Toward Explicit Prioritization for the Caribbean: An EQ-5D Value Set for Trinidad and Tobago

The EQ-5D-3L valuation study for Bermuda: using an on-line EQ-VT protocol

BACKGROUND

In many countries, methods of economic evaluation and Health Technology Assessment are used to inform healthcare resource allocation decisions. These approaches often require EQ-5D health outcomes measures. This study aimed to create an EQ-5D-3L value set for Bermuda from which EQ-5D-5L Crosswalk values could be obtained.

METHODS

Respondents in Bermuda were recruited locally. A team of Trinidad-based interviewers with prior EQ-5D-3L valuation experience conducted valuation interviews on-line using the EQ-VT protocol. Respondents completed composite time-trade off (cTTO) and discrete choice experiment (DCE) tasks. A hybrid model that included both the cTTO and DCE data was estimated. An EQ-5D-5L crosswalk value set was then created from the EQ-5D-3L index values. Coefficients in the resulting crosswalk model were compared with those of crosswalk and valuation studies from other countries.

RESULTS

The valuation tasks were completed by a near-representative sample of 366 adult Bermuda citizens. Half of the respondents reported being in state 11111. The lowest EQ VAS and EQ-5D-3L index values were 20 and - 0.120 respectively. The hybrid model produced all logically consistent and statistically significant coefficients that in turn produced index values that were very similar to those obtained in a preliminary model (MAD of 0.027).

DISCUSSION

The on-line EQ-VT valuation study was successfully conducted in Bermuda and the values therein can now be used for economic analysis in Bermuda. The Bermuda values differed considerably from those of the other countries against which they were compared. Challenges were encountered with recruitment for an on-line survey in a small population.

The EQ-5D-5L valuation study for Trinidad and Tobago

PURPOSE

The 2016 EQ-5D-3L value set for Trinidad and Tobago (T&T) allows for the calculation of EQ-5D-5L values via the crosswalk algorithm. The 2016 value set was based on methods predating the EQ-VT protocol, now considered the gold standard for developing EQ-5D value sets. Furthermore, direct elicitation of EQ-5D-5L is preferred over crosswalked values. This study aimed to produce an EQ-5D-5L value set for T&T.

METHODS

A representative sample (age, sex, geography) of adults each completed 10 composite Time Trade-Off (cTTO) tasks and 12 Discrete Choice Experiment (DCE) tasks in face-to-face interviews. The cTTO data were analyzed using a Tobit model that corrects for heteroskedasticity. DCE data were analyzed using a mixed logit model. The cTTO and DCE data were combined in hybrid models.

RESULTS

One thousand and seventy-nine adults completed the valuation interviews. Among the modelling approaches that were explored, the hybrid heteroskedastic Tobit model produced all internally consistent, statistically significant coefficients, and performed best in terms of out-of-sample predictivity for single states. Compared to the existing EQ-5D-5L crosswalk set, the new value set had a higher number of negative values (236 or 7.6% versus 21 or 0.7%). The mean absolute difference was 0.157 and the correlation coefficient between the two sets was 0.879.

CONCLUSION

This study provides a value set for the EQ-5D-5L for T&T using the EQ-VT protocol. We recommend this value set for QALY computations relating to T&T.

Quality of life of MS patients in Trinidad and Tobago: Anomaly or adaptation?

BACKGROUND AND OBJECTIVE

There has been growing interest in quality of life associated with multiple sclerosis but the research has been overwhelmingly carried out in developed countries. This study aimed to assess quality of life of multiple sclerosis patients in Trinidad and Tobago.

METHODS

All multiple sclerosis patients were asked to complete demographic, EQ-5D-5L and MSQOL-54 questionnaires. EQ-5D data were compared with population norms for Trinidad and Tobago. MSQOL-54 data were compared with results from a matching cohort of non-MS respondents. Regression analyses were used to explore the association between MSQOL-54 scales and EQ-5D utility.

RESULTS

The 97 patients were mainly urban, highly educated and 75% female. EQ-5D-5L data showed more frequent and more severe problems and lower index values than the population and patients of other chronic illness clinics in Trinidad and Tobago. MSQOL-54 results showed that patients were more affected by physical items, but had high scores on mental and emotional items when compared with the matching cohort and patients in other countries.

CONCLUSION

The low prevalence and demographics of patients suggest the possibility of undetected cases in rural areas and/or among less educated groups. Further investigation into the high levels of mental and emotional health among patients may lead to the design of interventions to help patients of multiple sclerosis and other illnesses.

Evaluating Health Inequality in Five Caribbean Basin Countries Using EQ-5D-5L

BACKGROUND

EQ-5D-5L is a standardized health outcomes instrument that can be added to national surveys to measure inequality in health outcomes. The aim of this study was to produce baseline values of health inequality using EQ-5D-5L for five countries in the Caribbean Basin region based on national surveys in 2012-2014.

METHODS

The EQ-5D-5L questionnaire was included in adult population surveys of Barbados, Belize, Colombia, Jamaica and Trinidad and Tobago. EQ-5D-5L measures were calculated for demographic groups using stratifiers from the World Health Organization's PROGRESS-Plus framework, and generalized linear models were used to test for association between EQ-5D-5L and the PROGRESS-Plus variables. Ordered logit models were used to obtain odds ratios for the effect of the PROGRESS-Plus variables on reporting problems on the EQ-5D-5L dimensions. The Kakwani index was calculated for each country.

RESULTS

Data were obtained for representative samples in each country, giving a combined total of 11,284 respondents. Different patterns of inequality were observed among the five countries. The biggest drivers of inequality were age and gender, and the biggest EQ-5D factors were self-care in Belize and pain/discomfort in the other four countries.

CONCLUSION

This study demonstrated that the EQ-5D-5L instrument can easily be added to national surveys. Inequality measures from this study can be used as baseline values for comparisons with future similar surveys in these five countries to infer changes in health inequality as measured by EQ-5D outcomes. These can be used to track the performance of policy initiatives aimed at specific demographic groups.

Removing a bent femoral nail - man versus metal: A case report

Introduction

Intramedullary nailing is the treatment of choice for femoral shaft fractures in adults with excellent clinical results and low complication rates reported in the literature. However, in situ bending of a femoral nail is a rare complication that merits special attention. While there are several extraction techniques and algorithms the scientific evidence to support these decision-making tools is unconvincing.

Presentation of case

A 26-year old man presented to the Accident and Emergency Department with a deformed thigh following a low-energy injury. Radiographs showed a bent femoral nail in situ and the patient disclosed that he had surgery four weeks earlier for a fractured femur sustained in a motor vehicle accident. A treatment algorithm was followed in planning the surgical strategy, but ultimately a simple hacksaw blade was used to cut and remove the nail. The fracture which was stabilised by exchange nailing went on to uncomplicated union and the patient recovered fully.

Discussion

Non-invasive methods of removing a bent femoral nail are often unsuccessful and may result in iatrogenic injuries. Surgeons should assess the available local resources and first consider using simple open methods when attempting to remove a bent femoral nail.

Conclusion

Open extraction methods often disregard the low-resource environment in which many surgeons work. We describe a simple and economical technique that uses a regular hacksaw blade to cut and remove a bent femoral nail.

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Using modern implants, insitu bending of a femoral nail is a rare occurrence.

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Closed extraction methods are often unsuccessful and may lead to iatrogenic injuries.

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An open technique using a simple hacksaw can be used in low-resource settings without access to sophisticated extraction tools.

Health-Related Quality of Life Population Norms for Belize Using EQ-5D-5L

OBJECTIVES

There has been a growing interest in the use of EQ-5D health outcomes measures in Latin America and the Caribbean. Population norms data provide a benchmark against which clinicians, researchers, and policy makers can compare the health status of patient, treatment, or demographic groups. This study aimed to provide EQ-5D-5L population norms for Belize.

METHODS

The EQ-5D-5L questionnaire was included in a national survey in Belize in 2014. The survey also captured key demographic variables. EQ-5D-5L health states, EQ-5D visual analog scale (EQ VAS) scores, and EQ-5D-5L index values (based on the Trinidad and Tobago value set) were obtained for key demographic groups in Belize.

RESULTS

A representative sample of 2078 respondents completed the survey. The mean index value, EQ VAS score, and ceiling level for Belize were 0.947, 82.6, and 67.8%, respectively. Similar to other Caribbean countries, Belizeans self-reported relatively high EQ VAS scores and ceiling levels compared with non-Caribbean regions. Men reported generally higher health status than women, health status declined as age rises, and the dimensions with the highest burden were pain/discomfort and mobility.

CONCLUSIONS

This study provides researchers and practitioners in Belize with tools to use EQ-5D-5L. Users can apply the EQ VAS scores and EQ-5D-5L states presented herein as reference values. Until an EQ-5D-5L value set is created for Belize, the Trinidad and Tobago index values can be applied to Belizean-reported EQ-5D-5L states, which can then be compared with the index values presented in this study.

Quality of Life Experienced by Major Lower Extremity Amputees

Lower extremity amputations and diabetic foot-related complications in the Caribbean population have been previously reported. However, there is a lack of evidence that assess the quality of life experienced in such amputees. This study aimed to determine the health-related quality of life (HRQoL) in patients after a major lower limb amputation.

Data collection was performed for all major lower limb amputations undertaken at a tertiary care institution in Trinidad and Tobago, between January 2012 to December 2016. The quality of life for patients who were accessible, alive, and willing to participate was assessed using the EuroQol 5D-5L tool. Statistical analysis was performed using the Mann-Whitney U and Kruskal-Wallis tests comparing medians across various subgroups.

A total of 134 individuals were still alive and willing to participate in the study. The average EQ-5D-5L index value for the cohort was (0.598), which was significantly lower compared to EQ-5D-5L population norms for Trinidad and Tobago p < 0.05. Statistically significant differences were also seen in median EQ-5D-5L index value for patients who ambulated with a prosthesis (0.787) compared to those who used another device for mobilization (0.656), p < 0.05, and to those patients who did not ambulate (0.195), p < 0.05. A comparable Quality of life was seen between the level of amputation (transtibial versus transfemoral) and gender (males versus females), p-values were 0.21 and 1.0, respectively.

Overall quality of life after major amputation, as well as independent mobilization with a prosthesis, continues to be problematic in the Caribbean population. Factors adversely related to the quality of life post major amputation include increasing age, problems related to mobility, and non-ambulatory patients.

Quality of Life and Health Status Among Patients Receiving Renal Replacement Therapy in Trinidad and Tobago, West Indies

PURPOSE

The determinants of quality of life for patients on renal replacement therapy vary across the world. The aim of this study is to determine the quality of life of patients on renal replacement therapy in Trinidad and Tobago and predictors thereof.

PATIENTS AND METHODS

This cross-sectional study took place over a 1-year period. Data were obtained from 530 out of 1383 patients meeting inclusion criteria (100 transplants, 80 peritoneal dialyses, 350 hemodialyses) using the survey instruments. Stratified random sampling with proportional allocation was used to select patients at hemodialysis centres. The Kidney Disease Quality of Life questionnaire (KDQOL-36), EuroQol and demographic questionnaires were administered via face-to-face interviews. SPSS24, STATA14 and MINITAB18 were used for descriptive and inferential data analysis.

RESULTS

Of the 530 patients, 52.5% were male, 37.5% were in the 56-65 years age group and 51.3% were of Indo-Trinbagonian descent. Hypertension (25.5%) and type 2 diabetes mellitus (62.0%) were reported as the main causes of kidney disease in the dialysis group. In the transplant category, chronic glomerulonephritis (45%) was the main aetiology of kidney disease. The KDQOL-36 domain scores and significantly associated variables included modality of renal replacement, Charlson's Comorbidity Index, ethnicity, income and employment status. Transplant patients had higher mean subcomponent Kidney Disease Quality of Life scores and performed better in the EuroQol than patients on dialysis. Patients on peritoneal dialysis had a better quality of life than hemodialysis patients. Among patients on hemodialysis, an arteriovenous fistula significantly impacted their quality of life.

CONCLUSION

Renal transplant recipients enjoy the best quality of life and health state among patients on renal replacement therapy in Trinidad and Tobago. Increasing patients' access to renal transplantation or peritoneal dialysis will markedly improve health status for the number of years of renal replacement therapy.

EQ-5D-5L Population Norms and Health Inequality in Colombia

OBJECTIVES

The EQ-5D-3L and EQ-5D-5L instruments have been used in studies of patient and demographic groups in Colombia, but to date there are no 5L population norms. This study aimed to produce a set of EQ-5D-5L population norms for Colombia and to see what insights into health inequality in Colombia can be discerned from these norms.

METHODS

The EQ-5D-5L self-reported health questionnaire was included in a survey of a representative sample of 3400 adults aged 18 to 64 in Colombia. EQ-5D-5L states, mean EQ VAS, and index values were obtained by sex, age, education, income group, ethnicity, residence, employment status, health insurance status, and household size. EQ-5D-5L index values from Uruguay were used. Regression models were used to investigate inequality.

RESULTS

The mean EQ VAS value was 85.3, the mean index value was 0.953, and 52.2% of the sample reported being in state 11111. Self-reported health was higher for men, declined in higher age groups, and was lower for lower-income and education groups. The EQ-5D-5L instrument was observed to be more sensitive than the EQ-5D-3L instrument in Colombia. The dimensions with the highest prevalence of reported problems were anxiety/depression and pain/discomfort. The main drivers of inequality were age, sex, income, and education.

CONCLUSIONS

The population norms developed in this study can be used as baseline values for future studies of patient or treatment groups, and for investigations into the health of specific demographic groups.

EQ-5D self-reported health in Barbados and Jamaica with EQ-5D-5L population norms for the English-speaking Caribbean

Background

The EQ-5D instrument is increasingly used in clinical and resource allocation decision making in developed and developing countries. EQ-5D valuation and population norms studies have been undertaken for Trinidad and Tobago, however no population norms or value sets have been generated for the other Caribbean countries. The aims of this study were to provide population norms for Barbados and Jamaica, and to develop a set of population norms that could be used by the other English-speaking Caribbean countries.

Methods

The EQ-5D-5L self-reported health questionnaire was included in surveys of representative samples of adults in Barbados and adults in Jamaica in 2013. EQ-5D health states, mean EQ VAS scores and mean EQ-5D-5L index values (using the Trinidad and Tobago value set) were calculated for demographic groups in both countries based on 2347 respondents from Barbados and 1423 from Jamaica. A set of ‘Caribbean’ norms were developed by combining the Barbados and Jamaica data with norms recently published for Trinidad and Tobago.

Results

Data were obtained for 2347 and 1423 respondents in Barbados and Jamaica respectively. The mean index and EQ VAS values were 0.943 and 81.9 for Barbados, and 0.948 and 87.8 for Jamaica. The health states most commonly observed in the two countries were similar. Generally the demographic patterns of self-reported health were consistent with those found in other studies. Some differences between the countries were observed in the patterns of rates of reporting problems on the EQ-5D dimensions among age-gender groups specifically for anxiety/depression and pain/discomfort

Conclusion

This study has produced a set of EQ-5D population norms that can be used as base-line values in clinical and clinico-economic analyses for Barbados and Jamaica and for the English-Speaking Caribbean region.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-021-01734-8.

EQ-5D-5L population norms and health inequalities for Trinidad and Tobago

The EQ-5D instrument is now used in many health systems as a health outcomes measure. Recently an EQ-5D valuation study was conducted for Trinidad and Tobago, but thus far there have been no population norms published for Trinidad and Tobago or for any Caribbean country. The objective of this study is to provide a set of population norms, and to investigate inequalities in health in Trinidad and Tobago. The EQ-5D-5L questionnaire was included in the 2012/2013 Adult Population Survey of the Global Entrepreneurship Monitor for Trinidad and Tobago. This survey covered a representative sample of 2,036 adults aged 18 and over. Demographic data and self-reported health using EQ-5D-5L were collected. The Trinidad and Tobago value set was used to obtain EQ-5D index values. The Kakwani index and logistic regression models were used to evaluate inequalities in health. Mean EQ-5D index values and EQ-VAS values were calculated by age group, ethnicity, gender, income, educational attainment, employment status and place of residence. The 10 most commonly observed EQ-5D-5L states accounted for 90% of the respondents. The mean VAS value for the sample was 83.6 and the mean EQ-5D-5L index value was 0.95. Pain/discomfort was found to be the EQ-5D dimension with the highest prevalence of reported problems with 22% of the population reporting pain at any level. Self-care was the dimension with the lowest prevalence of problems reported at any level (3%). Health declines with increasing age, and men reported fewer problems and higher levels of self-reported health than women. Age, gender and education level were found to be important drivers of health status as measured by the EQ-5D instrument. Being in a very low income group was also observed to affect EQ-VAS values among younger respondents. The population norms provided in this study can be used by clinicians, academics and policy makers in several ways. They can be used in comparing different demographic groups or patient groups, or as a basis for tracking the progress of patients through a treatment regimen. They can also provide a baseline for cost utility analysis of health interventions for Trinidad and Tobago.

One Method, Many Methodological Choices: A Structured Review of Discrete-Choice Experiments for Health State Valuation

BACKGROUND

Discrete-choice experiments (DCEs) are used in the development of preference-based measure (PBM) value sets. There is considerable variation in the methodological approaches used to elicit preferences.

OBJECTIVE

Our objective was to carry out a structured review of DCE methods used for health state valuation.

METHODS

PubMed was searched until 31 May 2018 for published literature using DCEs for health state valuation. Search terms to describe DCEs, the process of valuation and preference-based instruments were developed. English language papers with any study population were included if they used DCEs to develop or directly inform the production of value sets for generic or condition-specific PBMs. Assessment of paper quality was guided by the recently developed Checklist for Reporting Valuation Studies. Data were extracted under six categories: general study information, choice task and study design, type of designed experiment, modelling and analysis methods, results and discussion.

RESULTS

The literature search identified 1132 published papers, and 63 papers were included in the review. Paper quality was generally high. The study design and choice task formats varied considerably, and a wide range of modelling methods were employed to estimate value sets.

CONCLUSIONS

This review of DCE methods used for developing value sets suggests some recurring limitations, areas of consensus and areas where further research is required. Methodological diversity means that the values should be seen as experimental, and users should understand the features of the value sets produced before applying them in decision making.