Whose quality of life? A commentary exploring discrepancies between health state evaluations of patients and the general public

One and the same or different? An empirical comparison of aged care recipient and non-aged care recipient preferences for quality of aged care amongst older Australians

The Quality of Care Experience Aged Care Consumers (QCE-ACC) is a new preference-based instrument recently adopted by the Australian government nationally as a new quality indicator for aged care. This study employed a discrete choice experiment (DCE) approach to develop an aged care user-specific value set for the QCE-ACC instrument. This is crucial for establishing the relative importance of key QCE-ACC dimensions for informing quality assessment and economic evaluation in aged care. We further empirically compared the preferences of aged care recipients and non-aged care recipients amongst the older Australian population (65 years and above) for quality of care experience using the QCE-ACC. A total of 201 older people (age 74.2 ± 6.2; 59.7% female) receiving aged care services completed the DCE survey between August and September 2022. The comparison of relative importance indicated some divergence in the preferences between the aged care recipients and non-aged care recipients. Amongst aged care recipients, being treated with "Respect & Dignity" was the most important quality of care experience defining dimension, with "Health & Wellbeing" ranked second and "Skills & Training" (of staff) ranked third. However, within non-aged care recipients, "Skills Training" (of staff) was considered the most important quality of care dimension. Distinction in the QCE-ACC utility weights distributions and mean values were also observed, suggesting that aged care recipients may have different opinions about the quality of aged care compared to those who have not accessed aged care services. The findings shed light on the unique preferences of aged care recipients, indicating that aged care recipients and non-aged care recipients' preferences for quality of aged care are not interchangeable. The value set developed in this study is specifically tailored for assessing the quality of aged care using the QCE-ACC instrument from the perspective of aged care users in Australia.

"You Take This Day by Day, Come What May": A Qualitative Study of the Psychosocial Impacts of Living with Duchenne Muscular Dystrophy

INTRODUCTION

Studies have reported health-related quality-of-life impacts of Duchenne muscular dystrophy (DMD); however, further research is needed to understand how those with DMD experience their condition and how psychosocial impacts evolve over time in response to disease progression. This qualitative study explores the social and emotional implications of key transitions, challenges and adaptations throughout the disease course from the perspective of patients and family caregivers.

METHODS

Semi-structured interviews were conducted with men and boys with DMD, and/or their caregivers, in the USA. Thematic analysis was used to examine patterns in data collected across the interviews.

RESULTS

Nineteen participants were included. Three major themes were identified: (1) barriers to participation are multifaceted; (2) an emotional journey shaped by 'inevitable progression;' (3) family provides critical tangible and emotional support. This study illustrates that psychosocial impacts of DMD are shaped by knowledge of the condition's natural history alongside other factors including the extent of social barriers, personal growth and adaptation, and family support.

CONCLUSIONS

Findings provide insight into the strength and resilience with which individuals and their families respond to daily challenges and major clinical milestones and highlight the relative importance of loss of upper limb function as a transition in DMD affecting health-related quality-of-life.

Differences in health utilities between cancer patients and the general population: The case of Quebec using the SF-6Dv2

A considerable debate persists in the literature about whose preferences should be considered in the calculation of quality-adjusted life-years. Some suggest considering only the preferences of the general population, while others advocate for the consideration of those of patients or a combination of both. This study aims to inform and measure the differences in health preferences between cancer patients and the general population in Quebec. A total of 60,976 observations representing the preferences of the general population for various health states were collected and used to develop a new value set using the SF-6Dv2. This value set was generated by combining 34,299 observations with time trade-off (TTO) and 26,677 observations with discrete choice experiment (DCE). Utility scores derived from this value set were compared to those of patients' preferences from a new value set in breast and colorectal patients for the SF-6Dv2. For both patients and the general population, the 'Pain' dimension was the highest contributor to the utility score. However, noticeable differences were observed in the estimates. Estimates of levels 2 and 3 were generally lower for cancer patients, while they were more likely to have greater estimates in severe levels. Significant differences in utility scores were also noticed with the general population showing higher mean utility scores for the same health states. These differences increased as the health states worsened. This study sheds light on the existing differences in preferences between cancer patients and the general population of Quebec for a better consideration in healthcare decision-making.

Estimating the disutility of relapse in relapsing-remitting and secondary progressive multiple sclerosis using the EQ-5D-5L, AQoL-8D, EQ-5D-5L-psychosocial, and SF-6D: implications for health economic evaluation models

BACKGROUND AND AIMS

Relapses are an important clinical feature of multiple sclerosis (MS) that result in temporary negative changes in quality of life (QoL), measured by health state utilities (HSUs) (disutilities). We aimed to quantify disutilities of relapse in relapsing remitting MS (RRMS), secondary progressive MS (SPMS), and relapse onset MS [ROMS (including both RRMS and SPMS)] and examine these values by disability severity using four multi-attribute utility instruments (MAUIs).

METHODS

We estimated (crude and adjusted and stratified by disability severity) disutilities (representing the mean difference in HSUs of 'relapse' and 'no relapse' groups as well as 'unsure' and 'no relapse' groups) in RRMS (n = 1056), SPMS (n = 239), and ROMS (n = 1295) cohorts from the Australian MS Longitudinal Study's 2020 QoL survey, using the EQ-5D-5L, AQoL-8D, EQ-5D-5L-Psychosocial, and SF-6D MAUIs.

RESULTS

Adjusted mean overall disutilities of relapse in RMSS/SPMS/ROMS were - 0.101/- 0.149/- 0.129 (EQ-5D-5L), - 0.092/- 0.167/- 0.113 (AQoL-8D), - 0.080/- 0.139/- 0.097 (EQ-5D-5L-Psychosocial), and - 0.116/- 0.161/- 0.130 (SF-6D), approximately 1.5 times higher in SPMS than in RRMS, in all MAUI. All estimates were statistically significant and/or clinically meaningful. Adjusted disutilities of RRMS and ROMS demonstrated a U-shaped relationship between relapse disutilities and disability severity. Relapse disutilities were higher in 'severe' disability than 'mild' and 'moderate' in the SPMS cohort.

CONCLUSION

MS-related relapses are associated with substantial utility decrements. As the type and severity of MS influence disutility of relapse, the use of disability severity and MS-type-specific disutility inputs is recommended in future health economic evaluations of MS. Our study supports relapse management and prevention as major mechanisms to improve QoL in people with MS.

Comparison of Preferences and Data Quality between Discrete Choice Experiments Conducted in Online and Face-to-Face Respondents

INTRODUCTION

Discrete choice experiments (DCE) are increasingly being conducted using online panels. However, the comparability of such DCE-based preferences to traditional modes of data collection (e.g., in-person) is not well established. In this study, supervised, face-to-face DCE was compared with its unsupervised, online facsimile on face validity, respondent behavior, and modeled preferences.

METHODS

Data from face-to-face and online EQ-5D-5L health state valuation studies were compared, in which each used the same experimental design and quota sampling procedure. Respondents completed 7 binary DCE tasks comparing 2 EQ-5D-5L health states presented side by side (health states A and B). Data face validity was assessed by comparing preference patterns as a function of the severity difference between 2 health states within a task. The prevalence of potentially suspicious choice patterns (i.e., all As, all Bs, and alternating As/Bs) was compared between studies. Preference data were modeled using multinomial logit regression and compared based on dimensional contribution to overall scale and importance ranking of dimension-levels.

RESULTS

One thousand five Online respondents and 1,099 face-to-face screened (F2FS) respondents were included in the main comparison of DCE tasks. Online respondents reported more problems on all EQ-5D dimensions except for Mobility. The face validity of the data was similar between comparators. Online respondents had a greater prevalence of potentially suspicious DCE choice patterns ([Online]: 5.3% [F2FS] 2.9%, P = 0.005). When modeled, the relative contribution of each EQ-5D dimension differed between modes of administration. Online respondents weighed Mobility more importantly and Anxiety/Depression less importantly.

DISCUSSION

Although assessments of face validity were similar between Online and F2FS, modeled preferences differed. Future analyses are needed to clarify whether differences are attributable to preference or data quality variation between modes of data collection.

Second Version of the Short Form 6-Dimension Value Set Elicited From Patients With Breast and Colorectal Cancer: A Hybrid Approach

BACKGROUND

Quality-adjusted life-year instruments help comparison among programs by capturing their effects in terms of utility. Generic instruments are applicable to everyone, and for this reason, they are known to lack sensitivity when measuring gains in some domains. Specific instruments tend to fill this gap but, in domains like cancer, existing instruments are either nonpreferences-based or based on the general population's preferences.

PATIENTS AND METHODS

This study describes the development of a new value set for a well-known and highly used generic instrument, the Second Version of the Short Form 6-Dimension, to better consider the preferences of patients with cancer. In this aim, a hybrid approach combining the time trade-off and the discrete choice experiment was used. The population of interest was the Quebec population, Canada, with breast or colorectal cancer. Their preferences were elicited in 2 periods: before (T1) and 8 days after the beginning of a chemotherapy procedure (T2).

RESULTS

A total of 2808 observations for the time trade-off and 2520 observations for the discrete choice experiment were used. The parsimonious model encompassing the 2 periods was the preferred model. The new value set allows a greater utility range than the EQ-5D-5L and the Second Version of the Short Form 6-Dimension reference value sets and helps in better considering patients experiencing severe health situations. A good correlation between these 2 instruments and other specific cancer instruments (ie, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, QLU-C10D, and Functional Assessment of Cancer Therapy-General) was observed. Significative differences in utility values were also noted within periods and types of cancer.

Noninvasive respiratory assistance as aid for respiratory care in neuromuscular disorders

Chronic respiratory failure is a common complication of neuromuscular disease. The use of noninvasive ventilation and mechanically assisted cough can reduce symptoms of hypoventilation, slow lung function decline, improve sleep quality, and in some cases prolong survival in patients with neuromuscular disease. In this article, we review indications for the initiation of noninvasive ventilation and mechanically assisted cough as well as provide recommendations for settings and titration. We discuss the evidence supporting the use of noninvasive ventilation as an adjunct to rehabilitation in patients with neuromuscular disease. Lastly, we review the ethical considerations that are relevant to decisions regarding initiation and cessation of noninvasive ventilation. While noninvasive ventilation and mechanically assisted cough have become standards of care in many forms of neuromuscular disease, most current recommendations are based on expert opinion rather than much-needed data from prospective clinical trials and we emphasize topics requiring future research.

Do Misconceptions About Health-Related Quality of Life Affect General Population Valuations of Health States?

OBJECTIVES

Healthcare resource allocation decisions are often informed by the expected gains in patients' quality-adjusted life-years. Misconceptions about ill-health's consequences for quality of life (QOL) may however affect evaluations of health states by the general population and hence affect resource allocation decisions informed by quality-adjusted life-years. We examine whether people selectively misestimate the QOL consequences of moderate anxiety or depression compared with other dimensions of health, and we test whether informing people of actual changes in QOL associated with health states changes appraisals of their relative undesirability.

METHODS

UK general population participants (N = 1259; in 2017) expressed preferences over moderate problems: anxiety or depression, self-care, and pain or discomfort. A randomized control trial design was used whereby a control group was given a functional description of each health state, and 2 intervention groups were additionally given information on the actual differences in either life satisfaction (LS) or day affect (DA) associated with experiencing each health state.

RESULTS

The LS (DA) group reported a higher preference for avoiding living with moderate anxiety or depression, being 13.4% (13.9%) more likely to choose it as most undesirable.

CONCLUSION

Informing people of the change in LS or DA associated with health states before they appraise them is a feasible way to obtain informed preferences.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Time trade-off health state utility values for depression: a systematic review and meta-analysis

PURPOSE

This study aims to systematically review the literature on health utility in depression generated by time trade-off (TTO) method and to compare health state vignettes.

METHODS

Systematic literature search was conducted following PRISMA guideline in 2020 November (updated in 2022 March) in Pubmed, Web of Science, PsycInfo, and Cochrane Database of Systematic Reviews. Random effect meta-analysis was conducted to pool vignette-based utility values of mild, moderate, and severe depression and to compare the preferences of depressed and nondepressed population.

RESULTS

Overall, 264 records were found, 143 screened by title and abstract after removing duplicates, 18 assessed full text, and 14 original publications included. Majority of the studies (n = 9) used conventional TTO method, and most of the studies (n = 8) applied 10-year timeframe. Eight studies evaluated self-experienced health (own-current depression). Six studies assessed vignette-based health states of remitted, mild, moderate, and severe depression, half of them applied McSad measure based health description. Altogether, 61 different utility values have been cataloged, mean utility of self-experienced depression states (n = 33) ranged between 0.89 (current-own depression) and 0.24 (worst experienced depression). Pooled utility estimates for vignette-based mild, moderate, and severe depression was 0.75, 0.66 and 0.50, respectively. Meta-regression showed that severe depression (β = -0.16) and depressed sample populations (β =  -0.13) significantly decrease vignette-based utility scores.

CONCLUSION

Our review revealed extent heterogeneity both in TTO methodology and health state vignette development. Patient's perception of depression health states was worse than healthy respondents.

Individual differences in numerical representations of risk in health decision making: A fuzzy-trace theory approach

Fuzzy-trace theory predicts that decisionmakers process numerical information about risk at multiple levels in parallel: the simplest level, nominal (categorical some-none) gist, and at more fine-grained levels, involving relative comparison (ordinal less-more gist) and exact quantities (verbatim representations). However, little is known about how individual differences in these numerical representations relate to judgments and decisions, especially involving health tradeoffs and relative risks. To investigate these differences, we administered measures of categorical and ordinal gist representations of number, objective numeracy, and intelligence in two studies (Ns = 978 and 956). In both studies, categorical and ordinal gist representations of number predicted risk judgments and decisions beyond objective numeracy and intelligence. Participants with higher scores in categorical gist were more likely to choose options to avoid cancer recurrence risks; those who were higher in ordinal gist of numbers were more likely to discriminate relative risk of skin cancer; and those with higher scores in objective numeracy were more likely to choose options that were numerically superior overall in terms of relative risk of skin cancer and of genetic risks of breast cancer (e.g., lower numerical probability of cancer). Results support parallel-processing models that assume multiple representations of numerical information about risk, which vary in precision, and illustrate how individual differences in numerical representations are relevant to tradeoffs and risk comparisons in health decisions. These representations cannot be reduced to one another and explain psychological variations in risk processing that go beyond low versus high levels of objective numeracy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Listening to the elephant in the room: response-shift effects in clinical trials research

Background

While a substantial body of work postulates that adaptation (response-shift effects) may serve to hide intervention benefits, much of the research was conducted in observational studies, not randomized-controlled trials. This scoping review identified all clinical trials that addressed response shift phenomena, and characterized how response-shift effects impacted trial findings.

Methods

A scoping review was done of the medical literature from 1968 to 2021 using as keywords “response shift” and “clinical trial.” Articles were included if they were a clinical trial that explicitly examined response-shift effects; and excluded if they were not a clinical trial, a full report, or if response shift was mentioned only in the discussion. Clinical-trials papers were then reviewed and retained in the scoping review if they focused on randomized participants, showed clear examples of response shift, and used reliable and valid response-shift detection methods. A synthesis of review results further characterized the articles’ design characteristics, samples, interventions, statistical power, and impact of response-shift adjustment on treatment effect.

Results

The search yielded 2148 unique references, 25 of which were randomized-controlled clinical trials that addressed response-shift effects; 17 of which were retained after applying exclusion criteria; 10 of which were adequately powered; and 7 of which revealed clinically-important response-shift effects that made the intervention look significantly better.

Conclusions

These findings supported the presumption that response shift phenomena obfuscate treatment benefits, and revealed a greater intervention effect after integrating response-shift related changes. The formal consideration of response-shift effects in clinical trials research will thus not only improve estimation of treatment effects, but will also integrate the inherent healing process of treatments.

Key points

This scoping review supported the presumption that response shift phenomena obfuscate treatment benefits and revealed a greater intervention effect after integrating response-shift related changes.

The formal consideration of response-shift effects in clinical trials research will not only improve estimation of treatment effects but will also integrate the inherent healing process of treatments.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Determinants of Health Preferences Using Data from the Egyptian EQ-5D-5L Valuation Study

Objective

The aim of this study was to explore the impact of sociodemographic characteristics and illness experience on time trade-off (TTO)-based utility scores using data from the EQ-5D-5L Egyptian valuation study.

Methods

Data were from the Egyptian valuation study that was conducted using the adapted translated version of the EQ-VT to develop the Egyptian Tariff for the EQ-5D-5L based on preferences of the Egyptian population. Data were analysed using a series of univariate and multivariable censored linear regression models adjusted for severity of health states where the dependent variable was the TTO scores and the independent variables included age, sex, education, geographical region, dwelling, marital status, number of people in the household, employment status, having health insurance, number of chronic conditions, previous experience with illness, and self-rated health.

Results

Age, sex, education, marital status, dwelling, region of residence, health insurance and multimorbidity were significantly associated with health state valuations, while employment status, number of people in a household, religion, and previous experience with illness had non-significant associations.

Conclusion

Age, sex and marital status are the main determinants of health state valuation in the Egyptian population, a finding consistent with those from other countries. Knowing these factors will help tailor health services provided and improve patient-centered care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-022-00572-0.

Why Intellectual Disability is Not Mere Difference

A key question in disability studies, philosophy, and bioethics concerns the relationship between disability and well-being. The mere difference view, endorsed by Elizabeth Barnes, claims that physical and sensory disabilities by themselves do not make a person worse off overall-any negative impacts on welfare are due to social injustice. This article argues that Barnes's Value Neutral Model does not extend to intellectual disability. Intellectual disability is (1) intrinsically bad-by itself it makes a person worse off, apart from a non-accommodating environment; (2) universally bad-it lowers quality of life for every intellectually disabled person; and (3) globally bad-it reduces a person's overall well-being. While people with intellectual disabilities are functionally disadvantaged, this does not imply that they are morally inferior-lower quality of life does not mean lesser moral status. No clinical implications concerning disability-based selective abortion, denial of life-saving treatment, or rationing of scarce resources follow from the claim that intellectual disability is bad difference.

No Time to Waste: An Appraisal of Value at the End of Life

OBJECTIVES

The use of economic evaluations of end-of-life interventions may be limited by an incomplete appreciation of how patients and society perceive value at end of life. The objective of this study was to evaluate how patients, caregivers, and society value gains in quantity of life and quality of life (QOL) at the end of life. The validity of the assumptions underlying the use of the quality-adjusted life-years (QALY) as a measure of preferences at end of life was also examined.

METHODS

MEDLINE, Embase, CINAHL, PsycINFO, and PubMed were searched from inception to February 22, 2021. Original research studies reporting empirical data on healthcare priority setting at end of life were included. There was no restriction on the use of either quantitative or qualitative methods. Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all included studies. The primary outcomes were the value of gains in quantity of life and the value of gains in QOL at end of life.

RESULTS

A total of 51 studies involving 53 981 participants reported that gains in QOL were generally preferred over quantity of life at the end of life across stakeholder groups. Several violations of the underlying assumptions of the QALY to measure preferences at the end of life were observed.

CONCLUSIONS

Most patients, caregivers, and members of the general public prioritize gains in QOL over marginal gains in life prolongation at the end of life. These findings suggest that policy evaluations of end-of-life interventions should favor those that improve QOL. QALYs may be an inadequate measure of preferences for end-of-life care thereby limiting their use in formal economic evaluations of end-of-life interventions.

Two Minds, One Patient: Clearing up Confusion About "Ambivalence"

Patients who experience difficulty making medical decisions are often referred to as "ambivalent." However, the current lack of attention to the nuances between a cluster of phenomena that resemble ambivalence means that we are not always recognizing what is really going on with a patient. Importantly, different kinds of "ambivalence" may call for different approaches. In this paper, we present a taxonomy of ambivalence-related phenomena, provide normative analysis of some of the effects of-and common responses to-such mental states, and sketch some practical strategies for addressing ambivalence. In applying lessons from the philosophical literature and decision theory, our aim is to provide ethicists and clinicians with the tools to better understand and effectively intervene in cases of ambivalence.

The EORTC QLU-C10D discrete choice experiment for cancer patients: a first step towards patient utility weights

Background

The European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Utility-Core 10 Dimensions (QLU-C10D) is a novel cancer-specific preference-based measure (PBM) for which value sets are being developed for an increasing number of countries. This is done by obtaining health preferences from the respective general population. There is an ongoing discussion if instead patients suffering from the disease in question should be asked for their preferences. We used the QLU-C10D valuation survey, originally designed for use in the general population, in a sample of cancer patients in Austria to assess the methodology’s acceptability and applicability in this target group before obtaining QLU-C10D patient preferences.

Methods

The core of the QLU-C10D valuation survey is a discrete choice experiment in which respondents are asked to give preferences for certain health states (described by a relatively large number of 10 quality of life domains) and an associated survival time. They therewith are asked to trade off quality of life against life time. As this might be a very burdensome task for cancer patients undergoing treatment, a cognitive interview was conducted in a pilot sample to assess burden and potential additional needs for explanation in order to be able to use the DCE for the development of QLU-C10D patient preferences. In addition, responses to general feedback questions on the survey were compared against responses from a matched control group from the already completed Austrian general population valuation survey.

Results

We included 48 patients (mean age 59.9 years; 46% female). In the cognitive interview, the majority indicated that their experience with the survey was positive (85%) and overall clarity as good (90%). In response to the general feedback questions, patients rated the presentation of the health states less clear than matched controls (p = 0.008). There was no difference between patients and the general population concerning the difficulty in choosing between the health states (p = 0.344).

Conclusion

Despite the relatively large number of DCE domains the survey was manageable for patients and allows going on with the QLU-C10D patient valuation study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00430-5.

Nurses' Quality of Life Scale: validation and psychometric properties

The Nursing Quality of Life Scale (NQOLS) is a 28-item self-report measure evaluating the four dimensions of nurses' quality of life, namely, the physical, emotional, working, and social dimensions. The purpose of this study is to assess the psychometric properties, including validity and reliability, of the NQOLS. The study enrolled 1,105 nurses who provided direct assistance to patients. The NQOLS factorial structure was tested using a cross-validation approach via Exploratory Structural Equational Modeling, which confirmed the instrument's four-dimension structure. Reliability was assessed using omega coefficients, proving excellent for all factors. Cluster analysis identified five distinct groups, each composed of participants sharing a substantial similarity with respect to their profile in the NQOLS. These five identifiable clusters presented significant differences not only in the NQOLS but also in the risk of work-related stress, emotional labour and burnout. The results show that NQOLS is a simple, reliable, lean tool for measuring nurses' overall QoL, whose various parts can additionally be used to answer specific research questions.

QALYs and ambulatory status: societal preferences for healthcare decision making

BACKGROUND

This research aimed to review the theoretical and methodological aspects of the quality-adjusted life year (QALY) which give rise to potential for bias against certain patient populations, including those with problems with walking or an inability to walk (ambulatory disabilities), when health technology assessment decisions rely on QALY gain to show cost-effectiveness. Societal preferences for treating ambulatory versus non-ambulatory patients were also investigated.

METHODS

We reviewed published literature to identify information on theoretical underpinnings of the QALY, measurement of utilities for QALY assessment, and empirical evidence of societal preferences for the treatment of ambulatory and non-ambulatory patients.

RESULTS AND DISCUSSION

Health states which represent mobility impairment and the inability to walk receive low valuation from general public preferences. Non-ambulatory patients, for example those with advanced neuromuscular disease, have lower utilities determined by standardized preference-based measurement (PBM) tools. Any treatment that increases survival but could not restore ambulation would result in lower lifetime QALY gains for non-ambulatory versus ambulatory patients. Treatments could therefore potentially be deemed less cost-effective, or not cost-effective at all for this patient population.Empirical research indicates a societal preference for equal treatment of patients regardless of ambulatory status. The main limitation of our review was the non-systematic approach to evidence search and review, however, given the broad scope of content required to meet the aims of the review, we believe that the targeted approach was appropriate. The evidence presented in this article highlights the need for alternatives to strict QALY-based approaches to prevent avoidable health inequities when determining cost-effectiveness of healthcare interventions for non-ambulatory populations against fixed cost-effectiveness thresholds. An alternative metric, the Equal Value of Life Years Gained (evLYG), has been proposed as a supplementary measure for use alongside the QALY for its potential to alleviate bias against disabled patient populations during the assessment of healthcare treatments.

Disability and the Goods of Life

The so-called Disability Paradox arises from the apparent tension between the popular view that disability leads to low well-being and the relatively high life-satisfaction reports of disabled people. Our aim in this essay is to make some progress toward dissolving this alleged paradox by exploring the relationship between disability and various "goods of life"-that is, components of a life that typically make a person's life go better for them. We focus on four widely recognized goods of life (happiness, rewarding relationships, knowledge, achievement) and four common types of disability (sensory, mobility, intellectual, and social) and systematically examine the extent to which the four disability types are in principle compatible with obtaining the four goods of life. Our findings suggest that there is a high degree of compatibility. This undermines the widespread view that disabilities, by their very nature, substantially limit a person's ability to access the goods of life, and it provides some guidance on how to dissolve the Disability Paradox.

A Systematic Review of Health State Utility Values in the Plastic Surgery Literature

Cost-utility analyses assess health gains acquired by interventions by incorporating weighted health state utility values (HSUVs). HSUVs are important in plastic and reconstructive surgery (PRS) because they include qualitative metrics when comparing operative techniques or interventions. We systematically reviewed the literature to identify the extent and quality of existing original utilities research within PRS.

Methods

A systematic review of articles with original PRS utility data was conducted in accordance with the Preferred Reporting Items for a Systematic Review and Meta-Analysis guidelines. Subspecialty, survey sample size, and respondent characteristics were extracted. For each HSUV, the utility measure [direct (standard gamble, time trade off, visual analog scale) and/or indirect], mean utility score, and measure of variance were recorded. Similar HSUVs were pooled into weighted averages based on sample size if they were derived from the same utility measure.

Results

In total, 348 HSUVs for 194 disease states were derived from 56 studies within seven PRS subspecialties. Utility studies were most common in breast (n = 17, 30.4%) and hand/upper extremity (n = 15, 26.8%), and direct measurements were most frequent [visual analog scale (55.4%), standard gamble (46.4%), time trade off (57.1%)]. Studies surveying the general public had more respondents (n = 165, IQR 103-299) than those that surveyed patients (n = 61, IQR 48-79) or healthcare professionals (n = 42, IQR 10-109). HSUVs for 18 health states were aggregated.

Conclusions

The HSUV literature within PRS is scant and heterogeneous. Researchers should become familiar with these outcomes, as integrating utility and cost data will help illustrate that the impact of certain interventions are cost-effective when we consider patient quality of life.

How older people living with HIV narrate their quality of life: Tensions with quantitative approaches to quality-of-life research

This article draws on life-history interviews with older (aged 50+) people living with HIV in England to uncover the interpretive practices in which they engaged as they evaluated their own quality of life (QoL). Our paper highlights the distinctive insights that biographical and narrative approaches can bring to QoL research. While accounts of subjectively 'poor' QoL were relatively straightforward and unequivocally phrased, accounts of subjectively 'good' and 'OK' QoL were produced using complex interpretive and evaluative practices. These practices involved biographical reflection and contextualization, with participants weighing up and comparing their current lives' 'pros' and 'cons', their own lives with the lives of others, and their present lives with lives they had imagined having at the time of interview. Thus, 'good' and 'OK' QoL were constructed using practical, relational, and interpretive work - features of QoL analytically unavailable in quantitative data gathered through standardised measures (including our own survey data collected from these same participants). Our findings underscore the uneasy fit between QoL's quantitative measurement and its subjective understandings and evaluations, on the one hand, and the interpretive work that goes into achieving these understandings and evaluations, on the other.

Will to Live in Older Nursing Home Residents: A Cross-Sectional Study in Switzerland

CONTEXT

The will to live (WTL) is an important indicator of subjective well-being. It may enable a deeper understanding of the well-being of nursing home residents.

OBJECTIVES

To evaluate the intensity of WTL, its association with various factors, and its temporal evolution among residents ≥ 65 years old; we also aimed to compare it with proxy assessments of WTL.

METHODS

A cross-sectional study was conducted in five nursing homes in Switzerland. Participants with decisional capacity were asked to rate the intensity of their WTL on a single-item numerical rating scale ranging from 0-10. A short-term follow-up was conducted among a sub-sample of 17 participants after three and six weeks. Proxy assessment by residents' next of kin and professional caregivers was conducted, and inter-rater agreement was calculated.

RESULTS

Data from 103 participants (75.7% women, 87.3 ± 8.0 years) was analyzed. The median intensity of WTL was 8. Higher WTL was significantly associated with better physical mobility and shorter duration of daily care but not with age, gender, pre-admission care setting, or prognosis. Significant independent predictors of WTL were physical mobility and provenance from rehabilitative care. In the short-term follow-up assessment, WTL remained highly stable. Intraclass correlation coefficients were moderate for residents' next of kin and nurse assistants but poor for physicians and nurses; all proxy assessments underestimated the participants' WTL.

CONCLUSION

Nursing home residents expressed a very strong WTL and proxy aents underestimated residents' WTL. It seems pivotal to proactively communicate with residents about their WTL.

A Comparison of Generic and Condition-Specific Preference-Based Measures Using Data From Nivolumab Trials: EQ-5D-3L, Mapping to the EQ-5D-5L, and European Organisation for Research and Treatment of Cancer Quality of Life Utility Measure-Core 10 Dimensions

OBJECTIVES

There is growing interest in condition-specific preference measures, including the European Organisation for Research and Treatment of Cancer Quality of Life Utility Measure-Core 10 Dimensions (QLU-C10D). This research assessed the implications of using utility indices on the basis of the EQ-5D-3L, a mapping of EQ-5D-3L to the EQ-5D-5L, and the QLU-C10D, and compared their psychometric properties.

METHODS

Data were taken from 8 phase 3 randomized controlled trials of nivolumab with or without ipilimumab for the treatment of solid tumors. Utilities for progression-related states were calculated using the UK and English value sets and incremental quality-adjusted life-years (QALYs) derived from established UK cost-effectiveness models. The psychometric properties of the utility indices were assessed using pooled trial data.

RESULTS

Compared with the EQ-5D-3L index, the mapped EQ-5D-5L index yielded an average of 6% more and the QLU-C10D index an average of 2% fewer incremental QALYs for nivolumab versus comparators. All indices could differentiate between groups defined by performance status, cancer stage, or self-reported health status at baseline and detect meaningful changes in performance status, tumor response, health status, and quality of life over approximately 12 weeks of treatment.

CONCLUSIONS

The lower QALY yield of the QLU-C10D was balanced by evidence of greater validity and responsiveness. Benefits gained from using the QLU-C10D may be apparent when treatments affect targeted symptoms and functional aspects, including sleep, bowel function, appetite, nausea, and fatigue. The observed differences in QALYs may not be sufficiently large to affect health technology assessment decisions.

Patient Utilities in Health States Based on Hoehn and Yahr and Off-Time in Parkinson's Disease: A Swedish Register-Based Study in 1823 Observations

BACKGROUND

Cost-effectiveness models in Parkinson's disease often include health states based on Hoehn and Yahr (H&Y) and time in 'off'. Few studies have investigated utilities in these health states.

OBJECTIVE

The aim of this study was firstly to explore utilities in health states based on H&Y and off-time, and secondly to investigate to what extent H&Y and off-time correlated with EQ-5D dimensions.

METHODS

Patients with idiopathic Parkinson's disease in the National Parkinson's Disease Patient Registry (PARKreg) in Sweden with observations of EQ-5D-3L, H&Y and off-time were included. Correlations with EQ-5D dimensions were analyzed. The relationship between the EQ-5D-3L and H&Y and off-time were estimated by a linear mixed-model with random intercept.

RESULTS

Among patients in PARKreg, 1823 observations fulfilled inclusion criteria. The dimensions 'self-care', 'mobility' and 'usual activities' correlated moderately with H&Y (r_s = 0.45, r_s = 0.46, r_s = 0.45). Weak correlations were found for 'anxiety/depression' and 'pain/discomfort' (r_s = 0.24, r_s = 0.22) (p values < 0.001). All dimensions correlated weakly with off-time. The fitted model included H&Y, time in 'off', and sex. All H&Y stages were found to be significant and had large and monotonous impact on EQ-5D. Off-time was not significant, but improved the model goodness of fit. Predicted values ranged from 0.733 to - 0.106.

CONCLUSION

This study provides utilities for health states reflecting the current modeling practice of interventions targeting motor symptoms in Parkinson's disease. Future research should investigate patient utilities in health states that also capture non-motor symptoms of the disease, as the management of and options for treatments targeting these symptoms increases.

Personality Traits and Perceptions of Major Life Events

Research examining the associations between major life events and personality trait development is mixed. Work that evaluates perceptions of life events and how those perceptions are themselves associated with personality traits may help clarify the existing literature. We used a large student sample ( N = 1,509) and a demographically diverse sample from a Qualtrics panel ( N = 552) to conduct exploratory analyses examining the associations between the big five personality traits and perceptions of life events. Results suggested that (a) associations between personality and beliefs about event-related personality change differ between students and more representative samples, (b) associations between personality and event perceptions are often nuanced, and (c) event perceptions are not merely proxies for personality traits. These studies highlight the importance of subjective event perceptions in the study of major life events and personality.

The challenge of mental simulation in preference-sensitive treatment decisions

This commentary discusses the importance for preference-sensitive treatment decisions of episodic future thinking, which is the capacity to mentally simulate and pre-experience what might occur in one's personal future. Our aim is to call attention to this important topic since patients confronted with preference-sensitive treatment decisions could benefit from professional support that promotes the construction of comprehensive and detailed mental simulations of what might affect their future well-being and satisfaction.

Assessing the Quality of Life of Parents of Children With Disabilities Using WHOQoL BREF During COVID-19 Pandemic

Background: Caring for a child with disabilities is a challenging journey, as the parents must meet greater demands when compared with the parents of children without disabilities. Looking after a child with disablities requires additional financial, social, emotional, and physical resources. Coronavirus 2019 (COVID-19) pandemic has made this even more challenging and impacted the quality of life of parents of children with disabilities.

Methods: The study was an analytical cross-sectional design with two comparison groups: parents of children with developmental disabilities and parents of children without disabilities. The Urdu version of the WHO Quality of Life Measure Abbreviated version (WHOQOL-BREF) was used to measure the quality of life (QoL) among parents. Sociodemographic data were also obtained from the parents.

Results: Parents of children with disabilities had lower overall scores when different domains of QoL were considered (physical health, psychological health, social relationships, and environment) using WHOQoL-BREF. Statistically significant differences were observed in the physical and environmental domains of parental QoL.

Further Reflections: Surrogate Decisionmaking When Significant Mental Capacities are Retained

Mackenzie Graham has made an important contribution to the literature on decisionmaking for patients with disorders of consciousness. He argues, and I agree, that decisions for unresponsive patients who are known to retain some degree of covert awareness ought to focus on current interests, since such patients likely retain the kinds of mental capacities that in ordinary life command our current respect and attention. If he is right, then it is not appropriate to make decisions for such patients by appealing to the values they had in the past, either the values expressed in an advance directive or the values recalled by a surrogate. There are two things I wish to add to the discussion. My first point is somewhat critical, for although I agree with his general conclusion about how, ideally, such decisions should be approached, I remain skeptical about whether his conclusion offers decisionmakers real practical help. The problem with these cases is that the evidence we have about the nature of the patient's current interests is minimal or nonexistent. However-and this is important-Graham's conclusion will be extremely relevant if in the future, our ability to communicate with such patients improves, as I hope it will. This leads to my second point. Graham's conclusion illustrates a more general problem with our standard framework for decisionmaking for previously competent patients, a problem that has not been adequately recognized. So, in what follows, I explain the problem I see and offer some brief thoughts about solutions.

Quantifying the Burden of Hyperphagia in Prader-Willi Syndrome Using Quality-Adjusted Life-years

BACKGROUND

Prader-Willi syndrome (PWS) is a rare disease associated with cognitive impairment, hypotonia, hyperphagia (an insatiable hunger), and obesity. Therapies that target hyperphagia are in development, but understanding the value of these therapies to inform patient-focused drug development (PFDD) requires valid data on disease burden. We estimated disease burden by measuring and comparing quality-adjusted life-years (QALYs) for 3 PWS health states relevant to current PFDD initiatives.

METHODS

Time trade-off (TTO) and a visual analog scale (VAS) were used to elicit PWS caregivers' values for 3 fixed health states for a standardized patient described with (1) untreated PWS, (2) PWS with controlled obesity, and (3) PWS with controlled obesity and hyperphagia. We excluded participants who left at least 1 TTO or VAS question blank or incomplete (noncompleters) and respondents who reported the same answer for all TTO scenarios (nontraders). The remaining group of respondents (traders) were used for all primary analyses. We assessed validity and bias of QALY estimates by comparing differences in health state valuations, treatment priorities, and characteristics among respondents who did and did not complete the TTO.

RESULTS

A total of 458 respondents completed the survey, including 226 traders, 93 nontraders, and 139 noncompleters. Traders valued untreated PWS at 0.69 QALYs, PWS with controlled obesity at 0.79 QALYs, and controlled hyperphagia/obesity at 0.91 QALY (P < 0.01 for differences among health state values). Reported VAS ratings were similar for traders versus nontraders for untreated PWS (38.64 vs 38.95, P = 0.89) and PWS with controlled obesity (57.36 vs 55.14, P = 0.35) but varied for PWS with controlled obesity and hyperphagia (70.70 vs 64.46, P = 0.02). Exclusion of noncompleters did not introduce obvious bias because traders and noncompleters were similar in treatment priorities and characteristics. The exclusion of nontraders did not meaningfully alter mean or distribution of valuations.

CONCLUSIONS

This study found that avoiding hyperphagia decreases the burden of PWS and that these results are robust, even once imposing strict inclusion criteria. Use of fixed health states to estimate QALYs addresses many of the complexities of measuring disease burden in rare and pediatric conditions, indicating the potential value of this approach to inform premarket decision makers in identifying outcome importance. (Clin Ther. 2021;XX:XXX-XXX) © 2021 Elsevier HS Journals, Inc.

What drives differences in preferences for health states between patients and the public? A qualitative investigation of respondents' thought processes

Cost-effectiveness analyses using quality-adjusted life-years (QALYs) are used in decision-making regarding which interventions are available via many national healthcare systems. QALYs are calculated based on health state values provided by preference elicitation techniques. Several national decision-making bodies recommend that health state values should be based on preferences elicited from general populations, rather than from patients. Previous studies have shown systematic differences between health state values elicited from members of the general population and from patients. Various explanations for this phenomenon have been proposed, however empirical evidence for these is scarce. We aimed to explore possible reasons for discrepancies between public and patient valuations by undertaking qualitative cognitive interviews, asking 14 members of the general population and 12 people with multiple sclerosis (MS) to think aloud while completing a preference elicitation task (time trade-off) for MS-related health states. The interviews were undertaken between December 2016 and October 2017 in the South West region of England, and were analysed using the Framework Method. As anticipated, we found that participants with MS had more experience of health problems and used this experience to consider how they might adapt to the health states over time, and which dimensions of health-related quality of life were most important to them. We found no evidence that participants with MS were less affected by framing effects and focusing illusions, more likely to prioritise non-physical dimensions of health, or more prone to loss aversion, endowment effects and non-compensatory decision-making. These findings contribute to our understanding of how patients and members of the general population respond to preference elicitation exercises, and why their preferences may differ, and may help to inform developing areas of research, such as the joint presentation of cost-effectiveness results from multiple perspectives, and the use of preferences elicited from patients for experienced health states.

Examining the effect of unintended pregnancy on health utility using four measures

OBJECTIVES

We measured women's preferences for avoiding an unintended pregnancy. We determined if young age (<25) was associated with lowest utility with an unintended pregnancy.

STUDY DESIGN

We conducted a cross sectional study of women presenting for hormonal contraception who did not desire a pregnancy. We used four techniques to elicit health prefences and calculate utilities for an unintended pregnancy: visual analog scale, and willingness to pay, time-tradeoff (TTO), and standard gamble. We dichotomized each measure to define lowest utility for each measure. We used predicted probabilities and multivariable logistic regression to estimate the association between age (≤25 vs ≥26 y) and lowest utility with an unintended pregnancy.

RESULTS

Our sample included 419 participants from four states. We found that younger age (≤25) was positively associated with reporting the lowest utility for unintended pregnancy. In absolute terms, with the visual analog scale, the probability that a woman 25 years or younger would have lower preference for an unintended pregnancy was 26.8% (95% CI 20.4-33.2%) versus (21.7% (95% CI 14.3-29.0%). Using the willingness to pay, the probability of the younger group having lower preference was 84.9% (CI 80.3-89.4%) compared to 57.3% (CI 49.3-65.3). With the TTO, Women 25 years old and younger had a 78.3% probability (CI 72.6-84.0%) of low utility on the TTO vs 48.9% (CI 40.9-56.9%) in the older group. With standard gamble, younger women had a 47.0% probability (CI 36.8-50.6%) versus 18.0% (CI 14.7-27.5%).

CONCLUSIONS

Women of all ages report a decrease in health utility with unintended pregnancy. This decrease in health utility is greater among young women (age <25).

IMPLICATIONS

Health utilities for unintended pregnancy can be used to guide cost effectiveness research and health policy.

Poor self-rated oral health associated with poorer general health among Indigenous Australians

Background

Oral diseases negatively impact general health, affecting physical, psychological, social and emotional wellbeing, and ability to give back to community. The relationship between poor oral health, and general health and wellbeing among Indigenous Australians has not been documented. Working in partnership with seven Indigenous communities in South Australia, this study aimed to: 1) quantify self-rated oral health and health-related quality of life and; 2) investigate associations between poor self-rated oral health and general health among Indigenous Australian adults.

Methods

Data was collected from a large convenience sample of Indigenous Australians aged 18+ years from Feb 2018 to Jan 2019. General health-related quality of life, as the main outcome variable, was measured by calculating disutility scores with the five individual EQ-5D dimensions (EuroQol instrument: EQ-5D-5L), then classified as ‘no problem’ and ‘at least one problem’. Self-reported oral health, as the main explanatory, was dichotomised into ‘fair or poor’ and ‘excellent, very good or good’. Multivariable log-Poisson regression models were used to estimate associations between poor self-rated oral health and general health by calculating mean rate ratios (MRR) for disutility scores and prevalence ratios (PR) for individual dimensions, after adjusting for social-demographic characteristics and health-related behaviours.

Results

Data were available for 1011 Indigenous South Australian adults. The prevalence of ‘fair or poor’ self-rated oral health was 33.5%. The mean utility score was 0.82 (95% CI: 0.81–0.83). Compared with those rating their oral health as ‘excellent or very good or good’, those who rated their oral health as ‘fair or poor’ had a mean disutility score that was 1.6 (95% CI: 1.1–2.2) times higher, and the prevalence of at least one problem ranged from 90 to 160% higher for individual EQ-5D dimensions.

Conclusions

Fair or poor self-rated oral health among Indigenous persons in South Australia was associated with poor general health as measured by EQ-5D-5L disutility. The relationship was especially evident with respect to mobility, self-care and anxiety/depression. The findings emphasise the importance of oral health as predictors of general health among Indigenous Australians.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10426-3.

Investigating the occurrence of selfie-based emotional contagion over social network

Happiness is obviously one of the most fundamental essence that affects many aspects of our lives. Past research found that happiness of one person affects that of other people. What occurs under this propagation of emotion is called “emotional contagion,” a phenomenon wherein through perception, people experience the same emotion expressed by someone when communicating with them. Although online communication is increasing due to growth of mobile computing, emotional contagion on online communication is not well studied yet. Particularly, it is not yet clear if emotional contagion among people occurs through selfie photographs posted on the social network media. We implemented “SmileWave,” the social networking system for investigating selfie-based emotional contagion. The key feature of SmileWave is detecting “smile degree” in user’s posting selfies and in reactive facial expressions when the user is viewing the posted photographs from others. Our in-the-wild user studies with 38 participants for 2 weeks revealed the occurrence of selfie-based emotional contagion over the social network, based on the results that the users’ smile degree improved (15% on average) when the user looked at posted selfie photographs.

Veil-of-ignorance reasoning mitigates self-serving bias in resource allocation during the COVID-19 crisis

The COVID-19 crisis has forced healthcare professionals to make tragic decisions concerning which patients to save. Furthermore, The COVID-19 crisis has foregrounded the influence of self-serving bias in debates on how to allocate scarce resources. A utilitarian principle favors allocating scarce resources such as ventilators toward younger patients, as this is expected to save more years of life. Some view this as ageist, instead favoring age-neutral principles, such as “first come, first served”. Which approach is fairer? The “veil of ignorance” is a moral reasoning device designed to promote impartial decision-making by reducing decision-makers’ use of potentially biasing information about who will benefit most or least from the available options. Veil-of-ignorance reasoning was originally applied by philosophers and economists to foundational questions concerning the overall organization of society. Here we apply veil-of-ignorance reasoning to the COVID-19 ventilator dilemma, asking participants which policy they would prefer if they did not know whether they were younger or older. Two studies (pre-registered; online samples; Study 1, N=414; Study 2 replication, N=1,276) show that veil-of-ignorance reasoning shifts preferences toward saving younger patients. The effect on older participants is dramatic, reversing their opposition toward favoring the young, thereby eliminating self-serving bias. These findings provide guidance on how to remove self-serving biases to healthcare policymakers and frontline personnel charged with allocating scarce medical resources during times of crisis.

The Impact of Pre- and Postarrival Mechanisms on Self-rated Health and Life Satisfaction Among Refugees in Germany

In this study, we focus on the evolution of refugees' well-being in the first years after their arrival in Germany. In contrast to other immigrants (e.g., labor migrants), refugees experience higher risks of unexpected and traumatic events and insecurity before and during their migration and face various legal and structural barriers in the receiving country. We contribute to the existing literature by exploring from a dynamic perspective possible pre- and postarrival determinants of refugees' life satisfaction and self-rated health upon arrival in Germany and the development of their life satisfaction and self-rated health in the process of becoming established. Applying linear regression and panel models with recent longitudinal data from the IAB-BAMF-SOEP Survey of Refugees in Germany, we find significant effects of prearrival factors, such as traumatic experiences and the complexity of migration, on both life satisfaction and self-rated health at the time of the first interview. Regarding postarrival factors, our results suggest that improvement in language proficiency and labor market status significantly shape refugees' life satisfaction and self-rated health. The time-dynamic analyses reveal substantial improvements in life satisfaction upon the approval of refugee status and the transition from shared housing to private accommodations. However, we find no improvements in self-rated health due to legal status but rather deterioration effects due to long-term residence in shared housing.

Disability, Disablism, and COVID-19 Pandemic Triage

Pandemics such as COVID-19 place everyone at risk, but certain kinds of risk are differentially severe for groups already made vulnerable by pre-existing forms of social injustice and discrimination. For people with disability, persisting and ubiquitous disablism is played out in a variety of ways in clinical and public health contexts. This paper examines the impact of disablism on pandemic triage guidance for allocation of critical care. It identifies three underlying disablist assumptions about disability and health status, quality of life, and social utility, that unjustly and potentially catastrophically disadvantage people with disability in COVID-19 and other global health emergencies.

Quality of Life and Value Assessment in Health Care

Proposals for health care cost containment emphasize high-value care as a way to control spending without compromising quality. When used in this context, 'value' refers to outcomes in relation to cost. To determine where health spending yields the most value, it is necessary to compare the benefits provided by different treatments. While many studies focus narrowly on health gains in assessing value, the notion of benefit is sometimes broadened to include overall quality of life. This paper explores the implications of using subjective quality of life measures for value assessment. This approach is claimed to be more respectful of patients and better capture the perspectival nature of quality of life. Even if this is correct, though, subjective measurement also raises challenging issues of interpersonal comparability when used to study health outcomes. Because such measures do not readily distinguish benefits due to medical interventions from benefits due to personal or other factors, they are not easily applied to the assessment of treatment value. I argue that when the outcome of interest in value assessment is broadened to include quality of life, the cost side of these measures should also be broadened. I show how one philosophical theory of well-being, Jason Raibley's "agential flourishing" theory, can be adapted for use in quality of life research to better fit the needs and aims of value assessment in health care. Finally, I briefly note some implications of this argument for debates about fairness in health care allocations.

Preference-based measurement of mobility-related quality of life: developing the MobQoL-7D health state classification system

PURPOSE

Generic preference-based measures often lack validity in states of impaired mobility. Our aim was to derive a novel health state classification system from the MobQoL tool, for the purpose of preference-based measurement of states of impaired mobility.

MATERIALS AND METHODS

Data were collected through online and postal surveys. Respondents were recruited through the NHS, charitable organisations and HealthWise Wales. Statistical and psychometric analyses were used to assess the validity and reliability of the MobQoL tool. Exploratory factor analysis and Rasch analysis were used to determine dimensional structure and to select items for the MobQoL health state classification system.

RESULTS

Three hundred and forty-two respondents completed the survey. Respondents had a wide range of different mobility impairments. Nine of the MobQoL items demonstrated adequate validity and reliability. Exploratory factor analysis and Rasch analysis confirmed two sub-scales within the item structure: 1) physical and role functioning, and 2) mental wellbeing. Seven items were found to have adequate model fit and were retained in the final health state classification system, called the MobQoL-7D.

CONCLUSIONS

The MobQoL-7D contains seven dimensions of mobility-related quality of life: accessibility, contribution, pain/discomfort, independence, self-esteem, mood/emotions and anxiety. Population level preference weights are now needed for different states of mobility impairment.IMPLICATIONS FOR REHABILITATIONMobility impairment has distinct impacts on mental wellbeing and physical/role functioning.The MobQoL-7D will facilitate accurate preference-based outcome measurement in populations with impaired mobility, which in turn will promote methods of economic evaluation in this context.MobQoL-7D offers a concise and valid tool for rehabilitation professionals to measure and monitor mobility-related quality of life as part of routine clinical practice.

Comparing the Preferences of Patients and the General Public for Treatment Outcomes in Type 2 Diabetes Mellitus

BACKGROUND

Healthcare treatments and interventions are traditionally evaluated from the societal perspective, but a more patient-centric perspective has been proposed in recent years. We sought to compare preferences of patients and the general public for treatment outcomes of type 2 diabetes using both best-worst scaling (BWS) and rating approaches.

METHODS

A survey evaluating the treatment priorities for type 2 diabetes was conducted in the United States. Members of the general public and patients with type 2 diabetes were recruited from a nationally sampled panel. Participants indicated the importance of seven potential treatment outcomes (hypoglycemic events, glycated hemoglobin [A1c], weight loss, mental health, functioning, glycemic stability, and cardiovascular health) using (1) BWS case 1 and (2) a rating task. Preference differences from BWS prioritizations were explored using mixed logistic regression (BWS preference weights were probability re-scaled so that the weightings of the seven items collectively summed to 100). The consistency of scale between samples was explored using heteroskedastic conditional logistic regression of BWS data. Spearman rank correlation was used to compare standardized BWS preference weights and rating scores for each group. Both groups evaluated the BWS and rating activities using debriefing questions.

RESULTS

The public and patient samples included 314 and 313 respondents, respectively. The public was on average 16 years younger than patients (48 vs 64 years, P < 0.001). In BWS, patients and the public both ranked A1c, glycemic stability, and cardiovascular health within their top three outcomes. Patients valued the outcome A1c most highly and found it twice as important as did the public (41.0 vs 20.2, P < 0.001). The public valued cardiovascular health most highly, and found it to be twice as important than did patients (31.3 vs 17.4, P < 0.001). Patients were more consistent in their preferences than the public (λ = 1.66, P = 0.01). Preferences elicited using BWS and rating approaches were highly correlated for both patients (ρ = 0.96) and the public (ρ = 0.92). Patients were more likely than the public to endorse the BWS as easy to answer (P < 0.001), easy to understand (P < 0.001), consistent with preferences (P < 0.001), and relevant (P < 0.001). Both patients and the public found the rating activity easier to answer and understand, and more consistent with their preferences, than the BWS (P < 0.001).

CONCLUSIONS

We provide some of the first evidence demonstrating a difference in patient and public treatment priorities for diabetes. That patients were more consistent in their preferences than the public and found the BWS and Likert rating instruments more relevant suggests that patient priorities may be more appropriate than those of the general public in some medical decision-making contexts.

Experience-Based Swedish TTO and VAS Value Sets for EQ-5D-5L Health States

BACKGROUND AND OBJECTIVE

Although value sets for the five-level version of the generic health-related quality-of-life instrument EQ-5D are emerging, there is still no value set available in the literature based on time trade-off valuations made by individuals experiencing the valued health states. The aim of this study was to estimate experience-based value sets for the EQ-5D-5L for Sweden using time trade-off and visual analogue scale valuation methods.

METHODS

In a large, cross-sectional, population-based, self-administered postal health survey, the EQ-5D-5L descriptive system, EQ visual analogue scale and a time trade-off question were included. Time trade-off and visual analogue scale valuations of the respondent's current health status were used in statistical modelling to estimate a single-index value of health for each of the 3125 health states. Ordinary least-squares and generalised linear models were estimated with the main effect within each of the five dimensions represented by 20 dummy variables reflecting the additional decrement in value for levels 2-5 when the severity increases by one level sequentially beginning from having no problem. Interaction variables representing the occurrence of severity levels in at least one of the dimensions were tested: severity level 2 or worse (N2); severity level 3 or worse (N3); severity level 4 or worse (N4); severity level 5 (N5).

RESULTS

A total of 896 health states (28.7% of the 3125 possible EQ-5D-5L health states) were reported by the 25,867 respondents. Visual analogue scale (n = 23,899) and time trade-off (n = 13,381) responders reported valuations of their currently experienced health state. The preferred regression models used ordinary least-squares estimation for both time trade-off and visual analogue scale values and showed consistency in all coefficients after combining certain levels. Levels 4 and 5 for the dimensions of mobility, self-care and usual activities were combined in the time trade-off model. Including the interaction variable N5, indicating severity level 5 in at least one of the five dimensions, made it possible to distinguish between the two worst severity levels where no other dimension is at level 5 as this coefficient is applied only once. In the visual analogue scale regression model, levels 4 and 5 of the mobility dimension were combined. The interaction variables N2-N4 were included, indicating that each of these terms reflect a statistically significant decrement in visual analogue scale value if any of the dimensions is at severity level 2, 3 or 4, respectively.

CONCLUSIONS

Time trade-off and visual analogue scale value sets for the EQ-5D-5L are now available for Sweden. The time trade-off value set is the first such value set based on experience-based time trade-off valuation. For decision makers with a preference for experience-based valuations of health states from a representative population-based sample, the reported value sets may be considered fit for purpose to support resource allocation decision as well as evaluating population health and healthcare performance.

You won't regret it (or love it) as much as you think: impact biases for everyday health behavior outcomes

When predicting the future, people tend to overestimate the intensity of their emotions, a phenomenon known as the impact bias. Design: In two studies, we examined the impact bias for health outcomes. In Study 1, participants were randomized to think about a negative health outcome in the future or one in the past. In Study 2, participants came to the laboratory and were asked to predict and report their emotions surrounding an actual health outcome (consuming an unhealthy food). Results: In both studies, an impact bias emerged. In Study 1, participants thinking about an outcome in the future estimated more negative emotion than those thinking about an outcome in the past. In Study 2, when facing an actual health outcome, participants anticipated more negative and positive emotion than they experienced. Impact biases were also associated with behavioral motivation - desire to change the outcome (Study 1) and increased preventive intentions (Study 2). Additional analyses revealed that regret was a particularly important emotion. Conclusion: Although research has highlighted an impact bias for severe health outcomes like disease, these studies provide evidence of an impact bias for health outcomes generally. They also suggest that the bias may have implications for behavior intentions.

Value judgment of new medical treatments: Societal and patient perspectives to inform priority setting in The Netherlands

BACKGROUND

In many countries, medical interventions are reimbursed on the basis of recommendations made by advisory boards and committees that apply multiple criteria in their assessment procedures. Given the diversity of these criteria, it is difficult to find common ground to determine what information is required for setting priorities.

OBJECTIVE

To investigate whether society and patients share the same interests and views concerning healthcare priorities.

METHODS

We applied a framework of discrete choice models in which respondents were presented with judgmental tasks to elicit their preferences. They were asked to choose between two hypothetical scenarios of patients receiving a new treatment. The scenarios graphically presented treatment outcomes and patient characteristics. Responses were collected through an online survey administered among respondents from the general population (N = 1,253) and patients (N = 1,389) and were analyzed using conditional logit and mixed logit models.

RESULTS

The respondents' preferences regarding new medical treatments revealed that they attached the most relative importance to additional survival years, age at treatment, initial health condition, and the cause of disease. Minor differences in the relative importance assigned to three criteria: age at treatment, initial health, and cause of disease were found between the general population and patient samples. Health scenarios in which patients had higher initial health-related quality of life (i.e., a lower burden of disease) were favored over those in which patients' initial health-related quality of life was lower.

CONCLUSIONS

Overall, respondents within the general population expressed preferences that were similar to those of the patients. Therefore, priority-setting studies that are based on the perspectives of the general population may be useful for informing decisions on reimbursement and other types of priority-setting processes in health care. Incorporating the preferences of the general population may simultaneously increase public acceptance of these decisions.

Working With People With Disabilities: An Interactive Video/Lecture Session for First- and Second-Year Medical Students

INTRODUCTION

Negative physician attitudes toward people with disabilities create barriers to health care for these individuals. Barriers can include withholding of standard medical and preventive care, provision of inferior treatment, and patient mistrust of the health care system. Thus, preparing medical students to care for people with disabilities is especially important. Educating health care providers early in their careers can shape their interactions while their approach to patients is still deliberate.

METHODS

We developed an interactive introductory session for first- and second-year medical students on how to approach individuals with observable disability in clinical settings. In the session, we explored-through a combination of lecture, discussion, and patient perspective-how negative physician behavior can create health care barriers, as well as proposed a framework for approaching patients with disability. We presented this session in two formats: (a) a slide deck with instructions that a presenter can use to deliver the session and (b) a stand-alone video introduction with reflective questions.

RESULTS

The session was evaluated by 151 first-year medical students, with 79% reporting either somewhat or much more comfort approaching individuals with disability following the session.

DISCUSSION

The integration of patient and physician perspectives, as well as the use of reflective questions, provides the opportunity for students to actively explore reasons for provider discomfort with disability and delineate clinical setting strategies to approach patients with disability.