Retaining, and enhancing, the QALY

How Much Better is Faster? Value Adjustments for Health-Improvement Sequences

While the quality-adjusted life-year construct has advantages of simplicity and consistency, simplicity requires strong assumptions. In particular, standard assumptions result in health-state utility functions that are unrealistically linear and separable in risk and duration. Consequently, sequencing of a series of health improvements has no effect on the total value of the sequence because each increment is assessed independently of previous increments. Utility functions in nearly all other areas of applied economics are assumed to be nonlinear with diminishing marginal utility so it matters where an improvement occurs in a sequence. We construct a conceptual framework that that demonstrates how diminishing marginal utility for health improvements could affect preferences for different sequence patterns. Using this framework, we derive conditions for which the sum of conventional health-state utilities understates, overstates, or approximates the sequence-sensitive value of health improvements. These patterns suggest the direction and magnitude of possible adjustments to conventional value calculations. We provide numerical examples and identify recent studies whose results are consistent with the conceptual model.

Outcome measures for economic evaluations and cost-effectiveness analyses of interventions for people with intellectual disabilities: A methodological systematic review

BACKGROUND

Mainstream economic evaluations methods may not be appropriate to capture the range of effects triggered by interventions for people with intellectual disabilities. In this systematic review, we aimed to identify, assess and synthesise the arguments in the literature on how the effects of interventions for people with intellectual disabilities could be measured in economic evaluations.

METHOD

We searched for studies providing relevant arguments by running multi-database, backward, forward citation and grey literature searches. Following title/abstract and full-text screening, the arguments extracted from the included studies were summarised and qualitatively assessed in a narrative synthesis.

RESULTS

Our final analysis included three studies, with their arguments summarised in different methodological areas.

CONCLUSIONS

Based on the evidence, we suggest the use of techniques more attuned to the population with intellectual disabilities, such sensitive preference-based instruments to collect health states data, and mapping algorithms to obtain utility values.

Analytical Frameworks and Outcome Measures in Economic Evaluations of Digital Health Interventions: A Methodological Systematic Review

BACKGROUND

Digital health interventions (DHIs) can improve the provision of health care services. To fully account for their effects in economic evaluations, traditional methods based on measuring health-related quality of life may not be appropriate, as nonhealth and process outcomes are likely to be relevant too.

PURPOSE

This systematic review identifies, assesses, and synthesizes the arguments on the analytical frameworks and outcome measures used in the economic evaluations of DHIs. The results informed recommendations for future economic evaluations.

DATA SOURCES

We ran searches on multiple databases, complemented by gray literature and backward and forward citation searches.

STUDY SELECTION

We included records containing theoretical and empirical arguments associated with the use of analytical frameworks and outcome measures for economic evaluations of DHIs. Following title/abstract and full-text screening, our final analysis included 15 studies.

DATA EXTRACTION

The arguments we extracted related to analytical frameworks (14 studies), generic outcome measures (5 studies), techniques used to elicit utility values (3 studies), and disease-specific outcome measures and instruments to collect health states data (both from 2 studies).

DATA SYNTHESIS

Rather than assessing the quality of the studies, we critically assessed and synthesized the extracted arguments. Building on this synthesis, we developed a 3-stage set of recommendations in which we encourage the use of impact matrices and analyses of equity impacts to integrate traditional economic evaluation methods.

LIMITATIONS

Our review and recommendations explored but not fully covered other potentially important aspects of economic evaluations that were outside our scope.

CONCLUSIONS

This is the first systematic review that summarizes the arguments on how the effects of DHIs could be measured in economic evaluations. Our recommendations will help design future economic evaluations.

HIGHLIGHTS

Using traditional outcome measures based on health-related quality of life (such as the quality-adjusted life-year) may not be appropriate in economic evaluations of digital health interventions, which are likely to trigger nonhealth and process outcomes.This is the first systematic review to investigate how the effects of digital health interventions could be measured in economic evaluations.We extracted and synthesized different arguments from the literature, outlining advantages and disadvantages associated with different methods used to measure the effects of digital health interventions.We propose a methodological set of recommendations in which 1) we suggest that researchers consider the use of impact matrices and cost-consequence analysis, 2) we discuss the suitability of analytical frameworks and outcome measures available in economic evaluations, and 3) we highlight the need for analyses of equity impacts.

The Impact of ADHD on Maternal Quality of Life

Childhood attention-deficit/hyperactivity disorder (ADHD) is associated with substantial burden to caregiver quality of life (QoL). However, a paucity of work has focused on quantifying QoL among caregivers of adolescents with a history of ADHD. The purpose of the current study was (1) to quantify maternal QoL in a sample of mothers of adolescents with and without childhood ADHD; and (2) to examine predictors (i.e., parent and child characteristics and behavior) associated with maternal QoL. Participants included mothers of adolescents with (N = 110) and without ADHD (N = 90) ranging in age from 13 to 18 (M = 16.09, 92% male). The Quality Adjusted Life-Year (QALY) was used to calculate maternal QoL using two health domains (i.e., anxiety/depression and disruption in daily activities) commonly impacted by raising youth with ADHD. QALYs are valued monetarily to estimate disease burden. Mothers of adolescents with childhood ADHD experienced significantly worse QoL relative to mothers in the comparison group. Maternal depression, as well as adolescent age, ADHD status, and discipline problems significantly predicted lower levels of maternal QALY health status index, with ADHD being the strongest predictor. This is equal to a reduction in 1.96 QALYs when summed over the course of a child's lifetime and is associated with a loss of $98,000 to $196,000. Results of the investigation help to further elucidate the health impacts incurred by families of adolescents with ADHD and have important public health implications. Further, parental QoL should be considered when conceptualizing the financial and negative health impact of ADHD.

The QALY is ableist: on the unethical implications of health states worse than dead

INTRODUCTION

A long-standing criticism of the QALY has been that it would discriminate against people in poor health: extending the lives of individuals with underlying health conditions gains fewer QALYs than extending the lives of 'more healthy' individuals. Proponents of the QALY counter that this only reflects the general public's preferences and constitutes an efficient allocation of resources. A pivotal issue that has thus far been overlooked is that there can also be negative QALYs.

METHODS AND RESULTS

Negative QALYs are assigned to the times spent in any health state that is considered to be worse than dead. In a health economic evaluation, extending the lives of people who live in such states reduces the overall population health; it counts as a loss. The problem with this assessment is that the QALY is not based on the perspectives of individual patients-who usually consider their lives to be well worth living-but it reflects the preferences of the general public. While it may be generally legitimate to use those preferences to inform decisions about the allocation of health care resources, when it comes to states worse than dead, the implications are deeply problematic. In this paper, I discuss the (un)ethical aspects of states worse than dead and demonstrate how their use in economic evaluation leads to a systematic underestimation of the value of life-extending treatments.

CONCLUSION

States worse than dead should thus no longer be used, and a non-negative value should be placed on all human lives.

Review: A Practical Guide to Understanding Cost-effectiveness Analyses

Cost-effectiveness analysis is a way to understand the value of a health care intervention in terms of assessing the money spent to produce beneficial outcomes. Cost-effectiveness analyses are used by various stakeholders for such purposes because health care resources and financing may be scarce, depending on the economy, and certain interventions may be costly to produce such outcomes compared with other options. These analyses are built on well-researched and robust inputs for costs and outcomes and may be modeled using a technique called Markov chain models, which allow transitions among various health states (eg, alive, dead, outgrow allergy, allergy relapses) relative to the condition of interest to reflect a base-case scenario. Then, the margins of the inputs are explored for a sensitivity analysis of potential findings. These analyses should be investigated from multiple perspectives (eg, society, health care payer). Limitations of the analysis should be clearly stated. Although such models are an informative way to explore a situation and can be performed without additional direct patient intervention, a weakness of the approach is that this may overlook individual patient nuances. Cost-effectiveness analyses are important policy tools to show, on average, an optimal way to improve value in population health.

The economic theory of cost-effectiveness thresholds in health: Domestic and international implications

Public health insurers often use an implicit or explicit cost-effectiveness threshold to determine which health products and services should be insured. We challenge the convention of a single threshold. For competitively provided products and services, prices are determined by cost; but for products with market power, patentees will increase the price according to the perceived threshold. As a result, a change in the threshold affects the prices of all patented products, including those which would have been developed even at a lower threshold. The insurer can increase efficiency by reducing the threshold for patented products, even accounting for the effect on innovation. We also model a multi-country setting, in which thresholds for patented products will fall below the globally cooperative solution because each country does not recognize the positive externality of its own spending on innovative medicines. We show that this tragedy of the commons problem can be partly corrected through referencing other countries' thresholds, but only when the countries have similar willingness to pay.

Social tariffs and democratic choice-Do population-based health state values reflect the will of the people?

In economic evaluations of health technologies, health outcomes are commonly measured in terms of quality-adjusted life years (QALYs). QALYs are the product of time and health-related quality of life. Health-related quality of life, in turn, is determined by a social tariff, which is supposed to reflect the public's preference over health states. This study argues that, because of the tariff's role in the societal decision-making process, it should not be understood as merely an operational (statistical) definition of health, but as a major instrument of democratic participation. I outline what implications this might have for both the method used to aggregate individual preferences, and the set of individuals whose preferences should count. Alternative tariff specifications and decision rules are explored, and future research directions are proposed.

Alternative Approaches to Quality-Adjusted Life-Year Estimation Within Standard Cost-Effectiveness Models: Literature Review, Feasibility Assessment, and Impact Evaluation

OBJECTIVES

The quality-adjusted life-year (QALY) has been long debated, but alternative estimation approaches have not been comprehensively evaluated. Our objective was to identify alternatives, characterize them by implementation feasibility, and evaluate the impact of implementing feasible options in cost-effectiveness models developed for the Institute for Clinical and Economic Review reports.

METHODS

We conducted a literature review combining keywords relating to QALYs, methodology alternatives, and cost-effectiveness in PubMed, EconLit, Web of Science, and MEDLINE. Articles that discussed alternatives to the conventional QALY were included. Alternatives were characterized by type, data availability, calculation burden, and overall implementation feasibility. The subset of feasible alternatives, that is, sufficient data and methodology compatible with incorporation into common modeling approaches, were evaluated according to impact on incremental QALYs, incremental net monetary benefit (iNMB), intervention rankings, and proportion of interventions with a positive iNMB.

RESULTS

We identified 28 articles discussing 9 alternatives. Feasible alternatives were using patient preference (PP) data; equity weighting according to baseline utility, fair innings, or proportional QALY shortfall; and the equal value of life-years-gained approach. All alternatives affected the incremental QALY and iNMB outcomes, rankings, and proportion of interventions with a positive iNMB. The PP alternative had the largest and most consistent impact. The PP impact on the proportion of interventions with a positive iNMB, was in the negative direction.

CONCLUSIONS

Our work is the first comprehensive evaluation of proposed alternatives to the conventional QALY. We found robust literature but few options that were feasible to be implemented in current healthcare decision-making processes.

Cost effectiveness and the role of the National Institute of Health and Care Excellence (NICE) in interventional radiology

Healthcare expenditure is continually increasing and projected to accelerate in the future, with an increasing proportion being spent on interventional radiology. The role of cost effectiveness studies in ensuring the best allocation of resources is discussed, and the role of National Institute of Health and Care Excellence (NICE) in determining this. Issues with demonstrating cost effectiveness have been discussed, and it has been found that there is significant scope for improving cost effectiveness, with suggestions made for how this can be achieved. In this way, more patients can benefit from better treatment given limited healthcare budgets.

The promise of Immuno-oncology: implications for defining the value of cancer treatment

The rapid development of immuno-oncology (I-O) therapies for multiple types of cancer has transformed the cancer treatment landscape and brightened the long-term outlook for many patients with advanced cancer. Responding to ongoing efforts to generate value assessments for novel therapies, multiple stakeholders have been considering the question of "What makes I-O transformative?" Evaluating the distinct features and attributes of these therapies, and better characterizing how patients experience them, will inform such assessments. This paper defines ways in which treatment with I-O is different from other therapies. It also proposes key aspects and attributes of I-O therapies that should be considered in any assessment of their value and seeks to address evidence gaps in existing value frameworks given the unique properties of patient outcomes with I-O therapy. The paper concludes with a "data needs catalogue" (DNC) predicated on the belief that multiple key, unique elements that are necessary to fully characterize the value of I-O therapies are not routinely or robustly measured in current clinical practice or reimbursement databases and are infrequently captured in existing research studies. A better characterization of the benefit of I-O treatment will allow a more thorough assessment of its benefits and provide a template for the design and prioritization of future clinical trials and a roadmap for healthcare insurers to optimize coverage for patients with cancers eligible for I-O therapy.

Cost-effectiveness of neuromuscular ultrasound in focal neuropathies

OBJECTIVE

To evaluate the cost-effectiveness of neuromuscular ultrasound (NMUS) for the evaluation of focal neuropathies.

METHODS

A prior prospective, randomized, double-blind controlled trial demonstrated that NMUS, when added to electrodiagnostic testing, resulted in improved clinical outcomes after 6 months of follow-up. From this study, we abstracted quality-adjusted life-years (QALYs) from the 36-item Short Form Health Survey and entered this health-utility estimate into a mixed trial and model-based cost-effectiveness analysis from the societal perspective. Costs of intervention (NMUS) were estimated from Medicare payment rates for Current Procedural Terminology codes. Health care use was otherwise estimated to be equal, but sensitivity analyses further examined this and other key assumptions. Incremental cost-effectiveness ratio (ICER) was used as the primary outcome with a willingness-to-pay threshold of $50,000 per QALY.

RESULTS

The predicted mean health outcome associated with use of NMUS was 0.079 QALY, and the mean cost was $37, resulting in an ICER of $463 per QALY. Results and conclusions remained robust across all sensitivity analyses, including variations in time horizon, initial distribution of health states, costs, and effectiveness.

CONCLUSIONS

From a societal perspective, the addition of NMUS to electrodiagnostic testing when evaluating a focal neuropathy is cost-effective. A study of longer follow-up incorporating total health care use would further quantify the value of NMUS.

CLINICALTRIALSGOV IDENTIFIER

NCT01394822.

Measuring Health Spillover Effects in Caregivers of Children with Autism Spectrum Disorder: A Comparison of the EQ-5D-3L and SF-6D

BACKGROUND AND OBJECTIVE

Healthcare interventions that improve the health of children with autism spectrum disorder (ASD) have the potential to affect the health of caregivers. This study compares the three-level EuroQoL-5 Dimension (EQ-5D-3L) and the Short Form-6 Dimension (SF-6D) in their ability to value such spillover effects in caregivers.

METHODS

Clinical data collected from two Autism Treatment Network (ATN) sites was combined with survey data of caregivers of children diagnosed with ASD. Caregivers completed instruments by proxy describing child health and completed the EQ-5D-3L and SF-6D preference-weighted instruments to describe their own health.

RESULTS

There was a strong correlation between the health utility scores of the two preference-weighted instruments (ρ = 0.6172, p < 0.001) measuring caregiver health-related quality of life. There was a similar correlation between both the SF-6D and EQ-5D-3L scores with a previously validated care-related quality of life measure (Care-related Quality of Life instrument [CarerQol-7D]) (ρ = 0.569, p < 0.001 and ρ = 0.541, p < 0.001, respectively). The mean SF-6D scores for caregivers differed significantly in relation to four of the five child health or behavior measures whereas the EQ-5D-3L differed for only two of them.

CONCLUSIONS

Health utility values of caregivers for children with ASD vary by the health characteristics of the child, suggesting significant potential for spillover effects. The comparison of the EQ-5D-3L and SF-6D demonstrated that both instruments can be used to estimate spillover effects of interventions to improve child health, but the SF-6D exhibited greater sensitivity to child health among children with ASD.

Comparing and transforming PROMIS utility values to the EQ-5D

PURPOSE

Summarizing patient-reported outcomes (PROs) on a quality-adjusted life year (QALY) scale is an essential component to any economic evaluation comparing alternative medical treatments. While multiple studies have compared PRO items and instruments based on their psychometric properties, no study has compared the preference-based summary of the EQ-5D-3L and Patient Reported Outcomes Measurement Information System (PROMIS-29) instruments. As part of this comparison, a major aim of this manuscript is to transform PROMIS-29 utility values to an EQ-5D-3L scale.

METHODS

A nationally representative survey of 2623 US adults completed the 29-item PROMIS health profile instrument (PROMIS-29) and the 3-level version of the EQ-5D instrument (EQ-5D-3L). Their responses were summarized on a health utility scale using published estimates. Using regression analysis, PROMIS-29 and EQ-5D-3L utility weights were compared with each other as well as with self-reported general health.

RESULTS

PROMIS-29 utility weights were much lower than the EQ-5D-3L weights. However, a correlation coefficient of 0.769 between the utility values of the two instruments suggests that the main discordance is simply a difference in scale between the measures. It is also possible to map PROMIS-29 utility weights onto an EQ-5D-3L scale. EQ-5D-3L losses equal .1784 × (PROMIS-29 Losses)^.7286.

CONCLUSIONS

The published estimates of the PROMIS-29 produce lower utility values than many other health instruments. Mapping the PROMIS-29 estimates to an EQ-5D-3L scale alleviates this issue and allows for a more straightforward comparison between the PROMIS-29 and other common health instruments.

Would it be legally justified to impose vaccination in Israel? Examining the issue in light of the 2013 detection of polio in Israeli sewage

Background

The detection of wild poliovirus in Israeli sewage in May 2013 led the health authorities to decide that children who had been vaccinated with IPV would also be vaccinated with OPV. The decision sought to protect vulnerable Israeli individuals who were either not vaccinated with IPV or who suffered from an immune deficiency, to preserve Israel’s status as a polio-free country, to prevent the virus’ “exportation” into vulnerable polio-free countries, and to participate in the global efforts toward the eradication of polio. After a massive public persuasion campaign, 79% of the children born after 2004 were vaccinated as well as 69% of the children residing in central Israel. A 2014 State Comptroller Report stated that the Ministry of Health should draw conclusions from the low compliance rates in certain Israeli regions.

Goals

The article seeks to examine the legal legitimacy of mandatory vaccination in the service of eradicating a contagious disease (as opposed to preventing a pandemic outbreak), which was one of the objectives in the 2013 Polio case. It more specifically relates to current Israeli law as well as to a hypothetical new public health law which would authorize health officials to oblige vaccination and enforce this through the use of criminal sanctions.

Method

Qualitative content analysis through the interpretation of court judgements, laws, legislative protocols, health ministry guidelines and documented discussions of the Advisory Committee on Infectious Diseases and Immunization.

Main findings and conclusion

A mandatory vaccination backed by criminal sanctions in the service of the eradication of contagious diseases would probably be perceived as infringing on the constitutional right to autonomy to a greater extent than necessary according to Israeli law and case law precedents. There may be some added value inherent in a new public health law which would authorize health officials to oblige vaccination where nonrestrictive measures have been ineffective. However, the law should also specify a variety of sanctions to accompany the enforcement of mandatory vaccinations which would be formulated from least to most restrictive according to the “intervention ladder” concept. The law should also describe the circumstances which would justify the implementation of each and every sanction as well as the procedural safeguards designed for established decisions and fairness toward the individual(s) whose rights are infringed by the application of these sanctions.

The International Decision Support Initiative Reference Case for Economic Evaluation: An Aid to Thought

BACKGROUND

Policymakers in high-, low-, and middle-income countries alike face challenging choices about resource allocation in health. Economic evaluation can be useful in providing decision makers with the best evidence of the anticipated benefits of new investments, as well as their expected opportunity costs-the benefits forgone of the options not chosen. To guide the decisions of health systems effectively, it is important that the methods of economic evaluation are founded on clear principles, are applied systematically, and are appropriate to the decision problems they seek to inform.

METHODS

The Bill and Melinda Gates Foundation, a major funder of economic evaluations of health technologies in low- and middle-income countries (LMICs), commissioned a "reference case" through the International Decision Support Initiative (iDSI) to guide future evaluations, and improve both the consistency and usefulness to decision makers.

RESULTS

The iDSI Reference Case draws on previous insights from the World Health Organization, the US Panel on Cost-Effectiveness in Health Care, and the UK National Institute for Health and Care Excellence. Comprising 11 key principles, each accompanied by methodological specifications and reporting standards, the iDSI Reference Case also serves as a means of identifying priorities for methods research, and can be used as a framework for capacity building and technical assistance in LMICs.

CONCLUSIONS

The iDSI Reference Case is an aid to thought, not a substitute for it, and should not be followed slavishly without regard to context, culture, or history. This article presents the iDSI Reference Case and discusses the rationale, approach, components, and application in LMICs.

Impact of work-related cancers in Taiwan-Estimation with QALY (quality-adjusted life year) and healthcare costs

This study estimates the annual numbers of eight work-related cancers, total losses of quality-adjusted life years (QALYs), and lifetime healthcare expenditures that possibly could be saved by improving occupational health in Taiwan. Three databases were interlinked: the Taiwan Cancer Registry, the National Mortality Registry, and the National Health Insurance Research Database. Annual numbers of work-related cancers were estimated based on attributable fractions (AFs) abstracted from a literature review. The survival functions for eight cancers were estimated and extrapolated to lifetime using a semi-parametric method. A convenience sample of 8846 measurements of patients' quality of life with EQ-5D was collected for utility values and multiplied by survival functions to estimate quality-adjusted life expectancies (QALEs). The loss-of-QALE was obtained by subtracting the QALE of cancer from age- and sex-matched referents simulated from national vital statistics. The lifetime healthcare expenditures were estimated by multiplying the survival probability with mean monthly costs paid by the National Health Insurance for cancer diagnosis and treatment and summing this for the expected lifetime. A total of 3010 males and 726 females with eight work-related cancers were estimated in 2010. Among them, lung cancer ranked first in terms of QALY loss, with an annual total loss-of-QALE of 28,463 QALYs and total lifetime healthcare expenditures of US$36.6 million. Successful prevention of eight work-related cancers would not only avoid the occurrence of 3736 cases of cancer, but would also save more than US$70 million in healthcare costs and 46,750 QALYs for the Taiwan society in 2010.

•

A practical approach to estimate impact of work-related cancers is demonstrated.

•

3010 male and 726 female cancers were estimated work-related in Taiwan in 2010.

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The impact included 46,750 QALYs annually, healthcare costs more than US$70 million.

Digital Cognitive Behavioural Therapy for Insomnia versus sleep hygiene education: the impact of improved sleep on functional health, quality of life and psychological well-being. Study protocol for a randomised controlled trial

BACKGROUND

Previous research has demonstrated that digital CBT (dCBT), delivered via the Internet, is a scalable and effective intervention for treating insomnia in otherwise healthy adults and leads to significant improvements in primary outcomes relating to sleep. The majority of people with insomnia, however, seek help because of the functional impact and daytime consequences of poor sleep, not because of sleep discontinuity per se. Although some secondary analyses suggest that dCBT may have wider health benefits, no adequately powered study has investigated these as a primary endpoint. This study specifically aims to investigate the impact of dCBT for insomnia upon health and well-being, and will investigate sleep-related changes as mediating factors.

METHODS/DESIGN

We propose a pragmatic, parallel-group, randomised controlled trial of 1000 community participants meeting criteria for insomnia disorder. In the DIALS trial (Digital Insomnia therapy to Assist your Life as well as your Sleep), participants will be randomised to dCBT delivered using web and/or mobile channels (in addition to treatment as usual (TAU)) or to sleep hygiene education (SHE), comprising a website plus a downloadable booklet (in addition to TAU). Online assessments will take place at 0 (baseline), 4 (mid-treatment), 8 (post-treatment), and 24 (follow-up) weeks. At week 25 all participants allocated to SHE will be offered dCBT, at which point the controlled element of the trial will be complete. Naturalistic follow-up will be invited at weeks 36 and 48. Primary outcomes are functional health and well-being at 8 weeks. Secondary outcomes are mood, fatigue, sleepiness, cognitive function, productivity and social functioning. All main analyses will be carried out at the end of the final controlled follow-up assessments and will be based on the intention-to-treat principle. Further analyses will determine whether observed changes in functional health and well-being are mediated by changes in sleep. The trial is funded by Big Health Ltd.

DISCUSSION

This study will be the first large-scale, specifically designed investigation of the health and well-being benefits of CBT for insomnia, and the first examination of the association between CBT-mediated sleep improvement and health status.

TRIAL REGISTRATION

ISRCTN60530898 .

Good reliability and validity for a new utility instrument measuring the birth experience, the Labor and Delivery Index

OBJECTIVES

To validate the Labor and Delivery Index (LADY-X), a new delivery-specific utility measure.

STUDY DESIGN AND SETTING

In a test-retest design, women were surveyed online, 6 to 8 weeks postpartum and again 1 to 2 weeks later. For reliability testing, we assessed the standard error of measurement (S.E.M.) and the intraclass correlation coefficient (ICC). For construct validity, we tested hypotheses on the association with comparison instruments (Mackey Childbirth Satisfaction Rating Scale and Wijma Delivery Experience Questionnaire), both on domain and total score levels. We assessed known-group differences using eight obstetrical indicators: method and place of birth, induction, transfer, control over pain medication, complications concerning mother and child, and experienced control.

RESULTS

The questionnaire was completed by 308 women, 257 (83%) completed the retest. The distribution of LADY-X scores was skewed. The reliability was good, as the ICC exceeded 0.80 and the S.E.M. was 0.76. Requirements for good construct validity were fulfilled: all hypotheses for convergent and divergent validity were confirmed, and six of eight hypotheses for known-group differences were confirmed as all differences were statistically significant (P-values: <0.001-0.023), but for two tests, difference scores did not exceed the S.E.M.

CONCLUSION

The LADY-X demonstrates good reliability and construct validity. Despite its skewed distribution, the LADY-X can discriminate between groups. With the preference weights available, the LADY-X might fulfill the need for a utility measure for cost-effectiveness studies for perinatal care interventions.

Validation of the underlying assumptions of the quality-adjusted life-years outcome: results from the ECHOUTCOME European project

BACKGROUND

Quality-adjusted life-years (QALYs) have been used since the 1980s as a standard health outcome measure for conducting cost-utility analyses, which are often inadequately labeled as 'cost-effectiveness analyses'. This synthetic outcome, which combines the quantity of life lived with its quality expressed as a preference score, is currently recommended as reference case by some health technology assessment (HTA) agencies. While critics of the QALY approach have expressed concerns about equity and ethical issues, surprisingly, very few have tested the basic methodological assumptions supporting the QALY equation so as to establish its scientific validity.

OBJECTIVES

The main objective of the ECHOUTCOME European project was to test the validity of the underlying assumptions of the QALY outcome and its relevance in health decision making.

METHODS

An experiment has been conducted with 1,361 subjects from Belgium, France, Italy, and the UK. The subjects were asked to express their preferences regarding various hypothetical health states derived from combining different health states with time durations in order to compare observed utility values of the couples (health state, time) and calculated utility values using the QALY formula.

RESULTS

Observed and calculated utility values of the couples (health state, time) were significantly different, confirming that preferences expressed by the respondents were not consistent with the QALY theoretical assumptions.

CONCLUSIONS

This European study contributes to establishing that the QALY multiplicative model is an invalid measure. This explains why costs/QALY estimates may vary greatly, leading to inconsistent recommendations relevant to providing access to innovative medicines and health technologies. HTA agencies should consider other more robust methodological approaches to guide reimbursement decisions.

Comparison of expected health impacts for major cancers: integration of incidence rate and loss of quality-adjusted life expectancy

PURPOSE

The study aims to quantify the expected impacts of different cancers through multiplying the incidence rate by loss-of-QALE (quality-adjusted life expectancy), with QALY (quality-adjusted life year) as the common unit, to aid prevention policy decisions.

METHODS

464,722 patients with pathologically verified cancer registered in the Taiwan Cancer Registry during 1998-2009 were used to estimate lifetime survival through Kaplan-Meier estimation combined with a semi-parametric method. A convenience sample for measuring the utility value with EQ-5D was conducted with 11,453 cancer patients, with the results then multiplied by the survival functions to estimate QALE. The loss-of-QALE was calculated by subtracting the QALE of each cancer cohort from the life expectancy of the corresponding age- and gender-matched reference population. The cumulative incidence rates from age 20 to 79 (CIR₂₀₋₇₉) were calculated to estimate the lifetime risk of cancer for each organ-system.

RESULTS

Liver and lung cancer were found the highest expected lifetime health impacts in males and females, or expected lifetime losses of 0.97 and 0.41 QALYs that could be averted, respectively. While the priority changes for prevention based on expected health impacts were slightly different for females based on standardized mortality rates, those of males involve a broader spectrum, including oral, colorectal, esophageal and stomach cancer.

CONCLUSION

The integration of incidence rate with loss-of-QALE could be used to represent the expected losses that could be averted by prevention, which may be useful in prioritizing strategies for cancer control.

Do health preferences contradict ordering of EQ-5D labels?

PURPOSE

The aim of this study was to test whether the ordering of item labels in EQ-5D instruments disagrees with the preferences of US adults.

METHODS

A preference inversion occurs when "worse" health along a scale or score is preferred. As a sub-study of the 2013 United States Measurement and Valuation of Health Study, we tested for 33 EQ-5D preference inversions using paired comparisons with unique samples of 50 or more US adults, aged 18 or older. Specifically, we tested whether health preferences contradicted ordering of EQ-5D labels.

RESULTS

The EQ-5D-3L and EQ-5D-Y item labels had no significant preference inversions. The EQ-5D-5L version had preference inversions between Levels 4 and 5. For example, 30 out of 59 respondents (51 %) preferred being "extremely" over "severely anxious or depressed," contrary to the ordering of labels for that item.

CONCLUSIONS

Preference inversions between Levels 4 and 5 on the EQ-5D-5L were tested and confirmed; therefore, valuation studies may find that Levels 4 and 5 have the same value. To mitigate such inversions, labels could be revised or a 4-level version could be considered.

US valuation of health outcomes measured using the PROMIS-29

OBJECTIVES

Health valuation studies enhance economic evaluations of treatments by estimating the value of health-related quality of life (HRQOL). The Patient-Reported Outcomes Measurement Information System (PROMIS) includes a 29-item short-form HRQOL measure, the PROMIS-29.

METHODS

To value PROMIS-29 responses on a quality-adjusted life-year scale, we conducted a national survey (N = 7557) using quota sampling based on the US 2010 Census. Based on 541 paired comparisons with over 350 responses each, pair-specific probabilities were incorporated into a weighted least-squared estimator.

RESULTS

All losses in HRQOL influenced choice; however, respondents valued losses in physical function, anxiety, depression, sleep, and pain more than those in fatigue and social functioning.

CONCLUSIONS

This article introduces a novel approach to valuing HRQOL for economic evaluations using paired comparisons and provides a tool to translate PROMIS-29 responses into quality-adjusted life-years.

Predicting health utilities for children with autism spectrum disorders

Comparative effectiveness of interventions for children with autism spectrum disorders (ASDs) that incorporates costs is lacking due to the scarcity of information on health utility scores or preference-weighted outcomes typically used for calculating quality-adjusted life years (QALYs). This study created algorithms for mapping clinical and behavioral measures for children with ASDs to health utility scores. The algorithms could be useful for estimating the value of different interventions and treatments used in the care of children with ASDs. Participants were recruited from two Autism Treatment Network sites. Health utility data based on the Health Utilities Index Mark 3 (HUI3) for the child were obtained from the primary caregiver (proxy-reported) through a survey (N = 224). During the initial clinic visit, proxy-reported measures of the Child Behavior Checklist, Vineland II Adaptive Behavior Scales, and the Pediatric Quality of Life Inventory 4.0 (start measures) were obtained and then merged with the survey data. Nine mapping algorithms were developed using the HUI3 scores as dependent variables in ordinary least squares regressions along with the start measures, the Autism Diagnostic Observation Schedule, to measure severity, child age, and cognitive ability as independent predictors. In-sample cross-validation was conducted to evaluate predictive accuracy. Multiple imputation techniques were used for missing data. The average age for children with ASDs in this study was 8.4 (standard deviation = 3.5) years. Almost half of the children (47%) had cognitive impairment (IQ ≤ 70). Total scores for all of the outcome measures were significantly associated with the HUI3 score. The algorithms can be applied to clinical studies containing start measures of children with ASDs to predict QALYs gained from interventions.

Cost-effectiveness of second-line chemotherapy/biologics among elderly metastatic colon cancer patients

Introduction

Advancements in chemotherapy treatment have improved the clinical management of metastatic colon cancer (mCC) patients. An increasing number of elderly mCC patients receive various combinations of regimens in second-line chemotherapy/biologics treatment (Tx2) after first-line treatment (Tx1) to prolong survival and/or palliate symptoms, but these regimens have higher costs. This analysis investigated the survival benefit and incremental cost associated with Tx2 among elderly mCC patients.

Methods

Elderly (aged ≥66 years) SEER-Medicare patients diagnosed with mCC in 2003–2007 were identified and followed until death or the end of 2009. Cox regression and partitioned least squares regression were utilized to obtain the survival benefit and incremental cost associated with Tx2 within a 5-year study period. A time-varying model was used to reduce bias due to sequential ordering of Tx1 and Tx2. The regressions controlled for patient demographic characteristics, clinical variables, and a proxy for poor performance. Bootstrapping was used to generate 95% confidence intervals (CI).

Results

Of the 3,266 elderly mCC patients who received Tx1, 2,744 (84%) died within the observation period; 1,440 (44%) received Tx2. The survival benefit associated with receipt of Tx2 was 0.33 years (95% CI 0.19–0.43), and the associated incremental cost was $40,888 (95% CI 3,044–44,324). The incremental cost-effectiveness ratio (ICER) for Tx2 was $123,903 per life year gained (95% CI 9,600–216,082).

Conclusion

The estimated survival benefit of receiving second-line chemotherapy/biologics was about 4 months, which is consistent with evidence from clinical trials. This improved survival was associated with an ICER that exceeds the traditional threshold.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-014-0134-8) contains supplementary material, which is available to authorized users.

Calibration of quality-adjusted life years for oncology clinical trials

CONTEXT

Quality-adjusted life year (QALY) estimation is a well-known but little used technique to compare survival adjusted for complications. Lack of calibration and interpretation guidance hinders implementation of QALY analyses.

OBJECTIVES

We conducted simulation studies to assess the impact of differences in survival, toxicity rates, and utility values on QALY results.

METHODS

Survival comparisons used both log-rank and Wilcoxon testing. We examined power considerations for a North Central Cancer Treatment Group Phase III lung cancer clinical trial (89-20-52).

RESULTS

Sample sizes of 100 events per treatment have low power to generate a statistically significant difference in QALYs unless the toxicity rate is 44% higher in one arm. For sample sizes of 200 per arm and equal survival times, toxicity needs to be at least 38% more in one arm for the result to be statistically significant, using a utility of 0.3 for days with toxicity. Sample sizes of 300 (500)/arm provide 80% power if there is a 31% (25%) toxicity difference. If the overall survival hazard ratio between the two treatment arms is 1.25, then samples of at least 150 patients and 13% increased toxicity are necessary to have 80% power to detect QALY differences. In study 89-20-52, there was only 56% power to determine the statistical significance of the observed QALY differences, clarifying the enigmatic conclusion of no statistically significant difference in QALY despite an observed 14.5% increase in toxicity between treatments.

CONCLUSION

This calibration allows researchers to interpret the clinical significance of QALY analyses and facilitates QALY inclusion in clinical trials through improved study design.

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.

Use of health-related quality of life measures to predict health utility in postmenopausal osteoporotic women: results from the Multiple Outcomes of Raloxifene Evaluation study

BACKGROUND

The aim of this study is to examine the associations between health utility (HU), health-related quality of life (HRQoL), and patient characteristics in postmenopausal osteoporotic (PMO) women.

METHODS

Baseline data from a subsample of 1,245 participants of the Multiple Outcomes of Raloxifene Evaluation study, a randomized, placebo-controlled, multinational clinical trial to evaluate the safety and efficacy of raloxifene, were analyzed. The study cohort included 694 participants from non-European Union (non-EU) countries and 551 participants from EU countries. All participants with complete baseline HU and HRQoL assessments were included in the following analyses: 1) HU (HUI or EQ-5D) and HRQoL (QualEFFO or OPAQ and NHP) associations; 2) HU variability explained by HRQoL domains; and 3) the percentage of HU variability explained by statistically significant (p < 0.05) HRQoL domains, after adjusting for baseline characteristics.

RESULTS

Several domains were significantly associated with HU scores. HU variance was well explained (41% to 61%) by 4 to 6 (p < 0.05) significant HRQoL domains. After controlling for baseline characteristics, 48% to 64% of the HU variance was well explained by 5 to 7 significant (p < 0.05) HRQoL domains. Additional trend analyses detected statistically significant decreases in HRQoL and HU scores with an increased number of vertebral and non-vertebral fractures.

CONCLUSIONS

Both disease-targeted and generic HRQoL domains were well correlated with HU. A large percentage (48% to 64%) of the HU variance was explained by HRQoL, after adjusting for baseline characteristics. Both disease-targeted and generic HRQoL measures were significant predictors of HU. HRQoL and HU scores decreased with increased vertebral and non-vertebral fractures.

Critical limb ischemia and its impact on patient health preferences and quality of life-an international study

Critical limb ischemia (CLI) has a significant impact on patients' quality of life (QoL). Despite cost utility evaluations being required by different authorities, data on patient health preferences and utilities for CLI are scarce. Hence, the objective of this study was to assess the impact of CLI on health preferences and health status of affected patients, and to generate health state utilities. In the International Study, 200 patients with CLI (stages III and IV according to Fontaine scale) were interviewed by trained interviewers with a discrete choice instrument, a standard gamble (SG), and the EuroQol-five dimension (EQ-5D) questionnaires (Marten Meesweg, Rotterdam, Netherland). Conjoint analysis showed that a planned amputation (33%) was the most relevant health attribute followed by ambulatory function (25%) and chronic pain (15%). Non-dependence on caregiver impacted on patient health state preference considerably, whereas healing of ulcer/skin lesions had less impact. Preference values obtained from the SG were 0.84, for an amputation subpopulation arriving at 0.70. The EQ-5D index values as well as the EQ-5D visual analog scale for patients with CLI were 0.56. The QoL data of patients with CLI result in decreased QoL and preference values with a planned amputation.

A Systematic Review of Quality of Life Measures in Pregnant and Postpartum Mothers

Quality of life has emerged as an essential health component that broadens the traditionally narrow concerns focused on only morbidity and life expectancy. Although a growing number of tools to measure quality of life are in circulation, there is a lack of guidelines as well as rigorous assessment for their use with pregnant and postpartum populations. It is also unclear whether these instruments could validly be employed to measure patient-reported outcomes in comparative effectiveness research of maternal care interventions. This paper reviews articles cited in CINAHL, COCHRANE, EMBASE, PSYCINFO, and PUBMED that addressed quality of life in pregnant and postpartum populations. Instruments used to measure quality of life in selected articles were assessed for their adherence to international guidelines for health outcomes instrument development and validation. The authors identified 129 articles that addressed quality of life in pregnant and/or postpartum women. Out of these, only 64 quality (generic and specific) scales were judged relevant to be included in this study. Analysis of measurement scales used in the pregnant and/or postpartum populations revealed important validity, reliability and psychometric inadequacies that negate their use in comparative effectiveness analysis in pregnant and post-partum populations. Valid, reliable, and responsive instruments to measure patient-reported outcomes in pregnant and postpartum populations are lacking. To demonstrate the effectiveness of various treatment and prevention programs, future research to develop and validate a robust and responsive quality of life measurement scale in pregnant and postpartum populations is needed.

Valuing the economic benefits of complex interventions: when maximising health is not sufficient

Complex interventions, involving interlinked packages of care, challenge the application of current methods of economic evaluation that focus on measuring only health gain. Complex interventions may be problematic on two levels. The complexity means the intervention may not fit into one of the current appraisal systems, and/or maximising health is not the only objective. This paper discusses the implications of a programme of work that focused on clinical genetics services, as an example of a complex intervention, and aimed to identify the following: the attributes that comprise both health and non-health aspects of benefits and whether it is possible to evaluate such an intervention using current National Institute for Health and Clinical Excellence appraisal processes. Genetic services and tests are a good example of a complex intervention and have broader objectives than just health gain, which may usefully be measured using the concept related to capability, which we have called 'empowerment'. Further methodological work is required to identify the trade-off between non-health (empowerment) and health benefits for other complex interventions. We do not advocate a move away from QALY maximisation but do suggest that there is a need for a more considered approach that can take account of the perceived value for non-health attributes for some complex interventions.

Consumer preferences for health and nonhealth outcomes of health promotion: results from a discrete choice experiment

OBJECTIVE

Health promotion (HP) interventions have outcomes that go beyond health. Such broader nonhealth outcomes are usually neglected in economic evaluation studies. To allow for their consideration, insights are needed into the types of nonhealth outcomes that HP interventions produce and their relative importance compared with health outcomes. This study explored consumer preferences for health and nonhealth outcomes of HP in the context of lifestyle behavior change.

METHODS

A discrete choice experiment was conducted among participants in a lifestyle intervention (n = 132) and controls (n = 141). Respondents made 16 binary choices between situations that can be experienced after lifestyle behavior change. The situations were described by 10 attributes: future health state value, start point of future health state, life expectancy, clothing size above ideal, days with sufficient relaxation, endurance, experienced control over lifestyle choices, lifestyle improvement of partner and/or children, monetary cost per month, and time cost per week.

RESULTS

With the exception of "time cost per week" and "start point of future health state," all attributes significantly determined consumer choices. Thus, both health and nonhealth outcomes affected consumer choice. Marginal rates of substitution between the price attribute and the other attributes revealed that the attributes "endurance," "days with sufficient relaxation," and "future health state value" had the greatest impact on consumer choices. The "life expectancy" attribute had a relatively low impact and for increases of less than 3 years, respondents were not willing to trade.

CONCLUSIONS

Health outcomes and nonhealth outcomes of lifestyle behavior change were both important to consumers in this study. Decision makers should respond to consumer preferences and consider nonhealth outcomes when deciding about HP interventions.

Preference-based health-related quality-of-life outcomes in children with autism spectrum disorders: a comparison of generic instruments

BACKGROUND

Cost-effectiveness analysis of pharmaceutical and other treatments for children with autism spectrum disorders (ASDs) has the potential to improve access to services by demonstrating the value of treatment to public and private payers, but methods for measuring QALYs in children are under-studied. No cost-effectiveness analyses have been undertaken in this population using the cost-per-QALY metric.

OBJECTIVE

This study describes health-related quality-of-life (HR-QOL) outcomes in children with ASDs and compares the sensitivity of two generic preference-based instruments relative to ASD-related conditions and symptoms.

METHODS

The study design was cross-sectional with prospectively collected outcome data that were correlated with retrospectively assessed clinical information. Subjects were recruited from two sites of the Autism Treatment Network (ATN) in the US: a developmental centre in Little Rock, Arkansas, and an outpatient psychiatric clinic at Columbia University Medical Center in New York. Children that met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for an ASD by a multidisciplinary team evaluation were asked to participate in a clinical registry. Families of children with an ASD that agreed to be contacted about participation in future research studies as part of the ATN formed the sampling frame for the study. Families were included if the child with the ASD was between 4 and 17 years of age and the family caregiver spoke English. Eligible families were contacted by mail to see if they would be interested in participating in the study with 150 completing surveys. HR-QOL outcomes were described using the Health Utilities Index (HUI) 3 and the Quality of Well-Being Self-Administered (QWB-SA) scale obtained by proxy via the family caregiver.

RESULTS

Children were diagnosed as having autistic disorder (76%), pervasive developmental disorder-not otherwise specified [PDD-NOS] (15%), and Asperger's disorder (9%). Average HUI3 and QWB-SA scores were 0.68 (SD 0.21, range 0.07-1) and 0.59 (SD 0.16, range 0.18-1), respectively. The HUI3 score was significantly correlated with clinical variables including adaptive behaviour (ρ = 0.52; p < 0.001) and cognitive functioning (ρ = 0.36; p < 0.001). The QWB-SA score had weak correlation with adaptive behaviour (ρ = 0.25; p < 0.001) and cognitive functioning (ρ = 0.17; p < 0.005). Change scores for the HUI3 were larger than the QWB-SA for all clinical measures. Scores for the HUI3 increased 0.21 points (95% CI 0.14, 0.29) across the first to the third quartile of the cognitive functioning measure compared with 0.05 (95% CI -0.01, 0.11) for the QWB-SA. Adjusted R2 values also were higher for the HUI3 compared with the QWB-SA across all clinical measures.

CONCLUSIONS

The HUI3 was more sensitive to clinical measures used to characterize children with autism compared with the QWB-SA score. The findings provide a benchmark to compare scores obtained by alternative methods and instruments. Researchers should consider incorporating the HUI3 in clinical trials and other longitudinal research studies to build the evidence base for describing the cost effectiveness of services provided to this important population.

Patient-reported measures of psychosocial issues and health behavior should be added to electronic health records

Recent legislation and delivery system reform efforts are greatly expanding the use of electronic health records. For these efforts to reach their full potential, they must actively involve patients and include patient-reported information about such topics as health behavior, preferences, and psychosocial functioning. We offer a plan for including standardized, practical patient-reported measures as part of electronic health records, quality and performance indexes, the primary care medical home, and research collaborations. These measures must meet certain criteria, including being valid, reliable, sensitive to change, and available in multiple languages. Clinicians, patients, and policy makers also must be able to understand the measures and take action based on them. Including more patient-reported items in electronic health records would enhance health, patient-centered care, and the capacity to undertake population-based research.

Does responsibility affect the public's valuation of health care interventions? A relative valuation approach to health care safety

OBJECTIVE

Health services often spend more on safety interventions than seems cost-effective. This study investigates whether the public value safety-related health care improvements more highly than the same improvements in contexts where the health care system is not responsible.

METHOD

An online survey was conducted to elicit the relative importance placed on preventing harms caused by 1) health care (hospital-acquired infections, drug administration errors, injuries to health care staff), 2) individuals (personal lifestyle choices, sports-related injuries), and 3) nature (genetic disorders). Direct valuations were obtained from members of the public by using a person trade-off or "matching" method. Participants were asked to choose between two preventative interventions of equal cost and equal health benefit per person for the same number of people, but differing in causation. If participants indicated a preference, their strength of preference was measured by using person trade-off.

RESULTS

Responses were obtained from 1030 people, reflecting the sociodemographic mix of the UK population. Participants valued interventions preventing hospital-acquired infections (1.31) more highly than genetic disorders (1.0), although drug errors were valued similarly to genetic disorders (1.07), and interventions to prevent injury to health care staff were given less weight than genetic disorders (0.71). Less weight was also given to interventions related to lifestyle (0.65) and sports injuries (0.41).

CONCLUSION

Our results suggest that people do not attach a simple fixed premium to "safety-related" interventions but that preferences depend more subtly on context. The use of the results of such public preference surveys to directly inform policy would therefore be premature.

Methods and issues associated with the use of quality-adjusted life-years

In this article, we will focus on how preferences and utilities are measured, including the strengths and limitations of various approaches, discuss their use in estimating quality-adjusted life-years (QALYs) and make some recommendations for further research. Preferences are either measured using direct (visual analog scale, time trade-off or standard gamble) or indirect methods. The most commonly used generic indirect measures include the Quality of Well-Being scale, EuroQol-5 Dimension, Health Utilities Index and Short Form-6 Dimension. Disease-specific preference measures are increasingly being developed and applied in studies as more sensitive measures of health status. Preference-based measures and QALY measurement need to be enhanced, and additional research is needed to improve scientific methods for estimating preferences for health assessment. Given the increased focus on comparative effectiveness research, QALYs have the potential for helping researchers, clinicians, health policy-makers and patients to understand the relative effectiveness of alternative interventions for treating medical conditions.

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.

Valuing Health for Clinical and Economic Decisions: Directions Relevant for Rheumatologists

The quality-adjusted life-year (QALY) is a construct that integrates the value or preference for a health state over the period of time in that health state. The main use of QALY is in cost-utility analysis, to help make resource allocation decisions when faced with choices. Although the concept of the QALY is appealing, there is ongoing debate regarding their usefulness and approaches to deriving QALY. In 2008, OMERACT engaged in an effort to agree on QALY approaches that can be used in rheumatology. Based on a Web questionnaire and a subsequent meeting, rheumatologists questioned whether it was relevant for OMERACT (1) to investigate use of a QALY that represents the patients’ perspective, (2) to explore the validity of the visual analog scale (VAS) to value health, and (3) to understand the validity of mapping health-specific instruments on existing preference instruments. This article discusses the pros and cons of these points in light of current insight from the point of view of health economics and decision-making theory. It also considers the further research agenda toward a QALY approach in rheumatology.

Is the United States ready for QALYs?

Quality-adjusted life-years (QALYs) are used in cost-effectiveness analyses to aid coverage and reimbursement decisions worldwide. QALYs provide a flexible and convenient metric for measuring and comparing health outcomes across diverse diseases and treatments. But their use has stirred controversy about how accurately they reflect preferences for health care and whether their use is fair. We review the debate and the use of QALYs in other countries and discuss prospects for using them in the U.S. health care system. Strict adherence to a QALY approach is likely to prove unacceptable in the United States, but a more flexible use of QALYs could be beneficial.

Imputing QALYs from single time point health state descriptions on the EQ-5D and the SF-6D: a comparison of methods for hepatitis a patients

OBJECTIVES

To explore the impact of applying different non-standardized analytical choices for quality of life measurement to obtain quality-adjusted life years (QALYs). In addition to more widely discussed issues such as the choice of instrument (e.g. EQ-5D or SF-6D?) researchers must also choose between different recall periods, scoring algorithms and interpolations between points of measurement.

METHODS

A prospective survey was made among 114 Belgian patients with acute hepatitis A illness. Using non-parametric tests and generalized linear models (GLM's), we compared four different methods to estimate QALY losses, two based on the EQ-5D (administered during the period of illness without recall period) and two based on the SF-6D (administered after illness with 4 weeks recall period).

RESULTS

We found statistically significant differences between all methods, with the non-parametric SF-6D-based method yielding the highest median QALY impact (0.032 QALYs). This is more than five times as high as the EQ-5D-based method with linear health improvement, which yields the lowest median QALY impact (0.006 QALYs).

CONCLUSIONS

Economic evaluations of health care technologies predominantly use QALYs to quantify health benefits. Non-standardised analytical choices can have a decision-changing impact on cost-effectiveness results, particularly if morbidity takes up a substantial part of the total QALY loss. Yet these choices are rarely subjected to sensitivity analysis. Researchers and decision makers should be aware of the influence of these somewhat arbitrary choices on their results.