Using Patient-Reported Outcomes for Economic Evaluation: Getting the Timing Right

Navigating Choices in Nephrology: The Role of Patient-Reported Outcomes and Preferences in Economic Evaluations and Decisions in Health Care

The increasing burden of chronic kidney disease (CKD) on the health care system highlights the need to prioritize services and manage the use of resources efficiently. Amid these financial constraints, key decision makers must weigh the impact of an intervention or program on health care expenditure when determining the allocation of limited resources. Patient-reported outcome measures (PROMs) are relevant in health economic decision-making within nephrology. Health-related quality of life, a patient-reported outcome, can provide data that inform economic evaluations of treatments for patients with CKD. PROMs help determine the value of different therapies by assessing their impact on patients' daily lives beyond clinical outcomes and can help policymakers make decisions about funding and reimbursement that consider the priorities and preferences of patients. Economic evaluations often employ cost-utility analyses, which use quality-adjusted life years as a key metric. Quality-adjusted life years combine both the quality and quantity of life lived, allowing for comparison of the effectiveness of different interventions in a standardized manner. By integrating utilities derived from PROMs, these analyses quantify the benefits of CKD treatments in terms of how patients feel and function. Furthermore, PROMs contribute to quality improvement initiatives by identifying areas where patient care can be enhanced, guiding the implementation of programs that improve health-related quality of life while maintaining cost-effectiveness. In value-based financing environments, the integration of PROMs ensures that patient-centered outcomes are prioritized, leading to more effective and equitable health care delivery. In this article, we discuss the role of PROMs in economic evaluations in CKD and provide an overview of approaches for using PROMs in economic evaluations to inform decision-making in nephrology.

Global mapping of institutional and hospital-based (Level II-IV) arthroplasty registries: a scoping review

PURPOSE

Four joint arthroplasty registries (JARs) levels exist based on the recorded data type. Level I JARs are national registries that record primary data. Hospital or institutional JARs (Level II-IV) document further data (patient-reported outcomes, demographic, radiographic). A worldwide list of Level II-IV JARs must be created to effectively assess and categorize these data.

METHODS

Our study is a systematic scoping review that followed the PRISMA guidelines and included 648 studies. Based on their publications, the study aimed to map the existing Level II-IV JARs worldwide. The secondary aim was to record their lifetime, publications' number and frequency and recognise differences with national JARs.

RESULTS

One hundred five Level II-IV JARs were identified. Forty-eight hospital-based, 45 institutional, and 12 regional JARs. Fifty JARs were found in America, 39 in Europe, nine in Asia, six in Oceania and one in Africa. They have published 485 cohorts, 91 case-series, 49 case-control, nine cross-sectional studies, eight registry protocols and six randomized trials. Most cohort studies were retrospective. Twenty-three per cent of papers studied patient-reported outcomes, 21.45% surgical complications, 13.73% postoperative clinical and 5.25% radiographic outcomes, and 11.88% were survival analyses. Forty-four JARs have published only one paper. Level I JARs primarily publish implant revision risk annual reports, while Level IV JARs collect comprehensive data to conduct retrospective cohort studies.

CONCLUSIONS

This is the first study mapping all Level II-IV JARs worldwide. Most JARs are found in Europe and America, reporting on retrospective cohorts, but only a few report on studies systematically.

A Systematic Review and Meta-Analysis of the Effects of Rehabilitation Using Digital Healthcare on Musculoskeletal Pain and Quality of Life

Rehabilitation using digital healthcare (DHC) has the potential to enhance the effectiveness of treatment for musculoskeletal disorders (MSDs) and associated pain by improving patient outcomes, while being cost-effective, safe, and measurable. This systematic review and meta-analysis aimed to evaluate the effectiveness of musculoskeletal rehabilitation using DHC. We searched PubMed, Ovid-Embase, Cochrane Library, and PEDro Physiotherapy Evidence Database from inception to October 28, 2022 for controlled clinical trials comparing DHC to conventional rehabilitation. We used a random-effects model for the meta-analysis, pooling the effects of DHC on pain and quality of life (QoL) by calculating standardized mean differences (SMDs) with 95% confidence intervals (CIs) between DHC rehabilitation and conventional rehabilitation (control). Fifty-four studies with 6240 participants met the inclusion criteria. The sample size ranged from 26 to 461, and the average age of the participants ranged from 21.9 to 71.8 years. The majority of the included studies focused on knee or hip joint MSD (n = 23), and the most frequently utilized DHC interventions were mobile applications (n = 26) and virtual or augmented reality (n = 16). Our meta-analysis of pain (n = 45) revealed that pain reduction was greater in DHC rehabilitation than in conventional rehabilitation (SMD: -0.55, 95% CI: -0.74, -0.36), indicating that rehabilitation using DHC has the potential to ameliorate MSD pain. Furthermore, DHC significantly improved health-related QoL and disease-specific QoL (SMD: 0.66, 95% CI: 0.29, 1.03; SMD: -0.44, 95% CI: -0.87, -0.01) compared to conventional rehabilitation. Our findings suggest that DHC offers a practical and flexible rehabilitation alternative for both patients with MSD and healthcare professionals. Nevertheless, further researches are needed to elucidate the underlying mechanisms by which DHC affects patient-reported outcomes, which may vary depending on the type and design of the DHC intervention.

Long-term survivorship and results in lower limb arthroplasty: a registry-based comparison study

INTRODUCTION

Popularity of joint replacement surgery due to ever aging population surges the demand for a proper national joint registry. Our Chinese University of Hong Kong - Prince of Wales Hospital (CUHK-PWH) joint registry has passed the 30^th year. The aims of this study are 1) summarize our territory-wide joint registry which has passed the 30th year since establishment and 2) compare our statistics with other major joint registries.

METHODS

Part 1 was to review the CUHK-PWH registry. Demographic characteristics of our patients who underwent knee and hip replacements had been summarized. Part 2 was a series of comparisons with registries from Sweden, UK, Australia and New Zealand.

RESULTS

CUHK-PWH registry captured 2889 primary total knee replacements (TKR) (110 (3.81%) revision) and 879 primary total hip replacements (THR) (107 (12.17%) revision). Median Surgery time of TKR was shorter than THR. Clinical outcome scores were much improved after surgery in both. Uncemented of hybrid in TKR were most popular in Australia (33.4%) and 40% in Sweden and UK. More than half of TKR and THR patients showed the highest percentage with ASA grade 2. New Zealand reflected the best cumulative percentage survival 20 years after surgery of 92.2%, 76.0%, 84.2% survivorship 20 years after TKR, unicompartmental knee replacement (UKR) and Hip.

CONCLUSION

A worldwide accepted patient-reported outcome measure (PROM) is recommended to develop to make comparisons among registries and studies feasible. Completeness of registry data is important and useful to improve surgical performance through data comparisons from different regions. Funding from government on sustaining registries is reflected. Registries from Asian countries have yet to be grown and reported.

Economic costs, health-related quality of life outcomes and cost-utility of a physical and psychological group intervention targeted at older adults with neurogenic claudication

BACKGROUND

Emerging evidence suggests that structured and progressive exercise underpinned by a cognitive behavioural approach can improve functional outcomes in patients with neurogenic claudication (NC). However, evidence surrounding its economic benefits is lacking.

OBJECTIVES

To estimate the economic costs, health-related quality of life outcomes and cost-effectiveness of a physical and psychological group intervention (BOOST programme) versus best practice advice (BPA) in older adults with NC.

METHODS

An economic evaluation was conducted based on data from a pragmatic, multicentre, superiority, randomised controlled trial. The base-case economic evaluation took the form of an intention-to-treat analysis conducted from a UK National Health Service (NHS) and personal social services (PSS) perspective and separately from a societal perspective. Costs (£ 2018-2019 prices) were collected prospectively over a 12 month follow-up period. A bivariate regression of costs and quality-adjusted life-years (QALYs), with multiple imputation of missing data, was conducted to estimate the incremental cost per QALY gained and the incremental net monetary benefit (INMB) of the BOOST programme in comparison to BPA. Sensitivity and pre-specified subgroup analyses explored uncertainty and heterogeneity in cost-effectiveness estimates.

RESULTS

Participants (N = 435) were randomised to the BOOST programme (n = 292) or BPA (n = 143). Mean (standard error [SE]) NHS and PSS costs over 12 months were £1,974 (£118) in the BOOST arm versus £1,827 (£169) in the BPA arm (p = 0.474). Mean (SE) QALY estimates were 0.620 (0.009) versus 0.599 (0.006), respectively (p = 0.093). The probability that the BOOST programme is cost-effective ranged between 67 and 83% (NHS and PSS perspective) and 79-89% (societal perspective) at cost-effectiveness thresholds between £15,000 and £30,000 per QALY gained. INMBs ranged between £145 and £464 at similar cost-effectiveness thresholds. The cost-effectiveness results remained robust to sensitivity analyses.

CONCLUSIONS

The BOOST programme resulted in modest QALY gains over the 12 month follow-up period. Future studies with longer intervention and follow-up periods are needed to address uncertainty around the health-related quality of life impacts and cost-effectiveness of such programmes. Trial registration This study has been registered in the International Standard Randomised Controlled Trial Number registry, reference number ISRCTN12698674. Registered on 10 November 2015.

Perspectives on Postmatch Fatigue From 300 Elite European Soccer Players

PURPOSE

To examine the general perspectives of elite soccer players on the time course of perceived postmatch fatigue and the influence of away matches on subjective perceptions.

METHODS

Adopting a cross-sectional study design, we invited 371 subjects from 14 top-division European clubs competing in the Belgian First Division A, English Premier League, French Ligue 1, Italian Serie A, Portuguese Primeira Liga, Russian Premier League, and Swiss Premier League to take part in a short survey on general issues relating to postmatch fatigue measurement and tracking in professional soccer.

RESULTS

Three hundred male professional soccer players completed the short questionnaire. For perceptions relevant to the time course of postmatch fatigue, two-thirds of respondents (67%) indicated higher postmatch fatigue perceived 2 days (48 h) after an official competition. Among these respondents, a higher proportion of answers was observed in wide midfielders (74%), attackers (74%), and central midfielders (68%). Approximately two-thirds of respondents (63%) indicated more than usual and much more than usual perceived postmatch fatigue following away matches.

CONCLUSIONS

For the first time, our investigation addressed practical aspects that remained unexplored and fundamental to the definition of an optimal player management process following a competition. From a practical standpoint, perspectives of individual elite soccer players substantiated the notion of implementing processes with dedicated recovery protocols within 48 hours postmatch and highlighted the need for differential strategies addressing the additional burden of away matches and travel.

SMART choice (knee) tool: a patient-focused predictive model to predict improvement in health-related quality of life after total knee arthroplasty

BACKGROUND

Current predictive tools for TKA focus on clinicians rather than patients as the intended user. The purpose of this study was to develop a patient-focused model to predict health-related quality of life outcomes at 1-year post-TKA.

METHODS

Patients who underwent primary TKA for osteoarthritis from a tertiary institutional registry after January 2006 were analysed. The primary outcome was improvement after TKA defined by the minimal clinically important difference in utility score at 1-year post-surgery. Potential predictors included demographic information, comorbidities, lifestyle factors, and patient-reported outcome measures. Four models were developed, including both conventional statistics and machine learning (artificial intelligence) methods: logistic regression, classification tree, extreme gradient boosted trees, and random forest models. Models were evaluated using discrimination and calibration metrics.

RESULTS

A total of 3755 patients were included in the study. The logistic regression model performed the best with respect to both discrimination (AUC = 0.712) and calibration (intercept = -0.083, slope = 1.123, Brier score = 0.202). Less than 2% (n = 52) of the data were missing and therefore removed for complete case analysis. The final model used age (categorical), sex, baseline utility score, and baseline Veterans-RAND 12 responses as predictors.

CONCLUSION

The logistic regression model performed better than machine learning algorithms with respect to AUC and calibration plot. The logistic regression model was well calibrated enough to stratify patients into risk deciles based on their likelihood of improvement after surgery. Further research is required to evaluate the performance of predictive tools through pragmatic clinical trials.

LEVEL OF EVIDENCE

Level II, decision analysis.

No Difference in Quality-Of-Life Outcomes in the First 7 Years Following Primary Total Knee Arthroplasty Performed Using Computer Navigation Versus Conventional Referencing: A Propensity Score-Matched Analysis

BACKGROUND

Computer navigation techniques can potentially improve both the accuracy and precision of prosthesis implantation in total knee arthroplasty (TKA) but its impact on quality-of-life outcomes following surgery remains unestablished.

METHODS

An institutional arthroplasty registry was queried to identify patients with TKA performed between January 1, 2007 and December 31, 2019. Propensity score matching based on demographical, medical, and surgical variables was used to match computer-navigated to conventionally referenced cases. The primary outcomes were Veterans RAND 12 Item Health Survey scores (VR-12 PCS and MCS), Short Form 6 Dimension utility values (SF-6D), and quality-adjusted life years (QALYs) in the first 7 years following surgery.

RESULTS

A total of 629 computer-navigated TKAs were successfully matched to 1,351 conventional TKAs. The VR-12 PCS improved by a mean of 12.75 and 11.94 points in computer-navigated and conventional cases at 12-month follow-up (P = .25) and the VR-12 MCS by 6.91 and 5.93 points (P = .25), respectively. The mean VR-12 PCS improvement at 7-year follow-up (34.4% of the original matched cohort) for navigated and conventional cases was 13.00 and 12.92 points (P = .96) and for the VR-12 MCS was 4.83 and 6.30 points (P = .47), respectively. The mean improvement in the SF-6D utility score was 0.164 and 0.149 points at 12 months (P = .11) and at 7 years was 0.115 and 0.123 points (P = .69), respectively. Computer-navigated cases accumulated 0.809 QALYs in the first 7 years, compared to 0.875 QALYs in conventionally referenced cases (P = .65). There were no differences in these outcomes among a subgroup analysis of obese patients (body mass index ≥ 30 kg/m²).

CONCLUSION

The use of computer navigation did not provide an incremental benefit to quality-of-life outcomes at a mean of 2.9 years following primary TKA performed for osteoarthritis when compared to conventional referencing techniques.

Physical activity telephone coaching intervention for insufficiently physically active ambulatory hospital patients: Economic evaluation of the Healthy 4U-2 randomised controlled trial

The Healthy 4U-2 randomised controlled trial demonstrated that a physical activity (PA) telephone coaching intervention was effective for improving objectively-measured PA and health-related outcomes. The current study reports on an economic evaluation performed alongside the trial to determine whether this effective intervention is also cost-effective from a healthcare funder perspective. Participants (N = 120) were insufficiently physically active adults recruited from an ambulatory care clinic in a public hospital in regional Australia. The primary outcome was change in moderate-to-vigorous physical activity (MVPA) measured using accelerometers. Changes in quality-adjusted life-years (QALYs) were derived from the 12-Item Short Form Health Survey Questionnaire (SF-12). Incremental cost-effectiveness ratios (ICERs) were calculated for each outcome. Uncertainty of cost-effectiveness results were estimated using non-parametric bootstrapping techniques and sensitivity analyses. The mean intervention cost was $132 per person. The control group incurred higher overall costs compared to intervention ($2,465 vs. $1,743, respectively). Relative to control, the intervention resulted in incremental improvements in MVPA and QALYs and was deemed cost-effective. Probabilistic sensitivity analysis indicated that compared to control, the intervention would be cost-effective for improving MVPA and QALYs at very low willingness to pay thresholds. Sensitivity analyses indicated that results were robust to varied assumptions. This study shows that PA telephone coaching was a low-cost strategy for increasing MVPA and QALYs in insufficiently active ambulatory hospital patients. Findings of health benefits and overall cost-savings are uncommon and PA telephone coaching offers a potentially cost-effective investment to produce important public health outcomes.

A Narrative Literature Review of Bias in Collecting Patient Reported Outcomes Measures (PROMs)

There is a growing interest in the collection and use of patient reported outcomes because they not only provide clinicians with crucial information, but can also be used for economic evaluation and enable public health decisions. During the collection phase of PROMs, there are several factors that can potentially bias the analysis of PROM data. It is crucial that the collected data are reliable and comparable. The aim of this paper was to analyze the type of bias that have already been taken into consideration in the literature. A literature review was conducted by the authors searching on PubMed database, after the selection process, 24 studies were included in this review, mostly regarding orthopedics. Seven types of bias were identified: Non-response bias, collection method related bias, fatigue bias, timing bias, language bias, proxy response bias, and recall bias. Regarding fatigue bias and timing bias, only one study was found; for non-response bias, collection mode related bias, and recall bias, no agreement was found between studies. For these reasons, further research on this subject is needed in order to assess each bias type in relation to each medical specialty, and therefore find correction methods for reliable and comparable data for analysis.

The Hidden Pandemic: the Cost of Postoperative Complications

Purpose of Review

Population-based increases in ageing and medical co-morbidities are expected to substantially increase the incidence of expensive postoperative complications. This threatens the sustainability of essential surgical care, with negative impacts on patients' health and wellbeing.

Recent Findings

Identification of key high-risk areas, and implementation of proven cost-effective strategies to manage both outcome and cost across the end-to-end journey of the surgical episode of care, is clearly feasible. However, good programme design and formal cost-effectiveness analysis is critical to identify, and implement, true high value change.

Summary

Both outcome and cost need to be a high priority for both fundholders and clinicians in perioperative care, with the focus for both groups on delivering high-quality care, which in itself, is the key to good cost management.

Patient-Reported Outcomes After Treatment Discontinuation: Commercial Clinical Trial Data From Four Cancer Types

OBJECTIVES

How frequently patient-reported outcome (PRO) data are collected in commercial cancer clinical trials after treatment discontinuation and the quality of that data are poorly understood. We reviewed treatment discontinuation follow-up PRO data collection to learn about trials collecting these data and understand data quality. The review included 4 cancer types representing potential for long- (prostate cancer), medium-/long- (breast cancer), and short-term (pancreatic cancer and hepatocellular carcinoma) follow-up owing to disease trajectory.

METHODS

We reviewed registration trials in US Food and Drug Administration databases between January 2010 and January 2019. Protocols were reviewed to determine whether PROs were collected and, if so, whether these included the follow-up phase. Clinical study reports were reviewed when follow-up PROs were collected to determine completion rates. Results were summarized using descriptive analyses.

RESULTS

Of the 46 trials containing PRO data, 46% had at least 1 follow-up PRO assessment. Follow-up schedules of assessment were wide ranging; the first assessment occurred between 30 days and 6 months after stopping treatment with follow-up for as long as 3 years. PRO completion rates were reported in 57% of 21 trials; at the first follow-up assessment, completion rates for the treatment arm ranged from 38% to 91% and from 41% to 100% in the control arm.

CONCLUSIONS

The quality of the follow-up PRO data, based on completion rates, was variable, as was the duration of follow-up. A clear research objective should be developed for follow-up PRO data, accounting for patient burden. If PRO data are collected, monitoring should be implemented to improve completion because poor completion limits data use in the benefit-risk assessment.

Total Hip and Knee Arthroplasties Are Highly Cost-Effective Procedures: The Importance of Duration of Follow-Up

BACKGROUND

Total hip and knee arthroplasties (THA/TKA) are clinically effective but high cost procedures. The aim of this study is to perform a cost-effectiveness analysis of THA and TKA in the New Zealand (NZ) healthcare system.

METHODS

Data were collected from 713 patients undergoing THA and 520 patients undergoing TKA at our local public hospital. SF-6D utility values were obtained from participants preoperatively and 1-year postoperatively, and deaths and any revision surgeries from patient records and the New Zealand Joint Registry at minimum 8-year follow-up. A continuous-time state-transition simulation model was used to estimate costs and health gains to 15 years. Quality-adjusted life years (QALYs), treatment costs, and incremental cost-effectiveness ratios (ICERs) were calculated to determine cost effectiveness. ICERs below NZ gross domestic product (GDP; NZ$60 600) and 0.5 times GDP per capita were considered "cost effective" and "highly cost effective" respectively.

RESULTS

Cumulative health gains were 2.8 QALYs (THA) and 2.3 QALYs (TKA) over 15 years. Cost effectiveness improved from ICERs of NZ$74,400 (THA) and NZ$93,000 (TKA) at 1 year to NZ$6000 (THA) and NZ$7500 (TKA) at 15 years. THA and TKA were cost effective after 2 years and highly cost effective after 3 years. QALY gains and cost effectiveness were greater in patients with worse preoperative functional status and younger age.

CONCLUSION

THA and TKA are highly cost-effective procedures over longer term horizons. Although preoperative status and age were associated with cost effectiveness, both THA and TKA remained cost effective in patients with less severe preoperative scores and older ages.

The cost-effectiveness of computer navigation in primary total knee replacement: a scoping review

Despite additional costs associated with the use of computer navigation technology in total knee replacement (TKR), its impact on quality-adjusted life years following surgery has not been demonstrated. Cost-effectiveness evaluations require a balanced assessment of both quality and cost metrics.

This review sought to evaluate the cost-effectiveness of computer navigation, identify barriers to translation, and suggest directions for further investigation. A systematic search of the Cost-Effectiveness Analysis Registry, PubMed, and Embase was undertaken.

Cost-effectiveness analyses of computer navigation in primary total knee replacement were identified. Only primary studies of cost-effectiveness analyses published in the English language from the year 2000 onwards were included. Studies that reported secondary data were excluded from the analysis. Four publications met the inclusion criteria.

Estimated gains in quality-adjusted life years attributed to reductions in revision surgery were 0.0148 to 0.0164 over 10 years, and 0.0192 (95% CI –0.002 to 0.0473) over 15 years. Cost estimates ranged from 952 kr (US $90, 2020) per case at 250 TKRs/year, to $1,920 US per case at 25 TKRs/year.

The estimated probability of meeting local cost-effectiveness thresholds was 54% in the United States and 92% in the United Kingdom. These data were not available for Norway.

The cost-effectiveness of computer navigation in current practice settings remains uncertain, with the use of this technology associated with marginal increased quality-adjusted life years (QALYs) at additional cost. Existing analyses demonstrated a number of limitations which restrict the potential for translation to practice and policy settings. Further research evaluating the impact of computer navigation on QALYs following primary TKR is required to inform contemporary cost-effectiveness evaluations.

Cite this article: EFORT Open Rev 2021;6:173-180. DOI: 10.1302/2058-5241.6.200073

Measuring Outcomes in Knee Articular Cartilage Pathology

Measuring outcomes following treatment of knee articular cartilage lesions is crucial to determine the natural history of disease and the efficacy of treatments. Outcome assessments for articular cartilage treatments can be clinical (based on failure, lack of healing, reoperation, need for arthroplasty), radiographic (X-ray, MRI), histologic, or patient reported and functional. The purpose of this review is to discuss the application and properties of patient-reported outcomes (PROs) with a focus on articular cartilage injuries and surgery in the knee. The most frequently used and validated PROs for knee articular cartilage studies include: the Knee injury and Osteoarthritis and Outcome Score, International Knee Documentation Committee Subjective Knee Form, and Lysholm score as knee-specific measures; the Marx Activity Rating Scale and Tegner Activity Scale as activity measures; and EQ-5D and SF-36/12 as generic quality-of-life measures. Incorporating these validated PROs in studies pertaining to knee articular cartilage lesions will allow researchers to fully capture clinically relevant outcomes that are most important to patients.

The Arthroplasty Candidacy Help Engine tool to select candidates for hip and knee replacement surgery: development and economic modelling

BACKGROUND

There is no good evidence to support the use of patient-reported outcome measures (PROMs) in setting preoperative thresholds for referral for hip and knee replacement surgery. Despite this, the practice is widespread in the NHS.

OBJECTIVES/RESEARCH QUESTIONS

Can clinical outcome tools be used to set thresholds for hip or knee replacement? What is the relationship between the choice of threshold and the cost-effectiveness of surgery?

METHODS

A systematic review identified PROMs used to assess patients undergoing hip/knee replacement. Their measurement properties were compared and supplemented by analysis of existing data sets. For each candidate score, we calculated the absolute threshold (a preoperative level above which there is no potential for improvement) and relative thresholds (preoperative levels above which individuals are less likely to improve than others). Owing to their measurement properties and the availability of data from their current widespread use in the NHS, the Oxford Knee Score (OKS) and Oxford Hip Score (OHS) were selected as the most appropriate scores to use in developing the Arthroplasty Candidacy Help Engine (ACHE) tool. The change in score and the probability of an improvement were then calculated and modelled using preoperative and postoperative OKS/OHSs and PROM scores, thereby creating the ACHE tool. Markov models were used to assess the cost-effectiveness of total hip/knee arthroplasty in the NHS for different preoperative values of OKS/OHSs over a 10-year period. The threshold values were used to model how the ACHE tool may change the number of referrals in a single UK musculoskeletal hub. A user group was established that included patients, members of the public and health-care representatives, to provide stakeholder feedback throughout the research process.

RESULTS

From a shortlist of four scores, the OHS and OKS were selected for the ACHE tool based on their measurement properties, calculated preoperative thresholds and cost-effectiveness data. The absolute threshold was 40 for the OHS and 41 for the OKS using the preferred improvement criterion. A range of relative thresholds were calculated based on the relationship between a patient's preoperative score and their probability of improving after surgery. For example, a preoperative OHS of 35 or an OKS of 30 translates to a 75% probability of achieving a good outcome from surgical intervention. The economic evaluation demonstrated that hip and knee arthroplasty cost of < £20,000 per quality-adjusted life-year for patients with any preoperative score below the absolute thresholds (40 for the OHS and 41 for the OKS). Arthroplasty was most cost-effective for patients with lower preoperative scores.

LIMITATIONS

The ACHE tool supports but does not replace the shared decision-making process required before an individual decides whether or not to undergo surgery.

CONCLUSION

The OHS and OKS can be used in the ACHE tool to assess an individual patient's suitability for hip/knee replacement surgery. The system enables evidence-based and informed threshold setting in accordance with local resources and policies. At a population level, both hip and knee arthroplasty are highly cost-effective right up to the absolute threshold for intervention. Our stakeholder user group felt that the ACHE tool was a useful evidence-based clinical tool to aid referrals and that it should be trialled in NHS clinical practice to establish its feasibility.

FUTURE WORK

Future work could include (1) a real-world study of the ACHE tool to determine its acceptability to patients and general practitioners and (2) a study of the role of the ACHE tool in supporting referral decisions.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Patient-reported symptom burden of chronic graft versus host disease: a systematic literature review

INTRODUCTION

Chronic graft-versus-host disease (GVHD) is a life-threating complication of allogeneic hematopoietic stem cell transplantation (HSCT) leading to high morbidity and quality of life issues. We conducted a systematic literature review on the patient reported symptom burden of chronic GVHD.

AREAS COVERED

English-language articles published between 2005 and November 2018 were searched using CENTRAL, EMBASE and MEDLINE. Studies that used the 2005 or 2015 National Institute of Health consensus criteria for the diagnosis and staging of chronic GVHD were included.

EXPERT OPINION

Patient reported symptom burden was widely assessed in the literature (n = 38). The Lee Chronic GVHD Symptom Scale was the most frequently used instrument (n = 28), followed by the NIH Patient-reported Symptom scores (n = 11). Association of symptom burden with clinical outcome assessment endpoints (e.g. mortality) and with quality of life measures was investigated by fairly low number of studies with limited generalizability. By systematically investigating the influencing factors of symptom burden this review helps to better understand patients' perceptions and may help improving the management and care of chronic GVHD. However, data on influencing factors was quite diverse, which indicates that specific questions identified as research gaps need to be incorporated in randomized clinical trials in a more systematic way.

Patient-reported outcome measures (PROMs): can they be used to guide patient-centered care and optimize outcomes in total knee replacement?

PURPOSE

As patient-reported outcome measures (PROMs) are increasingly integrated into clinical practice, there is a need to translate collected data into valuable information to guide and improve the quality and value of patient care. The purpose of this study was to investigate health-related quality-of-life (QoL) trajectories in the 5 years following total knee replacement (TKR) and the patient characteristics associated with these trajectories. The feasibility of translating QoL trajectories into valuable information for guiding patient-centered care was also explored.

METHODS

Data on patients who underwent TKR between 2006 and 2011 from a single-institution registry were extracted including patient-reported QoL (captured using the Short Form Survey (SF-12) instrument) up to 5 years post-surgery. QoL trajectories were modelled using latent class growth analysis. Quality-adjusted life-years (QALYs) were calculated to illustrate longer term health benefit. Multinomial logistic regression analyses were performed to examine the association between trajectory groups and baseline patient characteristics.

RESULTS

After exclusions, 1553 patients out of 1892 were included in the analysis. Six unique QoL trajectories were identified; with differing levels at baseline and improvement patterns post-surgery. Only 18.4% of patients were identified to be in the most positive QoL trajectory (low baseline, large sustainable improvement after surgery) associated with the greatest gain in QALY. These patients were likely to be younger, have no co-morbidities and report greater pain at pre-surgery than most in other QoL trajectories.

CONCLUSIONS

Our findings demonstrate the importance of underlying heterogeneity in QoL trajectories, resulting in variable QALY gains. There is scope in translating routinely collected PROMs to improve shared decision-making allowing for more patient engagement. However, further research is required to identify suitable approaches of its implementation into practice to guide clinical care and maximize patient outcomes.

Financial Aspects of Cervical Disc Arthroplasty: A Narrative Review of Recent Literature

Recently, there has been significant interest in understanding the cost-effectiveness of treatments in spine surgery as health care systems in the United States move toward value-based care and alternative payment models. Previous studies have shown comparable outcomes of cervical disc arthroplasty (CDA) and anterior cervical discectomy fusion; however, there is a lack of consensus on the cost-effectiveness of CDA to support full adoption. Evidence of the limitations of these cost-analysis studies also exists in the literature, including industry funding, potential selection bias, and varying methods of calculating value. The goal of this narrative review is to provide an overview of the cost-effectiveness of CDA compared with anterior cervical discectomy and fusion, and potential limitations with cost-analysis studies in spine surgery.

Measuring Quality-Adjusted Life-Years When Health Fluctuates

Recurrent fluctuations in health states can occur as a result of long-term conditions with episodic symptoms or through side effects of cycles of treatment. Fluctuations and associated duration of symptoms can be predictable (eg, side effects of chemotherapy treatment) or unpredictable (eg, relapse in multiple sclerosis). Such recurrent fluctuations in health states can have an important impact on a person's health-related quality of life. When symptoms vary by time of day, day of the week, or during the month, it is challenging to obtain reliable health-related quality of life estimates for use in assessing cost-effectiveness of interventions. The adequacy of the quality of life estimate will be affected by (1) the standard recall period associated with the chosen measure (eg, "health today" EQ-5D, "past 4 weeks" for SF-36/SF-6D) and the way that respondents understand and make judgments about these recall periods, (2) the chosen time points for assessing health-related quality of life in relation to the fluctuations in health, and (3) the assumptions used to interpolate between measurement time points and thus calculate the quality-adjusted life-years. These issues have not received sufficient methodological attention and instead remain poorly accounted for in economic analyses. There is potential for these issues to considerably distort treatment decisions away from the optimal allocation. This article brings together evidence from health economics, psychology, and behavioral economics to explore these challenges in depth; presents the solutions that have been applied to date; and details a methodological research agenda for measuring quality-adjusted life-years in recurrent fluctuating health states.

Co-Morbidities and Sex Differences in Long-Term Quality-of-Life Outcomes among Patients with and without Diabetes after Total Knee Replacement: Five-Year Data from Registry Study

Improved understanding of quality-of-life (QoL) outcomes can provide valuable information on intervention effectiveness and guide better patient care. The aim of this study was to examine whether QoL trajectories differ between patients with and without diabetes and identify to what extent patient characteristics are related to poor QoL outcomes after total joint replacement (TKR). Multilevel modelling was used to analyse long-term QoL patterns of patients undergoing TKR between 2006 and 2011. Patient-reported QoL at baseline and up to 5 years post-surgery were included. Of the 1553 TKR patients, one-fifth (n = 319) had diabetes. Despite there being no significant differences in QoL at baseline, patients with diabetes consistently reported lower QoL (on average by 0.028, p < 0.001) and did not improve to the same level as patients without the disease following surgery. Compared to males, females had significantly lower QoL (by 0.03, p < 0.001). Other baseline patient characteristics associated with important differences in QoL included presence of respiratory disease and mental health disorder. Patients with diabetes exhibit significantly poorer QoL compared to patients without diabetes, particularly among females. Knowledge of risk factors that impact on QoL can be useful for clinicians in identifying characteristics related to poor QoL outcomes and be used to guide patient-centered care.

Patient-reported outcome measures in total joint arthroplasty: defining the optimal collection window

Background

The purpose of this study was to determine the optimal window for collection of patient-reported outcome measures (PROMs) after total joint arthroplasty (TJA).

Methods

Our prospectively collected institutional joint registry was queried for patients who underwent primary, unilateral TJAs. The primary outcomes were the net changes in WOMAC, SF-12 MCS, SF-12 PCS, OHS, KSCRS, and UCLA activity rating system at 6, 12, and 24 months postoperatively. Secondary outcomes were data acquisition costs and follow-up attrition rates.

Results

Eight hundred sixty-six procedures (450 total hip arthroplasties, 416 TKAs) were analyzed. A consistent plateau in all PROMs was noted by 6 months postoperatively–except for SF-12 MCS which showed no significant changes at any time interval. For TKA, the percentage of overall improvement achieved by 6 months was 88.7%, 84.5%, 100%, and 90.5% for the WOMAC, SF-12 PCS, UCLA, and KSCRS, respectively. For total hip arthroplasty, these values were 92.7%, 83.5%, 88.0%, and 89.8% for WOMAC, SF-12 PCS, UCLA, and OHS, respectively. There were marginal improvements from 6 to 12 months and no improvement from 12 to 24 months. Follow-up rates at 6, 12, and 24 months were 85%, 69%, and 40%, respectively. Our institutional costs for collecting a complete data set per patient were $128, $158, and $272 for 6, 12, and 24 months, respectively.

Conclusions

Most of the improvement in PROMs after primary TJA occurs within the first 6 months. In addition, limiting PROMs collection to 6 months appears to be cost-efficient owing to increased attrition rates beyond this time interval.

The effect of rheumatoid arthritis on patient-reported outcomes following knee and hip replacement: evidence from routinely collected data

OBJECTIVES

To compare outcomes of total knee replacement (TKR) and total hip replacement (THR) for individuals with RA and OA.

METHODS

We performed a cohort study using routinely collected data. Oxford Knee Score, Oxford Hip Score, and EuroQol 5-dimension 3-level (EQ-5D-3L) questionnaires were collected before and 6 months after surgery. Multivariable regressions were used to estimate the association between diagnosis and post-operative scores after controlling for pre-operative scores and patient characteristics.

RESULTS

Study cohorts included 2070 OA and 142 RA patients for TKR and 2030 OA and 98 RA patients for THR. Following TKR, the median Oxford Knee Score was 37 [interquartile range (IQR) 29-43] for OA and 36 (27-42) for RA while the median EQ-5D-3L was 0.76 (0.69-1.00) and 0.69 (0.52-0.85), respectively. After THR, the Oxford Hip Score was 42 (IQR 36-46) for OA and 39 (30-44) for RA while the EQ-5D-3L was 0.85 (0.69-1.00) and 0.69 (0.52-1.00), respectively. The estimated effect of RA, relative to OA, on post-operative scores was -0.05 (95% CI -1.57, 1.48) for the Oxford Knee Score, -0.09 (-0.13, -0.06) for the EQ-5D-3L following TKR, -1.35 (-2.93, -0.22) for the Oxford Hip Score, and -0.08 (-0.12, -0.03) for the EQ-5D-3L following THR.

CONCLUSION

TKR and THR led to substantial improvements in joint-specific scores and overall quality of life. While diagnosis had no clinically meaningful effect on joint-specific outcomes, improvements in general quality of life were somewhat less for those with RA, which is likely due to the systemic and multijoint nature of rheumatoid disease.

Evidence-based sizing of non-inferiority trials using decision models

Background

There are significant challenges to the successful conduct of non-inferiority trials because they require large numbers to demonstrate that an alternative intervention is “not too much worse” than the standard. In this paper, we present a novel strategy for designing non-inferiority trials using an approach for determining the appropriate non-inferiority margin (δ), which explicitly balances the benefits of interventions in the two arms of the study (e.g. lower recurrence rate or better survival) with the burden of interventions (e.g. toxicity, pain), and early and late-term morbidity.

Methods

We use a decision analytic approach to simulate a trial using a fixed value for the trial outcome of interest (e.g. cancer incidence or recurrence) under the standard intervention (p_S) and systematically varying the incidence of the outcome in the alternative intervention (p_A). The non-inferiority margin, p_A – p_S = δ, is reached when the lower event rate of the standard therapy counterbalances the higher event rate but improved morbidity burden of the alternative. We consider the appropriate non-inferiority margin as the tipping point at which the quality-adjusted life-years saved in the two arms are equal.

Results

Using the European Polyp Surveillance non-inferiority trial as an example, our decision analytic approach suggests an appropriate non-inferiority margin, defined here as the difference between the two study arms in the 10-year risk of being diagnosed with colorectal cancer, of 0.42% rather than the 0.50% used to design the trial. The size of the non-inferiority margin was smaller for higher assumed burden of colonoscopies.

Conclusions

The example demonstrates that applying our proposed method appears feasible in real-world settings and offers the benefits of more explicit and rigorous quantification of the various considerations relevant for determining a non-inferiority margin and associated trial sample size.