Valuing health-related quality of life among the Indian population: a protocol for the Development of an EQ-5D Value set for India using an Extended design (DEVINE) Study

Health-related quality of life and its determinants among cancer patients: evidence from 12,148 patients of Indian database

BACKGROUND

Cancer survivors experience a decrement in health-related quality of life (HRQoL) resulting from the disease as well as adverse effects of therapy. We evaluated the HRQoL of cancer patients, stratified by primary cancer site, stage, treatment response and associated adverse events, along with its determinants.

METHODS

Data were collected from 12,148 patients, sampled from seven purposively chosen leading cancer hospitals in India, to elicit HRQoL using the EuroQol questionnaire comprising of 5-dimensions and 5-levels (EQ-5D-5L). Multiple linear regression was used to determine the association between HRQoL and various socio-demographic as well as clinical characteristics.

RESULTS

Majority outpatients (78.4%) and inpatients (81.2%) had solid cancers. The disease was found to be more prevalent among outpatients (37.5%) and inpatients (40.5%) aged 45-60 years and females (49.3-58.3%). Most patients were found to be in stage III (40-40.6%) or stage IV (29.4-37.3%) at the time of recruitment. The mean EQ-5D-5 L utility score was significantly higher among outpatients [0.630 (95% CI: 0.623, 0.637)] as compared to inpatients [0.553 (95% CI: 0.539, 0.567)]. The HRQoL decreased with advancing cancer stage among both inpatients and outpatients, respectively [stage IV: (0.516 & 0.557); stage III (0.609 & 0.689); stage II (0.677 & 0.713); stage I (0.638 & 0.748), p value < 0.001]. The outpatients on hormone therapy (B = 0.076) showed significantly better HRQoL in comparison to patients on chemotherapy. However, palliative care (B=-0.137) and surgery (B=-0.110) were found to be associated with significantly with poorer HRQoL paralleled to chemotherapy. The utility scores among outpatients ranged from 0.305 (bone cancer) to 0.782 (Leukemia). Among hospitalized cases, the utility score was lowest for multiple myeloma (0.255) and highest for testicular cancer (0.771).

CONCLUSION

Older age, lower educational status, chemotherapy, palliative care and surgery, advanced cancer stage and progressive disease were associated with poor HRQoL. Our study findings will be useful in optimising patient care, formulating individualized treatment plan, improving compliance and follow-up.

Heterogeneity of treatment effect of higher dose dexamethasone by geographic region (Europe vs. India) in patients with COVID-19 and severe hypoxemia - a post hoc evaluation of the COVID STEROID 2 trial

Background

In the COVID-STEROID 2 trial there was suggestion of heterogeneity of treatment effects (HTE) between patients enrolled from Europe vs. India on the primary outcome. Whether there was HTE for the remaining patient-centred outcomes is unclear.

Methods

In this post hoc analysis of the COVID-STEROID 2 trial, which compared 12 mg vs. 6 mg dexamethasone in adults with COVID-19 and severe hypoxemia, we evaluated HTE by geographical region (Europe vs. India) for secondary outcomes with analyses adjusted for stratification variables. Results are presented as risk differences (RDs) or mean differences (MDs) with 99% confidence intervals (CIs) and P-values from interaction tests.

Findings

There were differences in mortality at day 28 (RD for Europe -8.3% (99% CI: -17.7 to 1.0) vs. India 0.1% (99% CI: -10.0 to 10.0)), mortality at day 90 (RD for Europe -7.4% (99% CI: -17.1 to 2.0) vs. India -1.4% (99% CI: -12.8 to 9.8)), mortality at day 180 (RD for Europe -6.7% (99% CI: -16.4 to 2.9) vs. India -1.0% (99% CI: -12.3 to 10.3)), and number of days alive without life support at day 90 (MD for Europe 6.1 days (99% CI: -1.3 to 13.4) vs. India 1.7 days (99% CI: -8.4 to 11.8)). For serious adverse reactions, the direction was reversed (RD for Europe -1.0% (99% CI: -7.1 to 5.2) vs. India -5.3% (99% CI: -16.2 to 5.0).

Interpretation

Our analysis suggests higher dose dexamethasone may have less beneficial effects for patients in India as compared with those in Europe; however, the evidence is weak, and this could represent a chance finding.

Funding

None for this analysis. The COVID STEROID 2 trial was funded by The Novo Nordisk Foundation and supported by Rigshospitalet's Research Council.

Do people with different sociodemographic backgrounds value their health differently? Evaluating the role of positional objectivity

Objective

The fundamental disconnect between the actual and the perceived health of an individual raises considerable skepticism on the self-reported health data as it may be confounded by an individual's socio-economic status. In this light, the present study aims to assess if people with different sociodemographic backgrounds value their health differently.

Methods

The health-state valuation using time-trade off was performed in a cross-sectional survey among a representative sample of 2,311 adults from India. Individuals were selected using a multistage stratified random sampling from five Indian states to elicit their present health-state, and to perform the health-state valuation exercise using computer assisted personal interviewing. A single block of standardized health-states was valued by multiple individuals, each belonging to different socio-demographic group. The difference in the valuation of health was assessed using bivariate analysis. The impact of different sociodemographic factors on the health-state valuation was evaluated using Tobit regression model.

Results

Differences in the valuation of health were observed among different groups of age, religion, family type, state of residence, substance abuse, presence of ailments at the time of valuation, and number of dependent members in the household. Even after controlling for the severity of the administered health states, factors having a significant association with the valuation of health are age, religion, state of residence, substance abuse, family type, number of dependent members in the household, and presence of chronic or both acute and chronic ailments. Younger individuals place a higher value to their health as compared to their older counterparts. As compared to a healthy individual, a person with ailments rates the same health-state as worse.

Conclusion

Inequalities in self-reported ill-health cannot be attributed to positional objectivity; age, religion, state of residence, substance abuse, family type, dependents, and ailments impact individual health valuation.

Evaluation of EuroQol Valuation Technology (EQ-VT) Designs to Generate National Value Sets: Learnings from the Development of an EQ-5D Value Set for India Using an Extended Design (DEVINE) Study

INTRODUCTION

Countries develop their EQ-5D-5L value sets using the EuroQol Valuation Technology (EQ-VT) protocol. This study aims to assess if extension in the conventional EQ-VT design can lead to development of value sets with improved precision.

METHODS

A cross-sectional survey was undertaken in a representative sample of 3,548 adult respondents, selected from 5 different states of India using a multistage stratified random sampling technique. A novel extended EQ-VT design was created that included 18 blocks of 10 health states, comprising 150 unique health states and 135 observations per health state. In addition to the standard EQ-VT design, which is based on 86 health states and 100 observations per health state, 3 extended designs were assessed for their predictive performance. The extended designs were created by 1) increasing the number of observations per health state in the design, 2) increasing the number of health states in the design, and 3) implementing both 1) and 2) at the same time. Subsamples of the data set were created for separate designs. The root mean squared error (RMSE) and mean absolute error (MAE) were used to measure the predictive accuracy of the conventional and extended designs.

RESULTS

The average RMSE and MAE for the standard EQ-VT design were 0.055 and 0.041, respectively, for the 150 health states. All 3 types of design extensions showed lower RMSE and MAE values as compared with the standard design and hence yielded better predictive performance. RMSE and MAE were lowest (0.051 and 0.039, respectively) for the designs that use a greater number of health states. Extending the design with inclusion of more health states was shown to improve the predictive performance even when the sample size was fixed at 1,000.

CONCLUSION

Although the standard EQ-VT design performs well, its prediction accuracy can be further improved by extending its design. The addition of more health states in EQ-VT is more beneficial than increasing the number of observations per health state.

HIGHLIGHTS

The EQ-5D-5L value sets are developed using the standardized EuroQol Valuation Technology (EQ-VT) protocol. This is the first study to empirically assess how much can be gained from extending the standard EQ-VT design in terms of sample size and/or health states. It not only presents useful insights into the performance of the standard design of the EQ-VT but also tests the potential extensions in the standard EQ-VT design in terms of increasing the health states to be directly valued as well as the number of observations recorded to predict the utility value of each of these health states.The study demonstrates that the standard EQ-VT design performs good, and an extension in the design of the standard EQ-VT can lead to further improvement in its performance. The addition of more health states in EQ-VT is more beneficial than increasing the number of observations per health state. Extending the design with inclusion of more health states marginally improves the predictive performance even when the sample size was fixed at 1,000.The findings of the study will streamline the systematic process for generating precise EQ-5D-5L value sets, thus facilitating the conduct of credible, transparent, and robust outcome valuation in health technology assessments.

Health-related quality of life and associated factors among COVID-19 individuals managed with indian traditional medicine: A cross-sectional study from south India

Introduction

Coronavirus disease-2019 (COVID-19) had a multidimensional impact on human life. It affects the health-related quality of life (HRQoL) which is a perceived measure of physical and mental health. We estimated the EuroQol utility value for COVID-19 and the associated factors for those managed at Siddha COVID care centres in Tamil Nadu.

Methods

A cross-sectional study was conducted by a telephonic interview of 2000 randomly selected COVID-19 adults tested positive during June 2020 to Jan 2021. We collected sociodemographic, clinical and EQ-5D-5L profile. Mean EQ-5D-5L summary utility values and EQ-VAS scores were estimated. Multivariate regression was used to examine the factors associated with EQ-5D-5L. Study protocol was approved by the Institutional ethics committee of Government Siddha Medical College, Chennai (GSMC-CH-3401/ME-2/050/2021). The committee waived the written informed consent considering the pandemic situation of emerging infectious diseases.

Results

We interviewed 1047 participants. Of the total 68% were males with the median age (IQR) of 38 (29-51) years. The mean EQ-5D-5L utility score and EQ-VAS scores are 0.98 ± 0.05 and 92.14 ± 0.39 respectively. COVID-19 asymptomatic group reported a mean utility score of 0.99 ± 0.03 which is relatively more than the symptomatic group (0.97 ± 0.06),. EQ-VAS score was also reported high among the asymptomatic (95.45 ± 5.95) than the symptomatic (91.40 ± 8.69COVID-19.

Conclusion

The severity of illness and the comorbidity are significantly associated with a low HRQoL of COVID-19 patients.

Translation and cross-cultural adaptation of the Integrated Palliative Care Outcome Scale in Hindi: Toward capturing palliative needs and concerns in Hindi speaking patients

BACKGROUND

Culturally relevant patient-centered outcomes tools are needed to identify the needs of patients and to assess their palliative care concerns.

AIM

To translate and culturally adapt the Integrated Palliative Care Outcome Scale (IPOS) into Hindi.

DESIGN

The study applied a standardized methodology entailing six phases for translation and content validation: equivalence setting through a three-step process; forward translation; blind backward translation; expert review by a panel of the POS team; cognitive de-briefing with patients; and proof-reading of the final tool. All interviews and focus groups were audio-recorded, transcribed and analyzed using content analysis.

SETTING/PARTICIPANTS

(1) Healthcare professionals including doctors, nurses, psychologists, counselors, and volunteers working in Indian palliative care settings with expertise in both English and Hindi languages; (2) Hindi speaking patients diagnosed with cancer who were receiving palliative care in community settings. Caregivers, palliative care experts, and language translators contributed to the translation procedure.

RESULTS

Phrases like nausea, poor appetite, drowsiness, and depression were difficult to translate into Hindi. Response categories "occasional" and "sometimes" were overlapping. All items, instructions and response categories were simple to understand. A visual thermometer is a unique feature of Hindi IPOS to facilitate responses from less educated patients.

CONCLUSION

Hindi IPOS has face and content validity for use in clinical practice and research. The Hindi IPOS has implications beyond Indian palliative care settings. Millions of Hindi speakers can now respond to IPOS, and have a tool for communicating their palliative care needs in their mother tongue to inform patient-centered care.

Health-related quality of life among Indian population: The EQ-5D population norms for India

Background

The EuroQol 5 dimensions (EQ-5D) is the most used generic health-related quality of life (HRQoL) instrument for measuring population health and health outcomes. Since there are no EuroQol 5 dimensions 5 levels (EQ-5D-5L) population norms available for India, this study developed the Indian population norms for the EQ-5D-5L. The potential influencing factors of HRQoL of the Indian population have been identified.

Methods

The data was collected alongside the Indian EQ-5D-5L valuation study (Development of an EQ-5D Value Set for India Using an Extended Design: DEVINE Study). A cross-sectional survey of 3548 adult respondents was conducted across five states of India, in which respondents were asked to report their own health states using the EQ-5D-5L descriptive system and the EuroQol Visual Analog Scale (EQ VAS). The utility score was calculated using the EQ-5D-5L value set based on the preferences of the Indian population. Norm scores were generated for age, sex, and other important socio-demographic variables. The proportion of patients reporting problems in different dimensions of EQ-5D-5L was assessed. The impact of socio-economic determinants on health-related quality of life was evaluated using multiple linear regression.

Results

The mean EQ VAS score of the Indian population is 75.18 (95% confidence interval (CI) = 74.50-75.90), whereas mean utility score is 0.848 (95% CI = 0.840-0.857). The EQ VAS scores, and utility scores decreased with age. Males reported higher EQ VAS values than females. The highest mean utility score was observed for males of <20 years (0.936), whereas the lowest mean score was observed for females of >70 years (0.488). The mean VAS score ranged between 85.24 for females of <20 years and 50.67 for females of >70 years. Highest problems were reported in the dimension of "pain / discomfort", closely followed by "anxiety / depression". Age, educational qualification, marital status, substance abuse, presence of ailments, state / region of residence, number of dependent members in the household, and time spent on mobile are the significant determinants of HRQoL of Indian population.

Conclusions

These population norms will be used as reference values for comparative purposes in future Indian studies. Economic evaluations can use these average age-specific HRQoL population norms to value the health-state of not having the specific disease under investigation.

Protocol for estimating the willingness-to-pay-based value for a quality-adjusted life year to aid health technology assessment in India: a cross-sectional study

INTRODUCTION

To ensure that the evidence generated by health technology assessment (HTA) is translated to policy, it is important to generate a threshold value against which the outcomes of HTA studies can be compared. In this context, the present study delineates the methods that will be deployed to estimate such a value for India.

METHODS AND ANALYSIS

The proposed study will deploy a multistage sampling approach considering economic and health status for selection of states, followed by selection of districts based on Multidimensional Poverty Index (MPI) and identification of primary sampling units (PSUs) using the 30-cluster approach. Further, households within PSU will be identified using systematic random sampling and block randomisation based on gender will be done to select respondent from the household. A total of 5410 respondents will be interviewed for the study. The interview schedule will comprise of three sections including background questionnaire to elicit socioeconomic and demographic characteristics, followed by assessment of health gains, and willingness to pay (WTP). To assess the health gains and corresponding WTP, the respondent will be presented with hypothetical health states. Using time trade off method, the respondent will indicate the amount of time he/she is willing to give up at the end of life to avoid morbidities in the hypothetical health condition. Further, respondents will be interviewed about their WTP for treatment of respective hypothetical conditions using contingent valuation technique. These estimates of health gains and corresponding WTP will then be combined to ascertain the value of WTP per quality-adjusted life year.

ETHICS AND DISSEMINATION

The ethical approval has been obtained from the Institutional Ethics Committee (IEC) of Postgraduate Institute of Medical Education and Research, Chandigarh, India. The study outcomes will be made available for general use and interpretation of HTA studies commissioned by India's central HTA Agency.

Depression, Anxiety, and Quality of Life in Patients Treated with Single Infusion Tocilizumab for COVID-19: A Follow-up, Controlled Study

BACKGROUND

The inflammatory state that characterizes COVID-19 may contribute to depression, anxiety, other morbidities, and mortality. Interleukin-6 blocker tocilizumab has been used as a treatment modality in COVID-19 as an anti-inflammatory agent. Tocilizumab has also been studied for its potential use in preventing depression in other patient groups, with mixed results. This study was designed to study subsequent depression, anxiety, and quality of life (QOL) in patients treated with tocilizumab plus standard care versus standard care alone, for moderate to severe COVID-19 pneumonia.

METHODS

Patients admitted with moderate to severe COVID pneumonia, treated with tocilizumab plus standard treatment, and discharged from the hospital were identified. Age- and gender-matched controls who had received standard treatment alone for COVID-19 pneumonia during the same time frame were identified. After obtaining consent, these patients were followed up and assessed at 3 and 6 months on measures of depression (PHQ-9), anxiety (GAD-7), and QOL (EQ-5D-5L).

RESULTS

39 patients in the tocilizumab group and 41 in the control group were followed up at 3 and 6 months. Patients in both groups were comparable in sociodemographic and clinical parameters. The prevalence of clinically significant depression in the tocilizumab group at 3 and 6 months was 33.33% and 5.12%, respectively, whereas in control group it was 31.7% and 4.87%, respectively. Analysis of EQ-5D health profiles revealed that the maximum problems were reported in the dimension of mobility: 43.7% at 3 months and 35% at 6 months.

CONCLUSIONS

Depressive and anxiety symptoms and impairment in QOL were reported more frequently and with greater severity in patients in the tocilizumab group at three months but not at six months. Psychological morbidity and impairment in QOL were modest and improved from 3 to 6 months.

Health-related quality of life among breast cancer patients in India

PURPOSE

This study evaluated the health-related quality of life (HRQoL) among breast cancer patients during various phases of treatment and with different treatment modalities, which helps in monitoring treatment outcomes, assessing the well-being of patients, and conducting health technology assessments.

METHODS

A total of 534 interviews were conducted among the patients of breast cancer recruited at different stages of disease and with different treatment modalities. HRQoL was determined using EuroQoL five dimensions questionnaire with five levels (EQ-5D-5L), EuroQoL Visual Analogue Scale (EQ VAS), and the EORTC QLQ-BR23 instrument. The utility values were determined based on the Indian EQ-5D-5L value set. The socio-demographic and clinico-therapeutic determinants of HRQoL were evaluated using multiple linear regression.

RESULTS

The mean utility value of breast cancer patients was 0.602 (SD = 0.311) and mean EQ VAS score was 75 (SD = 12.3). The mean utility value at diagnosis was 0.628, whereas utility value was 0.55, 0.595, and 0.64 for post-surgery, post-chemotherapy, and post-radiotherapy treatment groups, respectively. The most frequently reported problem was pain/discomfort (in 84.3% patients), followed by anxiety/depression (83.5%). On EORTC QLQ-BR23, the maximum symptom scale scores for systemic therapy side effects were reported in the post chemotherapy group. The body image score and future perspective score were better in patients undergoing breast conservative surgery (BCS) compared to patients undergoing modified radical mastectomy. Age, education, and employment status of the patient, type of treatment modality, and use of taxanes are the determinants of HRQoL in breast cancer patients.

CONCLUSION

Clinical interventions should focus upon management of pain and anxiety. BCS should be offered to all eligible patients as it is associated with better HRQoL. Addressing the factors that independently affect the HRQoL will help in improving the treatment compliance and outcomes.

Development and economic evaluation of a patient-centered care model for children with Duchenne’s Muscular Dystrophy: A quasi-experimental study protocol (Preprint)

BACKGROUND

Duchenne muscular dystrophy (DMD) is a rare progressive muscular disease that primarily affects boys. A lack of comprehensive care for patients living with DMD is directly associated with a compromised quality of life (QoL) for those affected and their caregivers. This disease also has a huge economic impact on families as its treatment requires substantial direct, indirect, and informal care costs.

OBJECTIVE

This study presents a protocol developed to evaluate the feasibility and efficacy of a patient-centered care (PCC) model for children with DMD. The care model was designed with the aim to empower families, improve QoL, and reduce economic burden on their families.

METHODS

This study is planned as a quasi-experimental study that will enroll 70 consecutive families with boys (aged 5-15 years) with DMD visiting a tertiary care center. The study is being conducted in 2 phases (preintervention and postintervention phases, referred to as phase 1 and phase 2, respectively). During phase 1, the patients received routine care. The study is now in phase 2, with the intervention currently being administered. The intervention is based on the PCC model individualized by the intervention team. The model has a comprehensive DMD telecare component that includes teleconsultation as one of its key components to reduce in-person physician visits at the health facility. Teleconsultation is especially beneficial for late-ambulatory and nonambulatory patients. Data on economic burden are being collected for out-of-pocket expenses for both phases during in-person visits via telephone or messaging apps on a monthly basis. QoL data for patients and their primary caregivers are being collected at 3 time points (ie, time of enrollment, end of phase 1, and end of phase 2). Outcome measures are being assessed as changes in economic burden on families and changes in QoL scores.

RESULTS

Participant recruitment began in July 2021. The study is ongoing and expected to be completed by March 2023. The findings based on baseline data are expected to be submitted for publication in 2023.

CONCLUSIONS

This paper outlines a research proposal developed to study the impact of a PCC model for patients with DMD in low- and middle-income countries (LMICs). This study is expected to provide evidence of whether a multicomponent, patient-centric intervention could reduce economic burdens on families and improve their QoL. The results of this study could guide policy makers and health professionals in India and other LMICs to facilitate a comprehensive care program for patients living with DMD. The economic impact of a rare disease is an important consideration to formulate or evaluate any health policy or intervention related to new treatments and financial support schemes.

TRIAL REGISTRATION

Clinical Trials Registry India (ICMR-NIMS) CTRI/2021/06/034274; https://www.ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=56650.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/42491.

Yoga to improve maternal mental health and immune function during the COVID-19 crisis (Yoga-M2 trial): study protocol for a pilot randomized controlled trial

Background: Mental health of women is adversely affected during pregnancy. Stress and depression during pregnancy negatively impact birthweight and neuro-cognitive development of the fetus. The current crisis due to the COVID-19 pandemic further adds to the stressful situation. Yoga practiced during pregnancy has beneficial effects on improving stress and depression and preliminary evidence suggests that yoga-based interventions can improve immunity. This study aims to examine the feasibility, acceptability, and preliminary efficacy of a Yoga-based intervention for maternal Mental health and i Mmunity (Yoga-M ₂) in a rural community in India. 

  

Methods: The study design will be a single-blind individual randomized parallel group-controlled pilot trial with 1:1 allocation ratio. Adult pregnant women, with gestational age between 12–24 weeks will be randomly allocated to either the Yoga-M ₂ group or the Enhanced Usual Care (EUC) group. Participants in the Yoga-M ₂ arm will attend weekly group yoga sessions for 12 weeks and will be encouraged to practice yoga at home. In the EUC arm, participants will receive a single session of health education. Eligibility of the participants, recruitment, retention-in-care, and study completion rates will be estimated and feasibility of delivering Yoga-M ₂ and acceptability of this intervention by the participants will be assessed. Change in the scores of the Perceived Stress Scale (PSS), EuroQoL 5 Dimensions Score (EQ-5D-5L), Wisconsin Upper Respiratory Symptom Severity Scale (WURSS-21), and serum C-Reactive Protein at three-months from baseline will be used to assess preliminary efficacy.

Discussion: The key outputs of this trial will be a structured intervention manual and evidence about the feasibility, acceptability, and preliminary efficacy of the intervention, establishing the foundation to undertake an explanatory randomized controlled trial to assess efficacy and cost-effectiveness of Yoga-M ₂ intervention. 

Trial registration: CTRI/2022/01/039701. Prospectively registered with the Clinical Trials Registry of India on 25 January 2022.

Development of an EQ-5D Value Set for India Using an Extended Design (DEVINE) Study: The Indian 5-Level Version EQ-5D Value Set

OBJECTIVES

This study aimed to develop the Indian 5-level version EQ-5D (EQ-5D-5L) value set, which is a key input in health technology assessment for resource allocation in healthcare.

METHODS

A cross-sectional survey using the EuroQol Group's Valuation Technology was undertaken in a representative sample of 3548 adult respondents, selected from 5 different states of India using a multistage stratified random sampling technique. The participants were interviewed using a computer-assisted personal interviewing technique. This study adopted a novel extended EuroQol Group's Valuation Technology design that included 18 blocks of 10 composite time trade-off (c-TTO) tasks, comprising 150 unique health states, and 36 blocks of 7 discrete choice experiment (DCE) tasks, comprising 252 DCE pairs. Different models were explored for their predictive performance. Hybrid modeling approach using both c-TTO and DCE data was used to estimate the value set.

RESULTS

A total of 2409 interviews were included in the analysis. The hybrid heteroscedastic model with censoring at -1 combining c-TTO and DCE data yielded the most consistent results and was used for the generation of the value set. The predicted values for all 3125 health states ranged from -0.923 to 1. The preference values were most affected by the pain/discomfort dimension.

CONCLUSIONS

This is the largest EQ-5D-5L valuation study conducted so far in the world. The Indian EQ-5D-5L value set will promote the effective conduct of health technology assessment studies in India, thereby generating credible evidence for efficient resource use in healthcare.

Long-term outcomes of dexamethasone 12 mg versus 6 mg in patients with COVID-19 and severe hypoxaemia

PURPOSE

We assessed long-term outcomes of dexamethasone 12 mg versus 6 mg given daily for up to 10 days in patients with coronavirus disease 2019 (COVID-19) and severe hypoxaemia.

METHODS

We assessed 180-day mortality and health-related quality of life (HRQoL) using EuroQoL (EQ)-5D-5L index values and EQ visual analogue scale (VAS) in the international, stratified, blinded COVID STEROID 2 trial, which randomised 1000 adults with confirmed COVID-19 receiving at least 10 L/min of oxygen or mechanical ventilation in 26 hospitals in Europe and India. In the HRQoL analyses, higher values indicated better outcomes, and deceased patients were given a score of zero.

RESULTS

We obtained vital status at 180 days for 963 of 982 patients (98.1%) in the intention-to-treat population, EQ-5D-5L index value data for 922 (93.9%) and EQ VAS data for 924 (94.1%). At 180 days, 164 of 486 patients (33.7%) had died in the 12 mg group versus 184 of 477 (38.6%) in the 6 mg group [adjusted risk difference - 4.3%; 99% confidence interval (CI) - 11.7-3.0; relative risk 0.89; 0.72-1.09; P = 0.13]. The adjusted mean differences between the 12 mg and the 6 mg groups in EQ-5D-5L index values were 0.06 (99% CI - 0.01 to 0.12; P = 0.10) and in EQ VAS scores 4 (- 3 to 10; P = 0.22).

CONCLUSION

Among patients with COVID-19 and severe hypoxaemia, dexamethasone 12 mg compared with 6 mg did not result in statistically significant improvements in mortality or HRQoL at 180 days, but the results were most compatible with benefit from the higher dose.

Yoga to improve maternal mental health and immune function during the COVID-19 crisis (Yoga-M2 trial): study protocol for a pilot randomized controlled trial

Background: Mental health of women is adversely affected during pregnancy. A huge proportion of pregnant women suffer from stress and depression which negatively impacts birthweight and neuro-cognitive development of the fetus. The current crisis due to the COVID-19 pandemic further adds to the stressful situation. Yoga practiced during pregnancy has beneficial effects on improving stress and depression and preliminary evidence suggests that yoga-based interventions can improve immunity. This study aims to examine the feasibility, acceptability, and preliminary efficacy of a Yoga-based intervention for maternal Mental health and iMmunity (Yoga-M2) in a rural community in India.     Methods: The study design will be a single-blind individual randomized parallel group-controlled pilot trial with 1:1 allocation ratio. Adult pregnant women, with gestational age between 12–24 weeks will be randomly allocated to either the Yoga-M2 group or the Enhanced Usual Care (EUC) group. Participants in the Yoga-M2 arm will attend weekly group yoga sessions for 12 weeks and will be encouraged to practice yoga at home. In the EUC arm, participants will receive a single session of health education. Eligibility of the participants, recruitment, retention-in-care, and study completion rates will be estimated and feasibility of delivering Yoga-M2 and acceptability of this intervention by the participants will be assessed. Change in the scores of the Perceived Stress Scale (PSS), EuroQoL 5 Dimensions Score (EQ-5D-5L), Wisconsin Upper Respiratory Symptom Severity Scale (WURSS-21), and serum C-Reactive Protein at three-months post-randomization will be used to assess preliminary efficacy.   Discussion: The key outputs of this trial will be a structured intervention manual and evidence about the feasibility, acceptability, and preliminary efficacy of the intervention, establishing the foundation to undertake an explanatory randomized controlled trial to assess efficacy and cost-effectiveness of Yoga-M2 intervention.  Trial registration: CTRI/2022/01/039701. Prospectively registered with the Clinical Trials Registry of India on 25 January 2022.

Extending the straight leg raise test for improved clinical evaluation of sciatica: validity and diagnostic performance with reference to the magnetic resonance imaging

BACKGROUND

The straight leg raise test (SLR) is one of the most utilized and studied physical tests in patients with low back pain (LBP) for the detection of lumbar disc herniation (LDH), showing high sensitivity and heterogeneous or low specificity. The high incidence of asymptomatic 'pathologic' findings in the magnetic resonance imaging (MRI) scans may cause verification bias to these results. We studied an extended SLR (ESLR) by adding location-specific structural differentiation movements (hip internal rotation or ankle dorsiflexion) to the traditional SLR for it to better differentiate neural symptoms from musculoskeletal. Previously, the ESLR has shown almost perfect interrater reliability between examiners and ability to detect sciatic patients. In this study, we investigated whether a 'positive' ESLR finding is associated with pathology seen on MRI.

METHODS

Forty subjects comprised the study population, 20 in sciatic group and 20 in control group. The ESLR was performed 'blinded' to the subjects. After the ESLR, each subject's lumbar MRI was evaluated. The MRIs were analyzed independently by 2 senior radiologists and a spine specialist clinician. The ESLR and MRI results were cross-tabulated. To obtain the odds ratio (OR) with positive ESLR or SLR results for LDH or nerve root compression (NC), a binary logistic regression analysis with subjects' age, gender, height and weight was performed. ESLR's validity was assessed by combination of interrater agreement and percentage prevalence of both LDH and NC.

RESULTS

Of sciatic (ESLR+) patients, 85 % had LDH and 75 % NC in the MRI. Not surprisingly, MRI showed a very high incidence of 'false-positive' findings with the ESLR negative group. The ESLR showed 0.85 sensitivity and 0.45 specificity for LDH and 0.75 sensitivity and 0.50 specificity for NC. A positive result in the ESLR was found to be strongly associated with for both LDH and NC: the OR was 8.0 (p = 0.028) and 5.6 (p = 0.041), respectively.

CONCLUSIONS

The ESLR shows high validity in detecting neural symptoms and is strongly associated with pathology seen in the MRI when judged positive. We suggest the use of ESLR in clinical practice as a part of clinical examination, where it may prove to be a valuable tool in detecting patients with sciatic symptoms.

Development of National Cancer Database for Cost and Quality of Life (CaDCQoL) in India: a protocol

INTRODUCTION

The rising economic burden of cancer on healthcare system and patients in India has led to the increased demand for evidence in order to inform policy decisions such as drug price regulation, setting reimbursement package rates under publicly financed health insurance schemes and prioritising available resources to maximise value of investments in health. Economic evaluations are an integral component of this important evidence. Lack of existing evidence on healthcare costs and health-related quality of life (HRQOL) makes conducting economic evaluations a very challenging task. Therefore, it is imperative to develop a national database for health expenditure and HRQOL for cancer.

METHODS AND ANALYSIS

The present study proposes to develop a National Cancer Database for Cost and Quality of Life (CaDCQoL) in India. The healthcare costs will be estimated using a patient perspective. A cross-sectional study will be conducted to assess the direct out-of-pocket expenditure (OOPE), indirect cost and HRQOL among cancer patients who will be recruited at seven leading cancer centres from six states in India. Mean OOPE and HRQOL scores will be estimated by cancer site, stage of disease and type of treatment. Economic impact of cancer care on household financial risk protection will be assessed by estimating prevalence of catastrophic health expenditures and impoverishment. The national database would serve as a unique open access data repository to derive estimates of cancer-related OOPE and HRQOL. These estimates would be useful in conducting future cost-effectiveness analyses of management strategies for value-based cancer care.

ETHICS AND DISSEMINATION

Approval was granted by Institutional Ethics Committee vide letter no. PGI/IEC-03/2020-1565 of Post Graduate Institute of Medical Education and Research, Chandigarh, India. The study results will be published in peer-reviewed journals and presented to the policymakers at national level.

Cost effectiveness of typhoid vaccination in India

INTRODUCTION

World Health Organization has prequalified the use of typhoid conjugate vaccine (TCV) in children over six months of age in typhoid endemic countries. We assessed the cost-effectiveness of introducing TCV separately for urban and rural areas of India.

METHODS

A decision analytic model was developed, using a societal perspective, to compare long-term costs and outcomes (3% discount rate) in a new-born cohort of 100,000 children immunized with or without TCV. Three vaccination scenarios were modelled, assuming the protective efficacy of TCV to last for 5, 10 and 15 years following immunization. Incidence of typhoid infection estimated under 'National Surveillance System for Enteric Fever' (NSSEFI)' was used. The prices of vaccine and cost of service delivery were included for vaccination arm. Both health system cost and out-of-pocket expenditures for treatment of typhoid illness and its complications was included.

RESULTS

TCV introduction in urban areas would result in prevention of 17% to 36% typhoid cases and deaths. With exclusion of indirect costs, the incremental cost per QALY gained was ₹ 151,346 (54,730-307,975), ₹ 61,710 (-5250 to 163,283) and ₹ 45,188 (-17,069 to 141,093) for scenario 1, 2 and 3 respectively. While, with inclusion of indirect costs, all 3 scenarios were cost saving. Further, in rural areas, TCV is estimated to reduce the typhoid cases and deaths by 19% to 36%, with ICER (incremental cost per QALY gained) ranging from ₹ 2340 (1316-4370) to ₹ 3574 (2057 - 6691) thousand (inclusive of indirect costs) among the 3 vaccination scenarios.

CONCLUSION

From a societal perspective, introduction of TCV is a cost saving strategy in urban India. Further, due to low incidence of typhoid infection, introduction of TCV is not cost-effective in rural settings of India.