What difference does it make? The calculation of QALY gains from health profiles using patient and general population values

Cost effectiveness and health-related quality of life of chemoradiotherapy versus radiation therapy alone in elderly head and neck cancer patients

Purpose

Radiotherapy (RT) constitutes a mainstay in the treatment of elderly patients with head and neck cancer (HNC), but use of simultaneous chemoradiotherapy (CRT) remains controversial. We have conducted a prospective analysis based on real-world patient data to examine the health-related quality of life (HRQoL) and cost effectiveness (CE) of CRT vs. RT in elderly HNC patients.

Methods

Eligible participants ≥ 65 years treated in a large tertiary cancer center between July 2019 and February 2020 who completed the validated EQ-5D-5L questionnaire (health state index [HI] and visual analog scale [VAS]) before and after RT were included. CE referred to direct medical costs, including diagnosis-related group (DRG)-based billings for inpatients and uniform assessment standard (EBM)-based costs for outpatients. The primary endpoint was cost (euros [€]) per quality-adjusted life year (QALY). The incremental cost-effectiveness ratios (ICERs) were calculated. Costs and QALYs were not discounted for short overall survival (OS).

Results

Baseline HRQoL was 0.878 (±0.11) in the CRT group and 0.857 (±0.17) in the RT group. Upon completion of therapy, HRQoL amounted to 0.849 (±0.14) in the CRT and 0.850 (±0.13) in the RT group. The mean treatment-related cost in the CRT cohort was €22,180.17 (±8325.26) vs. €18,027.87 (±26,022.48) in the RT group. The corresponding QALYs amounted to 2.62 in the CRT and 1.91 in the RT groups. The ICER was €5848.31.

Conclusion

This is the first analysis from the German health care system demonstrating that the addition of chemotherapy to RT for selected elderly HNC patients is cost effective and not associated with a significant HRQoL decline.

Whom should we ask? A systematic literature review of the arguments regarding the most accurate source of information for valuation of health states

To determine and critically evaluate the arguments in the published literature regarding the most accurate source of information for valuation of health states: values based on experienced health states (patient values) or values based on described health states (general public values).

Using Time Trade-Off Methods to Elicit Short-Term Utilities Associated with Treatments for Bulbar Urethral Stricture

BACKGROUND

Recurrent urethral stricture is usually treated with either open urethroplasty or endoscopic urethrotomy. Both of the procedures cause short-term utility loss, which may not be captured by standard utility questionnaires due to the challenges of completing a standard instrument at the time of an acute episode of short duration, especially within a clinical trial setting. We propose to use time trade-off (TTO) methods to estimate these short-term utility losses.

OBJECTIVE

The aim was to compare the use of two alternative TTO methods to elicit patients' short-term utilities following surgical treatments for recurrent urethral stricture.

METHOD

Two variants of TTO (chained and conventional) were used. Six health profiles were developed-three for each procedure. Forty participants took part, with 20 randomly allocated to each TTO method.

RESULTS

Thirty-eight participants provided usable data for analysis. Estimated utility values decreased as the severity of the health profiles increased. There was no evidence that utility values differed between elicitation methods or procedures for mild {ranging from 0.79 (standard deviation [SD] 0.17) to 0.83 [SD 0.20]} and moderate (ranging from 0.54 [SD 0.24] to 0.67 [SD 0.21]) health states, although they appeared to differ for severe health states (ranging from 0.29 [SD 0.20] to 0.56 [SD 0.24]).

CONCLUSION

The study demonstrates the feasibility and value of eliciting patients' short-term utilities. Given the small sample size, the study findings are tentative. Further research with a larger sample size is needed to determine the appropriate TTO method to use and how the elicited utilities can be used in combination with standard cost-utility assessments to aid decision making.

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

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

Challenges in Valuing Temporary Health States for Economic Evaluation: A Review of Empirical Applications of the Chained Time Trade-Off Method

BACKGROUND

The time trade-off (TTO) technique is commonly used to elicit health state utilities. Nevertheless, when the health states being valued are temporary, the TTO approach may be unsuitable. A variant of TTO- chained TTO-has been suggested to be used when the health states are temporary, but little research has been done on how chained TTO should be conducted.

OBJECTIVES

To systematically review the use of chained TTO in valuing temporary health states.

METHODS

A systematic literature search was conducted using the following major databases: Ovid MEDLINE(R), Embase, EBM Reviews, and PsycINFO. Abstracts (full articles if necessary) were screened by two independent reviewers, with a third reviewer resolving any disagreements.

RESULTS

The resulting number of articles for review was low (n = 9). All the reviewed studies used face-to-face interviews, most had small sample sizes (<100), and all studies valued a small number of health states (<7), with time horizons typically ranging from 4 weeks to 1 year. All studies discussed methodological issues of using chained TTO, and some compared the results with those generated using other preference elicitation methods.

CONCLUSIONS

Chained TTO appears to be feasible, consistent, and responsive and allows the valuation of temporary health states that would improve the efficiency and accuracy of decision making in health and health care. Nevertheless, the evidence is limited due to the low number of relevant studies in the literature. Further research is needed to examine the performance and validity of chained TTO compared with conventional TTO in the valuation of temporary health states.

Disability weights based on patient-reported data from a multinational injury cohort

Objective

To create patient-based disability weights for individual injury diagnosis codes and nature-of-injury classifications, for use, as an alternative to panel-based weights, in studies on the burden of disease.

Methods

Self-reported data based on the EQ-5D standardized measure of health status were collected from 29 770 participants in the Injury-VIBES injury cohort study, which covered Australia, the Netherlands, New Zealand, the United Kingdom of Great Britain and Northern Ireland and the United States of America. The data were combined to calculate new disability weights for each common injury classification and for each type of diagnosis covered by the 10th revision of the International statistical classification of diseases and related health problems. Weights were calculated separately for hospital admissions and presentations confined to emergency departments.

Findings

There were 29 770 injury cases with at least one EQ-5D score. The mean age of the participants providing data was 51 years. Most participants were male and almost a third had road traffic injuries. The new disability weights were higher for admitted cases than for cases confined to emergency departments and higher than the corresponding weights used by the Global Burden of Disease 2013 study. Long-term disability was common in most categories of injuries.

Conclusion

Injury is often a chronic disorder and burden of disease estimates should reflect this. Application of the new weights to burden studies would substantially increase estimates of disability-adjusted life-years and provide a more accurate reflection of the impact of injuries on peoples’ lives.

Validity of standard gamble utilities in patients referred for aortic valve replacement

PURPOSE

Standard gamble (SG) is the preferred method of assessing preferences in situations with uncertainty and risk, which makes it relevant to patients considered for aortic valve replacement (AVR). The present study assesses SG preferences in patients with severe aortic stenosis (AS).

METHODS

All patients >18 years old with severe AS referred for AVR to our institution were invited to enroll in the study. The SG was administered by a clinical research nurse. The SF-36, EQ-5D 3L, Hospital Anxiety and Depression Scale (HADS), and AS symptoms were administered by self-completed questionnaire. We hypothesized that SG utilities would have low-to-moderate correlations with physical and mental aspects of health based on our pathophysiological understanding of severe AS. No correlations were expected with echocardiographic measures of the aortic valve.

RESULTS

The response rate for SG was 98 %. SG moderately correlated with physical aspects of SF-36 (PCS, role-physical, vitality), health transition, AS symptoms, and EQ-VAS (ρ S = 0.31-0.39, p < 0.001) and had low correlation with mental aspects of SF-36 and EQ-5D (ρ S = 0.17-0.28, p < 0.001). No correlation was found between SG and HADS, echocardiographic measures, age, gender, or education level (ρ S = 0.01-0.06).

CONCLUSIONS

SG is an acceptable and feasible method of assessing preferences in patients with severe AS that has evidence for validity. The inclusion of uncertainty lends the SG face validity in this population as a direct approach to assessing preferences and basis for QALY calculations.

Axiomatic foundations for cost-effectiveness analysis

We show that individual utilities can be measured in units of healthy life years. Social preferences over these life metric utilities are assumed to satisfy the Pareto principle, anonymity, and invariance to a change in origin. These axioms generate a utilitarian social welfare function implying the use of cost-effectiveness analysis in ordering health projects, based on maximizing the healthy years equivalents gained from a fixed health budget. For projects outside the health sector, our cost-effectiveness axioms imply a form of cost-benefit analysis where both costs and benefits are measured in equivalent healthy life years.

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

PURPOSE

To estimate Swedish experience-based value sets for EQ-5D health states using general population health survey data.

METHODS

Approximately 45,000 individuals valued their current health status by means of time trade off (TTO) and visual analogue scale (VAS) methods and answered the EQ-5D questionnaire, making it possible to model the association between the experience-based TTO and VAS values and the EQ-5D dimensions and severity levels. The association between TTO and VAS values and the different severity levels of respondents' answers on a self-rated health (SRH) question was assessed.

RESULTS

Almost all dimensions (except usual activity) and severity levels had less impact on TTO valuations compared with the UK study based on hypothetical values. Anxiety/depression had the greatest impact on both TTO and VAS values. TTO and VAS values were consistently related to SRH. The inclusion of age, sex, education and socioeconomic group affected the main effect coefficients and the explanatory power modestly.

CONCLUSIONS

A value set for EQ-5D health states based on Swedish valuations has been lacking. Several authors have recently advocated the normative standpoint of using experience-based values. Guidelines of economic evaluation for reimbursement decisions in Sweden recommend the use of experience-based values for QALY calculations. Our results that anxiety/depression had the greatest impact on both TTO and VAS values underline the importance of mental health for individuals' overall HRQoL. Using population surveys is in line with recent thinking on valuing health states and could reduce some of the focusing effects potentially appearing in hypothetical valuation studies.

Cost-effectiveness of multiple sclerosis disease-modifying therapies: a systematic review of the literature

Objective. To provide a current and comprehensive understanding of the cost-effectiveness of DMTs for the treatment of MS by quantitatively evaluating the quality of recent cost-effectiveness studies and exploring how the field has progressed from past recommendations. Methods. We assessed the quality of studies that met our systematic literature search criteria using the Quality of Health Economic Studies validated instrument. Results. Of the 82 studies that met our initial search criteria, we included 22 in this review. Four studies (18%) achieved quality category 2, three studies (14%) achieved quality category 3, and 15 studies (68%) achieved the highest quality category 4. 91% of studies were simulation models. 13 studies (59%) had quality-adjusted life years (QALYs) as the primary outcome measure, included a societal perspective in the analysis, and utilized time horizons of 10 years to lifetime. Conclusions. To continue to improve the cost-effectiveness evidence of DMTs, we recommend: lifetime horizons, societal perspectives, and QALYs; supplemental evidence with shorter horizons, payer perspectives, and clinical outcomes to inform multiple decision makers; development of modeling and input standards for comparability; head-to-head RCTs between DMTs and long-term prospective studies; and comprehensive cost-effectiveness studies that compare all appropriate DMTs.

Decomposing cross-country differences in quality adjusted life expectancy: the impact of value sets

Background

The validity, reliability and cross-country comparability of summary measures of population health (SMPH) have been persistently debated. In this debate, the measurement and valuation of nonfatal health outcomes have been defined as key issues. Our goal was to quantify and decompose international differences in health expectancy based on health-related quality of life (HRQoL). We focused on the impact of value set choice on cross-country variation.

Methods

We calculated Quality Adjusted Life Expectancy (QALE) at age 20 for 15 countries in which EQ-5D population surveys had been conducted. We applied the Sullivan approach to combine the EQ-5D based HRQoL data with life tables from the Human Mortality Database. Mean HRQoL by country-gender-age was estimated using a parametric model. We used nonparametric bootstrap techniques to compute confidence intervals. QALE was then compared across the six country-specific time trade-off value sets that were available. Finally, three counterfactual estimates were generated in order to assess the contribution of mortality, health states and health-state values to cross-country differences in QALE.

Results

QALE at age 20 ranged from 33 years in Armenia to almost 61 years in Japan, using the UK value set. The value sets of the other five countries generated different estimates, up to seven years higher. The relative impact of choosing a different value set differed across country-gender strata between 2% and 20%. In 50% of the country-gender strata the ranking changed by two or more positions across value sets. The decomposition demonstrated a varying impact of health states, health-state values, and mortality on QALE differences across countries.

Conclusions

The choice of the value set in SMPH may seriously affect cross-country comparisons of health expectancy, even across populations of similar levels of wealth and education. In our opinion, it is essential to get more insight into the drivers of differences in health-state values across populations. This will enhance the usefulness of health-expectancy measures.

Assessing costs and potential returns of evidence-based programs for seniors

The authors describe the customary tools used by health services researchers to conduct economic evaluations of health interventions. Recognizing the inherent challenges of these tools for utilization in contemporary public health practice, we recommend a practical cost-benefit analysis (PCBA) to allow public health practitioners to assess the economic merits of their existing public health programs. The PCBA estimates what health effects and corresponding medical cost avoidance would be required to support the costs associated with implementing a community-based prevention program. We apply the PCBA to evaluate a statewide evidence-based falls prevention program for seniors in Texas. We estimate a positive return on realized costs due to avoided direct and indirect medical expenses if the program averts 7 falls among 140 participants within the first year. While acknowledging the demonstrated health-related benefits of public health interventions, we provide a practical ex-post economic evaluation methodology to assess return on investment as a more simplistic yet effective alternative for public health practitioners versus contemporary analyses of health services researchers.

Valuation of health states in the US study to establish disability weights: lessons from the literature

The metric of disability-adjusted life years (DALYs) has become the global standard of measuring burden of disease. DALYs are comprised of years of life lost due to premature mortality and years of healthy life lost due to living with disability. In order to calculate the second part of the DALY equation, disease specific disability weights have to be established, i.e. measures for the decline of health associated with these disease states, which vary between zero for perfect health and one for death. Although these disability weights are key for estimating DALYs, there have not been many comprehensive studies with empirical determinations of them. This article describes a systematic review on the state of the art with respect to empirically determining disability weights. Based on this review, a multi-method approach is outlined, which has also been implemented in a US study to measure burden of disease. This approach involves the use of psychometric methodology as well as economic trade-off methods for determining the value of health states. It is conceptualized as a disaggregated approach, where the disability weight of any health state can be calculated if the attributes of this health state are known. The US study received the collaboration of experts from more than 20 institutes of the National Institutes of Health and of the Centers for Disease Control and Prevention. First results will be available by the end of this year.