Measuring health outcomes--putting gains into perspective

Long-term mortality of academy award winning actors and actresses

BACKGROUND

Social status gradients are powerful health determinants for individuals living in poverty. We tested whether winning an Academy award (Oscar) for acting was associated with long-term survival.

METHODS

We conducted a longitudinal cohort analysis of all actors and actresses nominated for an Academy award in a leading or a supporting role. For each, a control was identified based on age, sex, and co-staring in the same film.

RESULTS

Overall, 2,111 individuals were analyzed with 1,122 total deaths occurring during a median follow-up of 68.8 years. Comparisons of winners to controls yielded a 4.8% relative difference average life-span (95% confidence interval: 1.6 to 7.9, p = 0.004), a 5.1 year absolute increase in life expectancy (95% confidence interval: 3.0 to 7.2, p < 0.001), and a 41% improvement in mortality hazard (95% confidence interval: 19 to 68, p < 0.001). The increased survival tended to be greater in recent years, for individuals winning at a younger age, and among those with multiple wins. The increased survival replicated in secondary analyses comparing winners to nominees and was not observed in analyses comparing nominees to controls.

CONCLUSIONS

Academy award winning actors and actresses show a positive association between success and survival, suggesting the importance of behavioral, psychological, or other modifiable health factors unrelated to poverty.

Quality-Adjusted Life Years Gained by Hip and Knee Replacement Surgery and Its Aftercare

OBJECTIVES

To determine the lifetime quality-adjusted life years (QALYs) gained by total joint arthroplasty (TJA), and assess the QALYs attributed to specific postoperative rehabilitation interventions.

DESIGN

Secondary analysis of 2 multicenter, randomized controlled trials (RCTs) with 3-, 6-, 12-, and 24-month follow-up.

SETTING

Two university hospitals, 2 municipal hospitals, and 1 rural hospital.

PARTICIPANTS

Patients (N=827) who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA).

INTERVENTIONS

RCT A: 465 patients were randomly assigned to receive aquatic therapy (pool exercises aimed at training of proprioception, coordination, and strengthening) 6 versus 14 days after THA or TKA.

RCT B

362 patients were randomly assigned to either perform or not perform ergometer cycling beginning 2 weeks after THA or TKA.

MAIN OUTCOME MEASURE

QALYs, based on the Short Form-6 Dimensions utility, measured at baseline and 3, 6, 12, and 24 months' follow-up.

RESULTS

After hip arthroplasty, the lifetime QALYs increased by 2.35 years in the nonergometer group, and by 2.30 years in the early aquatic therapy group. However, after knee arthroplasty, the lifetime QALYs increased by 1.81 years in the nonergometer group, and by 1.60 years in the early aquatic therapy group. By ergometer cycling, .55 additional QALYs could be gained after hip and .10 additional QALYs after knee arthroplasty, while the additional QALYs attributed to the timing of aquatic therapy were .12 years after hip and .01 years after knee arthroplasty.

CONCLUSIONS

This analysis provides a sound estimate for the determination of the lifetime QALYs gained by THA and TKA. In addition, this analysis demonstrates that specific postoperative rehabilitation can result in an additional mean QALY gain of .55 years, which represents one fourth of the effect of surgery. Even if this is interpreted as a small effect at an individual level, it is important when extrapolated to all patients undergoing TJA. At a national level, these improvements appear to have a similar magnitude of QALY gain when compared with published data regarding medications to lower blood pressure in all persons with arterial hypertension.

Improving life expectancy and decreasing the incidence of complications associated with type 2 diabetes: a modelling study of HbA1c targets

To project the long-term clinical and cost outcomes that accompany predefined improvements in glycaemic control in patients with type 2 diabetes. A peer-reviewed, validated, non-product-specific Markov model of type 2 diabetes was used to project the long-term clinical and cost outcomes associated with three HbA1c reduction scenarios (vs. no reduction): (i) decreasing mean HbA1c from 9.5% to 8.0%; (ii) from 8.0% to 7.0%; and (iii) from 7.0% to 6.5%. A typical baseline US type 2 diabetes cohort derived from National Health and Nutrition Examination Survey data was simulated over a lifetime horizon (35 years). Incidence of diabetes-related complications and costs (2005 USD) were accounted based on published data. Discount rates (3% per annum) were applied to clinical benefits and costs. Sensitivity analyses were performed. Stepwise reductions in HbA1c as an independent variable correlated with delayed time to diabetes-related complications and a reduced cumulative incidence of complications, including cardiovascular, renal and neurologic comorbidities. Related costs also decreased. Reductions in both poorly- (9.5-8.0%) and better-controlled (7.0-6.5%) patients produced incremental gains in undiscounted life expectancy (LE) [1.06 (0.31) and 0.32 (0.34) years [mean (SD)], respectively]. Similar improvement patterns were observed in quality-adjusted life expectancy (QALE). Benefits from sequential reduction scenarios, when aggregated, exhibited the most dramatic effect. Improved glycaemic control was associated with reductions in complication rates and costs, as well as increased LE and QALE among type 2 patients. These data illustrate the long-term importance of reaching normoglycaemia and support intensified HbA1c control as a cornerstone of effective long-term type 2 diabetes management.

Counting the costs of overweight and obesity: modeling clinical and cost outcomes

OBJECTIVE

To quantify changes in clinical and cost outcomes associated with increasing levels of body mass index (BMI) in a US setting.

RESEARCH METHODS AND PROCEDURES

A semi-Markov model was developed to project and compare life expectancy (LE), quality-adjusted life expectancy (QALE) and direct medical costs associated with distinct levels of BMI in simulated adult cohorts over a lifetime horizon. Cohort definitions included age (20-65 years), gender, race, and BMI (24-45 kg m(-2)). Cohorts were exclusively male or female and either Caucasian or African-American. Mortality rates were adjusted according to these factors using published data. BMI progression over time was modeled. BMI-dependent US direct medical costs were derived from published sources and inflated to year 2004 values. A third party reimbursement perspective was taken. QALE and costs were discounted at 3% per annum.

RESULTS

In young Caucasian cohorts LE decreased as BMI increased. However, in older Caucasian cohorts the BMI associated with greatest longevity was higher than 25 kg m(-2). A similar pattern was observed in young adult African-American cohorts. A survival paradox was projected in older African-American cohorts, with some BMI levels in the obese category associated with greatest longevity. QALE in all four race/gender cohorts followed similar patterns to LE. Sensitivity analyses demonstrated that simulating BMI progression over time had an important impact on results. Direct costs in all four cohorts increased with BMI, with a few exceptions.

CONCLUSIONS

Optimal BMI, in terms of longevity, varied between race/gender cohorts and within these cohorts, according to age, contributing to the debate over what BMI level or distribution should be considered ideal in terms of mortality risk. Simulating BMI progression over time had a substantial impact on health outcomes and should be modeled in future health economic analyses of overweight and obesity.

The longevity of Baseball Hall of Famers compared to other players

The authors compared the longevity of all baseball players alive at the time of their induction into the Baseball Hall of Fame with age-matched controls who were likewise alive at the time of the Hall of Famer's induction, and also matched them for career length, player position, and body-mass index, to assess if fame in sports is associated with increased longevity. Median post-induction survival for Hall of Famers was 5 years shorter than for noninducted players (18 vs. 23 years, respectively). In a second analysis, significantly more Hall of Famers died of cardiovascular or stroke causes than other players for whom cause of death was known. Baseball fame may have a hitherto unrecognized price.

Cost-effectiveness of irbesartan in diabetic nephropathy: a systematic review of published studies

BACKGROUND

To review published studies on the cost-effectiveness of the use of irbesartan for treatment of advance overt nephropathy in patients with type 2 diabetes and hypertension.

METHODS

Articles were identified based on a search of the PubMed databases using the keywords 'irbesartan', 'ESRD', 'cost-effectiveness', 'nephropathy' and 'costs', and by personal communication with the authors. Only studies published in the last 10 years were included. All costs data from the cost-effectiveness studies were inflated to 2003 Euros using published governmental conversion tables.

RESULTS

Seven published studies were identified, spanning the following country settings: the US, Belgium and France, Germany, Hungary, Italy, Spain, and the UK. In each, the same pharmacoeconomic model was adapted using country-specific data to project and evaluate the clinical and cost outcomes of the treatment arms of the Irbesartan in Diabetic Nephropathy Trial (IDNT) (irbesartan, amlodipine or standard blood pressure control). Mean time to onset of ESRD was 8.23 years for irbesartan, 6.82 years for amlodipine and 6.88 years for the control (values were the same for Belgium, France, Germany, Hungary, Italy and Spain as transition probabilities for progression to ESRD were all derived from the IDNT). Mean cumulative incidence of ESRD was 36% with irbesartan, 49% with amlodipine and 45% with control treatment. Treatment with irbesartan was projected to improve life expectancy compared to both amlodipine and control in all seven published studies. Analysis of total lifetime costs showed that irbesartan treatment was cost saving compared to the other two treatment regimens, due to the associated reduction in ESRD cases. Cost savings with irbesartan became evident very early; after 2-3 years of treatment in most settings.

CONCLUSIONS

Modelling studies based on the IDNT published to date suggest that irbesartan treatment in patients with type 2 diabetes, hypertension and advanced nephropathy is both life- and cost-saving compared to amlodipine or control.

What impact would pancreatic beta-cell preservation have on life expectancy, quality-adjusted life expectancy and costs of complications in patients with type 2 diabetes? A projection using the CORE Diabetes Model

OBJECTIVE

Type 2 diabetes is characterised by progressive failure of pancreatic beta-cell function against a background of insulin resistance. Multifactorial interventions, including intensive glycaemic and blood pressure control, reduce the risk of onset and progression of complications. However, current management of type 2 diabetes focuses on treatment of signs and symptoms of disease instead of targeting underlying causes. A number of newer pharmacological interventions, including thiazolidinediones and glucagon-like peptides, have shown early promise in preserving pancreatic beta-cell function. The aim of this study was to investigate the impact of stabilising beta-cell function on long-term outcomes in patients with type 2 diabetes.

METHODS

The CORE Diabetes Model was used to project life expectancy (LE), quality-adjusted LE (QALE) and total lifetime complication costs (TC) for a cohort of newly-diagnosed patients with type 2 diabetes, either with a typical increase of HbA1c over time as observed in the UKPDS, or assuming stabilisation of HbA1c after diagnosis with a hypothetical new treatment, representing beta-cell function stabilisation. Costs due to diabetes-related complications (from a US third-party payer perspective), were discounted at 3% annually. Both non-discounted and discounted (at 3% annually) LE and QALE were calculated. Sensitivity analyses were performed to test the robustness of results.

RESULTS

Over a time period of 50 years, in a cohort with no increase of HbA1c over time, LE and QALE were improved by mean (SD) 1.02 (0.36) and 0.96 (0.25) years, and total costs of complications were reduced by 6,377 dollars (2,568) per patient compared to the cohort with a typical increase in HbA1c over time. Results were robust under a wide range of plausible assumptions.

CONCLUSIONS

New interventions that stabilise pancreatic betacell function may have an important impact on length and quality of life, and lead to reduced costs of complications in patients with type 2 diabetes.

Intensive lifestyle changes or metformin in patients with impaired glucose tolerance: Modeling the long-term health economic implications of the diabetes prevention program in Australia, France, Germany, Switzerland, and the United Kingdom

BACKGROUND

In the Diabetes Prevention Program (DPP), interventions with metformin (plus standard lifestyle advice) or intensive lifestyle changes (ILC) reduced the risk of developing type 2 diabetes mellitus (DM) by 31% and 58%, respectively, versus control (standard lifestyle advice only) in patients with impaired glucose tolerance (IGT).

OBJECTIVE

The goal of this study was to establish whether implementing the active treatments used in the DPP would be cost-effective in Australia, France, Germany, Switzerland, and the United Kingdom.

METHODS

A Markov model simulated 3 states-IGT, type 2 DM, and deceased-using probabilities from the DPP and published data. Country-specific direct costs were used throughout.

RESULTS

Assuming only within-trial effects and costs of interventions, both metformin and ILC improved life expectancy versus control. Mean improvements in nondiscounted life expectancy were 0.11 and 0.22 years for metformin and ILC, respectively. Both interventions were associated with cost savings versus control in all countries except the United Kingdom, where a small increase in costs was observed in both intervention arms. When a lifetime effect of interventions was assumed, incremental improvements in life expectancy were 0.35 and 0.90 years for metformin and ILC, respectively. Results were sensitive to probabilities of developing type 2 DM, the projected long-term duration of effect of interventions after the 3-year trial period, the relative risk of mortality for type 2 DM compared with IGT, and the costs of implementing the interventions.

CONCLUSIONS

Based on probabilities from the DPP and published data, in this model analysis, incorporation of the DPP interventions into clinical practice in 5 developed countries was projected to lead to an increase in DM-free years of life, improvements in life expectancy, and either cost savings or minor increases in costs compared with standard lifestyle advice in a population with IGT. Thus, financial constraints should not prevent the implementation of DM prevention programs.

Longevity of screenwriters who win an academy award: longitudinal study

OBJECTIVE

To determine whether the link between high success and longevity extends to academy award winning screenwriters.

DESIGN

Retrospective cohort analysis.

PARTICIPANTS

All screenwriters ever nominated for an academy award.

MAIN OUTCOME MEASURES

Life expectancy and all cause mortality.

RESULTS

A total of 850 writers were nominated; the median duration of follow up from birth was 68 years; and 428 writers died. On average, winners were more successful than nominees, as indicated by a 14% longer career (27.7 v 24.2, P=0.004), 34% more total films (23.2 v 17.3, P<0.001), 58% more four star films (4.8 v 3.1, P<0.001), and 62% more nominations (2.1 v 1.3, P<0.001). However, life expectancy was 3.6 years shorter for winners than for nominees (74.1 v 77.7 years, P=0.004), equivalent to a 37% relative increase in death rates (95% confidence interval 10 to 70). After adjustment for year of birth, sex, and other factors, a 35% relative increase in death rates was found (7% to 70%). Additional wins were associated with a 22% relative increase in death rates (3% to 44%). Additional nominations and additional other films in a career otherwise caused no significant increase in death rates.

CONCLUSION

The link between occupational achievement and longevity is reversed in screenwriters who win academy awards. Doubt is cast on simple biological theories for the survival gradients found for other members of society.

Alliteration in medicine: a puzzling profusion of p's

PROBLEM

Puzzling, progressive profusion of alliterative "p's" in published papers.

PURPOSE

To depict this particular "p" predominance with pinpoint precision. PLAN: Periodic, painstaking perusal of periodicals by a professor of paediatrics.

PROPOSAL

The "p" plethora is positively perplexing and potentially perturbing.

Life expectancy estimation with breast cancer: bias of the declining exponential function and an alternative to its use

BACKGROUND

Life expectancy gain (LEG) is an outcome measure commonly estimated with a declining exponential function in a Markov model. The accuracy of such estimates has not been objectively evaluated.

PURPOSE

To compare LEGs from declining exponential function estimates with those calculated from population data, using published screening mammography studies as examples.

METHOD

SEER-based population data are used to compare LEG calculation with declining exponential function estimation and empiric population data in a new model, the "nested" Markov.

RESULTS

Analyses of the LEG of mammographic screening based on the declining exponential function significantly overestimate LEGs for younger women and underestimate them for older women. Because of offsetting errors, all-age analyses paradoxically appear accurate.

CONCLUSION

Declining exponential function estimates of LEGs for chronic diseases with low mortality rates and long time horizons are liable to significant bias, especially with limited age cohorts.

Assessment of biotechnology drugs: what are the issues?

Biotechnology is increasingly regarded as an important reservoir for the development of new and innovative, but generally expensive, pharmaceuticals. At the same time, concerns about cost containment have triggered a keen interest in evaluating and comparing the values of diverse health care interventions. In this paper we studied the process of assessment and diffusion of biotechnology drugs by studying three cases, i.e. nebacumab, colony stimulating factors and recombinant human growth hormone. These cases are evaluated in a standardised format, concerning safety, efficacy, cost-effectiveness and ethical, legal and social issues. Many factors that determine the fate of a biotechnology drug seemed to be similar to those of 'classical' drugs. The definition and measurement of clinically relevant outcomes has been identified as a key factor in the assessment process. Another important issue is the relatively small population for the primary indications of biotechnology drugs and the subsequent process of broadening of indications. Paradoxically, the current trend towards evidence-based medicine means that we will increasingly have to make decisions based on 'incomplete' knowledge'.