Estimation of utilities for the effects of depression from the SF-12

The role of symptom reduction in improving health-related quality of life through brief cognitive behavioral therapy

Brief cognitive behavior therapy (bCBT) is effective in reducing symptoms of depression and anxiety disorders and improving health-related quality of life (HRQoL). However, the mechanisms through which cognitive behavior therapy impact HRQoL are not well understood. This study evaluated whether anxiety and depression symptom reduction is a mechanism of treatment for HRQoL outcomes.

METHOD

Using secondary data from a multisite, pragmatic, randomized trial, this study evaluated bCBT vs enhanced usual care in 16 VA community-based outpatient clinics. Ordinary least-squares path analysis testing multiple mediators was used to evaluate the role of change in depression and anxiety symptoms in the relationship between treatment condition and HRQoL.

RESULTS

Receiving bCBT (vs. enhanced usual care) was significantly negatively associated with change (reduction) in depression and anxiety scores. The indirect effect of treatment on mental HRQoL was significant with change in depression scores as mediator. A similar pattern was observed for physical HRQoL and change in anxiety scores as mediator.

CONCLUSION

Findings suggest reduction of depression and anxiety symptoms as a mechanism through which bCBT for depression promoted improvements in HRQoL, with important implications for understanding how CBT impacts functioning, as well as the utility of bCBT in nontraditional mental health settings.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02466126.

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.

Anxiety, Depression and Quality of Life-A Systematic Review of Evidence from Longitudinal Observational Studies

This review aimed to systematically review observational studies investigating the longitudinal association between anxiety, depression and quality of life (QoL). A systematic search of five electronic databases (PubMed, PsycINFO, PSYNDEX, NHS EED and EconLit) as well as forward/backward reference searches were conducted to identify observational studies on the longitudinal association between anxiety, depression and QoL. Studies were synthesized narratively. Additionally, a random-effects meta-analysis was performed using studies applying the mental and physical summary scores (MCS, PCS) of the Short Form Health Survey. The review was prospectively registered with PROSPERO and a study protocol was published. n = 47 studies on heterogeneous research questions were included, with sample sizes ranging from n = 28 to 43,093. Narrative synthesis indicated that QoL was reduced before disorder onset, dropped further during the disorder and improved with remission. Before onset and after remission, QoL was lower in comparison to healthy comparisons. n = 8 studies were included in random-effects meta-analyses. The pooled estimates of QoL at follow-up (FU) were of small to large effect sizes and showed that QoL at FU differed by disorder status at baseline as well as by disorder course over time. Disorder course groups differed in their MCS scores at baseline. Effect sizes were generally larger for MCS relative to PCS. The results highlight the relevance of preventive measures and treatment. Future research should consider individual QoL domains, individual anxiety/depressive disorders as well as the course of both over time to allow more differentiated statements in a meta-analysis.

Prevalence and predictors of probable depression in prostate cancer survivors

BACKGROUND

The early diagnosis and treatment of depression are cancer care priorities. These priorities are critical for prostate cancer survivors because men rarely seek mental health care. However, little is known about the epidemiology of depression in this patient population. The goal of this study was to describe the prevalence and predictors of probable depression in prostate cancer survivors.

METHODS

The data were from a population-based cohort of North Carolinian prostate cancer survivors who were enrolled from 2004 to 2007 in the North Carolina-Louisiana Prostate Cancer Project (n = 1031) and were prospectively followed annually from 2008 to 2011 in the Health Care Access and Prostate Cancer Treatment in North Carolina study (n = 805). Generalized estimating equations were used to evaluate an indicator of probable depression (Short Form 12 mental composite score ≤48.9; measured at enrollment and during the annual follow-up) as a function of individual-level characteristics within the longitudinal data set.

RESULTS

The prevalence of probable depression fell from 38% in the year of the cancer diagnosis to 20% 6 to 7 years later. Risk factors for probable depression throughout the study were African American race, unemployment, low annual income, younger age, recency of cancer diagnosis, past depression, comorbidities, treatment decisional regret, and nonadherence to exercise recommendations.

CONCLUSIONS

Depression is a major challenge for prostate cancer survivors, particularly in the first 5 years after the cancer diagnosis. To the authors' knowledge, this is the first study to demonstrate an association between treatment decisional regret and probable depression.

Descriptive Cost-Effectiveness Analysis of a Counseling and Coordination Model in Psychosocial Care. Integration of Health Care and Social Rehabilitation

INTRODUCTION

A psychosocial outreach clinic was established to offer counseling and coordination of healthcare and complementary services for persons with psychosocial and mental problems. The cost-effectiveness of these services was measured based on a pre-post comparison.

METHODS

A prospective observational study was conducted with clients of the outreach clinic. Data on resource consumption and quality of life were collected at baseline and follow-up after 3, 6, and 12 months using the Client Sociodemographic and Service Receipt Inventory to assess service utilization, and the 12-Item Short Form Health Survey to assess quality of life. The objective of the present analysis was to estimate the relation between monetary expenditure and QALYs (quality-adjusted life-years), before and after the outreach clinic was established, descriptively. The analysis was constructed from payer's perspective and was supplemented by a sensitivity analysis.

RESULTS

A total of 85 participants were included. Total annual expenditures before the intervention were 5,832 € per client for all service segments. During the 12-months study duration expenditures decreased to 4,350 € including the costs associated with outreach clinic services. QALYs for the 12-month study period were 0.6618 and increased about 0.0568 compared to the period before.

DISCUSSION

Despite methodological limitations due to small sample size, a pre-post comparison and the retrospective cost data collection, this study suggests acceptability of the outreach clinic as cost-effective.

CONCLUSION

The activities of the outreach clinic as an integrated care model seem to be cost-effective regarding the relation between monetary expenditures and clients' quality of life.

Efficacy and safety of escitalopram in treatment of severe depression in Chinese population

Severe depression accounts for one-third of depressed patients. Increasing severity of depression usually hinders patients from achieving remission. This study evaluated the efficacy and safety of escitalopram in acute-phase treatment of severe major depressive disorder (MDD). A total of 225 participants with severe MDD (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition criteria), with a current depressive episode and Montgomery-Asberg Depression Rating Scale (MADRS) score of ≥30 were enrolled. Participants received flexible dose escitalopram (10-20 mg/d) treatment for 8 weeks. Symptoms status was assessed by MADRS, Hamilton Depression Rating Scale (HAM-D-17), and Hamilton Anxiety Rating Scale (HAM-A). Quality of life was assessed by Short Form-12 (SF-12) and safety by adverse events, laboratory investigations, vital signs and physical findings. The remission (MADRS total score ≤ 10) rate in the intent-to-treat set (n = 207) was 72.9% at week 8. Significant improvement in symptoms compared to baseline, as evaluated by MADRS, HAMD-17 and HAMA scores at baseline, week 1, week 2, week 4, and week 8 (p < 0.0001 for all), was noted. Mean (SD) reduction from baseline in MADRS total score was 26.6 (11.38). Improvements in SF-12 score were significant (p = 0.000) and positively related to symptom improvement and negatively related to treatment-emergent adverse events (TEAEs). TEAEs were reported in 28.38% of participants. Most common TEAEs (>4%) were somnolence (9.0%), nausea (7.7%), hyperhidrosis (4.5%), dry mouth and dizziness (4.1% each). No serious TEAEs were reported. Escitalopram was effective and well-tolerated for acute-phase treatment of severe depression in Chinese population.

Efficacy and tolerability of escitalopram in treatment of major depressive disorder with anxiety symptoms: a 24-week, open-label, prospective study in Chinese population

BACKGROUND

Significant anxiety symptoms are associated with poor clinical course and outcome in major depressive disorder (MDD). This single-arm, open-label study aimed to evaluate the efficacy and tolerability of escitalopram treatment in patients with MDD and anxiety symptoms.

METHODS

Adult patients with MDD and anxiety symptoms (Montgomery-Asberg Depression Rating Scale [MADRS] ≥22 and Hamilton Anxiety Rating Scale [HAM-A] ≥14) were enrolled and received escitalopram (10-20 mg/day) treatment for 24 weeks. Symptom status was assessed by MADRS, 17-item-Hamilton Depression Rating Scale, HAM-A, and Clinical Global Impression Scale at baseline and the following visits. Quality of life was assessed by Short Form-12, and safety was evaluated by adverse events, laboratory investigations, vital signs, and physical findings.

RESULTS

Overall, 200 of 318 (66.2%) enrolled patients completed the 24-week treatment. The remission (MADRS ≤10 and HAM-A ≤7) rate in the full analysis set (N=285) was 73.3% (95% confidence interval: 67.80, 78.38) at week 24. Mean (± standard deviation) MADRS total score was 33.4 (±7.13) and HAM-A score was 27.6 (±7.26) at baseline, which reduced to 6.6 (±10.18) and 6.0 (±8.39), respectively, at week 24. Patients with higher baseline depression and anxiety level took longer to achieve similar remission rates. Overall, 80 of the 302 (26.5%) patients included in the safety set reported at least 1 treatment-emergent adverse event (TEAE). Most frequently reported TEAEs (>2%) were headache (4.0%), nasopharyngitis (3.6%), nausea (3.0%), and dizziness (2.6%). Serious TEAEs were reported by 1.3% patients; no deaths were reported.

CONCLUSION

Escitalopram 10-20 mg/day was effective and well-tolerated in the long-term treatment of MDD with anxiety symptoms in adult Chinese population.

Mapping the SF-12 to the EuroQol EQ-5D Index in a National US Sample

Background. Preference scores for the Medical Outcomes Study (MOS) SF-12 would enable its use in cost-effectiveness analyses. Previous mapping studies of MOS instruments to preference-based instruments have not examined performance in national samples. Participants. 15,000 adults in the 2000 Medical Expenditure Panel Survey annual survey including the SF-12 and EQ-5D Index. Methods. Regression of the EQ-5D Index scores onto the physical and mental component summary scores of the SF-12, testing 2nd-4th degree polynomial and spline models, including and excluding sociodemographics. Results. A 2nd degree polynomial model explained 63% of the variance in EQ-5D scores, with robust internal and external validation. More complex models explained minimally additional variance. Compared with EQ-5D valuations, prediction models overestimated the lowest health states (6% of the population). Conclusions. The mapped SF-12 yields usable preference-scaled scores, with some caution for the lowest health states.

Development of a preference-based index from the National Eye Institute Visual Function Questionnaire-25

IMPORTANCE

Understanding how individuals value health states is central to patient-centered care and to health policy decision making. Generic preference-based measures of health may not effectively capture the impact of ocular diseases. Recently, 6 items from the National Eye Institute Visual Function Questionnaire-25 were used to develop the Visual Function Questionnaire-Utility Index health state classification, which defines visual function health states.

OBJECTIVE

To describe elicitation of preferences for health states generated from the Visual Function Questionnaire-Utility Index health state classification and development of an algorithm to estimate health preference scores for any health state.

DESIGN, SETTING, AND PARTICIPANTS

Nonintervention, cross-sectional study of the general community in 4 countries (Australia, Canada, United Kingdom, and United States). A total of 607 adult participants were recruited from local newspaper advertisements. In the United Kingdom, an existing database of participants from previous studies was used for recruitment.

INTERVENTIONS

Eight of 15,625 possible health states from the Visual Function Questionnaire-Utility Index were valued using time trade-off technique.

MAIN OUTCOMES AND MEASURES

A θ severity score was calculated for Visual Function Questionnaire-Utility Index-defined health states using item response theory analysis. Regression models were then used to develop an algorithm to assign health state preference values for all potential health states defined by the Visual Function Questionnaire-Utility Index.

RESULTS

Health state preference values for the 8 states ranged from a mean (SD) of 0.343 (0.395) to 0.956 (0.124). As expected, preference values declined with worsening visual function. Results indicate that the Visual Function Questionnaire-Utility Index describes states that participants view as spanning most of the continuum from full health to dead.

CONCLUSIONS AND RELEVANCE

Visual Function Questionnaire-Utility Index health state classification produces health preference scores that can be estimated in vision-related studies that include the National Eye Institute Visual Function Questionnaire-25. These preference scores may be of value for estimating utilities in economic and health policy analyses.

Utility Values for Adults with Unipolar Depression: Systematic Review and Meta-Analysis

BACKGROUND

Unipolar depression is a mental illness with a substantial health-related and economic burden. Health interventions for depression predominately focus on improving sufferers' health-related quality of life (HRQoL). Utility is a measure of HRQoL that is required for use in model-based cost-utility analyses to assess the added value of health interventions. This review aimed to identify, summarize, and where feasible, synthesize published utilities for unipolar depression.

METHODS

A structured electronic search combining common terms for unipolar depression and utility was conducted in MEDLINE, EMBASE, and PsycINFO. Utility values identified were summarized, and the study designs were appraised in terms of the patient population and valuation method used to generate utilities. Random-effect meta-analyses were applied to pool mean utilities identified for 3 depressive health states (mild, moderate, and severe) elicited from direct and indirect valuation methods separately.

RESULTS

Thirty-five studies were identified that reported utilities for various levels of depression severity. The most commonly used direct valuation method for eliciting utilities was standard gamble (SG) (n = 5), and the most commonly used indirect valuation method was EQ-5D (n = 20). The pooled mean (standard deviation) utilities from studies using SG as a direct valuation method were mild = 0.69 (0.14), moderate = 0.52 (0.28), and severe = 0.27 (0.26). The pooled utilities from studies using EQ-5D as an indirect valuation method were mild = 0.56 (0.16), moderate = 0.45 (0.18), and severe = 0.25 (0.15).

CONCLUSIONS

This systematic review is a useful resource for decision analysts who need health-related utility values to populate model-based cost-utility analyses of health interventions for the management of unipolar depression. Further research is necessary to understand whether direct or indirect valuation methods are the most robust sources for utilities in depression.

The estimation of utility weights in cost-utility analysis for mental disorders: a systematic review

OBJECTIVE

To systematically review approaches and instruments used to derive utility weights in cost-utility analyses (CUAs) within the field of mental disorders and to identify factors that may have influenced the choice of the approach.

METHODS

We searched the databases DARE (Database of Abstracts of Reviews of Effects), NHS EED (National Health Service Economic Evaluation Database), HTA (Health Technology Assessment), and PubMed for CUAs. Studies were included if they were full economic evaluations and reported quality-adjusted life-years as the health outcome. Study characteristics and instruments used to estimate utility weights were described and a logistic regression analysis was conducted to identify factors associated with the choice of either the direct (e.g. standard gamble) or the preference-based measure (PBM) approach (e.g. EQ-5D).

RESULTS

We identified 227 CUAs with a maximum in 2009, 2010, and 2012. Most CUAs were conducted in depression, dementia, or psychosis, and came from the US or the UK, with the EQ-5D being the most frequently used instrument. The application of the direct approach was significantly associated with depression, psychosis, and model-based studies. The PBM approach was more likely to be used in recent studies, dementia, Europe, and empirical studies. Utility weights used in model-based studies were derived from only a small number of studies.

LIMITATIONS

We only searched four databases and did not evaluate the quality of the included studies.

CONCLUSIONS

Direct instruments and PBMs are used to elicit utility weights in CUAs with different frequencies regarding study type, mental disorder, and country.

The cost-effectiveness of depression treatment for co-occurring disorders: a clinical trial

The authors aimed to determine the economic value of providing on-site group cognitive behavioral therapy (CBT) for depression to clients receiving residential substance use disorder (SUD) treatment. Using a quasi-experimental design and an intention-to-treat analysis, the incremental cost-effectiveness and cost-utility ratio of the intervention were estimated relative to usual care residential treatment. The average cost of a treatment episode was $908, compared to $180 for usual care. The incremental cost effectiveness ratio was $131 for each point improvement of the BDI-II and $49 for each additional depression-free day. The incremental cost-utility ratio ranged from $9,249 to $17,834 for each additional quality adjusted life year. Although the intervention costs substantially more than usual care, the cost effectiveness and cost-utility ratios compare favorably to other depression interventions. Health care reform should promote dissemination of group CBT to individuals with depression in residential SUD treatment.

Comparison of health-related quality of life among patients using atypical antipsychotics for treatment of depression: results from the National Health and Wellness Survey

Background

Use of atypical antipsychotics (AA) in combination with an antidepressant is recommended as an augmentation strategy for patients with depression. However, there is a paucity of data comparing aripiprazole and other AAs in terms of patient reported outcomes. Therefore, the objective of this study was to examine the levels of HRQoL and health utility scores in patients with depression using aripiprazole compared with patients using olanzapine, quetiapine, risperidone and ziprasidone.

Methods

Data were obtained from the 2009, 2010, and 2011 National Health and Wellness Survey (NHWS), a cross-sectional, internet-based survey that is representative of the adult US population. Only those patients who reported being diagnosed with depression and taking an antidepressant and an atypical antipsychotic for depression were included. Patients taking an atypical antipsychotic for less than 2 months or who reported being diagnosed with bipolar disorder or schizophrenia were excluded. Patients taking aripiprazole were compared with patients taking other atypical antipsychotics. Health-related quality of life (HRQoL) and health utilities were assessed using the Short Form 12-item (SF-12) health survey. Differences between groups were analyzed using General Linear Models (GLM) controlling for demographic and health characteristics.

Results

Overall sample size was 426 with 59.9% taking aripiprazole (n = 255) and 40.1% (n = 171) taking another atypical antipsychotic (olanzapine (n = 19), quetiapine (n = 127), risperidone (n = 14) or ziprasidone (n = 11)). Of the SF-12 domains, mean mental component summary (MCS) score (p = .018), bodily pain (p = .047), general health (p = .009) and emotional role limitations (p = .009) were found to be significantly higher in aripiprazole users indicating better HRQoL compared to other atypical antipsychotics. After controlling for demographic and health characteristics, patients taking aripiprazole reported significantly higher mean mental SF-12 component summary (34.10 vs. 31.43, p = .018), bodily pain (55.19 vs. 49.05, p = .047), general health (50.05 vs. 43.07, p = .009), emotional role limitations (49.44 vs. 41.83, p = .009), and SF-6D utility scores (0.59 vs. 0.56, p = .042).

Conclusions

Comparison of patients taking aripiprazole with a cohort of patients using another AA for depression demonstrated that aripiprazole was independently associated with better (both statistically and clinically) HRQoL and health utilities.

The development of a model for translation of the Neck Disability Index to utility scores for cost-utility analysis in cervical disorders

BACKGROUND CONTEXT

The Neck Disability Index (NDI) is a commonly used disease-specific instrument for cervical spine disorders with good responsiveness and psychometric properties compared with general health status measures. However, NDI scores are unitless and do not have an intrinsic value that is comparable to other health status measures, and these scores have limited value in cost-utility analysis. The translation of disease-specific measures to Short Form-6 Dimensions (SF-6D) utility scores may be useful in cost-utility analysis.

PURPOSE

The purpose of this study is to present a model for translating the NDI to SF-6D utility scores, permitting the use of NDI scores in the cost-utility analysis of cervical disorders.

STUDY DESIGN/SETTING

A secondary analysis of a multicenter prospective clinical trial of the Synthes ProDisc-C (Synthes, West Chester, PA, USA) was performed.

PATIENT SAMPLE

Patients included were randomized to receive either a total disc arthroplasty or anterior cervical discectomy and fusion for treatment of symptomatic cervical disc disease involving one vertebral level between C3 and C7. All subjects completed NDI and 36-Item Short Form Health Survey (SF-36) self-assessments at preoperative and postoperative follow-ups of 6 weeks, 3, 6, 12, 18, and 24 months.

OUTCOME MEASURES

The NDI is a validated and widely used self-reported questionnaire designed to assess patient-determined disability resulting from neck pain, including pain level and effects on activities of daily living. The SF-6D is a preference-based health state classification system derived from six health dimensions of the SF-36 self-reported questionnaire, including the domains of physical functioning, role limitation, social functioning, bodily pain, mental health, and vitality.

METHODS

The collected data points were divided into two cohorts: one for model formation and one for the assessment of model validity. SF-36 scores were converted to SF-6D utilities via three previously published methods. Correlation analyses and linear regression modeling between SF-6D and NDI created the models for translating scores. For validation, Spearman and Pearson correlations were calculated between the observed and predicted SF-6D utilities, and prediction errors were calculated.

RESULTS

Four hundred thirty patients with 2,137 time points were used for creation and validation of the model. Pearson and Spearman correlation coefficients between the NDI and the SF-6D derived from each conversion method were found to be between -0.8255 and -0.8504 (p<.01). R(2) values ranged from 0.68 to 0.71 and root mean squared error (RMSE) from 0.092 to 0.084. Correlations between estimated and observed SF-6D scores ranged from 0.8325 to 0.8372 (p<.01). The mean prediction error was less than 0.006, with standard deviation (SD) between 0.082 and 0.093.

DISCUSSION

Correlations between NDI and SF-6D utility scores are strong and statistically significant. The model has a large R(2) and small RMSE. The prediction models produce a small mean prediction error, but the SD of the prediction errors is large. High correlations between NDI and SF-6D permit these models to be used to calculate overall utilities, changes in utilities, and quality-adjusted life-years for large data samples. However, the relatively large observed prediction error SDs may limit the accuracy of translation of individual data points or small sample sizes.

Rasch analysis in the development of a simplified version of the National Eye Institute Visual-Function Questionnaire-25 for utility estimation

PURPOSE

Preference-based health measures value how people feel about the desirability of a health state. Generic measures may not effectively capture the impact of vision loss from ocular diseases. Disease-targeted measures could address this limitation. This study developed a vision-targeted health state classification system based on the National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25).

METHODS

Secondary analysis of NEI VFQ-25 data from studies of patients with central (n = 932)- and peripheral-vision loss (n = 2,451) were used to develop a health state classification system. Classical test theory and Rasch analyses were used to identify a smaller set of NEI VFQ-25 items suitable for the central- and peripheral-vision-loss groups.

RESULTS

Rasch analysis of the NEI VFQ-25 items using the peripheral vision-loss data indicated that 11 items fit a unidimensional model, while 14 NEI VFQ-25 items fit using the central-vision-loss data. Combining peripheral-vision-loss data and central-vision-loss data resulted in 9 items fitting a unidimensional model. Six items covering near vision, distance vision, social vision, role difficulties, vision dependency, and vision-related mental health were selected for the health-state classification.

CONCLUSIONS

The derived health-state classification system covers relevant domains of vision-related functioning and well-being.

Predicting SF-6D utility scores from the neck disability index and numeric rating scales for neck and arm pain

STUDY DESIGN

Cross-sectional cohort.

OBJECTIVE

This study aims to provide an algorithm to estimate Short Form-6D (SF-6D) utilities using data from the Neck Disability Index (NDI), neck pain, and arm pain scores.

SUMMARY OF BACKGROUND DATA

Although cost-utility analysis is increasingly used to provide information about the relative value of alternative interventions, health state values or utilities are rarely available from clinical trial data. The Neck Disability Index (NDI) and numerical rating scales for neck and arm pain are widely used disease-specific measures in patients with cervical degenerative disorders. The purpose of this study is to provide an algorithm to allow estimation of SF-6D utilities using data from the NDI, and numerical rating scales for neck and arm pain.

METHODS

SF-36, NDI, neck and arm pain rating scale scores were prospectively collected before surgery, at 12 and 24 months after surgery in 2080 patients undergoing cervical fusion for degenerative disorders. SF-6D utilities were computed, and Spearman correlation coefficients were calculated for paired observations from multiple time points between NDI, neck and arm pain scores, and SF-6D utility scores. SF-6D scores were estimated from the NDI, neck and arm pain scores were estimated using a linear regression model. Using a separate, independent dataset of 396 patients in which NDI scores were available, SF-6D was estimated for each subject and compared to their actual SF-6D.

RESULTS

The mean age for those in the development sample was 50.4 ± 11.0 years and 33% were male. In the validation sample, the mean age was 53.1 ± 9.9 years and 35% were male. Correlations between the SF-6D and the NDI, neck and arm pain scores were statistically significant (P < 0.0001) with correlation coefficients of 0.82, 0.62, and 0.50, respectively. The regression equation using NDI aloneto predict SF-6D had an R of 0.66 and a root mean square error of 0.056. In the validation analysis, there was no statistically significant difference (P 5 0.961) between actual mean SF-6D (0.49 6 0.08) and the estimated mean SF-6D score (0.49 6 0.08), using the NDI regression model.

CONCLUSION

This regression-based algorithm may be a useful tool to predict SF-6D scores in studies of cervical degenerative disease that have collected NDI but not utility scores.

Predicting SF-6D utility scores from the Oswestry disability index and numeric rating scales for back and leg pain

STUDY DESIGN

Cross-sectional cohort.

OBJECTIVE

The purpose of this study is to provide a model to allow estimation of utility from the Short Form (SF)-6D using data from the Oswestry Disability Index (ODI), Back Pain Numeric Rating Scale (BPNRS), and the Leg Pain Numeric Rating Scale (LPNRS).

SUMMARY OF BACKGROUND DATA

Cost-utility analysis provides important information about the relative value of interventions and requires a measure of utility not often available from clinical trial data. The ODI and numeric rating scales for back (BPNRS) and leg pain (LPNRS), are widely used disease-specific measures for health-related quality of life in patients with lumbar degenerative disorders. The purpose of this study is to provide a model to allow estimation of utility from the SF-6D using data from the ODI, BPNRS, and the LPNRS.

METHODS

SF-36, ODI, BPNRS, and LPNRS were prospectively collected before surgery, at 12 and 24 months after surgery in 2640 patients undergoing lumbar fusion for degenerative disorders. Spearman correlation coefficients for paired observations from multiple time points between ODI, BPNRS, and LPNRS, and SF-6D utility scores were determined. Regression modeling was done to compute the SF-6D score from the ODI, BPNRS, and LPNRS. Using a separate, independent dataset of 2174 patients in which actual SF-6D and ODI scores were available, the SF-6D was estimated for each subject and compared to their actual SF-6D.

RESULTS

In the development sample, the mean age was 52.5 +/- 15 years and 34% were male. In the validation sample, the mean age was 52.9 +/- 14.2 years and 44% were male. Correlations between the SF-6D and the ODI, BPNRS, and LPNRS were statistically significant (P < 0.0001) with correlation coefficients of 0.82, 0.78, and 0.72, respectively. The regression equation using ODI, BPNRS,and LPNRS to predict SF-6D had an R of 0.69 and a root mean square error of 0.076. The model using ODI alone had an R of 0.67 and a root mean square error of 0.078. The correlation coefficient between the observed and estimated SF-6D score was 0.80. In the validation analysis, there was no statistically significant difference (P = 0.11) between actual mean SF-6D (0.55 +/- 0.12) and the estimated mean SF-6D score (0.55 +/- 0.10) using the ODI regression model.

CONCLUSION

This regression-based algorithm may be used to predict SF-6D scores in studies of lumbar degenerative disease that have collected ODI but not utility scores.

Nonresponse, partial response, and failure to achieve remission: humanistic and cost burden in major depressive disorder

OBJECTIVE

To characterize the spectrum of clinical outcomes achieved with depression treatment and the associated impact on quality of life (QOL), functional status, overall well-being, health-care costs, and productivity.

SOURCES

Electronic databases including Medline were searched for English language sources between 1995 and 2007 using key words of depression, nonresponse, partial response, and remission and QOL, functional status, utility, cost, and productivity.

STUDY SELECTION

Relevant abstracts were obtained for 488 references and full-text articles were reviewed that included primary data and compared outcomes by treatment response. Data were abstracted from 26 full-text articles.

DATA ABSTRACTION

Detailed evidence tables were prepared with the relevant data as well as information on the study design. All data abstracted were checked for accuracy. synthesis: Treatment remitters and partial responders reported clinically and statistically significant improvements in QOL, functional status, and overall well-being compared to nonresponders. Annual health-care costs and productivity losses were significantly lower for remitters and partial responders compared to nonresponders.

CONCLUSIONS

The reduced disease burden for remitters and partial responders compared to nonresponders indicates that new treatment strategies that improve the rates of response/remission with initial treatment might have value to patients and to society.

Converting the SF-12 into the EQ-5D: an empirical comparison of methodologies

BACKGROUND

For cost-utility analysis, analysts need a measure that summarizes health-status utilities in a single index of health-related quality of life (HR-QOL). It is common to find in clinical studies that only an HR-QOL profile measure such as the SF-36 is included, but not the summary HR-QOL index. Therefore, the economist's usual practice is to reprocess the profile data into a single index format. Several 'after-market' tools are available to convert the SF-36 or SF-12 into a single form with or without utility-weighting metric property. However, there has been no consensus with regard to a regression method that should be recommended for such a mapping task.

OBJECTIVE

To report on the performance of different regression methods that have previously been applied to the conversion of SF-12 data in the analysis of a single common dataset. The mapping between the SF-12 and EQ-5D is the focus.

METHODS

The data were adopted from the Medical Expenditure Panel Survey 2003 where 19 678 adults completed both EQ-5D and SF-12 questionnaires. Four econometric techniques, namely ordinary least squares (OLS), censored least absolute deviation, multinomial logit model and two-part model regressions were investigated together with two main types of model specifications: item-based and summary score-based. The performance of each examined model was judged by various criteria, including its estimated mean, the size of mean absolute error and the number of errors.

RESULTS

Among four compared econometric techniques, OLS regression was the most accurate model in estimating the group mean. Models with item-based model specification performed better than those with summary score-based regardless of the chosen econometric technique. Nevertheless, the accuracy of OLS deteriorates in older and less healthy subgroups. The results also suggested that the two-part model, which addresses the heterogeneity issue, performs better in these vulnerable subgroups.

CONCLUSIONS

None of the mapping methods included in the current study are suitable for estimating at the individual level. The methodology exemplified here has wider applicability and might just as readily be applied to other members of the SF family or indeed to other profile measures of HR-QOL. However, it is recommended that a preference-based, single index measure of HR-QOL should be included in the clinical studies for the purpose of economic evaluation.

Comparing the Incomparable? A Systematic Review of Competing Techniques for Converting Descriptive Measures of Health Status into QALY-Weights

Background . Algorithms for converting descriptive measures of health status into quality-adjusted life year (QALY)—weights are now widely available, and their application in economic evaluation is increasingly commonplace. The objective of this study is to describe and compare existing conversion algorithms and to highlight issues bearing on the derivation and interpretation of the QALY-weights so obtained. Methods . Systematic review of algorithms for converting descriptive measures of health status into QALY-weights. Results . The review identified a substantial body of literature comprising 46 derivation studies and 16 studies that provided evidence or commentary on the validity of conversion algorithms. Conversion algorithms were derived using 1 of 4 techniques: 1) transfer to utility regression, 2) response mapping, 3) effect size translation, and 4) “revaluing” outcome measures using preference-based scaling techniques. Although these techniques differ in their methodological/theoretical tradition, data requirements, and ease of derivation and application, the available evidence suggests that the sensitivity and validity of derived QALY-weights may be more dependent on the coverage and sensitivity of measures and the disease area/patient group under evaluation than on the technique used in derivation. Conclusions . Despite the recent proliferation of conversion algorithms, a number of questions bearing on the derivation and interpretation of derived QALY-weights remain unresolved. These unresolved issues suggest directions for future research in this area. In the meantime, analysts seeking guidance in selecting derived QALY-weights should consider the validity and feasibility of each conversion algorithm in the disease area and patient group under evaluation rather than restricting their choice to weights from a particular derivation technique.

Measuring preferences for cost-utility analysis: how choice of method may influence decision-making

Preferences for health are required when the economic value of healthcare interventions are assessed within the framework of cost-utility analysis. The objective of this paper was to review alternative methods for preference measurement and to evaluate the extent to which the method may affect healthcare decision-making. Two broad approaches to preference measurement that provide societal health state values were considered: (i) direct measurement; and (ii) preference-based health state classification systems. Among studies that compared alternative preference-based systems, the EQ-5D tended to provide larger change scores and more favourable cost-effectiveness ratios than the Health Utilities Index (HUI)-2 and -3, while the SF-6D provided smaller change scores and less favourable ratios than the other systems. However, these patterns may not hold for all applications. Empirical evidence comparing systems and decision-making impact suggests that preferences will have the greatest impact on economic analyses when chronic conditions or long-term sequelae are involved. At present, there is no clearly superior method, and further study of cost-effectiveness ratios from alternative systems is needed to evaluate system performance. Although there is some evidence that incremental cost-effectiveness ratio (ICER) thresholds (e.g. $US50,000 per QALY gained) are used in decision-making, they are not strictly applied. Nonetheless, as ICERs rise, the probability of acceptance of a new therapy is likely to decrease, making the differences in QALYs obtained using alternative methods potentially meaningful. It is imperative that those conducting cost-utility analyses characterise the impact that uncertainty in health state values has on the economic value of the interventions studied. Consistent reporting of such analyses would provide further insight into the policy implications of preference measurement.

Costs and consequences of enhanced primary care for depression: systematic review of randomised economic evaluations

BACKGROUND

A number of enhancement strategies have been proposed to improve the quality and outcome of care for depression in primary care settings. Decision-makers are likely to need to know whether these interventions are cost-effective in routine primary care settings.

METHOD

We conducted a systematic review of all full economic evaluations (cost-effectiveness and cost-utility analyses) accompanying randomised controlled trials of enhanced primary care for depression. Costs were standardised to UK pounds/US dollars and incremental cost-effectiveness ratios (ICERs) were visually summarised using a permutation matrix.

RESULTS

We identified 11 full economic evaluations (4757 patients). A near-uniform finding was that the interventions based upon collaborative care/case management resulted in improved outcomes but were also associated with greater costs. When considering primary care depression treatment costs alone, ICER estimates ranged from 7 ($13, no confidence interval given) to 13 UK pounds ($24,95% CI -105 to 148) per additional depression-free day. Educational interventions alone were associated with increased cost and no clinical benefit.

CONCLUSIONS

Improved outcomes through depression management programmes using a collaborative care/case management approach can be expected, but are associated with increased cost and will require investment.

A comparison of outcomes among patients with schizophrenia in two mental health systems: a health state approach

This paper introduces a health state modeling approach using clustering and Markov analysis to compare short- and long-term outcomes among health care populations. We provide a comparison to more conventional mixed effects regression methods and show that discrete state modeling offers a richer portrait of patient outcomes than the standard univariate techniques. We demonstrate our approach using primary data from a three year observational study of patients treated for schizophrenia at a VA Medical Center (VA) and in a Community Mental Health Center (CMHC) in the same urban community. Randomly selected samples of outpatients treated for schizophrenia or schizoaffective disorder were interviewed every six months using standardized psychiatric assessments such as the Positive and Negative Syndrome Scale (PANSS). Items from the PANSS were used to define 7 discrete health states representing different levels of severity and diverse mixtures of psychiatric symptoms. Conventional analysis showed that VA patients exhibited increasingly severe symptoms, while CMHC patients remained more stable over the study period. Health state analysis reinforced these results but also identified which subpopulations of VA patients were deteriorating. In particular they showed that there was little change over time among VA patients in the best and worst health states. Instead the deterioration was caused by VA patients with: a) mild symptoms and hallucinations and b) serious positive and negative symptoms, being more likely to enter a state with severe positive and negative symptoms accompanied by moderate general distress.

A survey of quality of life and depression for police officers in Kaohsiung, Taiwan

OBJECTIVE

The enormous job stress of police work may result in depression, which is highly correlated with work disability and poor quality of life. We investigated the quality of life, the probability of depression, and the related risk factors for police officers in Kaohsiung, Taiwan.

METHODS

We used the 12-item Short-Form Health Survey (SF-12) and the Disaster-Related Psychological Screening Test (DRPST) to assess the quality of life and prevalence of depression for 832 police officers in Kaohsiung.

RESULTS

The estimated rate of probable major depression was 21.6% (180/832). Those with an educational level of university or above and nondepressed police officers had higher scores in every subscale for quality of life. Police officers older than 50 had higher scores in the mental aspects of quality of life. Family problems and job stress related to achievement, peer pressure about performance, and heavy workloads were predictive factors for depression.

CONCLUSION

Police officers might have a higher estimated rate of depression than previously thought, and those with depression have a poorer quality of life.

Receipt of Disability Payments by Substance Users: Mental and Physical Health Correlates

Since 1997, substance users have received disability benefits only for impairments apart from their substance use disorders. It is hypothesized that substance users currently receiving disability benefits would be more severely compromised, medically and/or psychiatrically, than those not receiving disability. Enrolling a community sample of 330 heroin and cocaine users between January 2002 and January 2004, it was found that individuals who were not receiving disability payments had similar mental health scores, current depressive symptoms scores, and lifetime rates of major depression compared to those receiving payments, but significantly lower rates of bipolar or psychotic disorders and psychiatric hospitalization (p < .01). Physically disabled persons had lower physical function scores and were more likely to be HIV-infected or taking medications regularly (p < .001). The authors conclude that schizophrenia, bipolar disorders, and chronic physical illness, but not major depression, are qualifying substance users for disability benefits. Longitudinal studies of disability status and its effects on the lives of substance users are warranted.

Application of a disease-specific mapping function to estimate utility gains with effective treatment of schizophrenia

Background

Most tools for estimating utilities use clinical trial data from general health status models, such as the 36-Item Short-Form Health Survey (SF-36). A disease-specific model may be more appropriate. The objective of this study was to apply a disease-specific utility mapping function for schizophrenia to data from a large, 1-year, open-label study of long-acting risperidone and to compare its performance with an SF-36-based utility mapping function.

Methods

Patients with schizophrenia or schizoaffective disorder by DSM-IV criteria received 25, 50, or 75 mg long-acting risperidone every 2 weeks for 12 months. The Positive and Negative Syndrome Scale (PANSS) and SF-36 were used to assess efficacy and health-related quality of life. Movement disorder severity was measured using the Extrapyramidal Symptom Rating Scale (ESRS); data concerning other common adverse effects (orthostatic hypotension, weight gain) were collected. Transforms were applied to estimate utilities.

Results

A total of 474 patients completed the study. Long-acting risperidone treatment was associated with a utility gain of 0.051 using the disease-specific function. The estimated gain using an SF-36-based mapping function was smaller: 0.0285. Estimates of gains were only weakly correlated (r = 0.2). Because of differences in scaling and variance, the requisite sample size for a randomized trial to confirm observed effects is much smaller for the disease-specific mapping function (156 versus 672 total subjects).

Conclusion

Application of a disease-specific mapping function was feasible. Differences in scaling and precision suggest the clinically based mapping function has greater power than the SF-36-based measure to detect differences in utility.

Gender patterns in cost effectiveness of quality improvement for depression: results of a randomized, controlled trial

BACKGROUND

Little is known about gender differences in the costs and outcomes of primary care quality improvement strategies for depression.

METHODS

Intent-to-treat analysis of data from a group-level controlled trial, in which matched primary care clinics in the US were randomized to usual care or to one of two interventions designed to increase the rate of effective depression treatment. One intervention facilitated medication management ("QI-Meds") and the other psychotherapy ("QI-Therapy"), but patients and clinicians could choose the type of treatment, or none. The study involved 46 clinics in 6 non-academic, managed care organizations; 181 primary care providers; and 375 male and 981 female patients with current depression. Outcomes are health care costs, quality-adjusted life years (QALY), depression burden, employment, and costs/QALY, over 24 months of follow-up.

RESULTS

Relative to usual care, QI-Therapy significantly reduced depression burden and increased employment, for men and women; but QI-Meds significantly reduced depression burden only among women. Average health care costs increased 429 USD in QI-Meds and 983 USD in QI-Therapy among men; corresponding cost increases were 424 and 275 USD for women. The estimated cost per QALY for men ranged between 16,600 and 42,600 USD under QI-Therapy. For women, estimated costs per QALY were 23,600 USD or below for QI-Meds and 12,500 USD or below under QI-Therapy.

LIMITATIONS

This study may be underpowered for some relevant outcomes, particularly costs. The study population is limited to patients who sought health care in primary care settings.

CONCLUSIONS

Both men and women can benefit substantially from quality improvement interventions for depression in primary care. Results are particularly favorable for the QI-Therapy intervention.

Overcoming Depression on the Internet (ODIN) (2): a randomized trial of a self-help depression skills program with reminders

Background

Guided self-help programs for depression (with associated therapist contact) have been successfully delivered over the Internet. However, previous trials of pure self-help Internet programs for depression (without therapist contact), including an earlier trial conducted by us, have failed to yield positive results. We hypothesized that methods to increase participant usage of the intervention, such as postcard or telephone reminders, might result in significant effects on depression.

Objectives

This paper presents a second randomized trial of a pure self-help Internet site, ODIN (Overcoming Depression on the InterNet), for adults with self-reported depression. We hypothesized that frequently reminded participants receiving the Internet program would report greater reduction in depression symptoms and greater improvements in mental and physical health functioning than a comparison group with usual treatment and no access to ODIN.

Methods

This was a three-arm randomized control trial with a usual treatment control group and two ODIN intervention groups receiving reminders through postcards or brief telephone calls. The setting was a nonprofit health maintenance organization (HMO). We mailed recruitment brochures by US post to two groups: adults (n = 6030) who received depression medication or psychotherapy in the previous 30 days, and an age- and gender-matched group of adults (n = 6021) who did not receive such services. At enrollment and at 5-, 10- and 16-weeks follow-up, participants were reminded by email (and telephone, if nonresponsive) to complete online versions of the Center for Epidemiological Studies Depression Scale (CES-D) and the Short Form 12 (SF-12). We also recorded participant HMO health care services utilization in the 12 months following study enrollment.

Results

Out of a recruitment pool of 12051 approached subjects, 255 persons accessed the Internet enrollment site, completed the online consent form, and were randomized to one of the three groups: (1) treatment as usual control group without access to the ODIN website (n = 100), (2) ODIN program group with postcard reminders (n = 75), and (3) ODIN program group with telephone reminders (n = 80). Across all groups, follow-up completion rates were 64% (n = 164) at 5 weeks, 68% (n = 173) at 10 weeks, and 66% (n = 169) at 16 weeks. In an intention-to-treat analysis, intervention participants reported greater reductions in depression compared to the control group (P = .03; effect size = 0.277 standard deviation units). A more pronounced effect was detected among participants who were more severely depressed at baseline (P = .02; effect size = 0.537 standard deviation units). By the end of the study, 20% more intervention participants moved from the disordered to normal range on the CES-D. We found no difference between the two intervention groups with different reminders in outcomes measures or in frequency of log-ons. We also found no significant intervention effects on the SF-12 or health care services.

Conclusions

In contrast to our earlier trial, in which participants were not reminded to use ODIN, in this trial we found a positive effect of the ODIN intervention compared to the control group. Future studies should address limitations of this trial, including relatively low enrollment and follow-up completion rates, and a restricted number of outcome measures. However, the low incremental costs of delivering this Internet program makes it feasible to offer this type of program to large populations with widespread Internet access.

Are decisions using cost-utility analyses robust to choice of SF-36/SF-12 preference-based algorithm?

Background

Cost utility analysis (CUA) using SF-36/SF-12 data has been facilitated by the development of several preference-based algorithms. The purpose of this study was to illustrate how decision-making could be affected by the choice of preference-based algorithms for the SF-36 and SF-12, and provide some guidance on selecting an appropriate algorithm.

Methods

Two sets of data were used: (1) a clinical trial of adult asthma patients; and (2) a longitudinal study of post-stroke patients. Incremental costs were assumed to be $2000 per year over standard treatment, and QALY gains realized over a 1-year period. Ten published algorithms were identified, denoted by first author: Brazier (SF-36), Brazier (SF-12), Shmueli, Fryback, Lundberg, Nichol, Franks (3 algorithms), and Lawrence. Incremental cost-utility ratios (ICURs) for each algorithm, stated in dollars per quality-adjusted life year ($/QALY), were ranked and compared between datasets.

Results

In the asthma patients, estimated ICURs ranged from Lawrence's SF-12 algorithm at $30,769/QALY (95% CI: 26,316 to 36,697) to Brazier's SF-36 algorithm at $63,492/QALY (95% CI: 48,780 to 83,333). ICURs for the stroke cohort varied slightly more dramatically. The MEPS-based algorithm by Franks et al. provided the lowest ICUR at $27,972/QALY (95% CI: 20,942 to 41,667). The Fryback and Shmueli algorithms provided ICURs that were greater than $50,000/QALY and did not have confidence intervals that overlapped with most of the other algorithms. The ICUR-based ranking of algorithms was strongly correlated between the asthma and stroke datasets (r = 0.60).

Conclusion

SF-36/SF-12 preference-based algorithms produced a wide range of ICURs that could potentially lead to different reimbursement decisions. Brazier's SF-36 and SF-12 algorithms have a strong methodological and theoretical basis and tended to generate relatively higher ICUR estimates, considerations that support a preference for these algorithms over the alternatives. The "second-generation" algorithms developed from scores mapped from other indirect preference-based measures tended to generate lower ICURs that would promote greater adoption of new technology. There remains a need for an SF-36/SF-12 preference-based algorithm based on the US general population that has strong theoretical and methodological foundations.

Arthritis and Heart Disease as Risk Factors for Major Depression

BACKGROUND

Major depression in later life is highest among people with chronic illness. Identifying amenable factors that mediate the relationship between known risk factors such as arthritis and heart disease with major depression is important to the design of clinical and public health strategies to reduce depression and its consequences.

OBJECTIVE

This study investigates factors amenable to clinical and public health intervention that could mediate the relationship between chronic illness and major depression.

DESIGN

Population-based national sample.

SETTING

United States preretirement age (54-65) adults.

PARTICIPANTS

A total of 7825 participants from the 1996 Health and Retirement Survey.

MEASUREMENT

The outcome is major depression based on standardized assessment. Independent variables include sociodemographics chronic illness profile, functional limitation, health and medical access.

RESULTS

A substantial burden of major depression is related to chronic illness, particularly arthritis (attributable risk [AR], 18.1%; 95% confidence interval [CI], 9.9-25.6) and heart disease (AR, 17.6%; 95% CI, 13.4-21.7). Functional limitation is the strongest investigated factor associated with depression (AR, 34.4%; 95% CI, 24.8-42.7) and attenuates the associations of arthritis and heart disease with depression.

CONCLUSION

Functional limitation mediates the association of arthritis and heart disease with major depression. This relationship offers potential clinical and public health strategies to reduce major depression in older adults through intervention and management of functional limitation. Alternatively, it might be possible to reduce functional loss through screening for depression, particularly among people with functional limitation, and effective mental health treatment. The importance for clinical management of depression, comorbidity, and functional limitation spectrum supports the value of systems-based medicine.

Quality of life assessments in major depressive disorder: a review of the literature

According to the DSM-IV classification, a diagnosis of Major Depressive Disorder (MDD) is possible only when there is evidence of significant inference with functioning. However, despite the high prevalence of MDD in the general population, it is uncommon for clinicians to assess overall functioning in a systematic way before making such diagnosis. An important correlate of functioning is quality of life, which is typically defined as "patients' own assessments of how they feel about what they have, how they are functioning, and their ability to derive pleasure from their life activities". In the present article, we review studies focusing on the relationship between depression and quality of life, particularly focusing on the impact of the treatment of depression on quality of life. Studies focusing on the quality of life in MDD are reviewed. Candidate studies published between 1970 and recently were initially identified by Pubmed and Ovid search cross-referencing the terms "quality of life," "psychosocial functioning" with "major depression" and "treatment." A number of studies report poorer quality of life in MDD patients compared to controls. Several studies also report an improvement in quality of life measures during various phases of treatment with antidepressants and/or psychotherapy. However, trials comparing the role of newer psychopharmacologic agents in the acute phase of treatment, and the role of newer psychotherapies in the continuation and maintenance phases of treatment in restoring psychosocial functioning and improving the quality of life in MDD are lacking. Exploring the impact of these modalities on psychosocial function and quality of life in MDD are necessary to help translate clinical response into restoration of psychosocial function and to thus further improve the standard of care.

Mapping the SF-12 to Preference-Based Instruments

BACKGROUND

The profile-based SF-12 has a low respondent burden and is used widely in clinical settings to monitor health and evaluate programs. Deriving preference scores for the SF-12 health profile would permit its use in cost-effectiveness analyses. Previous mapping studies of SF family instruments to preference-based instruments have not examined convergent validity or performance in low-income, minority populations.

OBJECTIVES

To map the SF-12 to the EuroQol (EQ-5D Index) and the Health Utilities Index Mark 3 (HUI3) in a low-income, predominantly minority sample.

RESEARCH DESIGN

We used a cross-sectional survey data.

SUBJECTS

We studied a convenience sample of 240 low-income, predominantly Latino and black patients attending a community health center in New York.

MEASURES

We used separate regressions of the EQ-5D Index and HUI3 onto the physical (PCS-12) and mental (MCS-12) components of the SF-12 scores as measures.

RESULTS

For the EQ-5D Index regression, the adjusted variance explained was 58% (bootstrap validation 95% confidence interval [CI], 46-66). For the HUI3 regression, the adjusted variance explained was 51% (bootstrap 95% CI, 39-59). The correlation coefficient between the 2 predicted measures was 0.96. The correlation of the predicted HUI3 with the EQ-5D Index (0.73) and the predicted EQ-5D Index with the HUI3 (0.70) exceeded that between the 2 original preference-based measures themselves (0.69).

CONCLUSIONS

These pilot results suggest that the SF-12 could be successfully mapped to both the EQ-5D Index and HUI3, yielding preference-based scores that demonstrate convergent validity in a low-income, minority sample.

iMPACT3: Internet-based development and administration of utility elicitation protocols

iMPACT3 (Internet Multimedia Preference Assessment Instrument Construction Tool, version 3) is a software development environment that helps researchers build Internet-capable multimedia utility elicitation software programs. The program is a free, openly accessible Web site (http.// preferences.ucsd.edu/impact3/asp). To develop a utility elicitation software program using iMPACT3, a researcher selects modular protocol components from a library and custom tailors the components to the details of his or her research protocol. iMPACT3 builds a Web site implementing the protocol and downloads it to the researcher's computer. In a study of 75 HIV-infected patients, an iMPACT3-generated protocol showed substantial evidence of construct validity and good internal consistency (logic error rates of 4% to 10% and procedural invariance error rates of 10% to 28%, depending on the elicitation method) but only fair 3- to 6-week test-retest reliability (intraclass correlation coefficient= 0.42 to 0.55). Further work may be needed on specific utility assessment procedures, but this study's results confirm iMPACT3's feasibility in facilitating the collection of health state utility data.

Cost-effectiveness of a program to prevent depression relapse in primary care

OBJECTIVE

Evaluate the incremental cost-effectiveness of a depression relapse prevention program in primary care.

MATERIALS AND METHODS

Primary care patients initiating antidepressant treatment completed a standardized telephone assessment 6-8 weeks later. Those recovered from the current episode but at high risk for relapse (based on history of recurrent depression or dysthymia) were offered randomization to usual care or a relapse prevention intervention. The intervention included systematic patient education, two psychoeducational visits with a depression prevention specialist, shared decision-making regarding maintenance pharmacotherapy, and telephone and mail monitoring of medication adherence and depressive symptoms. Outcomes in both groups were assessed via blinded telephone assessments at 3, 6, 9, and 12 months and health plan claims and accounting data.

RESULTS

Intervention patients experienced 13.9 additional depression-free days during a 12-month period (95% CI, -1.5 to 29.3). Incremental costs of the intervention were $273 (95% CI, $102 to $418) for depression treatment costs only and $160 (95% CI, -$173 to $512) for total outpatient costs. Incremental cost-effectiveness ratio was $24 per depression-free day (95% CI, -$59 to $496) for depression treatment costs only and $14 per depression-free day (95% CI, -$35 to $248) for total outpatient costs.

CONCLUSIONS

A program to prevent depression relapse in primary care yields modest increases in days free of depression and modest increases in treatment costs. These modest differences reflect high rates of treatment in usual care. Along with other recent studies, these findings suggest that improved care of depression in primary care is a prudent investment of health care resources.

Cost-effectiveness of preventive occupational therapy for independent-living older adults

OBJECTIVES

To evaluate the cost-effectiveness of a 9-month preventive occupational therapy (OT) program in the Well-Elderly Study: a randomized trial in independent-living older adults that found significant health, function, and quality of life benefits attributable to preventive OT.

DESIGN

A randomized trial.

SETTING

Two government-subsidized apartment complexes.

PARTICIPANTS

One hundred sixty-three culturally diverse volunteers aged 60 and older.

INTERVENTION

An OT group, a social activity group (active control), and a nontreatment group (passive control).

MEASUREMENTS

Use of healthcare services was determined by telephone interview during and after the treatment phase. A conversion algorithm was applied to the RAND 36-item Short Form Health Survey to derive a preference-based health-related quality of life index, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio for preventive OT relative to the combined control group.

RESULTS

Costs for the 9-month OT program averaged $548 per subject. Postintervention healthcare costs were lower for the OT group ($967) than for the active control group ($1,726), the passive control group ($3,334), or a combination of the control groups ($2,593). The quality of life index showed a 4.5% QALY differential (OT vs combined control), P <.001. The cost per QALY estimates for the OT group was $10,666 (95% confidence interval = $6,747-$25,430). For the passive and active control groups, the corresponding costs per QALY were $13,784 and $7,820, respectively.

CONCLUSION

In this study, preventive OT demonstrated cost-effectiveness in conjunction with a trend toward decreased medical expenditures.

Applications of cost-effectiveness methodologies in behavioral medicine

In 1996, the Panel on Cost-Effectiveness in Health and Medicine developed standards for cost-effectiveness analysis. The standards include the use of a societal perspective, that treatments be evaluated in comparison with the best available alternative (rather than with no care at all), and that health benefits be expressed in standardized units. Guidelines for cost accounting were also offered. Among 24,562 references on cost-effectiveness in Medline between 1995 and 2000, only a handful were relevant to behavioral medicine. Only 19 studies published between 1983 and 2000 met criteria for further evaluation. Among analyses that were reported, only 2 studies were found consistent with the Panel's criteria for high-quality analyses, although more recent studies were more likely to meet methodological standards. There are substantial opportunities to advance behavioral medicine by performing standardized cost-effectiveness analyses.

Can utility-weighted health-related quality-of-life estimates capture health effects of quality improvement for depression?

BACKGROUND

Utility methods that are responsive to changes in desirable outcomes are needed for cost-effectiveness (CE) analyses and to help in decisions about resource allocation.

OBJECTIVES

Evaluated is the responsiveness of different methods that assign utility weights to subsets of SF-36 items to average improvements in health resulting from quality improvement (QI) interventions for depression.

DESIGN

A group level, randomized, control trial in 46 primary care clinics in six managed care organizations. Clinics were randomized to one of two QI interventions or usual care.

SUBJECTS

One thousand one hundred thirty-six patients with current depressive symptoms and either 12-month, lifetime, or no depressive disorder identified through screening 27,332 consecutive patients.

MEASURES

Utility weighted SF-12 or SF-36 measures, probable depression, and physical and mental health-related quality of life scores.

RESULTS

Several utility-weighted measures showed increases in utility values for patients in one of the interventions, relative to usual care, that paralleled the improved health effects for depression and emotional well being. However, QALY gains were small. Directly elicited utility values showed a paradoxical result of lower utility during the first year of the study for intervention patients relative to controls.

CONCLUSIONS

The results raise concerns about the use of direct single-item utility measures or utility measures derived from generic health status measures in effectiveness studies for depression. Choice of measure may lead to different conclusions about the benefit and CE of treatment. Utility measures that capture the mental health and non-health outcomes associated with treatment for depression are needed.

The RAND-36 measure of health-related quality of life

The RAND-36 is perhaps the most widely used health-related quality of life (HRQoL) survey instrument in the world today. It is comprised of 36 items that assess eight health concepts: physical functioning, role limitations caused by physical health problems, role limitations caused by emotional problems, social functioning, emotional well-being, energy/fatigue, pain, and general health perceptions. Physical and mental health summary scores are also derived from the eight RAND-36 scales. This paper provides example applications of the RAND-36 cross-sectionally and longitudinally, provides information on what a clinically important difference is for the RAND-36 scales, and provides guidance for summarizing the RAND-36 in a single number. The paper also discusses the availability of the RAND-36 in multiple languages and summarizes changes that are incorporated in the latest version of the survey.