

RESULTS

EQ-5D scores were significantly (p < .01) lower (worse) in patients with GPP (mean [standard deviation (SD)] 0.613 [0.346]) vs. patients with plaque psoriasis (mean [SD] 0.715 [0.274]), indicating lower generic HRQoL of patients with GPP. Significantly (p < .01) higher (worse) total DLQI scores were observed for patients with GPP (mean [SD] 10.6 [8.9]) compared with patients with plaque psoriasis (mean [SD] 7.7 [7.1]), with proportionally more patients with GPP having severe (20% vs. 16%) and very severe (17% vs. 8%) problems. The worsened scores for GPP vs. plaque psoriasis were consistent across EQ-5D dimensions and DLQI questions.

CONCLUSIONS

Individuals with GPP have a considerable impairment in both generic and dermatology-specific HRQoL. The HRQoL was significantly worse in individuals with GPP compared to individuals with plaque psoriasis. The significant HRQoL impairment of GPP shows the potential value of better healthcare interventions for this multisystem disease.

Early symptom improvement and other clinical predictors of response to repetitive transcranial magnetic stimulation for depression

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) is a rapidly emerging treatment for depression, but outcome prediction is still a challenge. This study aimed to identify predictors of response to rTMS among baseline clinical factors and early symptomatic improvements.

METHODS

This cohort study comprised 136 patients with a unipolar or bipolar depressive episode referred for clinical intermittent theta-burst stimulation or right-sided 1 Hz rTMS at the Uppsala Brain Stimulation Unit. The co-primary outcomes used for logistic regression were response, defined as ≥50 % reduction of Montgomery and Åsberg Depression Rating Scale Self-assessment (MADRS-S) total score, and 1-2 points on the Clinical Global Impression Improvement (CGI-I) scale. Early improvement was defined as ≥20 % reduction in the MADRS-S total score, or ≥ 1 point reduction in each MADRS-S item, after two weeks of treatment.

RESULTS

The response rates were 21 % for MADRS-S and 45 % for CGI-I. A depressive episode >24 months had lower odds for MADRS-S response compared to ≤12 months. Early improvement of the MADRS-S total score predicted CGI-I response (95 % CI = 1.35-9.47, p = 0.011), Initiative6 predicted MADRS-S response (95 % CI = 1.08-9.05, p = 0.035), and Emotional involvement7 predicted CGI-I response (95 % CI = 1.03-8.66, p = 0.044).

LIMITATIONS

No adjustment for concurrent medication.

CONCLUSIONS

A depressive episode ≤12 months and early improvement in overall depressive symptoms, as well as the individual items, Initiative6 and Emotional involvement7, predicted subsequent rTMS response in a naturalistic sample of depressed patients. This could facilitate the early identification of patients who will benefit from further rTMS sessions.

Gothenburg Breast reconstruction (GoBreast) II protocol: a Swedish partially randomised patient preference, superiority trial comparing autologous and implant-based breast reconstruction

INTRODUCTION

Although breast reconstruction is an integral part of breast cancer treatment, there is little high-quality evidence to indicate which method is the most effective. Randomised controlled trials (RCTs) are generally thought to provide the most solid scientific evidence, but there are significant barriers to conducting RCTs in breast reconstruction, making both recruitment and achieving unbiased and generalisable results a challenge. The objective of this study is to compare implant-based and autologous breast reconstruction in non-irradiated patients. Moreover, the study aims to improve the evidence for trial decision-making in breast reconstruction.

METHODS AND ANALYSIS

The study design partially randomised patient preference trial might be a way to overcome the aforementioned challenges. In the present study, patients who consent to randomisation will be randomised to implant-based and autologous breast reconstruction, whereas patients with strong preferences will be able to choose the method. The study is designed as a superiority trial based on the patient-reported questionnaire BREAST-Q and 124 participants will be randomised. In the preference cohort, patients will be included until 62 participants have selected the least popular alternative. Follow-up will be 60 months. Embedded qualitative studies and within-trial economic evaluation will be performed. The primary outcome is patient-reported breast-specific quality of life/satisfaction, and the secondary outcomes are complications, factors affecting satisfaction and cost-effectiveness.

ETHICS AND DISSEMINATION

The study has been approved by the Swedish Ethical Review Authority (2023-04754-01). Results will be published in peer-reviewed scientific journals and presented at peer-reviewed scientific meetings.

TRIAL REGISTRATION NUMBER

NCT06195865.

Patient-reported outcomes after personalised dose-escalation for stage II-III non-small-cell lung cancer patients: Results from the randomised ARTFORCE PET-Boost trial

BACKGROUND AND PURPOSE

The ultimate challenge in dose-escalation trials lies in finding the balance between benefit and toxicity. We examined patient-reported outcomes (PROs), including health-related quality of life (HRQoL) in patients with locally advanced non-small cell lung cancer (LA-NSCLC), treated with dose-escalated radiotherapy.

MATERIALS AND METHODS

The international, randomised, phase 2 ARTFORCE PET-Boost study (NCT01024829) aimed to improve 1-year freedom from local failure rates in patients with stage II-III NSCLC, with a ≥ 4 cm primary tumour. Treatment consisted of an individualised, escalated fraction dose, either to the primary tumour as a whole or to its most FDG-avid subvolume (24 x 3.0-5.4 Gy). Patients received sequential or concurrent chemoradiotherapy, or radiotherapy only. Patients were asked to complete the EORTC QLQ-C30, QLQ-LC13, and the EuroQol-5D at eight timepoints. We assessed the effect of dose-escalation on C30 sum score through mixed-modelling and evaluated clinically meaningful changes for all outcomes.

RESULTS

Between Apr-2010 and Sep-2017, 107 patients were randomised; 102 were included in the current analysis. Compliance rates: baseline 86.3%, 3-months 85.3%, 12-months 80.3%; lowest during radiation treatment 35.0%. A linear mixed-effect (LME) model revealed no significant change in overall HRQoL over time, and no significant difference between the two treatment groups. Physical functioning showed a gradual decline in both groups during treatment and at 18-months follow-up, while clinically meaningful worsening of dyspnoea was seen mainly at 3- and 6-months.

CONCLUSION

In patients with LA-NSCLC treated with two dose-escalation strategies, the average patient-reported HRQoL remained stable in both groups, despite frequent patient-reported symptoms, including dyspnoea, dysphagia, and fatigue.

The association between body mass index, exercise capacity, and health-related quality of life in heart transplant recipients

Introduction

Pre-transplant obesity and weight gain after heart transplantation are both associated with increased risk of poor clinical outcomes. We aimed to assess the association between overweight or obesity, exercise capacity, and health-related quality of life in heart transplant recipients.

Methods

This study is based on baseline data from the IronIC trial, in which we randomized 102 heart transplant recipients with iron deficiency to ferric derisomaltose or placebo. We performed cardio pulmonary exercise testing in all participants. To assess quality of life, we used the SF-36v2 questionnaire, using two sum scores: the physical component summary and the mental component summary. A minimal clinically important difference was defined as ≥2 and ≥3 for the physical and the mental component summary, respectively.

Results

24/102 heart transplant recipients (24%) had a body mass index (BMI) ≥30 kg/m2. Peak oxygen consumption was 17.3 ± 4.6 ml/kg/min in the obese group vs. 24.7 ± 6.4 ml/kg/min in the group with a BMI <30 for a between-group difference of 7.4 (95% confidence interval 4.7-10.2) ml/kg/min: p < 0.001. The physical component summary score was on average 5.2 points lower in the patients with a body mass index ≥30 than in the lower weight group (p = 0.04).

Conclusion

Almost a quarter of our heart transplant recipients in long-term follow-up had a BMI ≥30 kg/m2. These patients had substantially lower exercise capacity and lower quality of life in the physical domain.

The Swedish version of the Motivation and Pleasure Scale self-report (MAP-SR): psychometric properties in patients with schizophrenia or depression

PURPOSE

Negative symptoms are commonly regarded as a symptom dimension belonging to schizophrenia spectrum disorders but are also present in depression. The recently developed Clinical Assessment Interview for Negative Symptoms (CAINS) has shown to be reliable and valid. A corresponding self-report questionnaire has also been developed, named the Motivation and Pleasure Scale - Self Report (MAP-SR). The purpose was to evaluate the psychometric properties of the Swedish version of the MAP-SR in patients with either schizophrenia or depression.

MATERIALS AND METHODS

The MAP-SR was translated to Swedish. Participants were 33 patients with schizophrenia spectrum disorders and 52 patients with a depressive disorder and they completed the MAP-SR, the CAINS and other measures assessing adjacent psychopathology, functioning and cognition.

RESULTS

The internal consistency for the MAP-SR was adequate in both groups (schizophrenia spectrum α = .93, depressive disorder α = .82). Furthermore, the MAP-SR had a large correlation to the motivation and pleasure subscale of the CAINS in patients with schizophrenia disorders (r = -0.75, p < .001), however among patients with depression this correlation was medium-to-large (r = -0.48, p < 0.001).

CONCLUSIONS

Findings suggest that the Swedish version of the MAP-SR shows promise as a useful measure of motivation and pleasure, especially in patients with schizophrenia spectrum disorders. Furthermore, results also suggest that the MAP-SR does not assess negative symptoms specifically, but that there is an overlap between depressive and negative symptoms.

A happiness approach to valuing health states for children

Preference weights are widely used to score generic health states into utility indexes for estimation of quality adjusted life years (QALYs) and to aid health care funding decisions. To date, health state utilities are predominantly derived using stated preference methods based on decision utility. This paper tests an alternative and generates preference weights using experienced utility for children based on the Child Health Utility 9D (CHU9D) descriptive system. We estimate the relative values of the CHU9D health states with regard to experienced utility, where experienced utility is approximated by self-reported happiness. A nationally-representative longitudinal survey was used including 6090 Australian children aged 12-17 years surveyed over 2014-2018. The derived weights were then applied to calculate the utility decrements for a few common child health conditions. We found that the estimated utility decrements are largely similar to those estimated using the published CHU9D Australian adolescent weights based on decision utility, except for pain and depression. A smaller utility decrement for pain and a larger utility decrement for depression were indicated by experienced utility. We contribute to the literature by showing that using experienced utility methods to generate preference weights for health states is possible, and we discuss some important methodological challenges for future studies such as the impracticability of anchoring to 'dead' when utilizing experienced utility.

Surgical and non-surgical treatment for fully displaced lateral clavicle fractures have similar outcomes: An observational register study of 113 patients

INTRODUCTION

Whether displaced lateral clavicle fractures should be treated surgically remains controversial. This study aims to compare outcomes after surgical versus non-surgical treatment of such fractures.

PATIENTS AND METHODS

113 patients with lateral clavicle fractures registered in the Swedish Fracture Register (SFR) during 2018 and with complete displacement on radiography were included in this cohort study. Linkage with the National Patient Register provided information on baseline medical comorbidities and further interventions. Patient-reported outcome measures (PROM) were assessed using the European Quality of Life Scale (EQ-5D-3L), the Short Musculoskeletal Function Assessment (SMFA), and the Quick Disabilities of the Arm, Shoulder and Hand (QDASH). The primary outcome was the total number of initial and delayed surgical procedures. The secondary outcome was difference in PROM between surgically and non-surgically treated patient groups.

RESULTS

At a mean follow-up of 4.4 (range 3.9-4.9) years, 35 (67 %) of the 52 patients initially treated surgically had undergone a secondary procedure, mostly for implant removal. Of the 61 initially non-surgically treated patients, 3 (5 %) underwent delayed surgical treatment due to non- or malunion. 45 (40 %) patients responded to follow-up questionnaires, but no statistically significant differences were found in any PROM between groups.

CONCLUSIONS

Two thirds of surgically treated patients with displaced lateral clavicle fractures underwent two procedures. The need for delayed surgical treatment in non-surgically treated patients was low and PROM was similar in both treatment groups. Nonsurgical treatment should be considered as an option to surgery for fully displaced lateral fractures of the clavicle more often.

Quality of Life and Bidirectional Gut-Brain Interactions in Irritable Bowel Syndrome From Adolescence to Adulthood

BACKGROUNDS AND AIMS

Reports on cross-sectional and longitudinal associations between health-related quality of life (HRQoL), psychological distress, and irritable bowel syndrome (IBS) in the adolescent and young adult general population are few. We aimed to describe cross-sectional associations between HRQoL and IBS in adolescence and young adulthood, and examine bidirectional gut-brain interactions in the transition from childhood to adulthood.

METHODS

We included 3391 subjects from a prospective birth cohort study, with data on IBS at 16 years of age and 24 years of age. IBS was assessed using the pediatric Rome III (16 years of age) and the adult Rome IV (24 years of age) diagnostic questionnaires. HRQoL and psychological distress were assessed through EQ-5D. Sex-adjusted logistic regression models were used to examine associations between overall HRQoL/psychological distress at 16 years of age and new-onset IBS at 24 years of age (brain-gut) and between IBS at 16 years of age and new-onset psychological distress at 24 years of age (gut-brain).

RESULTS

In subjects with vs without IBS at 16 and 24 years of age, overall HRQoL (EQ visual analog scale, EQ-5D index value) was lower, and it was more common reporting problems in 4 of 5 EQ-5D dimensions (all P < .05). EQ-5D index value at 16 years of age was inversely associated (odds ratio [OR], 0.1, 95% confidence interval [CI], 0.01-0.6), and psychological distress at 16 years of age was positively associated (OR, 1.6; 95% CI, 1.2-2.3), with new-onset IBS at 24 years of age. Having any abdominal pain-related disorder of gut-brain interaction at 16 years of age was associated with new-onset psychological distress at 24 years of age (OR, 1.7; 95% CI, 1.2-2.5).

CONCLUSIONS

Adolescents and young adults with IBS in the general population have impaired HRQoL. Bidirectional gut-brain interactions are relevant for symptom generation in abdominal pain-related disorders of gut-brain interaction, and for HRQoL impairment and psychological distress in the transition from childhood to adulthood.

Construct validity of EQ-5D-5L among patients with inflammatory bowel disease-a study based on real-world data from the Swedish Inflammatory Bowel Disease Registry

OBJECTIVES

The Swedish Inflammatory Bowel Disease Registry (SWIBREG) includes approximately 84% of all patients with inflammatory bowel disease (IBD) treated with immunomodulators, biologics or surgery in Sweden. Data on health-related quality of life (HRQoL) have been collected using EQ-5D-5L in the registry since 2012. Nevertheless, there are few studies assessing the validity of EQ-5D-5L in this patient population. Thus, the aim of this study was to assess the construct validity of EQ-5D-5L amongst patients with IBD (ulcerative colitis and Crohn's disease).

METHODS

Individual-level data on EQ-5D-5L and other disease-specific measures were extracted from SWIBREG. Known-groups validity was assessed by analysing whether the EQ-5D-5L captured expected differences between patient groups with different activity levels of the disease. Convergent validity was assessed by analysing whether the reported problems in the dimensions of EQ-5D-5L, EQ VAS, and the EQ-5D-5L index value correlated, as hypothesized, with the four dimensions in the Short Health Scale, a symptom index question, and the Physician Global Assessment (PGA) score.

RESULTS

In total, 9769 patients with IBD were included in the study. Patients with active IBD reported more health problems in the EQ-5D-5L descriptive system than patients being in remission. The effect sizes for the differences in reported problems between patients with active and inactive disease were at least small (≥0.1) or medium (≥0.3) in all dimensions except self-care. Differences in the mean EQ-5D-5L index and EQ-VAS score between patients with active and inactive disease were statistically significant (p < 0.001) and larger than pre-defined cut-offs for minimally important differences (>0.08 for the index and >11.0 for EQ-VAS). The analysis of convergent validity showed that EQ-5D-5L results correlated as expected with the disease-specific measures in 16 of the 21 analyses. In total, 22 (79%) of the 28 hypotheses were supported.

CONCLUSION

The findings support the construct validity of EQ-5D-5L amongst patients with IBD and contribute to the scarce literature on the validity of the five-level version of EQ-5D in this patient population. These findings have important implications for the choice of HRQoL measure in routine health care registries like SWIBREG as well as for future clinical or health economic studies considering using EQ-5D-5L as a measure of HRQoL.

The ASAS Health Index and Environmental Factors Item Set: validity and reliability of the Swedish translations in Swedish patients with ankylosing spondylitis

OBJECTIVES

To translate the Assessment of SpondyloArthritis international Society (ASAS) Health Index (HI) Environmental Factors Item Set (EFIS) into Swedish and culturally adapt it for a Swedish context, and to assess the construct validity of the Swedish version of the ASAS HI and test-retest reliability in ASAS HI and EFIS in Swedish patients with ankylosing spondylitis (AS).

METHOD

Translation and cross-cultural adaptation of the EFIS were carried out according to a forward-backward procedure consisting of five steps. The construct validity of the ASAS HI was tested using Spearman correlation with standard health outcomes for axial spondyloarthritis (axSpA). Reliability was analysed by internal consistency with the Cronbach's alpha coefficient for ASAS HI, and test-retest reliability with intraclass correlation coefficients (ICCs) for ASAS HI and kappa agreement for the individual items of EFIS.

RESULTS

The translation of EFIS showed acceptable face and content validity. ASAS HI showed an acceptable internal consistency (Cronbach's alpha 0.79), and excellent test-retest reliability (ICC 0.87). Test-retest reliability for EFIS showed varied results, with kappa agreement for the individual items ranging from poor (-0.027) to good (0.80).

CONCLUSIONS

The Swedish version of ASAS HI proved to be valid and reliable and is recommended for assessing the impact of AS on global functioning and health. A Swedish version of EFIS has been produced and uploaded on the ASAS website. The EFIS proved to have acceptable face and content validity, and may contribute to the contextual interpretation of the ASAS HI.

Recent trends in disease-modifying therapy use and associated sickness absence and disability pension among people with multiple sclerosis in Sweden

BACKGROUND

Disease-modifying therapies (DMTs) have led to improved health and work productivity among people with multiple sclerosis (PwMS).

OBJECTIVES

To describe trajectories of recent DMT use and their association with sickness absence and/or disability pension (SADP) among PwMS in Sweden.

METHODS

A longitudinal register-based study was conducted among 1395 PwMS with treatment start in 2014/2015. While DMT use over 5 years was assessed using sequence analysis resulting in four clusters, a 7-year (Y-2 toY4) trend of SADP was analyzed using zero-inflated negative binomial regression.

RESULTS

Four clusters of DMT use trajectories were identified: long-term non-high-efficacy (483, 34.6%), long-term high-efficacy (572, 41%), escalation (221, 15.8%), and discontinuation (119, 8.5%). Progressive MS and higher expanded disability status scale scores were associated with the escalation, long-term high-efficacy, or discontinuation clusters. PwMS in the long-term high-efficacy and escalation clusters had higher likelihood of being on SADP. However, PwMS initiating high-efficacy DMTs demonstrated steeper decline in SADP than others.

CONCLUSION

Using sequence analysis, this study showed recent DMT use trajectories among PwMS where initiation of high-efficacy DMTs has become more common. The trend of SADP was stable and lower in those using non-high-efficacy DMTs and larger improvements were shown in those initiating high-efficacy DMTs.

Interdisciplinary pain rehabilitation for immigrants with chronic pain who need language interpretation

OBJECTIVE

To investigate outcomes in patients with chronic pain after participation in an interdisciplinary pain rehabilitation programme with language interpreters, and to investigate the outcomes in women and men separately.

DESIGN

Prospective multi-centre cohort study.

PATIENTS

Ninety-five patients in Sweden with chronic pain who have insufficient knowledge of the Swedish language.

METHODS

Duration and intensity of pain, anxiety and depression, health-related quality of life and fear of movement were evaluated before and after the programme. Patients were compared with a reference group comprising Swedish-speaking patients participating in an ordinary interdisciplinary pain rehabilitation programme.

RESULTS

Before the interdisciplinary pain rehabilitation programme with language interpreters, all variables except pain duration differed significantly to the detriment of the studied group. The studied group showed significant improvements after the interdisciplinary pain rehabilitation programme with language interpreters, with regards to pain intensity, depression and fear of movement. The reference group improved significantly for all variables. The women in the studied group showed significant improvements for the same variables as the whole group, while the men in the studied group did not improve in any of the variables.

CONCLUSION

This study indicates that patients with chronic pain, and especially women, who have insufficient knowledge of Swedish seem to benefit from participating in an interdisciplinary pain rehabilitation programme with language interpreters. The result may be of value for the further development of rehabilitation programmes with language interpreters.

Living with dizziness impacts health-related quality of life among older adults

Objective

This study aimed to compare older adults reporting dizziness to those not reporting dizziness regarding health-related quality of life (HRQL), distress due to dizziness, and balance confidence. A secondary aim was to investigate potential association between HRQL, number of falls, balance confidence, and distress due to dizziness.

Methods

Patients coming for bone density measurements answered questions regarding occurrence of dizziness. Patients reporting dizziness on a daily or weekly basis were considered eligible and invited for investigation at the Ear, Nose and Throat clinic at Södra Älvsborg Hospital, Sweden. Patients not reporting dizziness were considered eligible as controls. All patients answered the Dizziness Handicap Inventory (DHI), Activity Balance Confidence Scale (ABC-scale), and Euro-QoL-5D-3L questionnaires.

Results

A total of 55 dizzy patients came for physical investigation and answered the questionnaires and 47 non-dizzy participants only answered the questionnaires. The dizzy participants reported lower levels of balance confidence, lower HRQL, more prior falls, and higher levels of distress due to dizziness than the non-dizzy controls. Lower levels of balance confidence and higher level of distress due to dizziness were each associated with lower HRQL.

Conclusion

Dizziness, unsteadiness, and low balance confidence are associated with HRQL in a negative way. This is important to consider when measuring HRQL in a senior population, since a sensation of unsteadiness may indirectly contribute to low HRQL together with other symptoms.

Level of evidence

2b.

Elbow hemiarthroplasty and total elbow arthroplasty provided a similar functional outcome for unreconstructable distal humeral fractures in patients aged 60 years or older: a multicenter randomized controlled trial

BACKGROUND

Semiconstrained total elbow arthroplasty (TEA) is an established treatment for elderly patients with distal humeral fractures not amenable to stable internal fixation (unreconstructable). In recent years, there has been increasing interest in elbow hemiarthroplasty (EHA), a treatment option which does not entail restrictions on weight-bearing as opposed to TEA. These 2 treatments have not been compared in a randomized controlled trial (RCT). The aim of this study was to compare the functional outcome of EHA and TEA for the treatment of unreconstructable distal humeral fractures in elderly patients.

MATERIAL AND METHODS

This was a multicenter randomized controlled trial (RCT). Patients were included between January 2011 and November 2019 at one of 3 participating hospitals. The inclusion criteria were an unreconstructable distal humeral fracture, age ≥60 years and independent living. The final follow-up took place after ≥2 years. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Secondary outcome measures were the Mayo Elbow Performance Score (MEPS), the EQ-5D index, range of motion (flexion, extension, pronation, and supination) and grip strength.

RESULTS

Forty patients were randomized to TEA (n = 20) and EHA (n = 20). Five patients died before completing the final follow-up, leaving 18 EHA and 17 TEA patients for analysis. There were 31 women. The mean age was 74.0 (SD, 8.5) years in the EHA group and 76.9 (SD, 7.6) in the TEA group (P = .30). The mean DASH score was 21.6 points in the EHA group and 27.2 in the TEA group (P = .39), a difference of -5.6 points (95% CI: -18.6 to 7.5). There were no differences between treatment with EHA and TEA for the mean values of the MEPS (85.0 vs. 88.2, P = .59), EQ-5D index (0.92 vs. 0.86, P = .13), extension (29° vs. 29°, P = .98), flexion (126° vs. 136°, P = .05), arc of flexion-extension (97° vs. 107°, P = .25), supination (81° vs. 75°, P = .13), pronation (78° vs. 74°, P = .16) or grip strength (17.5 kg vs. 17.2 kg, P = .89). There were 6 adverse events in each treatment group.

CONCLUSION

In this RCT, both elbow hemiarthroplasty (EHA) and total elbow arthroplasty (TEA) resulted in a good and similar functional outcome for unreconstructable distal humeral fractures in elderly patients at a minimum of 2 years of follow-up.

Socioeconomic per-case costs of stroke, myocardial infarction, and preterm birth attributable to air pollution in Sweden

BACKGROUND

Incident cases of stroke, myocardial infarction, and preterm birth have established exposure-response functions associated with air pollution. However, there are no studies reporting detailed costs per case for these health outcomes that are adapted to the cost-benefit tools that guide the regulation of air pollution.

OBJECTIVES

The primary objective was to establish non-fatal per-case monetary estimates for stroke, myocardial infarction, and preterm birth attributable to air pollution in Sweden, and the secondary objective was to ease the economic evaluation process of air pollution morbidity effects and their inclusion in cost-benefit assessments.

METHODS

Based on recommendations from the literature, the case-cost analysis considered direct and indirect medical costs, as well as production losses and informal costs relevant for the calculation of the net present value. A literature search was conducted to estimate the costs of each category for each incident case in Sweden. Informal costs were estimated using the quality-adjusted life-years approach and the corresponding willingness-to-pay in the Swedish population. The total average per-case cost was estimated based on specific health outcome durations and severity and was discounted by 3.5% per year. Sensitivity analysis included varying discount rates, severity of health outcome, and the range of societal willingness to pay for quality-adjusted life years.

RESULTS

The average net present value cost estimate was €2016 460k (185k-1M) for non-fatal stroke, €2016 24k (16k-38k) for myocardial infarction, and €2016 34k (19k-57k) for late preterm birth. The main drivers of the per-case total cost estimates were health outcome severity and societal willingness to pay for risk reduction. Varying the discount rate had the largest effect on preterm birth, with costs changing by ±30% for the discount rates analysed.

RECOMMENDATION

Because stroke, myocardial infarction, and preterm birth have established exposure-response functions linking these to air pollution, cost-benefit analyses should include the costs for these health outcomes in order to adequately guide future air pollution and climate change policies.

The Sukaribit Smartphone App for Better Self-Management of Type 2 Diabetes: Randomized Controlled Feasibility Study

BACKGROUND

A new app, Sukaribit, was designed to enable contact between the caregiver and the patient with the intent to improve self-care and glycemic control (hemoglobin A1c [HbA1c]).

OBJECTIVE

This study investigated the feasibility of the study methodology and the intervention in preparation for a larger effectiveness study.

METHODS

Adults with type 2 diabetes were recruited in this randomized controlled feasibility study with a mixed methods design. The intervention group (n=28) tried Sukaribit for 2 months. They were encouraged to report blood glucose levels and medications, and they received feedback from a physician. The control group (n=31) received standard care. Both groups were evaluated with pre and postmeasurements of glycemic control (HbA1c), diabetes distress, physical activity, and self-care. Feasibility was evaluated against 5 progression criteria regarding recruitment, study methods, and active participation.

RESULTS

Of the 5 progression criteria, only 2 were met or partially met. The recruitment process exceeded expectations, and data collection worked well for self-reported data but not for HbA1c measured with a home testing kit. The participants were less active than anticipated, and the effect sizes were small. Only the number of blood glucose tests per day was positively affected by the intervention, with 0.6 more tests per day in the intervention group.

CONCLUSIONS

Recruitment of participants to a future fully powered study may work with minor adjustments. The collection of HbA1c using home testing constituted a major problem, and an alternative strategy is warranted. Finally, the app was not used as intended. In order to proceed with a larger study, the app and study procedures need improvement.

Health-related quality of life in primary care patients: a comparison between EQ-5D-5L utility score and EQ-visual analogue scale

OBJECTIVE

The EQ-VAS is an important component of the EQ-5D questionnaire. However, there is limited evidence comparing its performance to the EQ-5D utility score, which restricts its use in the population. This study aimed to EQ-5D-5L utility score and EQ-visual analogue scale (EQ-VAS) in primary care patients in Hong Kong (HK).

METHODS

Secondary data analysis was performed on the data collected from a cross-sectional survey to investigate patient engagement in HK. Participants were recruited through random sampling from a single general outpatient clinic. Trained investigators conducted face-to-face interviews with all eligible patients attending the clinic. Patients who were: 1) ≥ 18 years old, 2) have visited the clinic at least once in the last 6 months, 3) no cognitive problems, and 4) can speak and understand the local language. Pearson correlation was used to explore the association between EQ-5D utility and EQ-VAS score. Ordinary least squares regression and heteroscedastic Tobit regression models were adopted to analyze the EQ-VAS and EQ-5D utility data, respectively.

RESULTS

The analysis included data from 1,004 responses (response rate = 65%). Around 52.7% of participants were female, 25.9% completed tertiary or above education, and 75.1% living with chronic disease. The mean EQ-5D utility and EQ-VAS score were 0.92 (SD = 0.13) and 72.27 (SD = 14.69), respectively. A significant association was found between EQ-5D utility and EQ-VAS score, with coefficients ranging from 0.335 (participants who divorced) to 0.744 (participants living alone). Around 98.5% reported having no problems with 'Self-care', followed by 'Usual activities' (96.3%), 'Mobility' (91.5%) and 'Anxiety/depression' (79.9%). The correlation between EQ-VAS score and EQ-5D utility was positive for each dimension of the EQ-5D instrument (correlation coefficients ranged between 0.211 and 0.623). Age strongly influenced the magnitude and trajectory of EQ-VAS score and utility, as observed in the changes. The regression model showed that 'Mobility', 'Pain/discomfort', and 'Anxiety/depression' have considerable influence on EQ-VAS score.

CONCLUSIONS

This study compared the EQ-5D utility score and EQ-VAS in HK primary care setting. Although heterogeneity existed, the EQ-VAS and utility score are significantly correlated and reliable for evaluating health-related quality of life in this population.

What Aspects of Quality of Life are Important from Palliative Care Patients' Perspectives? A Framework Analysis to Inform Preference-Based Measures for Palliative and End-of-Life Settings

BACKGROUND AND OBJECTIVE

Preference-based outcome measures are commonly applied in economic analyses to inform healthcare resource allocation decisions. Few preference-based outcome measures have been specifically developed for palliative and end-of-life settings. This study aimed to identify which quality-of-life domains are most important to Australians receiving specialised palliative care services to help determine if the development of a new condition-specific preference-based outcome measure is warranted.

METHODS

In-depth face-to-face interviews were conducted with 18 participants recruited from palliative care services in South Australia. Data were analysed using a framework analysis drawing on findings from a systematic review of international qualitative studies investigating the quality-of-life preferences of patients receiving palliation (domains identified included cognitive, emotional, healthcare, personal autonomy, physical, preparatory, social, spiritual). Participants identified missing or irrelevant domains in the EQ-5D and QLU-C10D questionnaires and ranked the importance of domains.

RESULTS

A priori domains were refined into cognitive, environmental, financial, independence, physical, psychological, social and spiritual. The confirmation of the eight important quality-of-life domains across multiple international studies suggests there is a relatively high degree of convergence on the perspectives of patients in different countries. Four domains derived from the interviews are not covered by the EQ-5D and QLU-C10D (cognitive, environmental, financial, spiritual), including one of the most important (spiritual).

CONCLUSIONS

Existing, popular, preference-based outcome measures such as the EQ-5D do not incorporate the most important, patient-valued, quality-of-life domains in the palliative and end-of-life settings. Development of a new, more relevant and comprehensive preference-based outcome measure could improve the allocation of resources to patient-valued services and have wide applicability internationally.

Fast track to stroke unit for patients not eligible for acute intervention, a case-control register study on 1066 patients

Stroke patients not eligible for acute intervention often have low priority and may spend long time at the emergency department (ED) waiting for admission. The aim of this retrospective case-control register study was to evaluate outcomes for such "low priority" stroke patients who were transported via Fast Track directly to the stroke unit, according to pre-specified criteria by emergency medical service (EMS). The outcomes of Fast Track patients, transported directly to stroke unit (cases) were compared with the outcomes of patients who fulfilled these critera for Fast Track, but instead were transported to the ED (controls). In all, 557 cases and 509 controls were identified. The latter spent a mean time of 237 min in the ED before admission. The 90-day mortality rate was 12.9% for cases and 14.7% for controls (n.s.). None of the secondary outcome events differed significantly between the groups: 28-day mortality rate; death rate during hospitalisation; proportion of pneumonias, falls or pressure ulcers; or health-related outcomes according to the EQ-5D-5L questionnaire. These findings indicates that the Fast Track to the stroke unit by an EMS is safe for selected stroke patients and could avoid non-valuable time in the ED.

Health-related quality of life in stroke survivors: a 5-year follow-up of The Fall Study of Gothenburg (FallsGOT)

BACKGROUND

There are limited data on long-term prevalence and predictors of health-related quality of life (HRQoL) in stroke survivors. Therefore, the aim was to describe the prevalence of impaired HRQoL, and to identify factors in acute stroke that are associated with impaired HRQoL, 5 years after stroke.

METHODS

The 305 (60.5%) stroke survivors of the original 504 participants from The Fall Study of Gothenburg were invited to participate in a 5-year follow-up including assessment of HRQoL using the EuroQol 5 Dimensions 3 Levels questionnaire (EQ-5D-3L). To identify baseline predictors of impaired HRQoL, based on the EQ-5D-3L's five dimensions, univariate and multivariate logistic regression analyses were performed.

RESULTS

A total of 129 participants (42.3% of the survivors) completed the questionnaire at a median follow-up time of 58 months. At baseline, their mean age was 70.6 years, and they had a median NIHSS score of 1. The median (interquartile range [IQR]) EQ-5D-3L index score was 0.87 (0.71-0.93) and the median (IQR) EQ-visual analogue scale was 70 (49.8-88). In total, 102 (79%) participants were classified as having impaired HRQoL, stated primarily (among 68.5%) related to Pain/Discomfort. Higher age was identified as a predictor of impaired HRQoL related to Mobility (Odds ratio (OR) 1.05, 95% confidence interval (CI) 1.01-1.10) and Self-Care (OR 1.09, 95% CI 1.02-1.17), and longer hospital stay at baseline was identified as a predictor related to Mobility (OR 1.09, 95% CI 1.01-1.18), Self-Care (OR 1.10, 95% CI 1.02-1.18)) and Usual Activities. (OR 1.10, 95% CI 1.03-1.18).

CONCLUSION

At 5 years after stroke, four out of five participants (79%) reported impaired HRQoL related to any of the five dimensions assessed by using the EQ-5D-3L. Most reported, impaired HRQoL was related to Pain/Discomfort. Higher age and longer hospital care period at index stroke were associated with impaired HRQoL. The findings could assist to identify individuals at high risk of low HRQoL, who might benefit from special attention and psychological support.

Increased patient satisfaction by integration of palliative care into geriatrics-A prospective cohort study

BACKGROUND

Integration of oncology and palliative care has been shown to increase quality of life in advanced disease. To meet the needs of the growing older population, integration of palliative care and geriatrics has been proposed but scarcely described.

OBJECTIVES

The aim of this study was to integrate palliative care into geriatrics by a structured care guide, the Swedish Palliative Care Guide, and to evaluate its effect on patient satisfaction, health-related quality of life and symptom burden, compared to a control group.

METHODS

Geriatric in-patients over 65 years of age were included in the study, those with cognitive impairment were excluded. Data was collected before (baseline) and after the implementation (intervention) of the Swedish Palliative Care Guide. Patient satisfaction was evaluated two weeks after discharge with questions from a national patient survey. Health-related quality of life was measured with EQ-5D-3L and symptom burden with Edmonton Symptom Assessment Scale.

RESULTS

In total, 400 patients were included, 200 in the baseline- and intervention group, respectively. Mean age was 83 years in both groups. Patient satisfaction was significantly higher in nine out of ten questions (p = 0.02-<0.001) in the intervention group compared to baseline. No differences between the groups were seen in health-related quality of life or symptom burden.

CONCLUSION

A significant effect on patient satisfaction was seen after implementation of the Swedish Palliative Care Guide in geriatric care. Thus, integration of palliative care and geriatrics could be of substantial benefit in the growing population of older adults with multimorbidity and frailty.

A randomized trial comparing percutaneous endoscopic gastrostomy (PEG) and radiologically inserted percutaneous gastrostomy (RIG)

BACKGROUND AND OBJECTIVE

At present, percutaneous endoscopic gastrostomy (PEG) is the procedure of choice in establishing a permanent feeding tube in patients with chronic severe dysphagia. This is the first prospective randomized study in adults comparing PEG with radiologically inserted gastrostomy (RIG).

METHODS

Randomization of 106 patients, eligible for both techniques, to PEG (pull method) or RIG. The groups were comparable in terms of age, body mass index, and underlying diseases. Adverse events were reported 10 and 30 days after the operative procedure, and mortality was up until 6 months. The validated European Quality of life 5 Dimensions 3 level version (EQ-5D) questionnaire was used for health status measurements.

RESULTS

The procedures were successfully completed in all patients. The median operative time was 10 min for PEG and 20 min for RIG (p < 0.001). The overall rate of adverse events was lower for PEG (22%) than for RIG (51%, p = 0.002), mostly due to less local self-limiting stoma reactions and tube problems. The 30-day mortality was lower after PEG (2% versus 14%, p = 0.020). Patient-scored health status remained low for the entire cohort, with an EQ-5D utility index of 0.164. Self-rated health was low but improved in the RIG group (52.5 from 41.1, out of 100).

CONCLUSION

PEG can be recommended as the primary procedure in patients in need of a feeding gastrostomy, mainly due to a lower frequency of tube complications. However, as the two techniques complement each other, RIG is also a valid alternative method.

CLINICAL TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number ISRCTN17642761. https://doi.org/10.1186/ISRCTN17642761.

Experience-based health state valuation using the EQ VAS: a register-based study of the EQ-5D-3L among nine patient groups in Sweden

BACKGROUND

The EQ VAS component of the EQ-5D questionnaire has been used to assess patients' valuation of their own health besides its use for self-reporting of overall health status. The objective of the present study was to identify patients' valuation of EQ-5D-3L health states using the EQ VAS in different patient groups over time and in comparison to the general population.

METHODS

Data were obtained from patients from nine National Quality Registers (n = 172,070 patients) at baseline and at 1-year follow-up and compared with data from the general population (n = 41,761 participants). The correlation between EQ VAS scores and EQ-5D-3L index based on the Swedish experience-based VAS value set was assessed. Ordinary least squares (OLS) regression models were used to determine the association between EQ-5D-3L dimensions and EQ VAS valuation.

RESULTS

EQ VAS scores showed consistency with severity of health states both at baseline and at 1-year follow-up in the nine selected EQ-5D-3L health states. The regression models showed mostly consistent decrements by severity levels in each dimension at both time points and similar to the general population. The dimension mainly associated with inconsistency was the self-care severity level three. Problems in the anxiety/depression dimension had the largest impact on overall health status in most of the patient groups and the general population.

CONCLUSION

The study has demonstrated the important role EQ VAS can play in revealing patients' valuation of their health and showed the variation in valuation of EQ-5D-3L dimensions and levels of severity across different patient groups.

Hypothetical versus experienced health state valuation: a qualitative study of adult general public views and preferences

OBJECTIVES

Responses from hypothetical and experienced valuation tasks of health-related quality of life differ, yet there is limited understanding of why these differences exist, what members of the public think about them, and acceptable resolutions. This study explores public understanding of, opinions on, and potential solutions to differences between hypothetical versus experienced responses, in the context of allocating health resources.

METHODS

Six focus groups with 30 members of the UK adult public were conducted, transcribed verbatim, and analysed using framework analysis. Participants self-completed the EQ-5D-5L, before reporting the expected consequences of being in two hypothetical EQ-5D-5L health states for ten years. Second, participants were presented with prior results on the same task from a public (hypothetical) and patient (experienced) sample. Third, a semi-structured discussion explored participants': (1) understanding, (2) opinions, and (3) potential resolutions.

RESULTS

Twenty themes emerged, clustered by the three discussion points. Most participants found imagining the health states difficult without experience, with those aligned to mental health harder to understand. Participants were surprised that health resource allocation was based on hypothetical responses. They viewed experienced responses as more accurate, but noted potential biases. Participants were in favour of better informing, but not influencing the public. Other solutions included incorporating other perspectives (e.g., carers) or combining/weighting responses.

CONCLUSION

Members of the UK public appear intuitively not to support using potentially uninformed public values to hypothetical health states in the context of health resource allocation. Acceptable solutions involve recruiting people with greater experience, including other/combinations of views, or better informing respondents.

Health-related quality of life and long-term symptoms among patients with non-severe covid-19 - a prospective cohort study

BACKGROUND

The vast majority of covid-19 patients experience non-severe disease. Nonetheless, long-term symptoms may be common and the impact on quality of life is uncertain. This study aims to examine these aspects in a prospective, longitudinal cohort.

METHODS

Non-hospitalised patients with PCR-confirmed covid-19 were prospectively invited to self-report assessments of background data, symptoms and recovery, illness perception (BIPQ) and health-related quality of life (HR-Qol) measured by EQ5D-VAS.

RESULTS

154 patients were included (mean age 46 years, 69% female). The majority of participants (65%) had symptoms for 1-4 weeks and 12% more than 6 months. The most common symptoms were initially malaise, fatigue, headache, fever and cough and the most common long-term symptoms were impaired physical condition, fatigue, anosmia and headache. The BIPQ index had a negative correlation with the EQ5D-VAS score after the infection, but not with long-term symptoms. Mean differences in the EQ5D-VAS score were significantly lower after the infection and patients with long-term symptoms had a more pronounced negative effect in EQ5D-VAS scores.

CONCLUSION

We found that most patients with non-severe covid-19 reported symptoms for 1-4 weeks and approximately 10% developed long-term symptoms. Non-severe covid-19 seems to have a negative influence on HR-Qol, especially in patients with long-term symptoms and with a greater burden from the disease. None of the initial symptoms could predict the presence of long-term symptoms.

An experience- and preference-based EQ-5D-3L value set derived using 18 months of longitudinal data in patients who sustained a fracture: results from the ICUROS

INTRODUCTION

EQ-5D-3L preference-based value sets are predominately based on hypothetical health states and derived in cross-sectional settings. Therefore, we derived an experience-based value set from a prospective observational study.

METHODS

The International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS) was a multinational study on fragility fractures, prospectively collecting EQ-5D-3L and Time trade-off (TTO) within two weeks after fracture (including pre-fracture recall), and at 4, 12, and 18 months thereafter. We derived an EQ-5D-3L value set by regressing the TTO values on the ten impairment levels in the EQ-5D-3L. We explored the potential for response shift and whether preferences for domains vary systematically with prior impairment in that domain. Finally, we compared the value set to 25 other EQ-5D-3L preference-based value sets.

RESULTS

TTO data were available for 12,954 EQ-5D-3L health states in 4683 patients. All coefficients in the value set had the expected sign, were statistically significant, and increased monotonically with severity of impairment. We found evidence for response shift in mobility, self-care, and usual activities. The value set had good agreement with the only other experience- and preference-based value set, but poor agreement with all hypothetical value sets.

CONCLUSIONS

We present an experience- and preference-based value set with high face validity. The study indicates that response shift may be important to account for when deriving value sets. Furthermore, the study suggests that perspective (experienced versus hypothetical) is more important than country setting or demographics for valuation of EQ-5D-3L health states.

Integrating health promotion with and for older people - eHealth (IHOPe) - evaluating remote integrated person-centred care : Protocol of a randomised controlled trial with effectiveness, health economic, and process evaluation

BACKGROUND

Healthcare and welfare systems worldwide are unprepared to accommodate the growing population of older people. Simultaneously, the cost of reactive care for older people is increasing. However, healthcare systems in many countries are reforming towards integrated and person-centred care with a focus on health promotion and proactive actions. The Integrating Health Promotion with and for Older People - eHealth (IHOPe) project aims to describe and evaluate a person-centred e-support intervention that promotes a sustainable partnership between community-dwelling frail older people and health and social care professionals.

METHODS

The IHOPe project is designed as a randomised controlled trial comparing a control group receiving standard care with an intervention group receiving standard care and add-on person-centred care through telephone support and a digital platform. The primary outcome measure is a composite score of changes in general self-efficacy and the need for unscheduled hospital care. The project is conducted in Gothenburg, Sweden. At least 220 participants aged ≥ 75 years will be included after being screened using a frailty instrument. The study design, intervention components, digital platform, and questionnaires were developed in close collaboration with an advisory group of inter-professional researchers, stakeholders, clinicians, and older representatives. Data will mainly be collected through questionnaires at baseline and 3, 6, and 12 months after inclusion in the study. Recruitment is ongoing and should be completed during 2023. Data will be analysed using quantitative and qualitative methods. The evaluation will include effectiveness, process, and health economics. The study was approved by the Regional Ethical Review Board in Gothenburg, Sweden (Dnr 2019-05364, Dnr 2020-03550, Dnr 2021-03255).

DISCUSSION

The findings will expand our knowledge of remotely integrated person-centred care for frail older people. Thereby, the IHOPe project is expected to fill highlighted knowledge gaps on intervention evaluations including the triad of person-centred, digital, and integrated care elements, as well as economic evaluations of remote health services for frail older people. The study is ongoing, and the results are not completed but if they turn out to be positive, implementation is not limited to time or location.

TRIAL REGISTRATION

ClinicalTrial.gov: NCT04416815. Registered 07/06/2021.

Is ultra-hypo-fractionated radiotherapy more cost-effective relative to conventional fractionation in treatment of prostate cancer? A cost-utility analysis alongside a randomized HYPO-RT-PC trial

BACKGROUND

Economic evidence for comparing low fraction with ultra-hypo fractionated (UHF) radiation therapy in the treatment of intermediate-to-high-risk prostate cancer (PC) is lacking, especially in Europe. This study presents an economic evaluation performed alongside an ongoing clinical trial.

AIM

To investigate up to 6 years' follow-up whether conventional fractionation (CF, 78.0 Gy in 39 fractions, 5 days per week for 8 weeks) is more cost-effective than UHF (42.7 Gy in 7 fractions, 3 days per week for 2.5 weeks inclusive of 2 weekends) radiotherapy in treatment for patients with intermediate-to-high-risk PC.

METHOD

HYPO-RT-PC trial is an open-label, randomized, multicenter (10 in Sweden; 2 in Denmark) phase-3 trial. Patients from Sweden (CF 434; UHF 445) were included in this study. The trial database was linked to the National Patient Registry (NPR). Costs for inpatient/non-primary outpatient care for each episode were retrieved. For calculating Quality-adjusted life years (QALYs), the EORTC QLQ-C30 questionnaire was mapped to the EQ-5D-3L index. Multivariable regression analyses were used to compare the difference in costs and QALYs, adjusting for age and baseline costs, and health status. The confidence interval for the difference in costs, QALYs and incremental cost-effectiveness ratio effectiveness ratio (ICER) was estimated by the bootstrap percentile method.

RESULTS

No significant differences were found in ICER between the two arms after 6 years of follow-up.

CONCLUSION

The current study did not support that the ultra-hypo-fractionated treatment was more cost-effective than the conventional fraction treatment up to the sixth year of the trial.

Validity of the short musculoskeletal function assessment questionnaire in patients with a spine fracture

PURPOSE

The aim of this study was to validate the use of the Short Musculoskeletal Function Assessment (SMFA) questionnaire in patients with a spine fracture.

METHODS

Cross-sectional cohort of individuals that had sustained a spine fracture (C1-L5) one year earlier. Patients were asked to fill out SMFA, Oswestry Disability Index (ODI), EQ-5D-3L and EQ-VAS. Spearman's rank correlation coefficient (rho) was used to assess convergent validity for each patient-reported outcome measure (PROM). Bland-Altman plots were used to assess PROM agreement.

RESULTS

82 patients completed all questionnaires. The correlations between SMFA Dysfunction and Bother indices and ODI were 0.89 and 0.86, with EQ-5D-3L index 0.89 and 0.80, and with EQ-VAS 0.80 and 0.73, respectively. The correlation for separate categories of the SMFA dysfunction index (daily activities, emotional status, arm and hand function, mobility) ranged between 0.71-0.87 for ODI, 0.72-0.84 for EQ-5D-3L index, and 0.67-0.77 for EQ-VAS. A selection of the ten items of SMFA that had the highest correlations with ODI resulted in a correlation of 0.91. The agreements between SMFA indices and ODI in Bland-Altman plots were good with small differential biases and minimal proportional biases, but worse for SMFA and EQ-5D-3L index and EQ-VAS.

CONCLUSION

The SMFA indices are highly correlated with ODI in patients with a spine fracture. The Dysfunction index and Bother index, or selected SMFA items, may be used to assess outcome in patients with spine fractures as an alternative to ODI.

Long-term health-related quality of life after trauma with and without traumatic brain injury: a prospective cohort study

To purpose was to assess and compare the health-related quality of life (HRQoL) and risk of depression two years after trauma, between patients with and without traumatic brain injury (TBI) in a mixed Swedish trauma cohort. In this prospective cohort study, TBI and non-TBI trauma patients included in the Swedish Trauma registry 2019 at a level II trauma center in Stockholm, Sweden, were contacted two years after admission. HRQoL was assessed with RAND-36 and EQ-5D-3L, and depression with Montgomery Åsberg depression Rating Scale self-report (MADRS-S). Abbreviated Injury Score (AIS) head was used to grade TBI severity, and American Society of Anesthesiologists (ASA) score was used to assess comorbidities. Data were compared using Chi-squared test, Mann Whitney U test and ordered logistic regression, and Bonferroni correction was applied. A total of 170 of 737 eligible patients were included. TBI was associated with higher scores in 5/8 domains of RAND-36 and 3/5 domains of EQ-5D (p < 0.05). No significant difference in MADRS-S. An AIS (head) of three or higher was associated with lower scores in five domains of RAND-36 and two domains of EQ-5D but not for MADRS-S. An ASA-score of three was associated with lower scores in all domains of both RAND-36 (p < 0.05, except mental health) and EQ-5D (p < 0.001, except anxiety/depression), but not for MADRS-S. In conclusion, patients without TBI reported a lower HRQoL than TBI patients two years after trauma. TBI severity assessed according to AIS (head) was associated with HRQoL, and ASA-score was found to be a predictor of HRQoL, emphasizing the importance of considering pre-injury health status when assessing outcomes in TBI patients.

Long-Term Functional Outcome and Quality of Life After Surgical Evacuation of Spontaneous Supratentorial Intracerebral Hemorrhage: Results from a Swedish Nationwide Cohort

OBJECTIVE

To investigate long-term survival, neurologic outcome, and quality of life in patients with spontaneous supratentorial intracerebral hemorrhage (ICH) treated with craniotomy and hematoma evacuation.

METHODS

A nationwide multicenter retrospective analysis of 341 patients who underwent craniotomy and evacuation of supratentorial ICH between January 1, 2011, and December 31, 2015, was performed. Baseline characteristics associated with 6-month mortality and long-term mortality were investigated. Survivors received a questionnaire about their state of health from which EuroQol 5D (EQ-5D) and modified Rankin scale (mRS) were obtained. Predictors of mortality, unfavorable outcome, and life quality were analyzed.

RESULTS

The mean follow-up time was 55.2 months. Predictors of 6-month mortality in multiple regression analysis were age ≥75 years, previous myocardial infarction, lower level of consciousness, and mechanical ventilation. Predictors of long-term mortality were higher age and mechanical ventilation. At follow-up, 49.5% of survivors had a favorable neurologic outcome (mRS ≤3). Predictors of an unfavorable functional outcome were higher age and ICH volume ≥50 mL. The mean EQ-5D health index was 0.719, and the mean EQ-5D visual analog scale score was 53.9. In multiple regression, only a higher mRS score was significantly associated with worse life quality.

CONCLUSIONS

Knowledge about survival, functional outcome, and life quality as well as their predictors in this specific patient group is previously primarily described in short-term follow-up. This multicenter study provides novel information in the long-term perspective, which is important for improved surgical decision-making and prognostication.

Quality of life among female childhood cancer survivors with and without premature ovarian insufficiency

PURPOSE

Due to an increase in survival, a growing population of childhood cancer survivors (CCS) is present. However, female CCS are at risk of developing premature ovarian insufficiency (POI) after cancer treatment. POI involves a decreased chance of conceiving and the increased infertility state has a large impact on affected individuals' health and mental life. The objective of this study was to investigate health state and well-being among female CCS with and without POI and healthy controls (HC).

METHODS

Female CCS treated in southern Sweden between 1964 and 2008 were included. Each patient was matched with a HC. The final study population included 167 female CCS and 164 HC that were examined between October 2010 and January 2015 at the Reproductive Medicine Centre at Skåne University Hospital in Malmö, Sweden. All participants, except for two HCs, answered an EQ-5D-3L questionnaire for measuring health state including a visual analogue scale (VAS) for estimating well-being.

RESULTS

There were 22 CCS with POI, none of the HC had POI. The mean health state differed among groups (unadjusted: P = 0.002; adjusted: P = 0.007). A difference in mean experienced well-being among groups was noted (unadjusted: P = 0.003; adjusted: P = 0.012). Lowest well-being was found in the CCS group with POI (P = 0.024).

CONCLUSIONS

Female CCS have a significantly decreased health state and well-being. Female CCS with POI additionally have the lowest self-estimated well-being.

IMPLICATIONS FOR CANCER SURVIVORS

Female CCS with POI should be identified early in order to give them adequate information and support.

Do Patients Aged 85 Years and above Benefit from Their Cochlear Implants?

The present study aims to investigate the usage and benefits of cochlear implants (CIs) in elderly patients aged ≥85 years, including their device-handling issues, follow-ups, and the influence on their well-being. The patients answered one questionnaire regarding quality of life, EQ5D-3L, and one questionnaire, obtained from the Swedish CI quality register, regarding usage, handling, satisfaction, remaining difficulties, etc. The medical records were searched for the implantation date, implant model, speech processor model, monosyllabic (MS) word scores, infections over the implant, and compliance regarding scheduled visits to the clinic. The results show that most elderly patients are satisfied full-time users of their implants. Even though most patients had no problems handling their CI, handling issues must be considered. Recurring guidance and training on device operation are needed. We suggest that follow-up visits are essentially needed for this group of patients on a regular basis. CI surgery is considered a safe treatment, even for the elderly. Upgrads to new external equipment (e.g., sound processors) should not be excluded because of their age. The results suggested that the CI positively affected their well-being. This study was approved by the Swedish Ethical Review Authority (5/10-2021, Dnr: 2021-04970).

Cost-effectiveness analysis of bimekizumab for the treatment of active psoriatic arthritis in Sweden

AIMS

To evaluate the cost-effectiveness of bimekizumab, an inhibitor of IL-17F and IL-17A, against biologic and targeted synthetic disease-modifying antirheumatic drugs (DMARD) for psoriatic arthritis (PsA) from the Swedish healthcare system perspective.

MATERIALS AND METHODS

A Markov model was developed to simulate the clinical pathway of biologic [b] DMARD-naïve or tumor necrosis factor inhibitor experienced [TNFi-exp] PsA patients over a lifetime horizon. Treatment response was incorporated as achievement of the American College of Rheumatology 50% (ACR50) and Psoriasis Area and Severity Index 75% (PASI75) response, and changes in the Health Assessment Questionnaire-Disability Index (HAQ-DI) score. The efficacy of bimekizumab was obtained from the BE OPTIMAL (bDMARD-naïve) and BE COMPLETE (TNFi-experienced) trials while a network meta-analysis (NMA) informed the efficacy of the comparators. Resource use and drug costs were obtained from published studies and databases of drug retail prices in Sweden. A willingness-to-pay threshold of €50,000 per quality-adjusted life year (QALY) was applied.

RESULTS

In bDMARD-naïve patients, bimekizumab achieved greater QALYs (14.08) than with all comparators except infliximab (14.22), dominated guselkumab every 4 and 8 weeks, ixekizumab, secukinumab 300 mg, ustekinumab 45 mg and 90 mg, and was cost-effective against risankizumab, tofacitinib, upadacitinib and TNFis, except adalimumab biosimilar. In TNFi-experienced patients, bimekizumab led to greater QALYs (13.56) than all comparators except certolizumab pegol (13.84), and dominated ixekizumab and secukinumab 300 mg while being cost-effective against all other IL-17A-, IL-23- and JAK inhibitors.

LIMITATIONS

An NMA informed the comparative effectiveness estimates. Given gaps in evidence of disease management and indirect costs specific to HAQ-DI scores, and sequential clinical trial evidence in PsA, non-PsA cost data from similar joint conditions were used, and one line of active treatment followed by best supportive care was assumed.

CONCLUSIONS

Bimekizumab was cost-effective against most available treatments for PsA in Sweden, irrespective of prior TNFi exposure.

Estimating a social value set for EQ-5D-5L in Sweden

BACKGROUND

The study aims to elicit a value set based on the EQ-VT for the EQ-5D-5L that can be used to support decision-making in Sweden.

METHODS

Participants were recruited from the general population based on age, sex and urban/rural area quota sampling from five regions across Sweden. In total, 785 interviews were conducted from February 2020 to April 2021 using the EQVT 2.1 protocol, and both composite time trade-off (c-TTO) and discrete choice experiments (DCE) were used to elicit health preferences. A variety of models have been tested for the c-TTO data (generalized least square, Tobit, heteroskedastic models) and DCE data (conditional logit model), as well as the combined c-TTO and DCE data (hybrid modelling). Model selection was based on theoretical considerations, logical consistency of the parameter estimates, and significance of the parameters (p = 0.05). Model goodness-of-fit was assessed by AIC and BIC, and prediction accuracy was assessed in terms of mean absolute error. The predictions for the EQ-5D-5L health states between models were compared using scatterplots.

RESULTS

The preferred model for generating the value set was the heteroskedastic model based on the c-TTO data, with the health utilities ranging from -0.31 for the worst (55,555) to 1 for the best (11111) EQ-5D-5L states.

CONCLUSION

This is the first c-TTO-based social value set for the EQ-5D-5L in Sweden. It can be used to support the health utility estimation in economic evaluations for reimbursement decision making in Sweden.

Do they just know more, or do they also have different preferences? An exploratory analysis of the effects of self-reporting serious health problems on health state valuation

BACKGROUND

Health state valuation is often conducted by people valuing either only their own health state (experience-based valuation) or several stylised states (hypothetical valuation). The approach used can affect the elicited values, but it is not clear whether this is caused by different understandings of the states (an "information mechanism") and/or by different opinions of the states (a "preference mechanism"). Justifying privileging the valuations of those with the relevant health state experience solely because they are better informed is insufficient when their opinions differ. This study proposes a new framework to examine the effect of having health problems on health state valuation by distinguishing "within-dimensional" effects (which can be due to better information or due to differences in opinion) and "cross-dimensional" effects (which must be due to differences in opinion).

METHODS

Secondary data from the UK that valued EQ-5D-5L using Discrete Choice Experiments with duration (DCE_TTO) are remodelled controlling for whether a respondent self-reports serious (viz., severe or extreme) problems in "pain or discomfort" (PD) or "anxiety or depression" (AD). The main analysis uses respondents who have serious PD or serious AD alongside matched respondents who do not, and assumes constant proportional time trade-off.

RESULTS

Self-reporting serious PD or serious AD problems has no within-dimensional effect on health state preferences. However, self-reporting serious AD problems has negative cross-dimensional effects on the utility of having any problem in PD, which suggests that the preference mechanism is present. A similar pattern holds when all available (unmatched) data are used and when constant proportional time trade-off is relaxed.

CONCLUSIONS

Findings consistent with the preference mechanism indicate that those with serious health problems may have different opinions on the value of health states compared to the rest of the population, which has normative implications for the debate on which values to use.

Health-related quality of life in adolescents with idiopathic scoliosis: a cross-sectional study including healthy controls

PURPOSE

To describe health-related quality of life in adolescents with idiopathic scoliosis and controls.

METHODS

This cross-sectional study analysed data from 307 individuals with idiopathic scoliosis and 80 controls without scoliosis (mean age 15.5 ± 2.1 and 14.0 ± 2.2 years, respectively). Health-related quality of life (HRQoL) was assessed using EuroQol 5-dimensions (EQ-5D) questionnaire, and the scoliosis specific Scoliosis Research Society-22r questionnaire (SRS-22r). HRQoL data in individuals with scoliosis were compared to controls, between treatment groups (untreated, ongoing brace, previously braced and surgically treated) and stratified according to curve size.

RESULTS

Adolescents with idiopathic scoliosis had reduced HRQoL compared with controls, observed through lower SRS-22r subscore (respective means 4.16 and 4.68, p < 0.001) and lower EQ-5D index (respective means 0.92 and 0.95, p = 0.032). No differences in SRS-22r subscore or EQ-5D index were detected when comparing different scoliosis treatment groups. Within the SRS-22r function domain the surgically treated group scored 4.40, significantly lower compared to the untreated (4.65) and ongoing brace groups (4.68, p = 0.005). The surgically treated and untreated group were more affected by pain, compared to the ongoing brace group (p = 0.01) with the surgically treated group scoring lowest. Non-surgically treated scoliosis individuals with larger curves (> 30 degrees) had a lower SRS-22r subscore (4.08) compared to those with smaller curves (4.31, p = 0.001).

CONCLUSION

Adolescents with idiopathic scoliosis had a reduced HRQoL compared to healthy controls. Minor differences were detected when comparing between idiopathic scoliosis treatment groups. Non-surgically treated scoliosis patients with larger curves had a lower HRQoL shown by lower SRS-22r values.

Patient Reported Outcome and Quality of Life After Delayed Breast Reconstruction - An RCT Comparing Different Reconstructive Methods in Radiated and Non-radiated Patients

BACKGROUND

Health-related quality of life (HRQoL) is one of the core outcomes for breast reconstruction. The aim of this study was to evaluate whether the method of delayed breast reconstruction affects long-term HRQoL.

METHODS

Participants were divided into 2 arms depending on previous radiotherapy, and subsequently randomized between 2 methods of breast reconstruction: a latissimus dorsi flap or a deep inferior epigastric artery perforator flap in the radiated arm and a thoracodorsal flap and implant or an expander in the non-radiated arm. Validated HRQoL instruments were used: BREAST-Q to evaluate breast specific HRQoL and satisfaction, RAND-36 and EQ-5D to evaluate generic HRQoL, and BDI-21 to measure symptoms of depression and anxiety.

RESULTS

During the recruitment period (2009-2015), 233 patients were randomized. After opt-outs and exclusions, the remaining 107 participants comprise the study sample. Postoperative HrQoL was measured on average 7to 8years post-operatively. Response rates varied between 60 and 82 per cent. The BREAST-Q scores were higher after the reconstruction than before for the great majority of domains in both arms; albeit statistically significant only between the 2 methods for physical well-being chest in the radiated arm. Most participants in both arms had minimal or mild depression both before and after the operation.

CONCLUSION

No distinct differences in long-term HrQoL could be seen for different methods There was a clear improvement in HrQoL compared to pre-reconstruction in all groups, but the effect of specific reconstructive methods on scores could not be reliably demonstrated.

Patient-reported outcomes among patients undergoing total hip replacement in an integrated care system and in a standard care system in Region Stockholm, Sweden

BACKGROUND

Coordination, cooperation and efficient use of resources is vital for the health- and social care sector if it is to meet the needs of an aging population. Integrated care is a patient-centred approach to provision of care aiming to improve quality of care and overcome fragmented care through co-productive partnerships and may positively affect quality of care and health outcomes, especially among those in need of highly coordinated care services.

AIM

To compare patient-reported outcomes (PROs) among patients undergoing total hip replacement (THR) in the integrated care system in Norrtälje Municipality and in the standard care system in other municipalities in Region Stockholm, Sweden.

METHODS

Swedish Hip Arthroplasty Register PRO data during 2008-2015 were compared 1 year after THR among patients (≥50 years) in integrated care (n = 407) and standard care (n = 3501) systems using linear (EQ VAS score), logistic (EQ-5D-3L dimensions) and negative binomial (hip pain VAS score) regressions. Analyses were adjusted for the preoperative factors age, sex, BMI, ASA class and type of incision.

RESULTS

1-year postoperatively, patients in the integrated care system did not report their health significantly different from patients receiving standard care. Exceptions: Female patients in integrated care reported less problems with self-care (OR:0.52; 0.29-0.96) and patients above 70 years reported more problems with mobility (OR: 1.37; 1.01-1.87).

CONCLUSION

No significant differences were found between the two care systems for postoperative PROs. A longer follow-up time and analyses by socioeconomic groups would be valuable.

Hyperbaric oxygen for treatment of long COVID-19 syndrome (HOT-LoCO): protocol for a randomised, placebo-controlled, double-blind, phase II clinical trial

INTRODUCTION

Long COVID-19, where symptoms persist 12 weeks after the initial SARS-CoV-2-infection, is a substantial problem for individuals and society in the surge of the pandemic. Common symptoms are fatigue, postexertional malaise and cognitive dysfunction. There is currently no effective treatment and the underlying mechanisms are unknown, although several hypotheses exist, with chronic inflammation as a common denominator. In prospective studies, hyperbaric oxygen therapy (HBOT) has been suggested to be effective for the treatment of similar syndromes such as chronic fatigue syndrome and fibromyalgia. A case series has suggested positive effects of HBOT in long COVID-19. This randomised, placebo-controlled clinical trial will explore HBOT as a potential treatment for long COVID-19. The primary objective is to evaluate if HBOT improves health-related quality of life (HRQoL) for patients with long COVID-19 compared with placebo/sham. The main secondary objective is to evaluate whether HBOT improves endothelial function, objective physical performance and short-term HRQoL.

METHODS AND ANALYSIS

A randomised, placebo-controlled, double-blind, phase II clinical trial in 80 previously healthy subjects debilitated due to long COVID-19, with low HRQoL. Clinical data, HRQoL questionnaires, blood samples, objective tests and activity metre data will be collected at baseline. Subjects will be randomised to a maximum of 10 treatments with hyperbaric oxygen or sham treatment over 6 weeks. Assessments for safety and efficacy will be performed at 6, 13, 26 and 52 weeks, with the primary endpoint (physical domains in RAND 36-Item Health Survey) and main secondary endpoints defined at 13 weeks after baseline. Data will be reviewed by an independent data safety monitoring board.

ETHICS AND DISSEMINATION

The trial is approved by the Swedish National Institutional Review Board (2021-02634) and the Swedish Medical Products Agency (5.1-2020-36673). Positive, negative and inconclusive results will be published in peer-reviewed scientific journals with open access.

TRIAL REGISTRATION NUMBER

NCT04842448.

The health cost of reducing hospital bed capacity

In the past two decades, most high-income countries have reduced their hospital bed capacity. This could be a sign of increased efficiency but could also reflect a degradation in quality of care. In this paper, we use repeated cross-sections on mortality and staffed hospital beds per capita in all 21 Swedish regions to estimate the potential death toll from reduced bed capacity. Between 2001 and 2019, mortality and beds decreased across all regions, but regions making smaller bed reductions experienced on average greater decreases in mortality, equivalent to one less death per three beds retained. This estimate is stable to a wide range of specifications and to adjustment for potential confounders, which supports a causal interpretation. Our results imply that by providing one more bed, Swedish health care could produce about three quality-adjusted life years (QALYs) at a cost of SEK 400,000 (∼US$40,000) per QALY. These findings could be informative about the marginal productivity of health care and support the credibility of empirical work attempting to estimate the opportunity cost of funding new healthcare interventions subject to a constrained budget.

Completing the time trade-off with respondents who are older, in poorer health or with an immigrant background in an EQ-5D-5L valuation study

OBJECTIVES

To determine the effects of age, immigrant background, and poor self-reported health in a general population sample on the probability of non-completion or slow completion of the time trade-off (TTO).

METHODS

We used data from an interrupted Norwegian EQ-5D-5L valuation study conducted between 2019 and 2020. All participants responded to background items, irrespective of completion. We used mixed effect logistic regression analysis to assess the effect of old age, poor health, and immigrant background on the probability of non-completion of the TTO, and, for those who completed the TTO, of slow completion times.

RESULTS

First experiences from a Norwegian valuation study were that 29 (5.5%) respondents failed to complete the TTO tasks. For those reporting age over 65 years, poor health, or an immigrant background, 12% failed to complete the TTO. Adjusted odds ratios for predictors of non-completion were statistically significant (age > 65 years, 8.3; EQ-VAS ≤ 50, 3.49; immigrant background, 4.56). Being over 65 years or with an immigrant background also predicted slow completion of both the introduction and TTO tasks.

CONCLUSIONS

High age, poor health, and immigrant status increased the risk of not being able to complete the TTO tasks, and of slow completion. Higher non-completion rates and increased completion times suggest that elements of the TTO may be demanding for some respondent groups, with possible implications for representativeness.

Factors and Predictors of Health Related Quality of Life of the General Population of Pakistan

Background and Objective

The standards of living, improvement in public health, and medical care in Pakistan are increasing day by day, health-related quality of life (HRQoL) has been increasingly acknowledged in various patient's reported outcomes in Pakistan. However, a large-scale general population-based study on assessing HQRoL in Pakistan was not conducted. Therefore, this study aimed to evaluate HRQoL for the general Pakistani population.

Material and Methods

A cross-sectional study with a population sample (n = 16,672) was selected from all Pakistan provinces using a stratified sampling approach. The EQ-5D-3L tool was used to measure the HRQoL of the general population of Pakistan. The descriptive and inferential statistics have been done by using SPSS version 20.

Results

Overall, 121 health states were reported in this study. EQ-5D index and EQ-VAS scores were 0.74 ± 0.32 and 0.75 ± 0.25, respectively. The percentage of people responding to any problems increased with age. Males have better health as compared to females in all age groups. All demographics were significantly associated (P < 0.01) with the mean EQ5D index and VAS scores except residence (p > 0.05). The regression model reported that age was the best predictor of the EQ-5D index scores after adjusting for the covariates (beta = 0.19; p < 0.001). This study provides Pakistani population HRQoL data measured by the EQ-5D tool, based on a national representative sample.

Conclusion

The current study concluded that Age, City, Gender, Education, Occupation, Residence, and House occupancy are significantly affecting HRQOL. The socioeconomically deprived groups and females have inferior health status than more advantaged. The trends detected in high-income nations were usually similar to Pakistan.

What are the effects of implementing patient-controlled admissions in inpatient care? A study protocol of a large-scale implementation and naturalistic evaluation for adult and adolescent patients with severe psychiatric conditions throughout Region Stockholm

INTRODUCTION

Patient-controlled admissions (PCAs) represent a change in psychiatric inpatient care where patients are allowed to decide for themselves when hospitalisation might be required. Prior research has demonstrated that PCA increase the number of admissions, but decrease days in inpatient care, while both the admissions to and days in involuntary care decrease. However, investigations have been restricted to specific patient groups and have not examined other possible benefits, such as effects on symptoms, quality of life and autonomy.

METHODS AND ANALYSIS

This study explores the implementation process and effects of PCA in Region Stockholm, who is currently introducing PCA for all patients with severe psychiatric conditions and extensive healthcare utilisation. In total, the study comprises approximately 45 inpatient wards, including child and adolescent psychiatry. In a naturalistic evaluation, patients assigned PCA will be followed up to 36 months, both with regard to hospitalisation rates and self-reported outcomes. In addition, qualitative studies will explore the experiences of patients, caregivers of adolescents and healthcare providers.

ETHICS AND DISSEMINATION

Approval has been granted by the Swedish Ethical Review Authority (Dnr: 2020-06498). The findings from this study will be disseminated via publications in international peer-reviewed journals, at scientific conferences, as part of two doctoral theses, and through the Swedish Partnership for Mental Health.

TRIAL REGISTRATION NUMBER

NCT04862897.

Exploring the most important factors related to self-perceived health among older men in Sweden: a cross-sectional study using machine learning

OBJECTIVE

To evaluate which factors are the most strongly related to self-perceived health among older men and describe the shape of the association between the related factors and self-perceived health using machine learning.

DESIGN AND SETTING

This is a cross-sectional study within the population-based VAScular and Chronic Obstructive Lung disease study (VASCOL) conducted in southern Sweden in 2019.

PARTICIPANTS

A total of 475 older men aged 73 years from the VASCOL dataset.

MEASURES

Self-perceived health was measured using the first item of the Short Form 12. An extreme gradient-boosting model was trained to classify self-perceived health as better (rated: excellent or very good) or worse (rated: fair or poor) using self-reported data on 19 prevalent physician-diagnosed health conditions, intensity of 9 symptoms and 9 demographic and lifestyle factors. Importance of factors was measured in SHapley Additive exPlanations absolute mean and higher scores correspond to greater importance.

RESULTS

The most important factors for classifying self-perceived health were: pain (0.629), sleep quality (0.595), breathlessness (0.549), fatigue (0.542) and depression (0.526). Health conditions ranked well below symptoms and lifestyle variables. Low levels of symptoms, good sleep quality, regular exercise, alcohol consumption and a body mass index between 22 and 28 were associated with better self-perceived health.

CONCLUSIONS

Symptoms are more strongly related to self-perceived health than health conditions, which suggests that the impacts of health conditions are mediated through symptoms, which could be important targets to improve self-perceived health. Machine learning offers a new way to assess composite constructs such as well-being or quality of life.

Internet-based vestibular rehabilitation versus standard care after acute onset vertigo: a study protocol for a randomized controlled trial

Background

Dizziness and vertigo affect around 15% of adults annually and represent common reasons for contacting health services, accounting for around 3% of all emergency department visits worldwide. Vertigo is also associated with excessive use of diagnostic imaging and emergency care and decreased productivity, primarily because of work absenteeism. Vestibular rehabilitation is an evidence-based treatment for chronic dizziness and supervised group exercise therapy has recently been shown to be effective after vestibular neuritis, a common cause of acute onset vertigo. However, such interventions are not readily available and there is a need for more easily accessible tools. The purpose of this study is to investigate the effects on vestibular symptoms of a 6-week online vestibular rehabilitation tool after acute onset vertigo, with the aim of aiding vestibular rehabilitation by presenting a more accessible tool that can help to reduce recovery time.

Methods

Three hundred twenty individuals diagnosed with acute vestibular syndrome (AVS) will be recruited from multiple hospitals in Sweden and the effects of an online vestibular rehabilitation tool, YrselTräning, on vestibular symptoms after acute onset vertigo will be compared to standard care (written instructions leaflet) in a two-armed, evaluator-blinded, multicenter randomized controlled trial. The primary outcome will be the Vertigo Symptom Scale Short Form (VSS-SF) score at 6 weeks after symptom onset. Secondary outcomes include effects of the intervention on activities of daily living, mood and anxiety, vestibular function recovery, mobility measures, health economic effects, and the reliability of the Swedish VSS-SF translation.

Discussion

Participants using the online vestibular rehabilitation tool are expected to recover earlier and to a greater extent from their symptoms as compared to standard care. Since up to 50% of people with AVS without treatment develop persistent symptoms, effective treatment of AVS will likely lead to a higher quality of life and help reduce the societal costs associated with dizziness and vertigo.

Trial registration

Clinicaltrials.gov NCT05056324. Registered on September 24, 2021.

Intravenous iron supplement for iron deficiency in patients with severe aortic stenosis scheduled for TAVI Results of the IIISAS randomised trial

Aims

The aim of this trial was to evaluate whether intravenous iron could provide benefit beyond transcatheter aortic valve implantation (TAVI) in iron‐deficient patients with severe aortic stenosis.

Methods and results

In this randomised, placebo‐controlled, double‐blind, single‐centre trial, we enrolled patients with severe aortic stenosis and iron deficiency (defined as ferritin <100 µg/L, or 100–299 µg/L with a transferrin saturation <20%) who were evaluated for TAVI. Patients were randomly assigned (1:1) to receive intravenous ferric derisomaltose or placebo ∼3 months before TAVI. The primary endpoint was the between‐group, baseline‐adjusted 6‐min walk distance measured 3 months after TAVI. Secondary outcomes included quality of life, iron stores, hand grip strength, New York Heart Association (NYHA) class, and safety. Between January 2020 and September 2021, we randomised 74 patients to ferric derisomaltose and 75 patients to placebo. The modified intention‐to‐treat population comprised the 104 patients who completed the 6‐min walk test at baseline and 3 months after successful TAVI. Iron stores were restored in 76% of the patients allocated to iron and 13% of the patients allocated to placebo (p < 0.001). There was no difference in the baseline‐adjusted 6‐min walk distance between the two treatment arms (p = 0.82). The number of serious adverse events, quality of life, hand grip strength, and NYHA class did not differ between the treatment arms.

Conclusion

Treatment with intravenous iron did not provide clinical benefit beyond TAVI in iron‐deficient patients with severe aortic stenosis.

Clinical Trial Registration: ClinicalTrials.gov NCT04206228.