Predicting an SF-6D preference-based score using MCS and PCS scores from the SF-12 or SF-36

Projecting the economic burden of health impacts of aircraft noise: a case study of Baltimore Washington International Thurgood Marshall Airport

BACKGROUND

While the Next Generation Air Transportation System (NextGen) in the United States optimizes flight patterns, it has led to the unintended consequence of increasing aircraft noise exposure in some communities near airports. Despite the evidence that chronic exposure to high noise levels produces detrimental health effects, potential adverse health consequences due to increased noise in the affected communities have not been adequately considered in aviation policy discussions.

OBJECTIVE

We assessed the long-term health and associated economic burden of increased aircraft noise caused by NextGen near the Baltimore-Washington Thurgood Marshall International (BWI) airport in Maryland.

METHODS

A probabilistic Markov model projected the incremental health and associated economic burden over 30, 20, and 10 years, comparing post-NextGen noise exposure levels to pre-NextGen levels. Health outcomes included cardiovascular disease (CVD), anxiety disorders, noise annoyance, and low birth weight (LBW). Noise exposure was categorized into four levels (<55 dB DNL, 55-60 dB DNL, 60-65 dB DNL, >65 dB DNL). A Monte Carlo simulation with 2000 iterations was run to obtain incremental burden estimates and uncertainty intervals. One-way sensitivity analyses for noise effect parameters were conducted.

RESULTS

Increased aircraft noise exposure was estimated to produce (discounted) incremental mortality costs of $362 million, morbidity costs of $336 million, and losses of 15,326 Quality-Adjusted Life Years (QALYs) over the next 30 years. Sensitivity analyses revealed the greatest uncertainty for CVD outcomes.

IMPACT

NextGen is a system that can increase the operational efficiency of airports by optimizing flight patterns. While operational efficiency is beneficial in many ways, changes in flight patterns and volume can also produce noise pollution, a major public health concern that should be considered in policy decision-making. This study quantifies the long-term health and economic implications of increased aircraft noise exposure following the implementation of NextGen in communities near the Baltimore-Washington International Airport. Our findings underscore the importance of considering public health consequences of noise pollution.

A polyphenol fraction from Rosa multiflora var. platyphylala reduces body fat in overweight humans through appetite suppression - a randomized, double-blind, placebo-controlled trial

BACKGROUND

Rosa species are rich sources of polyphenols with physiological functions. In this study a polyphenol-rich Rosa multiflora (var. platyphylala) petal extract (RoseFit™) was investigated for weight loss in humans.

METHODS

In a randomized, placebo-controlled, parallel-group, double-blind clinical trial seventy overweight male and female subjects (20-50 years) with body mass index (BMI) 25-30 kg/m2 were randomly allocated to the active treatment group (RoseFit) and placebo group in a 1:1 ratio. The subjects received 300 mg capsules twice daily for 12 weeks. The primary efficacy outcome measures included body weight, BMI, and body composition, as determined using Dual-energy X-ray absorptiometry (DEXA). Secondary measures consisted of serum lipid profile and appetite marker (leptin and ghrelin) analyses. Safety analyses included biochemical and hematological assessments.

RESULTS

At the end of the study, a marked reduction in body weight (-1.20 ± 2.62 kg, p < 0.05) and BMI from baseline was observed in the RoseFit group. In addition, the body fat % (RoseFit = -1.69 ± 2.59%, placebo = 0.96 ± 3.21%; p < 0.001) and fat mass (RoseFit = -1.75 ± 1.80 kg, placebo = 1.61 ± 3.82 kg; p < 0.001) were significantly abated in RoseFit group. Importantly, the lean mass was maintained during the intervention. RoseFit ingestion significantly increased the serum leptin levels compared to the placebo (4.85%; p < 0.05). Further, RoseFit group showed reduction in the hunger hormone ghrelin level (2.27%; p < 0.001) from baseline to the end of study, compared to the placebo. The subjective evaluation of appetite using visual analog scale (VAS) questionnaires further confirmed the appetite-suppression effects of RoseFit. The lipid profile significantly improved in RoseFit-treated subjects. No serious adverse events were observed during the study, indicating the tolerability of RoseFit.

CONCLUSIONS

Supplementation with RoseFit significantly impacts body weight management and can thus be a potential nutraceutical ingredient for sustainable weight loss.

TRIAL REGISTRATION

CTRI/2019/10/021584 dated 09/10/2019.

Exploring humanistic burden of fatigue in adults with multiple sclerosis: an analysis of US National Health and Wellness Survey data

BACKGROUND

This retrospective study examined the humanistic burden of fatigue in patients with relapsing-remitting multiple sclerosis (RRMS), compared with adults without MS, using data from the 2017 and 2019 US National Health and Wellness Survey.

METHODS

The 5-item Modified Fatigue Impact Scale (MFIS-5) was used to assess level of fatigue (MFIS-5 score <15: low fatigue [LF]; MFIS-5 score ≥15: high fatigue [HF]) in patients with RRMS. Health-related quality of life (HRQoL) measures (Short Form 36-Item Health Survey version 2, Euroqol-5 Dimensions-5 Levels [EQ-5D-5L], Patient Health Questionnaire-9 [PHQ-9], Generalized Anxiety Disorder-7 [GAD-7], Perceived Deficits Questionnaire-5) and treatment-related characteristics were assessed.

RESULTS

In total, 498 respondents were identified as RRMS (n=375 RRMS+LF, n=123 RRMS+HF) and compared with 1,494 matched non-MS controls. RRMS+LF and RRMS+HF had significantly lower Short Form 6 Dimensions health utility, Mental and Physical Component Summary, and EQ-5D-5L scores and higher PHQ-9 and GAD-7 scores, compared with matched non-MS controls (all p<0.001); scores were worse for RRMS+HF than RRMS+LF across all measures (all p<0.001). A higher proportion of RRMS+HF reported moderate-to-severe depression and moderate-to-severe anxiety, compared with RRMS+LF and matched non-MS controls (both p<0.001). Fatigue was a significant predictor of poor HRQoL across all measures (all p<0.001).

CONCLUSIONS

Patients with RRMS experienced lower HRQoL with higher levels of fatigue, highlighting an unmet need. Results may help to inform physician-patient communication and shared decision-making to address fatigue and its associated impact on patients' HRQoL.

Comparison of Stage I Non-Small-Cell Lung Cancer Treatments for Patients Living With HIV: A Simulation Study

INTRODUCTION

Non-small-cell lung cancer (NSCLC) is a leading cause of death for people living with HIV (PWH). Nevertheless, there are no clinical trial data regarding the management of early-stage lung cancer in PWH. Using data from large HIV and cancer cohorts we parameterized a simulation model to compare treatments for stage I NSCLC according to patient characteristics.

MATERIALS AND METHODS

To parameterize the model we analyzed PWH and NSCLC patient outcomes and quality of life data from several large cohort studies. Comparative effectiveness of 4 stage I NSCLC treatments (lobectomy, segmentectomy, wedge resection, and stereotactic body radiotherapy) was estimated using evidence synthesis methods. We then simulated trials comparing treatments according to quality adjusted life year (QALY) gains by age, tumor size and histology, HIV disease characteristics and major comorbidities.

RESULTS

Lobectomy and segmentectomy yielded the greatest QALY gains among all simulated age, tumor size and comorbidity groups. Optimal treatment strategies differed by patient sex, age, and HIV disease status; wedge resection was among the optimal strategies for women aged 80 to 84 years with tumors 0 to 2 cm in size. Stereotactic body radiotherapy was included in some optimal strategies for patients aged 80 to 84 years with multimorbidity and in sensitivity analyses was a non-inferior option for many older patients or those with poor HIV disease control.

CONCLUSION

In simulated comparative trials of treatments for stage I NSCLC in PWH, extensive surgical resection was often associated with the greatest projected QALY gains although less aggressive strategies were predicted to be non-inferior in some older, comorbid patient groups.

Factors associated with patient activation among individuals with depression within racial/ethnic groups in the United States

Increasing patient activation may be vital for improving quality of care for individuals with depression. Among adults with depression who reside in the United States, we sought to examine the association of depression severity, race/ethnicity, and household income with patient activation and within identify factors associated with patient activation within race/ethnicity groups. Data from the 2020 US National Health and Wellness Survey, a cross-sectional, general population survey, were used to identify White, Black/African American, Asian, and Hispanic respondents with self-reported physician-diagnosed depression. Generalized linear models were used to identify factors associated with patient activation. Analyses included 8,216 respondents (mean age = 44 years, 68.0% female). Depression severity was negatively associated with patient activation (β = -0.29, p < 0.001). Patient activation was significantly higher in Black vs. White respondents (β = 1.50, p = 0.001) and in respondents with a household income of $25,000-$49,999 (β = 0.96, p = 0.015), $50,000-$99,000 (β = 0.88, p = 0.031), and ≥$100,000 (β = 1.78, p < 0.001) vs. <$25,000. Adjusted mean patient activation scores were highest among Black respondents (61.1), followed by Hispanic (60.2), White (59.6), and Asian (59.0) respondents. Neither race/ethnicity nor household income moderated the relationship between depression severity and patient activation; however, the factors most strongly associated with patient activation differed by race/ethnicity. These results indicate that the pathway to improving patient activation in individuals with depression may vary by race/ethnicity. Understanding factors associated with patient activation can help inform the design of interventions to increase patient activation in individuals with depression.

The real-world burden of adults with major depressive disorder with moderate or severe insomnia symptoms in the United States

BACKGROUND

Although insomnia is a common core symptom of major depressive disorder (MDD), the burden of moderate-to-severe insomnia symptoms in patients with MDD is not well-understood. This study quantified the clinical, patient-centric, and economic burden of adults with MDD with moderate-to-severe insomnia symptoms (MDDIS) compared to adults with MDD with no-to-mild insomnia symptoms (other-MDD) and adults without MDD.

METHODS

Data from 2019 US National Health and Wellness Survey identified adults self-reporting physician-diagnosed depression, stratified by insomnia status (MDDIS: Insomnia Severity Index [ISI] score ≥15; other-MDD: ISI score <15), and adults not reporting depression (non-MDD). Other-MDD and non-MDD were matched 2:1 to MDDIS on age/sex/race. Matched bivariate analyses examined differences in health-related outcomes by depression-insomnia status.

RESULTS

Of 74,994 survey respondents, 2045 (2.7%) were classified as MDDIS, 8220 (11.0%) as other-MDD, and 59,859 (79.8%) as non-MDD. MDDIS respondents (vs other-MDD and non-MDD) reported greater depression severity, anxiety severity, daytime sleepiness, activity impairment, direct costs, and costs due to work productivity impairments, and lower mental and physical functioning (all P < 0.05).

LIMITATIONS

Depression diagnosis was not based on clinical/diagnostic interview; causal relationships cannot be determined due to the cross-sectional design.

CONCLUSIONS

Among US adults with MDD, presence of moderate-to-severe insomnia symptoms is associated with additional burden and notable impairments across several health outcomes versus those with MDD but no-to-minimal insomnia symptoms and general population without MDD. This study highlights the burden of MDDIS and the need for better identification and management of moderate-to-severe insomnia symptoms in adults with MDD.

A population-based study on the risk of prescription opioid abuse in patients with chronic opioid use and cost-effectiveness of prescription drug monitoring program using a patient simulation model in South Korea

BACKGROUND

Concerns regarding the burden of inappropriate opioid use are growing. We examined the association between prescription opioid abuse and patient characteristics and estimated the cost-effectiveness of the prescription drug monitoring program (PDMP) implemented in South Korea, considering patient-level information.

METHODS

A retrospective cohort study was conducted to explore the association between opioid abuse and patient characteristics using the National Health Insurance Service-National Sample Cohort (NHIS-NSC) database. We selected non-cancer patients with chronic opioid use and investigated the incidence of opioid abuse between 2010 and 2015. The association between opioid abuse and patient characteristics was assessed using the Cox proportional hazards model. The cost-effectiveness of the PDMP was assessed using discrete event simulation (DES) with a time horizon of 30 years from a societal perspective. Time-to-event data and event costs were obtained from the NHIS-NSC database. The abuse rate was adjusted for each patient based on the baseline characteristics and history of abuse experienced in the model. Program effectiveness, program costs, and health-state utilities were obtained from the published literature. The incremental cost-utility ratio (ICUR) was estimated at a discount rate of 5% for both costs and quality-adjusted life-years (QALYs).

RESULTS

We identified 22,524 patients with chronic opioid use in the NHIS-NSC database. Every one-year increase in age (hazard ratio: 1.002 [95% CI: 1.000-1.003]), medical aid program (1.130 [95% CI: 1.072-1.191]), high Charlson Comorbidity Index (1.054 [95% CI: 1.044-1.065]), and history of opioid abuse (1.501 [95% CI: 1.391-1.620] and 3.005 [95% CI: 2.387-3.783] for 1-2 and ≥3 abuse events, respectively) significantly increased the risk of opioid abuse. In the DES, the PDMP was cost-effective, with an estimated ICUR of $2,227/QALY, which was most affected by the program's effectiveness.

CONCLUSION

Patient characteristics and history of opioid abuse affected the risk of opioid abuse. Considering patient-level information, the PDMP implemented in South Korea is likely to be cost-effective.

The benefits and harms of adjuvant chemotherapy for non-small cell lung cancer in patients with major comorbidities: A simulation study

BACKGROUND

Randomized controlled trials (RCTs) have demonstrated a survival benefit for adjuvant platinum-based chemotherapy after resection of locoregional non-small cell lung cancer (NSCLC). The relative benefits and harms and optimal approach to treatment for NSCLC patients who have major comorbidities (chronic obstructive pulmonary disease [COPD], coronary artery disease [CAD], and congestive heart failure [CHF]) are unclear, however.

METHODS

We used a simulation model to run in-silico comparative trials of adjuvant chemotherapy versus observation in locoregional NSCLC in patients with comorbidities. The model estimated quality-adjusted life years (QALYs) gained by each treatment strategy stratified by age, comorbidity, and stage. The model was parameterized using outcomes and quality-of-life data from RCTs and primary analyses from large cancer databases.

RESULTS

Adjuvant chemotherapy was associated with clinically significant QALY gains for all patient age/stage combinations with COPD except for patients >80 years old with Stage IB and IIA cancers. For patients with CHF and Stage IB and IIA disease, adjuvant chemotherapy was not advantageous; in contrast, it was associated with QALY gains for more advanced stages for younger patients with CHF. For stages IIB and IIIA NSCLC, most patient groups benefited from adjuvant chemotherapy. However, In general, patients with multiple comorbidities benefited less from adjuvant chemotherapy than those with single comorbidities and women with comorbidities in older age categories benefited more from adjuvant chemotherapy than their male counterparts.

CONCLUSIONS

Older, multimorbid patients may derive QALY gains from adjuvant chemotherapy after NSCLC surgery. These results help extend existing clinical trial data to specific unstudied, high-risk populations and may reduce the uncertainty regarding adjuvant chemotherapy use in these patients.

A National Catalog of Mapped Short-Form Six-Dimension Utility Scores for Chronic Conditions in the United States From 2010 to 2015

OBJECTIVES

This study examined health preference utility weights and utility decrements associated with different types of chronic conditions in the United States.

METHODS

We used the 2010-2015 Medical Expenditure Panel Survey data for persons aged ≥ 18 years with 12-Item Short-Form Survey Physical and Mental Component Summary scores. 12-Item Short-Form Survey scores were converted to Short-Form Six-Dimension (SF-6D) preference scores to measure utilities of different chronic diseases. We used the Clinical Classification Code to identify 30 chronic diseases from 12 categories, such as cardiovascular diseases, cerebrovascular diseases, hypertension, hyperlipidemia, obesity, cancers, musculoskeletal diseases, endocrine or metabolic diseases, oral diseases, respiratory diseases, and mental disorders. A generalized linear model was used to quantify the utility decrements for 30 chronic diseases, controlling for demographic characteristics.

RESULTS

We identified 132 737 adults (mean age 47.2 years, 52.2% female, 80% white); 73% had at least one identified chronic disease, and the mean SF-6D was 0.786. Among 30 chronic diseases, the unadjusted mean SF-6D scores of patients with cognitive disorder (0.607) were the lowest, followed by congestive heart failure (0.629), rheumatoid arthritis (0.654), and lung cancer (0.662). After controlling for demographic variables (ie, age, sex) and comorbidities, cognitive disorders (-0.116), mood disorders (-0.099), rheumatoid arthritis (-0.090), liver cancer (-0.078), and stroke (-0.063) showed the highest decrements in the SF-6D scores (P < .05).

CONCLUSIONS

This study provides a nationally representative catalog of utility weights for major chronic diseases in the US general population. The utility decrements will enable researchers to calculate the health utilities of patients with multiple comorbid diseases.

Assessment of Treatment Strategies for Stage I Non-small Cell Lung Cancer in Patients with Comorbidities

INTRODUCTION

Non-small cell lung cancer (NSCLC) patients frequently have major comorbidities but there is scarce data regarding the impact of these conditions on management strategies. We used simulation modeling to compare different treatments for stage I NSCLC for patients with common major comorbidities.

METHODS

We used data on NSCLC patinet outcomes and quality of life from: (1) the Surveillance Epidemiology and End Results (SEER) database linked to Medicare claims; (2) Kaiser Permanente Southern California electronic health records; and (3) SEER-Medical Health Outcomes Survey to parameterize a novel simulation model of management and outcomes for stage I NSCLC. Relative efficacy of treatment modalities (lobectomy, segmentectomy, wedge resection and stereotactic body radiotherapy [SBRT]) was collected from existing literature and combined using evidence synthesis methods. We then simulated multiple randomized trials comparing these treatments in a variety of scenarios, estimating quality adjusted life expectancy (QALE) according to age, tumor size, histologic subtype, and comorbidity status.

RESULTS

Lobectomy and segmentectomy yielded the greatest QALE gains among all simulated age, tumor size and comorbidity groups. Optimal treatment strategies differed by patient sex and age; wedge resection was among the optimal strategies for women aged 80-84 with tumors 0-2 cm in size. SBRT was included in some optimal strategies for patients aged 80-84 with multimorbidity.

CONCLUSIONS

In simulated comparative trials of four common treatments for stage I NSCLC, aggressive surgical management was typically associated with the greatest projected QALE gains despite the presence of comorbidities, although less aggressive strategies were predicted to be non-inferior in some older comorbid patient groups.

Cost-effectiveness of anterior surgical decompression surgery for cervical degenerative disk disease: a systematic review of economic evaluations

PURPOSE

No clear consensus exists on which anterior surgical technique is most cost-effective for treating cervical degenerative disk disease (CDDD). One of the most common treatment options is anterior cervical discectomy with fusion (ACDF). Anterior cervical discectomy with arthroplasty (ACDA) was developed in an effort to reduce the incidence of clinical adjacent segment pathology and associated additional surgeries by preserving motion. This systematic review aims to evaluate the evidence regarding the cost-effectiveness of anterior surgical decompression techniques used to treat radiculopathy and/or myelopathy caused by CDDD.

METHODS

The search was conducted in PubMed, EMBASE, Web of Science, CINAHL, EconLit, NHS-EED and the Cochrane Library. Studies were included if healthcare costs and utility or effectivity measurements were mentioned.

RESULTS

A total of 23 studies were included out of the 1327 identified studies. In 9 of the 13 studies directly comparing ACDA and ACDF, ACDA was the most cost-effective technique, with an incremental cost effectiveness ratio ranging from $2.900/QALY to $98.475/QALY. There was great heterogeneity between the costs of due to different in- and exclusion criteria of costs and charges, cost perspective, baseline characteristics, and calculation methods. The methodological quality of the included studies was moderate.

CONCLUSION

The majority of studies report ACDA to be a more cost-effective technique in comparison with ACDF. The lack of uniform literature impedes any solid conclusions to be drawn. There is a need for high-quality cost-effectiveness research and uniformity in the conduct, design and reporting of economic evaluations concerning the treatment of CDDD.

TRIAL REGISTRATION

PROSPERO Registration: CRD42020207553 (04.10.2020).

Validation of the European Quality of Life-5 Dimensions, 3-Level Version (EQ-5D-3L) in Patients With Osteoporotic Vertebral Fracture and Comparing Their Health-Related Quality of Life with That of the General Population in Korea

Objective

This study examined the validity of the European Quality of Life-5 dimensions, 3-Level version (EQ-5D-3L) in patients with osteoporotic vertebral compression fractures (OVCF) and compared the health-related quality of life (HRQOL) of these patients with that of the general population in Korea.

Methods

Study participants completed several questionnaires, such as the EQ-5D-3L, 12-item short-form health survey version 2.0 (SF-12v2), Roland-Morris disability questionnaire (RMQ), and Pain Numeric Rating Scale (Pain NRS). Spearman’s correlation analyses of the questionnaire results were conducted to examine the discriminant and convergent validity of the EQ-5D-3L. Finally, EQ-5D-3L results from study participants were compared with those from the comparison group of the general population that were match-sampled according to age and sex from the 2013 Korean National Health and Nutritional Examination Survey.

Results

Spearman’s correlation coefficients between EQ-5D-3L and pain NRS, SF-12v2, and RMQ were statistically significant. The coefficients between the relevant dimensions, such as mobility in the EQ-5D-3L and physical functioning in the SF-12v2, were higher than those between irrelevant ones. Problems reported by study participants in each dimension of EQ-5D-3L showed statistically significant lower scores in pain NRS, PCS, and MCS from the SF-12v2 and RMQ scores. In comparison with the general population, the problems reported in the patient group were statistically higher than those reported by the general population.

Conclusion

This study showed that EQ-5D-3L will be useful for patients with OVCF in Korea because it could be valid. The HRQOL of patients with OVCF was very low in all dimensions of the EQ-5D-3L.

Health-Related Quality of Life and Health Utilities of Mild, Moderate, and Severe Asthma: Evidence from the Medical Expenditure Panel Survey

Background

Little information is known about the health-related quality of life (HRQOL) and the patient's preference values by the severity of asthma. We evaluated the HRQOL and health utility impairment associated with asthma severity using the SF-12 and SF-6D.

Methods

We conducted a cross-sectional analysis of 2010-2016 Medical Expenditure Panel Survey database of asthma patients aged ≥18 years and categorized them into mild, moderate, and severe asthma. Study outcomes included the SF-12 physical component summary (PCS) and mental component summary (MCS) for measuring HRQOL and SF-6D for health utility. Survey regression models were used to estimate HRQOL and utilities for mild, moderate, and severe asthma.

Results

Of 10,222 patients with asthma, 75.4%, 23.9%, and 0.8% had mild, moderate and severe asthma. We observed that the greater the severity, the lower the SF-6D scores: 0.731 in mild, 0.723 in moderate, and 0.659 in severe asthma (P < 0.001). Patients with severe asthma had a significantly lower PCS compared to those with mild asthma (-5.3; P < 0.001) but there was no significant difference in MCS (-1.9; P = 0.309) controlling for socioeconomic and clinical variables. Asthma severity, women, older age, and having a lower level education and public insurance were significantly associated with lower PCS (P < 0.01).

Conclusion

Asthma patients had worse physical HRQOL than mental health, especially patients with severe asthma. These data suggest that the management of physical health of female, older aged, and low education patients with asthma should be focused on improving HRQOL.

Efficacy of Vitamin D Supplementation in Addition to Aerobic Exercise Training in Obese Women with Perceived Myalgia: A Single-Blinded Randomized Controlled Clinical Trial

Obese women were more susceptible to myalgia because of their significantly lower vitamin D concentrations; the present study investigated the efficacy of vitamin D in addition to an aerobic interval training in the management of obese women with myalgia. Forty-five obese women with vitamin D deficiency and myalgia (30 to 40 years old) were assigned randomly into three equal groups. Group A received an aerobic interval training with vitamin D supplementation, Group B received vitamin D supplementation only, and Group C received aerobic interval training only; participants in all groups were on calorie deficient diets. The study outcomes were the Visual Analog Scale (VAS) for Pain Evaluation, serum vitamin D level, and Cooper 12-Minute Walk Test for Functional Capacity Evaluation, while the Short-Form Health Survey (SF) was used for assessment of quality of life. We detected a significant improvement in pain intensity level, serum vitamin D level, and quality of life in all groups with significant difference between Group A and groups B and C. We also detected a significant improvement in functional capacity in groups A and C, with no significant change in Group B. Aerobic interval training with vitamin D supplementation was more effective for the management of obese women with perceived myalgia.

Mapping the Memorial Anxiety Scale for Prostate Cancer to the SF-6D

PURPOSE

To create a crosswalk that predicts Short Form 6D (SF-6D) utilities from Memorial Anxiety Scale for Prostate Cancer (MAX-PC) scores.

METHODS

The data come from prostate cancer patients enrolled in the North Carolina Prostate Cancer Comparative Effectiveness & Survivorship Study (NC ProCESS, N = 1016). Cross-sectional data from 12- to 24-month follow-up were used as estimation and validation datasets, respectively. Participants' SF-12 scores were used to generate SF-6D utilities in both datasets. Beta regression mixture models were used to evaluate SF-6D utilities as a function of MAX-PC scores, race, education, marital status, income, employment status, having health insurance, year of cancer diagnosis and clinically significant prostate cancer-related anxiety (PCRA) status in the estimation dataset. Models' predictive accuracies (using mean absolute error [MAE], root mean squared error [RMSE], Akaike information criterion [AIC] and Bayesian information criterion [BIC]) were examined in both datasets. The model with the highest prediction accuracy and the lowest prediction errors was selected as the crosswalk.

RESULTS

The crosswalk had modest prediction accuracy (MAE = 0.092, RMSE = 0.114, AIC = - 2708 and BIC = - 2595.6), which are comparable to prediction accuracies of other SF-6D crosswalks in the literature. About 24% and 52% of predictions fell within ± 5% and ± 10% of observed SF-6D, respectively. The observed mean disutility associated with acquiring clinically significant PCRA is 0.168 (standard deviation = 0.179).

CONCLUSION

This study provides a crosswalk that converts MAX-PC scores to SF-6D utilities for economic evaluation of clinically significant PCRA treatment options for prostate cancer survivors.

A study protocol for a multicenter randomized pilot trial of a dyadic, tailored, web-based, psychosocial, and physical activity self-management program (TEMPO) for men with prostate cancer and their caregivers

Background

Prostate cancer predisposes patients and caregivers to a wide range of complex physical and psychosocial challenges, and interventions must incorporate a wide range of self-management strategies to help patients and their caregivers effectively cope with cancer challenges. To palliate this need, our team recently developed and evaluated the initial acceptability of a dyadic, Tailored, wEb-based, psychosocial, and physical activity self-Management PrOgram (TEMPO). TEMPO is a 10-week, interactive, web-based intervention consisting of five modules designed to help dyads manage their physical and psychosocial needs. It aims to teach dyads new self-management strategies and encourages them to increase their physical activity (PA) levels, mainly through walking and strength-based exercises. Initial acceptability evaluation of TEMPO revealed high user satisfaction, in addition to having a number of potential benefits for participants. After integrating suggested changes to TEMPO, the proposed pilot study aims to further test the acceptability and feasibility of TEMPO.

Methods

This study is a multicenter, stratified, parallel, two-group, pilot randomized control trial (RCT), where patient–caregiver dyads are randomized (stratified by anxiety level) to receive (a) TEMPO or (b) usual care. Participants (n goal = 40) are recruited across Canada at participating cancer centers and through self-referral (e.g., online recruitment). Patient inclusion criteria are (a) having received prostate cancer treatment within the past 2 years or scheduled to receive treatment, (b) identified a primary caregiver willing to participate in the study, and (c) has access to the Internet. Eligible caregivers are those identified by the patient as his primary source of support. Dyads complete a baseline questionnaire (T1) and another one 3 months later (T2) assessing various aspects of physical and emotional functioning (e.g., the Medical Outcomes Study (MOS) 12-item Short Form Health Survey (SF-12), the Hospital Anxiety and Depression Scale (HADS), and the Perceived Stress Scale (PSS)), self-management behaviors (e.g., the Health Education Impact Questionnaire (heiQ)), physical activity (the International Physical Activity Questionnaires (IPAQ) and the Multidimensional Self-efficacy for Exercise Scale (MSES)), and dyadic coping (the Dyadic Coping Inventory (DCI)). Dyads that used TEMPO are also asked to participate in a semi-structured exit interview exploring their overall experience with the program.

Discussion

This feasibility analysis will begin to develop the knowledge base on TEMPO’s value for men with prostate cancer and their caregivers to inform a larger trial.

Trial registration

NCT04304196

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00791-6.

Optimal treatment strategies for stage I non-small cell lung cancer in veterans with pulmonary and cardiac comorbidities

Background

Veterans are at increased risk of lung cancer and many have comorbidities such as chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD). We used simulation modeling to assess projected outcomes associated with different management strategies of Veterans with stage I non-small cell lung cancer (NSCLC) with COPD and/or CAD.

Patients and methods

Using data from a cohort of 14,029 Veterans (years 2000–2015) with NSCLC we extended a well-validated mathematical model of lung cancer to represent the management and outcomes of Veterans with stage I NSCLC with COPD, with or without comorbid CAD. We simulated multiple randomized trials to compare treatment with lobectomy, limited resection, or stereotactic body radiation therapy (SBRT). Model output estimated expected quality adjusted life years (QALY) of Veterans with stage I NSCLC according to age, tumor size, histologic subtype, COPD severity and CAD diagnosis.

Results

For Veterans <70 years old lobectomy was associated with greater projected quality-adjusted life expectancy regardless of comorbidity status. For most combinations of tumors and comorbidity profiles there was no dominant treatment for Veterans ≥80 years of age, but less invasive treatments were often superior to lobectomy. Dominant treatment choices differed by CAD status for older patients in a third of scenarios, but not for patients <70 years old.

Conclusions

The harm/benefit ratio of treatments for stage I NSCLC among Veterans may vary according to COPD severity and the presence of CAD. This information can be used to direct future research study design for Veterans with stage I lung cancer and COPD and/or CAD.

Cost-Effectiveness of an Opioid Abuse-Prevention Program Using the Narcotics Information Management System in South Korea

OBJECTIVES

To assess the cost-effectiveness of an opioid abuse-prevention program embedded in the Narcotics Information Management System ("the Network System to Prevent Doctor-Shopping for Narcotics") in South Korea.

METHODS

Using a Markov model with a 1-year cycle length and 30-year time horizon, we estimated the incremental cost-utility ratio (ICUR) of implementing an opioid abuse-prevention program in patients prescribed outpatient opioids from a Korean healthcare payer's perspective. The model has 6 health states: no opioid use, therapeutic opioid use, opioid abuse, overdose, overdose death, and all-cause death. Patient characteristics, healthcare costs, and transition probabilities were estimated from national population-based data and published literature. Age- and sex-specific utilities of the general Korean population were used for the no-use state, whereas the other health-state utilities were obtained from published studies. Costs (in 2019 US dollars) included the expenses of the program, opioids, and overdoses. An annual 5% discount rate was applied to the costs and quality-adjusted life-years (QALYs). Parameter uncertainties were explored via deterministic and probabilistic sensitivity analyses.

RESULTS

The program was associated with 2.27 fewer overdoses per 100 000 person-years, with an ICUR of $227/QALY. The ICURs were generally robust to parameter changes, although the program's effect on abuse reduction was the most influential parameter. Probabilistic sensitivity analysis showed that the program reached a 100% probability of cost-effectiveness at a willingness-to-pay threshold of $900/QALY.

CONCLUSIONS

The opioid abuse-prevention program appears to be cost-effective in South Korea. Mandatory use of the program should be considered to maximize clinical and economic benefits of the program.

Cost-Effectiveness of Intranasal Naloxone Distribution to High-Risk Prescription Opioid Users

OBJECTIVES

To determine the cost-effectiveness of pharmacy-based intranasal naloxone distribution to high-risk prescription opioid (RxO) users.

METHODS

We developed a Markov model with an attached tree for pharmacy-based naloxone distribution to high-risk RxO users using 2 approaches: one-time and biannual follow-up distribution. The Markov structure had 6 health states: high-risk RxO use, low-risk RxO use, no RxO use, illicit opioid use, no illicit opioid use, and death. The tree modeled the probability of an overdose happening, the overdose being witnessed, naloxone being available, and the overdose resulting in death. High-risk RxO users were defined as individuals with prescription opioid doses greater than or equal to 90 morphine milligram equivalents (MME) per day. We used a monthly cycle length, lifetime horizon, and US healthcare perspective. Costs (2018) and quality-adjusted life-years (QALYs) were discounted 3% annually. Microsimulation was performed with 100 000 individual trials. Deterministic and probabilistic sensitivity analyses were conducted.

RESULTS

One-time distribution of naloxone prevented 14 additional overdose deaths per 100 000 persons, with an incremental cost-effectiveness ratio (ICER) of $56 699 per QALY. Biannual follow-up distribution led to 107 additional lives being saved with an ICER of $84 799 per QALY compared with one-time distribution. Probabilistic sensitivity analyses showed that a biannual follow-up approach would be cost-effective 50% of the time at a willingness-to-pay (WTP) threshold of $100 000 per QALY. Naloxone effectiveness and proportion of overdoses witnessed were the 2 most influential parameters for biannual distribution.

CONCLUSION

Both one-time and biannual follow-up naloxone distribution in community pharmacies would modestly reduce opioid overdose deaths and be cost-effective at a WTP of $100 000 per QALY.

Reliability and Validity of the Short-Form 12 Item Version 2 (SF-12v2) Health-Related Quality of Life Survey and Disutilities Associated with Relevant Conditions in the U.S. Older Adult Population

This study aimed to validate the Short-Form 12-Item Survey—version 2 (SF−12v2) in an older (≥65 years old) US population as well as estimate disutilities associated with relevant conditions, using data from the Medical Expenditure Panel Survey longitudinal panel (2014–2015). The physical component summary (PCS) and mental component summary (MCS) scores were examined for reliability (internal consistency, test-retest), construct validity (convergent and discriminant, structural), and criterion validity (concurrent and predictive). The study sample consisted of 1040 older adults with a mean age of 74.09 years (standard deviation: 6.19) PCS and MCS demonstrated high internal consistency (Cronbach’s alpha—PCS: 0.87, MCS: 0.86) and good and moderate test-retest validity, respectively (intraclass correlation coefficient: PCS:0.79, MCS:0.59)). The questionnaire demonstrated sufficient convergent and discriminant ability. Confirmatory factor analysis showed adequate fit with the theoretical model and structural validity (goodness of fit = 0.9588). Concurrent criterion validity and predictive criterion validity were demonstrated. Activity limitations, functional limitations, arthritis, coronary heart disease, diabetes, myocardial infarction, stroke, angina, and high blood pressure were associated with disutilities of 0.18, 0.15, 0.06, 0.07, 0.07, 0.06, 0.09, 0.06, and 0.08, respectively, and demonstrated the responsiveness of the instrument to these conditions. The SF−12v2 is a valid and reliable instrument in an older US population.

Bayesian Hierarchical Models for Meta-Analysis of Quality-of-Life Outcomes: An Application in Multimorbidity

BACKGROUND

Health-related quality of life (HRQoL) is a key outcome in cost-utility analyses, which are commonly used to inform healthcare decisions. Different instruments exist to evaluate HRQoL, however while some jurisdictions have a preferred system, no gold standard exists. Standard meta-analysis struggles with the variety of outcome measures, which may result in the exclusion of potentially relevant evidence.

OBJECTIVE

Using a case study in multimorbidity, the objective of this analysis is to illustrate how a Bayesian hierarchical model can be used to combine data across different instruments. The outcome of interest is the slope relating HRQoL to the number of coexisting conditions.

METHODS

We propose a three-level Bayesian hierarchical model to systematically include a large number of studies evaluating HRQoL using multiple instruments. Random effects assumptions yield instrument-level estimates benefitting from borrowing strength across the evidence base. This is particularly useful where little evidence is available for the outcome of choice for further evaluation.

RESULTS

Our analysis estimated a reduction in quality of life of 3.8-4.1% per additional condition depending on HRQoL instrument. Uncertainty was reduced by approximately 80% for the instrument with the least evidence.

CONCLUSION

Bayesian hierarchical models may provide a useful modelling approach to systematically synthesize data from HRQoL studies.

Mapping function from FACT-B to EQ-5D-5 L using multiple modelling approaches: data from breast cancer patients in China

BACKGROUND

The Functional Assessment of Cancer Therapy-Breast (FACT-B) is the most commonly used scale for assessing quality of life in patients with breast cancer. The lack of preference-based measures limits the cost-utility of breast cancer in China. The goal of this study was to explore whether a mapping function can be established from the FACT-B to the EQ-5D-5 L when the EQ-5D health-utility index is not available.

METHODS

A cross-sectional survey of adults with breast cancer was conducted in China. All patients included in the study completed the EQ-5D-5 L and the disease-specific FACT-B questionnaire, and demographic and clinical data were also collected. The Chinese tariff value was used to calculate the EQ-5D-5 L utility scores. Five models were evaluated using three different modelling approaches: the ordinary least squares (OLS) model, the Tobit model and the two-part model (TPM). Total scores, domain scores, squared terms and interaction terms were introduced into models. The goodness of fit, signs of the estimated coefficients, and normality of prediction errors of the model were also assessed. The normality of the prediction error is determined by calculating the root mean squared error (RMSE), the mean absolute deviation (MAD), and the mean absolute error (MAE). Akaike information criteria (AIC) and Bayes information criteria (BIC) were also used to assess models and predictive performances. The OLS model was followed by simple linear equating to avoid regression to the mean.

RESULTS

The performance of the models was improved after the introduction of the squared terms and the interaction terms. The OLS model, including the squared terms and the interaction terms, performed best for mapping the EQ-5D-5 L. The explanatory power of the OLS model was 70.0%. The AIC and BIC of this model were the smallest (AIC = -705.106, BIC = -643.601). The RMSE, MAD and MAE of the OLS model, Tobit model and TPM were similar. The MAE values of the 5-fold cross-validation of the multiple models in this study were 0.07155~0.08509; meanwhile, the MAE of the TPM was the smallest, followed by that of the OLS model. The OLS regression proved to be the most accurate for the mean, and linearly equated scores were much closer to observed scores.

CONCLUSIONS

This study establishes a mapping algorithm based on the Chinese population to estimate the EQ-5D-5 L index of the FACT-B and confirms that OLS models have higher explanatory power and that TPMs have lower prediction error. Given the accuracy of the mean prediction and the simplicity of the model, we recommend using the OLS model. The algorithm can be used to calculate EQ-5D scores when EQ-5D data are not directly collected in a study.

The long-term effect of complex regional pain syndrome type 1 on disability and quality of life after foot injury

PURPOSE

To study the long-term evolution of patients with lower-limb Complex Regional Pain Syndrome (CRPS), focusing on functional and proprioceptive aspects and quality of life.

METHODS

In 20 patients suffering from chronic distal lower-limb CRPS diagnosed using Budapest criteria, we assessed joint position sense and strength of the knee muscles at the CRPS and unaffected leg, functional exercise capacity, pain, CRPS severity score, quality of life and kinesiophobia. Similar assessments were performed in 20 age-matched controls.

RESULTS

The joint position performance (at 45°) was significantly lower for the CRPS leg as compared to controls. The knee extensor strength of the CRPS leg was significantly reduced as compared to the unaffected leg (-27%) and controls (-42%). CRPS patients showed significantly reduced performance at the 6 min-walk test as compared to their age group predicted value and controls. Patients suffering from CRPS for 3.8 years in average still exhibit high pain, severity and kinesiophobia scores.

CONCLUSIONS

Long-term deficits in strength and proprioceptive impairments are observed at the knee joint of the CRPS leg. This persistent functional disability has significant repercussions on the quality of life. We highlight the importance of including strength and proprioceptive exercises in the therapeutic approaches for CPRS patients.IMPLICATIONS FOR REHABILITATIONThe long-term evolution of patients suffering from lower-limb Complex Regional Pain Syndrome is associated with persistent disability, pain and impacts the quality of life.Strength, proprioceptive, functional and subjective assessments are necessary to better identify deficits.Rehabilitation should focus on the overall deficit of the affected and contralateral limb.

An Updated Systematic Review of Studies Mapping (or Cross-Walking) Measures of Health-Related Quality of Life to Generic Preference-Based Measures to Generate Utility Values

BACKGROUND

Mapping is an increasingly common method used to predict instrument-specific preference-based health-state utility values (HSUVs) from data obtained from another health-related quality of life (HRQoL) measure. There have been several methodological developments in this area since a previous review up to 2007.

OBJECTIVE

To provide an updated review of all mapping studies that map from HRQoL measures to target generic preference-based measures (EQ-5D measures, SF-6D, HUI measures, QWB, AQoL measures, 15D/16D/17D, CHU-9D) published from January 2007 to October 2018.

DATA SOURCES

A systematic review of English language articles using a variety of approaches: searching electronic and utilities databases, citation searching, targeted journal and website searches.

STUDY SELECTION

Full papers of studies that mapped from one health measure to a target preference-based measure using formal statistical regression techniques.

DATA EXTRACTION

Undertaken by four authors using predefined data fields including measures, data used, econometric models and assessment of predictive ability.

RESULTS

There were 180 papers with 233 mapping functions in total. Mapping functions were generated to obtain EQ-5D-3L/EQ-5D-5L-EQ-5D-Y (n = 147), SF-6D (n = 45), AQoL-4D/AQoL-8D (n = 12), HUI2/HUI3 (n = 13), 15D (n = 8) CHU-9D (n = 4) and QWB-SA (n = 4) HSUVs. A large number of different regression methods were used with ordinary least squares (OLS) still being the most common approach (used ≥ 75% times within each preference-based measure). The majority of studies assessed the predictive ability of the mapping functions using mean absolute or root mean squared errors (n = 192, 82%), but this was lower when considering errors across different categories of severity (n = 92, 39%) and plots of predictions (n = 120, 52%).

CONCLUSIONS

The last 10 years has seen a substantial increase in the number of mapping studies and some evidence of advancement in methods with consideration of models beyond OLS and greater reporting of predictive ability of mapping functions.

Cost-Effectiveness of Operative Versus Nonoperative Treatment of Displaced Midshaft Clavicle Fractures: A Decision Analysis

BACKGROUND

While previous studies have shown higher union rates and a quicker return to work with operative treatment of substantially displaced clavicle fractures, there is disagreement whether operative treatment results in improved clinical outcomes. Patients who undergo operative treatment sometimes require additional surgery for implant removal. Nonoperative treatment may fail so that delayed surgical intervention is ultimately required. The duration for which the clinical benefits of operative treatment remain superior to those of nonoperative treatment has not been well established in the literature. Considering these uncertainties, surgeons are faced with a difficult decision regarding whether operative treatment of a midshaft clavicle fracture will be cost-effective. The purpose of this study was to identify the most cost-effective strategy by considering these uncertain parameters with use of decision-analysis techniques.

METHODS

An expected-value decision tree was built to estimate the quality-adjusted life years (QALYs) and costs for operative and nonoperative treatment of substantially displaced midshaft clavicle fractures. Values for parameters in the decision model were derived from the literature. Medical costs were obtained from the Medicare database. A Markov model was used to calculate the QALYs for the duration of life expectancy. The decision model was used to analyze the duration for which the clinical results of operative treatment were superior to those of nonoperative treatment during the first 5 years after the operation and during a lifetime. Sensitivity analysis was performed to determine which parameters have the most influence on cost-effectiveness.

RESULTS

Operative treatment was more cost-effective than nonoperative treatment in 54% and 68% of the Monte Carlo trials in the 5-year and lifetime analyses, respectively. The cost per QALY with operative management was <$38,000 and <$8,000 in the 5-year and lifetime analyses, respectively. This is below the willingness-to-pay threshold of $50,000 per QALY. For operative treatment to remain cost-effective, its clinical benefits must persist for at least 3 years.

CONCLUSIONS

Operative treatment is more cost-effective than nonoperative treatment for substantially displaced midshaft clavicle fractures. The clinical benefits derived with operative treatment must persist for at least 3 years for operative treatment to remain cost-effective. This research should not be used to conclude that all clavicle fractures should be treated surgically. It is best that such a decision is made through a patient-surgeon shared decision-making process.

LEVEL OF EVIDENCE

Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.

Cost-Effectiveness of Transjugular Intrahepatic Portosystemic Shunt versus Large-Volume Paracentesis in Refractory Ascites: Results of a Markov Model Incorporating Individual Patient-Level Meta-Analysis and Nationally Representative Cost Data

PURPOSE

To compare relative cost-effectiveness of serial large-volume paracentesis (LVP) and transjugular intrahepatic portosystemic shunt (TIPS) creation for treatment of refractory ascites.

MATERIALS AND METHODS

A decisional Markov model was developed to estimate payer cost and quality-adjusted life-ears (QALYs) associated with LVP and TIPS treatment strategies for cirrhotic patients with refractory ascites. Survival estimates were derived from an individual patient-level meta-analysis of prospective randomized clinical trials. Health utilities for potential health states were derived from a prospective study of patients with cirrhosis. Cost data were derived from national representative claims databases (MarketScan and Medicare) and included reimbursement amounts for relevant procedures, hospitalizations, and outpatient pharmaceutical costs. One-way and probabilistic sensitivity analyses were performed.

RESULTS

LVP resulted in 1.72 QALYs gained at a cost of $41,391, whereas TIPS resulted in 2.76 QALYs gained at a cost of $100,538. Incremental cost-effectiveness ratio of TIPS versus LVP was $57,003/QALY. At a willingness-to-pay ratio of $100,000/QALY, TIPS has a 62% probability of being acceptable compared with LVP.

CONCLUSIONS

This study suggests that TIPS should be considered cost-effective in a country that places a relatively high value on health improvements but less so in countries with lower levels of health care resources.

Assessment of Reliability and Validity of SF-12v2 among a Diabetic Population

OBJECTIVES

To validate the Medical Outcomes Study Short Form version 2 (SF-12v2) in diabetic patients.

METHODS

Adults with self-reported diabetes from the Medical Expenditure Panel Survey (2011-2013) were identified. Reliability (internal consistency and test-retest) and validity (construct, concurrent, criterion, and predictive) of the SF-12v2 were assessed. The SF-12v2 consists of two normalized composite scores: the physical component summary score (PCS12) and the mental component summary score (MCS12). Confirmatory factor analysis was conducted to assess the instrument structure. Concurrent (convergent and discriminant) validity was assessed by a multitrait-multimethod matrix using the Patient Health Questionnaire, the Kessler Scale, and perceived health and mental health questions. The predictive validity was assessed by estimating future limitations. The concurrent validity was tested by comparing the MCS12, PCS12, and utility scores (six-dimensional health state short form) across comorbidity scores.

RESULTS

The final sample comprised 2214 diabetic patients with mean normalized (population mean 50; range 0-100) PCS12 and MCS12 scores of 40.81 (standard error 0.33) and 49.82 (standard error 0.26), respectively. The PCS12 and MCS12 scores showed good internal consistency (Cronbach α: PCS12 0.85; MCS12 0.83) and acceptable test-retest reliability (intraclass correlation coefficient: PCS12 0.72; MCS12 0.63) and produced acceptable goodness-of-fit indices (normed fit index 0.95; comparative fit index 0.95; root mean square error of approximation 0.11 [95% confidence interval 0.1017-0.1188]). The PCS12 and MCS12 were moderately correlated with perceived health and perceived mental health. The MCS12 was highly correlated with the Patient Health Questionnaire and the Kessler Scale. Both the PCS12 and the MCS12 could predict the future health limitations. The PCS12, MCS12, and utility scores demonstrated sensitivity to the presence of comorbidity scores.

CONCLUSIONS

The SF-12v2 is a valid generic instrument for measuring quality of life in diabetic patients.

Cost-Effectiveness of Arthroscopic Rotator Cuff Repair Versus Reverse Total Shoulder Arthroplasty for the Treatment of Massive Rotator Cuff Tears in Patients With Pseudoparalysis and Nonarthritic Shoulders

PURPOSE

To determine the most cost-effective treatment strategy for patients with massive rotator cuff tears and pseudoparalysis of the shoulder without osteoarthritis of the glenohumeral joint (PP without OA). Specifically, we aimed to compare arthroscopic rotator cuff repair (ARCR) versus reverse total shoulder arthroplasty (RTSA) and investigate the effect of patient age on this decision.

METHODS

A Markov decision model was used to compare 3 treatment strategies for addressing PP without OA: (1) ARCR with option to arthroscopically revise once, (2) ARCR with immediate conversion to RTSA on potential failure, and (3) primary RTSA. Hypothetical patients were cycled through the model according to transition probabilities, meanwhile accruing financial costs, utility for time in health states, and disutilities for surgical procedures. Utilities were derived from the Short Form-6D scale and expressed as quality-adjusted life-years. Model parameters were derived from the literature and from expert opinion, and thorough sensitivity analyses were conducted. TreeAge Pro 2015 software was used to construct and assess the Markov model.

RESULTS

For the base-case scenario (60-year-old patient), ARCR with conversion to RTSA on potential failure was the most cost-effective strategy when we assumed equal utility for the ARCR and RTSA health states. Primary RTSA became cost-effective when the utility of RTSA exceeded that of ARCR by 0.04 quality-adjusted life-years per year. Age at decision did not substantially change this result.

CONCLUSIONS

Primary ARCR with conversion to RTSA on potential failure was found to be the most cost-effective strategy for PP without OA. This result was independent of age. Primary ARCR with revision ARCR on potential failure was a less cost-effective strategy.

LEVEL OF EVIDENCE

Level IV, economic and decision analysis.

Impact of old age on patient-report outcomes and cost utility for anterior cervical discectomy and fusion surgery for degenerative spine disease

PURPOSE

With growing older population and increasing rates of cervical spinal surgery, it is vital to understand the value of cervical surgery in this population. We set forth to determine the cost utility following anterior cervical decompression and fusion (ACDF) for degenerative disease in older patients.

METHODS

Patients undergoing ACDF for degenerative diseases were enrolled into prospective longitudinal registry. Patient-reported outcomes (PROs) were recorded at baseline, 1-year, and 2-year postoperatively. Two-year medical resource utilization, missed work, and health-state values [quality-adjusted life years (QALYs)] were assessed to compute cost per QALY gained. Patients were dichotomized based on age: <65 years (younger) and ≥65 years (older) to compare the cost utility in these age groups.

RESULTS

Total 218 (87%) younger patients and 33 (13%) older patients who underwent ACDF were analyzed. Both the groups demonstrated a significant improvement in PROs 2-year following surgery. The older patients had a lower mean cumulative gain in QALYs compared to younger patients at 1 year (0.141 vs. 0.28, P = 0.05) and 2 years (0.211 vs. 0.424, P = 0.04). There was no significant difference in the mean total 2-year cost between older [$21,041 (95% CI $18,466-$23,616)] and younger [$22,669 (95% CI $$21,259-$24,079)] patients (P = 0.27). Two-year cost per QALY gained in older vs. younger patients was ($99,720/QALYs gained vs. ($53,464/QALYs gained, P = 0.68).

CONCLUSION

ACDF surgery provided a significant gain in health-state utility in older patients with degenerative cervical pathology, with a mean cumulative 2-year cost per QALY gained of $99,720/QALY. While older patients have a slightly higher cost utility compared to their younger counterparts, surgery in the older cohort does provide a significant improvement in pain, disability, and quality-of-life outcomes.

The impact of surgical resection on headache disability and quality of life in patients with colloid cyst

Introduction Colloid cysts are histologically benign but can present with a broad spectrum of symptoms. A systematic review of the literature did not reveal any patient-centered data on the headache disability and quality of life (QoL) of these patients. Methods This is a retrospective cohort study of 187 colloid cyst patients from the Colloid Cyst Survival Group who completed a survey that included demographic data, clinical data, a modified QoL survey (SF36v2), and a headache disability inventory or index (HDI). Results Using multivariable linear regressions, we confirmed that the physical (PCS) and mental (MCS) components of SF-36 were significantly increased in the surgery group after adjustment for various baseline characteristics ( p = 0.025; p = 0.006). Self-reported headache disability was significantly decreased with surgery when adjusted for the same baseline characteristics ( p = 0.02). Finally, patients with an incidental diagnosis of colloid cyst reported similar benefits from surgery in PCS, MCS and HDI. Conclusion Our results suggest that colloid cyst patients who underwent a surgical resection self-report a better QoL and less headache disability compared with patients who did not undergo surgery. Future prospective studies with baseline measures of QoL are indicated to confirm our findings.

Comparison of Use of Short Form-36 Domain Scores and Patient Responses for Derivation of Preference-Based SF6D Index to Calculate Quality-Adjusted Life Years in Patients with Intermittent Claudication

BACKGROUND

The short form 36 (SF36) questionnaire is used for assessment of generic quality of life. Responses to the individual question in SF36 are also used for calculation of the SF6D index score. This score is used for calculation of quality adjusted-life years (QALYs) in economical analyses. As the individual patient questionnaires are not always available for performing systematic reviews and meta-analyses, a new formula has been developed for derivation of SF6D index score from the reported SF36-domain scores. This study aimed to evaluate the validity of this formula for use in patients with intermittent claudication.

METHODS

A retrospective review of a prospectively collected database of a randomized controlled trial was performed. A total of 178 patients were recruited. Clinical indicators of ischemia were recorded. All patients completed SF36 questionnaires. Response and domain-based SF6D scores (R-SF6D and D-SF6D) and QALYs were calculated. Correlation and agreement analysis were performed.

RESULTS

Response rate was 88% (n = 781) over a 1-year follow-up period. Domain-based SF6D score (mean, 0.684; standard deviation [SD] 0.110) was significantly higher (paired t-test, P = 0.001) than the response-based score (mean, 0.627; SD, 0.110) with a mean difference of 0.056 (95% confidence interval, 0.053-0.060). Mean QALY calculated using D-SF6D score (0.503; SD, 0.116) was also significantly higher than the QALY calculated from the R-SF6D score (0.467; SD, 0.121). Bland-Altman comparison showed strong agreement (limit of agreement -0.167 to 0.054) between the 2 methods with equal variances (Pitman's test, P = 0.629). D-SF6D scores showed stronger correlation with clinical indicators of ischemia (r = 0.246-0.602) compared with that of R-SF6D scores (r = 0.233-0.549).

CONCLUSIONS

Domain-based estimation of SF6D score is a valid and reliable method with strong agreement to the gold standard response-based scores in claudicants. However, adjustments may be required in studies using a mixture of D-SF6D and R-SF6D scores for QALY calculation.

Economic value of treating lumbar disc herniation in Brazil

OBJECT

Lumbar discectomy is one of the most common surgical spine procedures. In order to understand the value of this surgical care, it is important to understand the costs to the health care system and patient for good results. The objective of this study was to evaluate for the first time the cost-effectiveness of spine surgery in Latin America for lumbar discectomy in terms of cost per quality-adjusted life year (QALY) gained for patients in Brazil.

METHODS

The authors performed a prospective cohort study involving 143 consecutive patients who underwent open discectomy for lumbar disc herniation (LDH). Patient-reported outcomes were assessed utilizing the SF-6D, which is derived from a 12-month variation of the SF-36. Direct medical costs included medical reimbursement, costs of hospital care, and overall resource consumption. Disability losses were considered indirect costs. A 4-year horizon with 3% discounting was applied to health-utilities estimates. Sensitivity analysis was performed by varying utility gain by 20%. The costs were expressed in Reais (R$) and US dollars ($), applying an exchange rate of 2.4:1 (the rate at the time of manuscript preparation).

RESULTS

The direct and indirect costs of open lumbar discectomy were estimated at an average of R$3426.72 ($1427.80) and R$2027.67 ($844.86), respectively. The mean total cost of treatment was estimated at R$5454.40 ($2272.66) (SD R$2709.17 [$1128.82]). The SF-6D utility gain was 0.044 (95% CI 0.03197–0.05923, p = 0.017) at 12 months. The 4-year discounted QALY gain was 0.176928. The estimated cost-utility ratio was R$30,828.35 ($12,845.14) per QALY gained. The sensitivity analysis showed a range of R$25,690.29 ($10,714.28) to R$38,535.44 ($16,056.43) per QALY gained.

CONCLUSIONS

The use of open lumbar discectomy to treat LDH is associated with a significant improvement in patient outcomes as measured by the SF-6D. Open lumbar discectomy performed in the Brazilian supplementary health care system provides a cost-utility ratio of R$30,828.35 ($12,845.14) per QALY. The value of acceptable cost-effectiveness will vary by country and region.

Cost-effectiveness of new antiviral regimens for treatment-naïve U.S. veterans with hepatitis C

Recently approved, interferon-free medication regimens for treating hepatitis C are highly effective, but extremely costly. We aimed to identify cost-effective strategies for managing treatment-naïve U.S. veterans with new hepatitis C medication regimens. We developed a Markov model with 1-year cycle length for a cohort of 60-year-old veterans with untreated genotype 1 hepatitis C seeking treatment in a typical year. We compared using sofosbuvir/ledipasvir or ombitasvir/ritonavir/paritaprevir/dasabuvir to treat: (1) any patient seeking treatment; (2) only patients with advanced fibrosis or cirrhosis; or (3) patients with advanced disease first and healthier patients 1 year later. The previous standard of care, sofosbuvir/simeprevir or sofosbuvir/pegylated interferon/ribavirin, was included for comparison. Patients could develop progressive fibrosis, cirrhosis, or hepatocellular carcinoma, undergo transplantation, or die. Complications were less likely after sustained virological response. We calculated the incremental cost per quality-adjusted life year (QALY) and varied model inputs in one-way and probabilistic sensitivity analyses. We used the Veterans Health Administration perspective with a lifetime time horizon and 3% annual discounting. Treating any patient with ombitasvir-based therapy was the preferred strategy ($35,560; 14.0 QALYs). All other strategies were dominated (greater costs/QALY gained than more effective strategies). Varying treatment efficacy, price, and/or duration changed the preferred strategy. In probabilistic sensitivity analysis, treating any patient with ombitasvir-based therapy was cost-effective in 70% of iterations at a $50,000/QALY threshold and 65% of iterations at a $100,000/QALY threshold.

CONCLUSION

Managing any treatment-naïve genotype 1 hepatitis C patient with ombitasvir-based therapy is the most economically efficient strategy, although price and efficacy can impact cost-effectiveness. It is economically unfavorable to restrict treatment to patients with advanced disease or use a staged treatment strategy. (Hepatology 2016;63:428-436).

Cost-effectiveness of three treatment strategies for lumbar spinal stenosis: Conservative care, laminectomy, and the Superion interspinous spacer

BACKGROUND

Lumbar spinal stenosis is a painful and debilitating condition resulting in healthcare costs totaling tens of billions of dollars annually. Initial treatment consists of conservative care modalities such as physical therapy, NSAIDs, opioids, and steroid injections. Patients refractory to these therapies can undergo decompressive surgery, which has good long-term efficacy but is more traumatic and can be associated with high post-operative adverse event (AE) rates. Interspinous spacers have been developed to offer a less-invasive alternative. The objective of this study was to compare the costs and quality adjusted life years (QALYs) gained of conservative care (CC) and decompressive surgery (DS) to a new minimally-invasive interspinous spacer.

METHODS

A Markov model was developed evaluating 3 strategies of care for lumbar spinal stenosis. If initial therapies failed, the model moved patients to more invasive therapies. Data from the Superion FDA clinical trial, a prospective spinal registry, and the literature were used to populate the model. Direct medical care costs were modeled from 2014 Medicare reimbursements for healthcare services. QALYs came from the SF-12 PCS and MCS components. The analysis used a 2-year time horizon with a 3% discount rate.

RESULTS

CC had the lowest cost at $10,540, while Spacers and DS were nearly identical at about $13,950. CC also had the lowest QALY increase (0.06), while Spacers and DS were again nearly identical (.28). The incremental cost-effectiveness ratios (ICER) for Spacers compared to CC was $16,300 and for DS was $15,200.

CONCLUSIONS

Both the Spacer and DS strategies are far below the commonly cited $50,000/QALY threshold and produced several times the QALY increase versus CC, suggesting that surgical care provides superior value (cost / effectiveness) versus sustained conservative care in the treatment of lumbar spinal stenosis.

Quality of Life and General Health After Elective Surgery for Cervical Spine Pathologies

BACKGROUND:

As part of the Affordable Care Act, health utility metrics are being investigated to define a cost-effective, value-based health care model. EuroQOL-5D (EQ-5D) and Short Form-6D (SF-6D) are commonly used quality-of-life instruments. Domains in the EQ-5D questionnaire are thought to be less responsive in measuring quality of life after cervical surgery.

OBJECTIVE:

To evaluate the validity and responsiveness of SF-6D and EQ-5D in determining health and quality of life after elective cervical spine surgery.

METHODS:

A total of 420 patients undergoing elective cervical spine surgery over a period of 2 years were enrolled in a prospective longitudinal registry. Patient-reported outcomes Neck Disability Index (NDI), EQ-5D, and SF-12 were recorded. Based on previously published equations, SF-6D was calculated using NDI and SF-12 scores. Patients were asked whether “surgery met their expectations” (meaningful improvement). The validity and relative responsiveness of SF-6D (NDI), SF-6D (SF-12), and EQ-5D to discriminate between meaningful and nonmeaningful improvement were calculated.

RESULTS:

Sixty-six percent of patients (277) reported a level of improvement after surgery that met their expectations (meaningful improvement). SF-6D (NDI) (area under the curve [AUC] = 0.69) was a more valid discriminator of meaningful improvement compared with the SF-6D (SF-12) (AUC = 0.65) and EQ-5D (AUC = 0.62). SF-6D (NDI) was also a more responsive measure compared with SF-6D (SF-12) and EQ-5D (standardized response mean difference: 0.66, 0.48, and 0.44, respectively).

CONCLUSION:

SF-6D is a more valid and responsive measure of general health and quality of life compared with EQ-5D. SF-6D derived from disease-specific disability scores was more valid and responsive than that derived from the generic preference-based SF-12. Cost-effective studies should use SF-6D as a measure of QALY after cervical spine surgery.

Cost-utility of metal-on-metal hip resurfacing compared to conventional total hip replacement in young active patients with osteoarthritis

BACKGROUND

Metal-on-metal hip resurfacing arthroplasty (MoM HRA) has emerged as an alternative to total hip arthroplasty (THA) for younger active patients with osteoarthritis (OA). Birmingham hip resurfacing is the most common MoM HRA in Alberta, and is therefore compared with conventional THA.

OBJECTIVE

The objective of this study was to estimate the expected cost-utility of MoM HRA versus THA, in younger patients with OA, using a decision analytic model with a 15-year time horizon.

METHODS

A probabilistic Markov decision analytic model was constructed to estimate the expected cost per quality-adjusted life-year (QALY) of MoM HRA versus THA from a health care payer perspective. The base case considered patients with OA aged 50 years; men comprised 65.9% of the cohort. Sensitivity analyses evaluated cohort age, utility values, failure probabilities, and treatment costs. Data were derived from the Hip Improvement Project and the Hip and Knee Replacement Pilot databases in Alberta, the 2010 National Joint Replacement Registry of the Australian Orthopaedic Association, and the literature.

RESULTS

In the base case, THA was dominated by MoM HRA (incremental mean costs of -$583 and incremental mean QALYs of 0.079). In subgroup analyses, THA remained dominated when cohort age was 40 years instead of 50 years or when only men were assessed. THA dominated when the cohort age was 60 years or when only women were assessed. Results were sensitive to utilities, surgery costs, and MoM HRA revision and conversion probabilities. At a willingness-to-pay of Can $50,000/QALY, there was a 58% probability that MoM HRA is cost-effective.

CONCLUSIONS

The results show that, on average, MoM HRA was preferred to THA for younger and male patients, but THA is still a reasonable option if the patient or clinician prefers given the small absolute differences between the options and the confidence ellipses around the cost-effectiveness estimates.

Associations of cancer and other chronic medical conditions with SF-6D preference-based scores in Medicare beneficiaries

PURPOSE

Documenting the impact of different types of cancer on daily functioning and well-being is important for understanding burden relative to other chronic medical conditions. This study examined the impact of 10 different cancers and 13 other chronic medical conditions on health-related quality of life.

METHODS

Health-related quality of life data were gathered on the Medicare Health Outcomes Survey (MHOS) between 1998 and 2002. Cancer information was ascertained using the National Cancer Institute's surveillance, epidemiology, and end results program and linked to MHOS data.

RESULTS

The average SF-6D score was 0.73 (SD = 0.14). Depressive symptoms had the largest unique association with the SF-6D, followed by arthritis of the hip, chronic obstructive pulmonary disease/asthma, stroke, and sciatica. In addition, the majority of cancer types were significantly associated with the SF-6D score, with significant negative weights ranging from -0.01 to -0.02 on the 0-1 health utility scale. Distant stage of cancer was associated with large decrements in the SF-6D ranging from -0.04 (prostate) to -0.08 (female breast).

CONCLUSION

A large number of chronic conditions, including cancer, are associated uniquely with decrements in health utility. The cumulative effects of comorbid conditions have substantial impact on daily functioning and well-being of Medicare beneficiaries.

The effects of quality of care on costs: a conceptual framework

CONTEXT

The quality of health care and the financial costs affected by receiving care represent two fundamental dimensions for judging health care performance. No existing conceptual framework appears to have described how quality influences costs.

METHODS

We developed the Quality-Cost Framework, drawing from the work of Donabedian, the RAND/UCLA Appropriateness Method, reports by the Institute of Medicine, and other sources.

FINDINGS

The Quality-Cost Framework describes how health-related quality of care (aspects of quality that influence health status) affects health care and other costs. Structure influences process, which, in turn, affects proximate and ultimate outcomes. Within structure, subdomains include general structural characteristics, circumstance-specific (e.g., disease-specific) structural characteristics, and quality-improvement systems. Process subdomains include appropriateness of care and medical errors. Proximate outcomes consist of disease progression, disease complications, and care complications. Each of the preceding subdomains influences health care costs. For example, quality improvement systems often create costs associated with monitoring and feedback. Providing appropriate care frequently requires additional physician visits and medications. Care complications may result in costly hospitalizations or procedures. Ultimate outcomes include functional status as well as length and quality of life; the economic value of these outcomes can be measured in terms of health utility or health-status-related costs. We illustrate our framework using examples related to glycemic control for type 2 diabetes mellitus or the appropriateness of care for low back pain.

CONCLUSIONS

The Quality-Cost Framework describes the mechanisms by which health-related quality of care affects health care and health status-related costs. Additional work will need to validate the framework by applying it to multiple clinical conditions. Applicability could be assessed by using the framework to classify the measures of quality and cost reported in published studies. Usefulness could be demonstrated by employing the framework to identify design flaws in published cost analyses, such as omitting the costs attributable to a relevant subdomain of quality.

Predicting SF-6D from the European Organization for Treatment and Research of Cancer Quality of Life Questionnaire scores in patients with colorectal cancer

OBJECTIVES

To develop a mapping model for estimating six-dimensional health state short form (SF-6D) utility scores from the European Organization for Research and Treatment of Cancer Quality of Life Questionnaires (QLQ-C30 and QLQ-CR29) scores in patients with colorectal cancer (CRC), with and without adjustment for clinical and demographic characteristics.

METHODS

Ordinary least squares regression models were applied to a cross-sectional data set of 216 patients with CRC collected from a regional hospital in Hong Kong. Item responses or scale scores of cancer-specific (QLQ-C30) and colorectal-specific health-related quality-of-life (QLQ-CR38/CR29) data and selected demographic and clinical characteristics of patients were used to predict the SF-6D scores. Model goodness of fit was examined by using exploratory power (R(2) and adjusted R(2)), Akaike information criterion, and Bayesian information criterion, and predictive performance was evaluated by using root mean square error, mean absolute error, and Spearman's correlation coefficients between predicted and observed SF-6D scores. Models were validated by using an independent data set of 56 patients with CRC.

RESULTS

Both scale and item response models explained more than 67% of the variation in SF-6D scores. The best-performing model based on goodness of fit (R(2) = 75.02%), predictive ability in the estimation (root mean square error = 0.080, mean absolute error = 0.065), and validation data set prediction (root mean square error = 0.103, mean absolute error = 0.081) included variables of main and interaction effects of the QLQ-C30 supplemented by QLQ-CR29 subset scale responses and a demographic (sex) variable.

CONCLUSIONS

SF-6D scores can be predicted from QLQ-C30 and QLQ-CR38/CR29 scores with satisfactory precision in patients with CRC. The mapping model can be applied to QLQ-C30 and QLQ-CR38/CR29 data sets to produce utility scores for the appraisal of clinical interventions targeting patients with CRC using economic evaluation.

Preference-based SF-6D scores derived from the SF-36 and SF-12 have different discriminative power in a population health survey

OBJECTIVE

To compare the discriminative power of the SF-6D index scores derived from the SF-36 (SF-6D36) and SF-12 (SF-6D12) in the general population.

METHODS

Data from the National Health Measurement Study were used. The F statistic was used to compare the relative efficiency of the SF-6D36 and SF-6D12, as well as the EQ-5D, HUI2, and HUI3 index scores, in discriminating between respondents with and without 1 of the 11 chronic medical conditions. The efficiency of the multiattribute health classification systems of the study instruments was measured using the Shannon index (H'). The relative efficiency of the SF-6D36 and SF-6D12 was also compared in respondents who were on the ceilings of the EQ-5D, HUI2, and HUI3 scales.

RESULTS

The SF-6D36 score was systematically lower than the SF-6D12 score at the group level (range, 0.022-0.036). The SF-6D36 exhibited higher discriminative power in 8 and 5 conditions than the SF-6D12 and all other index scores, respectively. The SF-6D36 had higher H' values than the SF-6D12 in the dimensions of physical functioning (1.73 vs. 0.78), mental health (1.70 vs. 1.39), and bodily pain (2.16 vs. 1.56) as well as than all other instruments in similar health dimensions. In respondents reporting full health on the EQ-5D, HUI2, or HUI3, the SF-6D36 better discriminated between those with and without medical conditions than the SF-6D12.

CONCLUSIONS

The SF-6D derived from the SF-36 is more discriminative than that derived from the SF-12 and is therefore preferred for use in population health surveys where a preference-based health index is needed.

Health status in young adults two decades after pediatric liver transplantation

We conducted a cross-sectional study of patients who underwent pediatric liver transplant (LT) between 1988 and 1992 to evaluate long-term health status. Survivors completed socio-demographic, medical and Health-Related Quality of Life (HRQOL) surveys by mail including the SF-36v2, PedsQL™4.0 Generic Core Scale, PedsQL™ Cognitive Functioning Scale and PedsQL™3.0 Transplant Module. SF-36 scores were converted to SF6D-based utilities and risk factors for lower outcomes were assessed. Eighty-five of 171 patients had survived. Fifty-six were contacted with a response rate of 66%. Median age at LT was 0.86 years (IQR 0.58-3.0) and 64.3% had biliary atresia. Mean age at survey was 23.0 ± 4.4 years: 62% attended college, 68% lived with parents and 80% of those over 23 were employed. Patient health utilities were lower than norms (0.75 ± 0.12 vs. 0.82 ± 0.18, p < 0.01) and correlated with unemployment (p < 0.042), hospitalizations (p < 0.005) and lower education level (p < 0.016). Lower PedsQL™3.0 Transplant Module and PedsQL™ 4.0 Generic Core Scale scores correlated with unemployment (p = 0.006, p = 0.009) and hospitalizations (p = 0.006, p = 0.02). Pediatric transplant recipients who survive to adulthood have lower physical HRQOL, measurable transplant-related disability and lower health utility. Transplantation is life saving; however, physical and psychological sequelae continue to affect health status up to two decades later.

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.