Healthy-days time equivalents for outcomes of acute rotavirus infections

Line of therapy and patient preferences regarding lung cancer treatment: a discrete-choice experiment

OBJECTIVE

A growing literature on patient preferences informs decisions in research, regulatory science, and value assessment, but few studies have explored how preferences vary across patients with differing treatment experience. We sought to quantify patient preferences for the benefits and risks of lung cancer treatment and test how preferences differed by line of therapy (LOT).

METHODS

Preferences were elicited using a discrete choice experiment (DCE) following rigorous patient and stakeholder engagement. The DCE spanned five attributes (each with three levels): progression-free survival (PFS), short-term side effects, long-term side effects, risk of developing late-onset side effects, and mode of administration (MOA) - each defined across 3 relevant levels. A D-efficient design was used to generate 3 survey blocks of 9 paired-profile choice tasks each and respondents were asked which profile they preferred and then if they preferred to have no treatment (opt-out). A mixed logit model, controlling for opt-out, was used to estimate preferences. Preferences and trade-offs between PFS and other attributes were compared across two groups: those receiving ≤1 LOT and those receiving ≥2 LOT.

RESULTS

Of the 466 participants, 42% received ≤1 LOT and 58% received ≥2 LOT. Stated preferences differed between the groups overall (p<.001) and specifically for 18 months of PFS (p<.001), moderate short-term side effects (p<.001), no long-term side effects (p=.03), and 30% chance of late-onset side effects (p=.02). Those receiving differing amounts of LOT were willing to trade different amounts of PFS to change from moderate to mild short-term side effects (p<.001), moderate to no (p<.001) and mild to no (p<.001) long-term side effects. There were also differing amounts of tradeoff acceptable between the groups for a 10% decrease in risk of late-onset side effects (p=.016), a decrease in MOA from infusion every 3 weeks to pills taken daily at any time (p=.005) and from pills taken daily without food to pills taken daily at any time (p<.001).

CONCLUSION

We demonstrate differences in preferences based on experience with LOT, suggesting that patient treatment experience may have an impact on their preferences. As patient preference data become an important component of treatment decision making, preference differences should be considered when recommending therapies at different stages in the treatment journey. Understanding patient preferences regarding treatment decisions is essential to informing shared decision-making and ensuring treatment plans are consistent with patients' goals.

Comparing the Noncomparable: The Need for Equivalence Measures That Make Sense in Health-Economic Evaluations

BACKGROUND

The popularity of quality-adjusted life years (QALYs) has been resistant to concerns about validity and reliability. Utility-theoretic outcome equivalents are widely used in other areas of applied economics. Equivalence values can be derived for time, money, risk, and other metrics. These equivalence measures preserve all available information about individual preferences and are valid measures of individual welfare changes.

OBJECTIVE

The objective of this study was to derive alternative generalized equivalence measures from first principles and illustrate their application in an empirical comparative-effectiveness example.

METHODS

We specify a general-equilibrium model incorporating neoclassical utility functions, health production function, severity-duration preferences, and labor-market tradeoff function. The empirical implementation takes advantage of discrete-choice experiment methods that are widely accepted in other areas of applied economics and increasingly in health economics. We illustrate the practical significance of restrictive QALY assumptions using comparative-effectiveness results based on both QALYs and estimates of welfare-theoretic time-equivalent values for anti-tumor necrosis factor and prolonged corticosteroid treatments for Crohn's disease in three distinct preference classes.

RESULTS

The QALY difference between the two treatments is 0.2 months, while time-equivalent values range between 0.5 and 1.3 months for aggregate and class-specific differences. Thus, the QALY-based analysis understates welfare-theoretic values by 60%-85%.

CONCLUSION

These results suggest that using disease-specific equivalence values offer a meaningful alternative to QALYs to compare global outcomes across treatments. The equivalence values approach is consistent with principles of welfare economics and offers several features not represented in QALYs, including accounting for preference nonlinearities in disease severity and duration, inclusion of preference-relevant nonclinical healthcare factors, representing preferences of clinically-relevant patient subpopulations, and including utility losses related to risk aversion.

The use of the EQ-5D-Y health related quality of life outcome measure in children in the Western Cape, South Africa: psychometric properties, feasibility and usefulness - a longitudinal, analytical study

BACKGROUND

The EQ-5D-Y, an outcome measure of Health Related Quality of Life (HRQoL) in children, was developed by an international task team in 2010. The multinational feasibility, reliability and validity study which followed was undertaken with mainly healthy children. The aim of this study was to investigate the psychometric properties of the EQ-5D-Y when used to assess the HRQoL of children with different health states.

METHOD

A sample of 224 children between eight and twelve years were grouped according to their health state. The groups included 52 acutely ill children, 67 children with either a chronic health condition or disability and 105 mostly healthy, mainstream school children as a comparator. They were assessed at baseline, at three months and at six months. An analysis of the psychometric properties was performed to assess the reliability, validity and responsiveness of the EQ-5D-Y in the different groups of children. Cohen's kappa, the intraclass correlation coefficient, Pearson Chi-square, Kruskal-Wallis ANOVA and effect size of Wilcoxon Signed-rank test were used to determine the reliability, validity and responsiveness of the instrument.

RESULTS

The EQ-5D-Y dimensions were found to be reliable on test-retest (kappa varying from 0.365 to 0.653), except for the Usual Activities dimension (kappa 0.199). The Visual Analogue Scale (VAS) was also reliable (ICC = 0.77). Post-hoc analysis indicated that dimensions were able to discriminate between acutely ill and healthy children (all differences p < 0.001). The acutely ill children had the lowest ranked VAS (median 50, range 0-100), indicating worst HRQoL and was the only group significantly different from the other three groups (p < 0.001 in all cases). Convergent validity between all similar EQ-5D-Y and PedsQL, WeeFIM and Faces Pain Scale dimensions was only evident in the acutely ill children. As expected the largest treatment effect was also observed in these children (Wilcoxon Signed-rank test for VAS was 0.43). Six of the nine therapists who took part in the study, found the measure quick and easy to apply, used the information in the management of the child and would continue to use it in future.

CONCLUSIONS

The EQ-5D-Y could be used with confidence as an outcome measure for acutely-ill children, but demonstrated poorer psychometric properties in children with no health condition or chronic conditions. It appears to be feasible and useful to include the EQ-5D-Y in routine assessments of children.

Prevalence and Losses in Quality-Adjusted Life Years of Child Health Conditions: A Burden of Disease Analysis

OBJECTIVES

To estimate the prevalence and losses in quality-adjusted life years (QALYs) associated with 20 child health conditions.

METHODS

Using data from the 2009-2010 National Survey of Children with Special Health Care Needs, preference weights were applied to 14 functional difficulties to summarize the quality of life burden of 20 health conditions.

RESULTS

Among the 14 functional difficulties, "a little trouble with breathing" had the highest prevalence (37.1 %), but amounted to a loss of just 0.16 QALYs from the perspective of US adults. Though less prevalent, "a lot of behavioral problems" and "chronic pain" were associated with the greatest losses (1.86 and 3.43 QALYs). Among the 20 conditions, allergies and asthma were the most prevalent but were associated with the least burden. Muscular dystrophy and cerebral palsy were among the least prevalent and most burdensome. Furthermore, a scatterplot shows the association between condition prevalence and burden.

CONCLUSIONS

In child health, condition prevalence is negatively associated with quality of life burden from the perspective of US adults. Both should be considered carefully when evaluating the appropriate role for public health prevention and interventions.

Valuation of Child Health-Related Quality of Life in the United States

Many economic analyses fail to incorporate evidence on child health-related quality of life because of a paucity of quality-adjusted life year (QALY) estimates. This health valuation study is the first to summarize the EQ-5D-Y on a QALY scale. Drawn from a nationally representative panel, 5207 adult respondents were asked to choose between two losses in child health-related quality of life. Based on their choices, a 1-year increase in child pain/discomfort from 'some' to 'a lot' equals a loss of 4 QALYs (95% CI, 3.8-4.4). Likewise, a 1-year increase in child anxiety/depression from 'a bit' to 'very worried, sad, or unhappy' equals a loss of 2 QALYs (95% CI, 1.9-2.2). These findings enable the integration of child-reported outcomes with adult preferences to inform economic analysis. Results inform both clinical practice and resource allocation decisions by enhancing understanding of difficult tradeoffs in child-reported outcomes. Copyright © 2015 John Wiley & Sons, Ltd.

Valuation of Child Behavioral Problems from the Perspective of US Adults

OBJECTIVE

To assess preferences between child behavioral problems and estimate their value on a quality-adjusted life year (QALY) scale.

METHODS

Respondents, age 18 or older, drawn from a nationally representative panel between August 2012 and February 2013 completed a series of paired comparisons, each involving a choice between 2 different behavioral problems described using the Behavioral Problems Index (BPI), a 28-item instrument with 6 domains (Anxious/Depressed, Headstrong, Hyperactive, Immature Dependency, Anti-social, and Peer Conflict/Social Withdrawal). Each behavioral problem lasted 1 or 2 years for an unnamed child, age 7 or 10 years, with no suggested relationship to the respondent. Generalized linear model analyses estimated the value of each problem on a QALY scale, considering its duration and the child's age.

RESULTS

Among 5207 eligible respondents, 4155 (80%) completed all questions. Across the 6 domains, problems relating to antisocial behavior were the least preferred, particularly the items related to cheating, lying, bullying, and cruelty to others.

CONCLUSIONS

The findings are the first to produce a preference-based summary measure of child behavioral problems on a QALY scale. The results may inform both clinical practice and resource allocation decisions by enhancing our understanding of difficult tradeoffs in how adults view child behavioral problems. Understanding US values also promotes national health surveillance by complementing conventional measures of surveillance, survival, and diagnoses.

The Value Adults Place on Child Health and Functional Status

OBJECTIVES

To summarize the value adults place on child health and functional status and provide a new quantitative tool that enhances our understanding of the benefits of new health technologies and illustrates the potential contributions of existing data sets for comparative effectiveness research in pediatrics.

METHODS

Respondents, ages 18 years and older, were recruited from a nationally representative panel between August 2012 and February 2013 to complete an online survey. The survey included a series of paired comparisons that asked respondents to choose between child health and functional status outcomes, which were described using the National Survey of Children with Special Health Care Needs, a 14-item descriptive system of child health outcomes. Using respondent choices regarding an unnamed 7- or 10-year-old child, generalized linear model analyses estimated the value of child health and functional status on a quality-adjusted life-year scale.

RESULTS

Across the domains of health and functional status, repeated or chronic physical pain, feeling anxious or depressed, and behavioral problems (such as acting out, fighting, bullying, or arguing) were most valuable, as indicated by adult respondents' preference of other health problems to avoid outcomes along these domains.

DISCUSSION

These findings may inform comparative effectiveness research, health technology assessments, clinical practice guidelines, and public resource allocation decisions by enhancing understanding of the value adults place on the health and functional status of children.

CONCLUSIONS

Improved measurement of public priorities can promote national child health by drawing attention to what adults value most and complementing conventional measures of public health surveillance.

Rotavirus vaccination in Europe: drivers and barriers

Rotavirus gastroenteritis is a vaccine-preventable disease that confers a high medical and economic burden in more developed countries and can be fatal in less developed countries. Two vaccines with high efficacy and good safety profiles were approved and made available in Europe in 2006. We present an overview of the status of rotavirus vaccination in Europe. We discuss the drivers (including high effectiveness and effect of universal rotavirus vaccination) and barriers (including low awareness of disease burden, perception of unfavourable cost-effectiveness, and potential safety concerns) to the implementation of universal rotavirus vaccination in Europe. By February, 2014, national universal rotavirus vaccination had been implemented in Belgium, Luxembourg, Austria, Finland, Greece, Luxembourg, Norway, and the UK. Four other German states have issued recommendations and reimbursement is provided by sickness funds. Other countries were at various stages of recommending or implementing universal rotavirus vaccination.

Patients' preferences for treatment outcomes for advanced non-small cell lung cancer: a conjoint analysis

BACKGROUND

Treatment decisions for advanced non-small cell lung cancer (NSCLC) are complex and require trade-offs between the benefits and risks experienced by patients. We evaluated the benefits that patients judged sufficient to compensate for the risks associated with therapy for NSCLC.

METHODS

Participants with a self-reported diagnosis of NSCLC (n=100) were sampled from an online panel in the United Kingdom. Eligible and consenting participants then completed a self-administered online survey about their disease and their treatment preferences were assessed. This involved respondents choosing among systematically paired profiles that spanned eight attributes: progression-free survival [PFS], symptom severity, rash, diarrhoea, fatigue, nausea and vomiting, fever and infection, and mode of treatment administration (infusion and oral). A choice model was estimated using mixed-logit regression. Estimates of importance for each attribute level and attribute were then calculated and acceptable tradeoffs among attributes were explored.

RESULTS

A total of 89 respondents (73% male) completed all choice tasks appropriately. Increases in PFS together with improvements in symptom severity were judged most important and increased with PFS benefit - 4 months: 5.7; 95% CI: 3.5-7.9; 5 months: 7.1; 95% CI: 4.4-9.9; and 7 months: 10.0; 95% CI: 6.1-13.9. However, improvements in PFS were viewed as most beneficial when disease symptoms were mild and as detrimental when patients had severe symptoms. Fatigue (5.0; 95% CI: 2.7-7.3) was judged to be the most important risk, followed by diarrhoea (2.8; 95% CI: 0.7-4.9), nausea and vomiting (2.1; 95% CI: 0.1-4.1), fever and infection (2.1; 95% CI: 0.2-4.1), and rash (2.0; 95% CI: 0.2-3.9). Oral administration was preferred to infusion (1.8; 95% CI: 0.0-3.6). Patients with mild and moderate symptoms traded PFS for less risks or more convenience if the severe symptoms were not experienced.

CONCLUSION

This study demonstrates the value of conjoint analysis in the study of patient preferences for cancer treatments. In this small sample of patients with NSCLC from the UK, we demonstrate that the value of improvements in PFS is conditional upon the severity of disease symptoms; and that risks are valued differently.