Process utility in breast biopsy

Understanding Patient Preference in Female Pelvic Imaging: Transvaginal Ultrasound and MRI

RATIONALE AND OBJECTIVES

Women with pelvic pain or abnormal uterine bleeding may undergo diagnostic imaging. This study evaluates patient experience in transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) and explores correlations between preference and symptom severity.

MATERIALS AND METHODS

Institutional review board approval was obtained for this Health Insurance Portability and Accountability Act-compliant prospective study. Fifty premenopausal women with pelvic symptoms evaluated by recent TVUS and MRI and without history of gynecologic cancer or hysterectomy were included. A phone questionnaire used validated survey instruments including Uterine Fibroid Symptoms Quality of Life index, Testing Morbidities Index, and Wait Trade Off for TVUS and MRI examinations.

RESULTS

Using Wait Trade Off, patients preferred TVUS over MRI (3.58 vs 2.80 weeks, 95% confidence interval [CI] -1.63, 0.12; P = .08). Summary test utility of Testing Morbidities Index for MRI was worse than for TVUS (81.64 vs 87.42, 95%CI 0.41, 11.15; P = .03). Patients reported greater embarrassment during TVUS than during MRI (P <.0001), but greater fear and anxiety both before (P <.0001) and during (P <.001) MRI, and greater mental (P = .02) and physical (P = .02) problems after MRI versus TVUS. Subscale correlations showed physically inactive women rated TVUS more negatively (R = -0.32, P = .03), whereas women with more severe symptoms of loss of control of health (R = -0.28, P = .04) and sexual dysfunction (R = -0.30, P = .03) rated MRI more negatively.

CONCLUSION

Women with pelvic symptoms had a slight but significant preference for TVUS over MRI. Identifying specific distressing aspects of each test and patient factors contributing to negative perceptions can direct improvement in both test environment and patient preparation. Improved patient experience may increase imaging value.

Comparative Assessment of Patient Preferences and Tolerability in Barrett Esophagus Screening: Results From a Randomized Trial

GOALS

To determine patient preference for the Barrett esophagus (BE) screening techniques.

BACKGROUND

Sedated esophagogastroduodenoscopy (sEGD) and unsedated transnasal endoscopy (uTNE) are both potential techniques for BE screening. However, systematic assessment of patient preference for these 2 techniques is lacking. As part of a comparative effectiveness randomized trial of BE screening modalities, we measured short-term patient preferences for the following approaches: in-clinic uTNE (huTNE), mobile-based uTNE (muTNE), and sEGD using a novel assessment instrument.

STUDY

Consenting community patients without known BE were randomly assigned to receive huTNE, muTNE, or sEGD, followed by a telephone administered preference and tolerability assessment instrument 24 hours after study procedures. Patient preference was measured by the waiting trade-off method.

RESULTS

In total, 201 patients completed screening with huTNE (n=71), muTNE (n=71), or sEGD (n=59), and a telephone interview. Patients' preferences for sEGD and uTNE using the waiting trade-off method were comparable (P=0.51). Although tolerability scores were superior for sEGD (P<0.001) compared with uTNE, scores for uTNE examinations were acceptable.

CONCLUSIONS

Patient preference is comparable between sEGD and uTNE for diagnostic examinations conducted in an endoscopy suite or in a mobile setting. Given acceptable tolerability, uTNE may be a viable alternative to sEGD for BE screening.

A Systematic Review of the Techniques Used to Value Temporary Health States

BACKGROUND

A broad literature on health state utility values exists, but compared with chronic health states (HSs), issues surrounding the valuation of temporary health states (THSs) have been poorly explored.

OBJECTIVES

To assess the methods used by previous studies to value HSs that are considered temporary so as to determine the strengths and limitations associated with various approaches and to inform future study designs.

METHODS

A systematic review was undertaken to explore the methods used, assess how the valuation was conducted for diseases that might lead to HSs deemed as temporary, and identify the challenges encountered in the valuation of THSs.

RESULTS

Of the 36 relevant studies, 22 were explicit that the HS being valued was temporary. Most of the studies used more than one technique (often incorporating both conventional and adapted approaches). In using adapted techniques, the primary challenge was identifying an appropriate intermediate "anchor" HS and the possibility of negative utilities.

CONCLUSIONS

There is no agreement on the most methodologically robust approach to THS valuation. Valuation is complex and important issues relating to the validity, practicality, and reliability of the techniques used were not adequately covered by most of the studies identified.

Valuing Meta-Health Effects for Use in Economic Evaluations to Inform Reimbursement Decisions: A Review of the Evidence

OBJECTIVE

This review explores the evidence from the literature regarding how meta-health effects (effects other than health resulting from the consumption of health care) are valued for use in economic evaluations.

METHODS

A systematic review of the published literature (the EMBASE, MEDLINE, PsycINFO, CINAHL, EconLit and SocINDEX databases were searched for publications in March 2016, plus manual searching) investigated the associations between study methods and the resulting values for meta-health effects estimated for use in economic evaluations. The review considered which meta-health effects were being valued and how this differed by evaluation approach, intervention investigated, source of funds and year of publication. Detailed reasons for differences observed between values for comparable meta-health effects were explored, accounting for the method of valuation.

RESULTS

The search of the literature revealed 71 studies of interest; 35% involved drug interventions, with convenience, information and process of care the three meta-health effects most often investigated. Key associations with the meta-health effects were the evaluation method, the intervention, and the source of funds. Relative values for meta-health effects ranged from 0.9% to 68% of the overall value reported in a study. For a given meta-health effect, the magnitude of the effect evaluated and how the meta-health effect was described and framed relative to overall health explained the differences in relative values.

CONCLUSIONS

Evidence from the literature shows variability in how meta-health effects are being measured for use in economic evaluations. Understanding the sources of that variability is important if decision makers are to have confidence in how meta-health effects are valued.

Percutaneous breast biopsy: effect on short-term quality of life

PURPOSE

To examine the effects of percutaneous breast biopsy on short-term quality of life.

MATERIALS AND METHODS

The institutional review board approved this HIPAA-compliant prospective study. From December 1, 2007, through February 28, 2010, women undergoing percutaneous breast biopsy in an academic medical center were recruited to participate in a mixed-mode survey 2-4 days after biopsy. Patients described their biopsy experience by using the Testing Morbidities Index (TMI), a validated instrument for assessing short-term quality of life related to diagnostic testing. The scale ranged from 0 (worst possible experience) to 100 (no adverse effects). Seven attributes were assessed: pain or discomfort before and during testing, fear or anxiety before and during testing, embarrassment during testing, and physical and mental function after testing. Demographic and clinical information were also collected. Univariate and multivariate linear regression analyses were performed to identify significant predictors of TMI score.

RESULTS

In 188 women (mean age, 51.4 years; range, 22-80 years), the mean TMI score (±standard deviation) was 82 ± 12. Univariate analysis revealed age and race as significant predictors of the TMI score (P < .05). In the multivariate model, only patient age remained a significant independent predictor (P = .001). TMI scores decreased by approximately three points for every decade decrease in patient age, which suggests that younger women were more adversely affected by the biopsy experience.

CONCLUSION

Younger patient age is a significant predictor of decreased short-term quality of life related to percutaneous breast biopsy procedures. Tailored prebiopsy counseling may better prepare women for percutaneous biopsy procedures and improve their experience.

Patient preferences for coronary computed tomography angiography versus conventional catheter angiography for the diagnosis of coronary artery disease

RATIONALE AND OBJECTIVES

The aims of the study were: 1) to assess the baseline health-related quality of life (HRQOL) of patients with coronary artery disease (CAD) using the standard gamble; 2) to evaluate and compare patients' preference for catheter versus computed tomography (CT) coronary angiography using the wait tradeoff (WTO) and rating scales; and 3) to calculate test disutility for catheter and CT coronary angiography.

MATERIALS AND METHODS

Thirty patients with CAD who underwent both CT and catheter angiography were interviewed by telephone within 6 months of testing. Patients were asked about their baseline symptoms and quality of life, their experience preparing for both CT and catheter angiography, their desire to undergo CT or catheter angiography, and immediate treatment versus having a waiting period between test results and treatment for a hypothetical "ideal test" with no side effects. Test disutility for CT and catheter angiography were calculated and compared.

RESULTS

The mean and median baseline HRQOL utility values were 0.72 and 0.91. The patients were willing to wait a mean (median) time of 12 (3) days after the ideal test for the test results to avoid undergoing CT angiography. They were willing to wait a mean (median) of 7 (3) days after the ideal test for test results, to avoid undergoing catheter angiography. There was no significant difference between waiting times or between patients' rating for their experience preparing for the two tests. Test disutility for CT angiography was 1.30 quality-adjusted life days (QALD) versus 2.16 QALD for catheter angiography (P > .05).

CONCLUSION

There was no significant difference in patient preference and test disutility between CT and catheter angiography in our small series. Future rigorously planned and adequately powered studies are required to confirm these findings in larger patient populations.

Responsiveness of the testing morbidities index in colonoscopy

OBJECTIVES

The Testing Morbidities Index (TMI) was developed to measure the effects of any diagnostic or screening procedure on health-related quality of life (HRQOL); it includes seven domains incorporating mental and physical aspects before, during, and after testing. To add to prior work on the validity of the TMI classification, responsiveness of a summated scale version was evaluated in 71 colonoscopy patients. Further data on construct validity were also obtained.

METHODS

Patients enrolled in the study when scheduling colonoscopy days to weeks beforehand. The baseline survey included the EuroQol five-dimensional (EQ-5D) questionnaire with five levels in each attribute (EQ-5D-5L questionnaire) and its visual analogue scale (VAS) assessment (EQ-VAS), the Short Form 12 version 2 (SF-12v2) component summary scores and six-dimensional health state short-form (derived from the short-form 12v2 health survey [SF-6D] utilities), and an original construct-specific VAS (CS-VAS) for usual HRQOL using utility scale anchors. The TMI's highest possible summated score (all best levels) served as its baseline. Survey data were generally obtained by telephone interview. A postprocedure survey was given to patients after colonoscopy and interviews conducted as soon as possible after the day of the procedure. The postprocedure survey included the SF-12v2/SF-6D, EQ-5D questionnaire instruments, TMI items, and a CS-VAS incorporating the overall HRQOL effects of colonoscopy.

RESULTS

Standardized response means showed greatest responsiveness by the TMI (-1.52) followed by the CS-VAS instruments (-0.42). The EQ-5D-5L questionnaire, the EQ-VAS, and the SF-12 component summaries were unresponsive, and the SF-6D was minimally responsive (-0.05). Correlation of the post-CS-VAS with the TMI was substantial (r = -0.52), suggesting TMI construct validity. Moderate to strong correlation of the baseline CS-VAS with standard indexes was observed (r = 0.54-0.81).

CONCLUSION

The TMI appears responsive and exhibits further evidence of construct validity.

Incorporating process utility into quality adjusted life years: a systematic review of empirical studies

OBJECTIVE

This review aimed to identify published studies that provide an empirical measure of process utility, which can be incorporated into estimates of QALY calculations.

METHODS

A literature search was conducted in PubMed to identify published studies of process utility. Articles were included if they were written in the English language and reported empirical measures of process utility that could be incorporated into the QALY calculation; those studies reporting utilities that were not anchored on a scale of 0 representing dead and 1 representing full health were excluded from the review.

RESULTS

Fifteen studies published between 1996 and 2012 were included. Studies included respondents from the USA, Australia, Scotland and the UK, Europe and Canada. Eight of the included studies explored process utility associated with treatments; six explored process utility associated with screening procedures or tests; and one was performed in preventative care. A variety of approaches were used to detect and measure process utility: four studies used standard gamble techniques; four studies used time trade-off (TTO); one study used conjoint analysis and one used a combination of conjoint analysis and TTO; one study used SF-36 data; one study used both TTO and EQ-5D; and three studies used wait trade-off techniques. Measures of process utility for different drug delivery methods ranged from 0.02 to 0.27. Utility estimates associated with different dosing strategies ranged from 0.005 to 0.09. Estimates for convenience (able to take on an empty stomach) ranged from 0.001 to 0.028. Estimates of process utility associated with screening and testing procedures ranged from 0.0005 to 0.031. Both of these estimates were obtained for management approaches to cervical cancer screening.

CONCLUSION

The identification of studies through conventional methods was difficult due to the lack of consistent indexing and terminology across studies; however, the evidence does support the existence of process utility in treatment, screening and preventative care settings. There was considerable variation between estimates. The range of methodological approaches used to identify and measure process utility, coupled with the need for further research into, for example, the application of estimates in economic models, means it is difficult to know whether these differences are a true reflection of the amount of process utility that enters into an individual's utility function, or whether they are associated with features of the studies' methodological design. Without further work, and a standardised approach to the methodology for the detection and measurement of process utility, comparisons between estimates are difficult. This literature review supports the existence of process utility and indicates that, despite the need for further research in the area, it could be an important component of an individual's utility function, which should at least be considered, if not incorporated, into cost-utility analyses.

Patient and societal value functions for the testing morbidities index

BACKGROUND

We developed preference-based and summated scale scoring for the Testing Morbidities Index (TMI) classification, which addresses short-term effects on quality of life from diagnostic testing before, during, and after testing procedures.

METHODS

The two TMI preference functions use multiattribute value techniques; one is patient-based and the other has a societal perspective, informed by 206 breast biopsy patients and 466 (societal) subjects. Because of a lack of standard short-term methods for this application, we used the visual analog scale (VAS). Waiting tradeoff (WTO) tolls provided an additional option for linear transformation of the TMI. We randomized participants to 1 of 3 surveys: The first derived weights for generic testing morbidity attributes and levels of severity with the VAS; a second developed VAS values and WTO tolls for linear transformation of the TMI to a "dead-healthy" scale; the third addressed initial validation in a specific test (breast biopsy). The initial validation included 188 patients and 425 community subjects. Direct VAS and WTO values were compared with the TMI. Alternative TMI scoring as a nonpreference summated scale was included, given evidence of construct and content validity.

RESULTS

The patient model can use an additive function, whereas the societal model is multiplicative. Direct VAS and the VAS-scaled TMI were correlated across modeling groups (r = 0.45-0.62). Agreement was comparable to the value function validation of the Health Utilities Index 2. Mean absolute difference (MAD) calculations showed a range of 0.07-0.10 in patients and 0.11-0.17 in subjects. MAD for direct WTO tolls compared with the WTO-scaled TMI varied closely around 1 quality-adjusted life day.

CONCLUSIONS

The TMI shows initial promise in measuring short-term testing-related health states.

Cost-effectiveness of alternating magnetic resonance imaging and digital mammography screening in BRCA1 and BRCA2 gene mutation carriers

BACKGROUND

Current clinical guidelines recommend earlier, more intensive breast cancer screening with both magnetic resonance imaging (MRI) and mammography for women with breast cancer susceptibility gene (BRCA) mutations. Unspecified details of screening schedules are a challenge for implementing guidelines.

METHODS

A Markov Monte Carlo computer model was used to simulate screening in asymptomatic women who were BRCA1 and BRCA2 mutation carriers. Three dual-modality strategies were compared with digital mammography (DM) alone: 1) DM and MRI alternating at 6-month intervals beginning at age 25 years (Alt25), 2) annual MRI beginning at age 25 years with alternating DM added at age 30 years (MRI25/Alt30), and 3) DM and MRI alternating at 6-month intervals beginning at age 30 years (Alt30). Primary outcomes were quality-adjusted life years (QALYs), lifetime costs (in 2010 US dollars), and incremental cost-effectiveness (dollars per QALY gained). Additional outcomes included potential harms of screening, and lifetime costs stratified into component categories (screening and diagnosis, treatment, mortality, and patient time costs).

RESULTS

All 3 dual-modality screening strategies increased QALYs and costs. Alt30 screening had the lowest incremental costs per additional QALY gained (BRCA1, $74,200 per QALY; BRCA2, $215,700 per QALY). False-positive test results increased substantially with dual-modality screening and occurred more frequently in BRCA2 carriers. Downstream savings in both breast cancer treatment and mortality costs were outweighed by increases in up-front screening and diagnosis costs. The results were influenced most by estimates of breast cancer risk and MRI costs.

CONCLUSIONS

Alternating MRI and DM screening at 6-month intervals beginning at age 30 years was identified as a clinically effective approach to applying current guidelines, and was more cost-effective in BRCA1 gene mutation carriers compared with BRCA2 gene mutation carriers.

What is the optimal threshold at which to recommend breast biopsy?

Background

A 2% threshold, traditionally used as a level above which breast biopsy recommended, has been generalized to all patients from several specific situations analyzed in the literature. We use a sequential decision analytic model considering clinical and mammography features to determine the optimal general threshold for image guided breast biopsy and the sensitivity of this threshold to variation of these features.

Methodology/Principal Findings

We built a decision analytical model called a Markov Decision Process (MDP) model, which determines the optimal threshold of breast cancer risk to perform breast biopsy in order to maximize a patient’s total quality-adjusted life years (QALYs). The optimal biopsy threshold is determined based on a patient’s probability of breast cancer estimated by a logistic regression model (LRM) which uses demographic risk factors (age, family history, and hormone use) and mammographic findings (described using the established lexicon–BI-RADS). We estimate the MDP model's parameters using SEER data (prevalence of invasive vs. in situ disease, stage at diagnosis, and survival), US life tables (all cause mortality), and the medical literature (biopsy disutility and treatment efficacy) to determine the optimal “base case” risk threshold for breast biopsy and perform sensitivity analysis. The base case MDP model reveals that 2% is the optimal threshold for breast biopsy for patients between 42 and 75 however the thresholds below age 42 is lower (1%) and above age 75 is higher (range of 3–5%). Our sensitivity analysis reveals that the optimal biopsy threshold varies most notably with changes in age and disutility of biopsy.

Conclusions/Significance

Our MDP model validates the 2% threshold currently used for biopsy but shows this optimal threshold varies substantially with patient age and biopsy disutility.

Patient-centered outcomes in imaging: quantifying value

The Patient-Centered Outcomes Research Institute was created in response to a mandate to conduct comparative effectiveness research in clinical care to inform decision making. The institute will be funded by the Patient-Centered Outcomes Research Trust Fund, through congressional set-asides, and by Medicare and private health insurers, through a per beneficiary fee. The institute is governed by a board with a broad stakeholder constitution. Key committees set the national agenda for patient-centered outcomes research, the agenda for funding priorities, and communication and dissemination of the evidence with the goal of increasing the rate of implementation of the evidence into policy. In imaging, patient-centered outcomes go beyond the traditional metrics of patient satisfaction. Instead, these outcomes need to encompass the benefits and harms, focus on outcomes relevant to patients, and provide information to inform decision making. Therefore, radiologists need to be involved as stakeholders in the design, conduct, and dissemination of this research.

Quality-of-life assessment of fibroid treatment options and outcomes

PURPOSE

To obtain utilities (a unit of measure of a person's relative preferences for different health states compared with death or worst possible outcome) for uterine fibroids before and after treatment and to measure short-term utilities for the following uterine fibroid treatments: abdominal hysterectomy, magnetic resonance (MR) imaging-guided focused ultrasound surgery, and uterine artery embolization (UAE).

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board and was HIPAA compliant. The waiting trade-off (WTO) method, a variation on the time trade-off (TTO) method, is used to obtain utilities for diagnostic procedures on the basis of the fact that people wait longer to avoid noxious tests and/or procedures. The WTO method provides short-term quality of life tolls in terms of quality-adjusted life-weeks by scaling wait times with pre- and posttreatment utilities. Utilities for uterine fibroids before and after treatment were obtained with the TTO method and a visual analog scale (VAS) by using a questionnaire administered by means of a phone interview. WTO wait times were adjusted for quality of life with VAS and TTO utilities and a transformation of VAS. Wait times were compared by using nonparametric tests. The study participants included 62 patients who had undergone abdominal hysterectomy, 74 who had undergone UAE, and 61 who had undergone MR imaging-guided focused ultrasound surgery.

RESULTS

Quality of life increased with all treatments. The median WTO wait time was higher for hysterectomy (21.6 weeks) than for UAE or MR imaging-guided focused ultrasound surgery (14.1 weeks for both) (P < .05). Quality-adjusted life-week tolls were smaller when scaled according to TTO than when scaled according to VAS or transformation of VAS.

CONCLUSION

Quality of life increased after all fibroid treatments. WTO is feasible for assessing the quality-adjusted morbidity of treatment procedures.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11100704/-/DC1.

Cost-effectiveness of breast MR imaging and screen-film mammography for screening BRCA1 gene mutation carriers

PURPOSE

To evaluate the clinical effectiveness and cost-effectiveness of screening strategies in which MR imaging and screen-film mammography were used, alone and in combination, in women with BRCA1 mutations.

MATERIALS AND METHODS

Because this study did not involve primary data collection from individual patients, institutional review board approval was not needed. By using a simulation model, we compared three annual screening strategies for a cohort of 25-year-old BRCA1 mutation carriers, as follows: (a) screen-film mammography, (b) MR imaging, and (c) combined MR imaging and screen-film mammography (combined screening). The model was used to estimate quality-adjusted life-years (QALYs) and lifetime costs. Incremental cost-effectiveness ratios were calculated. Input parameters were obtained from the medical literature, existing databases, and calibration. Costs (2007 U.S. dollars) and quality-of-life adjustments were derived from Medicare reimbursement rates and the medical literature. Sensitivity analysis was performed to evaluate the effect of uncertainty in parameter estimates on model results.

RESULTS

In the base-case analysis, annual combined screening was most effective (44.62 QALYs), and had the highest cost ($110973), followed by annual MR imaging alone (44.50 QALYs, $108641), and annual mammography alone (44.46 QALYs, $100336). Adding annual MR imaging to annual mammographic screening cost $69125 for each additional QALY gained. Sensitivity analysis indicated that, when the screening MR imaging cost increased to $960 (base case, $577), or breast cancer risk by age 70 years decreased below 58% (base case, 65%), or the sensitivity of combined screening decreased below 76% (base case, 94%), the cost of adding MR imaging to mammography exceeded $100000 per QALY.

CONCLUSION

Annual combined screening provides the greatest life expectancy and is likely cost-effective when the value placed on gaining an additional QALY is in the range of $50000-$100000.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.09091086/-/DC1.

Measuring the quality-of-life effects of diagnostic and screening tests

Health-related quality of life (HRQL) is a central concept for understanding the outcomes of medical care. When used in cost-effectiveness analysis, HRQL is typically measured for conditions persisting over long time frames (years), and quality-adjusted life year (QALY) values are generated. Consequently, years are the basic unit of time for cost-effectiveness analysis results: dollars spent per QALY gained. However, shorter term components of health care may also affect HRQL, and there is increased interest in measuring and accounting for these events. In radiology, the short-term HRQL effects of screening and diagnostic testing may affect a test's cost-effectiveness, even though they may only last for days. The unique challenge in radiology HRQL assessment is to realistically tap into the testing and screening experience while remaining consistent with QALY theory. The authors review HRQL assessment and highlight methods developed to specifically address the short-term effects of radiologic screening and testing.

Identifying the best treatment among common nonsurgical neck pain treatments: a decision analysis

STUDY DESIGN

Decision analysis.

OBJECTIVE

To identify the best treatment for nonspecific neck pain.

SUMMARY OF BACKGROUND DATA

In Canada and the United States, the most commonly prescribed neck pain treatments are nonsteroidal anti-inflammatory drugs (NSAIDs), exercise, and manual therapy. Deciding which treatment is best is difficult because of the trade-offs between beneficial and harmful effects, and because of the uncertainty of these effects.

METHODS

(Quality-adjusted) life expectancy associated with standard NSAIDs, Cox-2 NSAIDs, exercise, mobilization, and manipulation were compared in a decisionanalytic model. Estimates of the course of neck pain, background risk of adverse events in the general population, treatment effectiveness and risk, and patient-preferences were input into the model. Assuming equal effectiveness, we conducted a baseline analysis using risk of harm only. We assessed the stability of the baseline results by conducting a second analysis that incorporated effectiveness data from a high-quality randomized trial.

RESULTS

There were no important differences across treatments. The difference between the highest and lowest ranked treatments predicted by the baseline model was 4.5 days of life expectancy and 3.4 quality-adjusted life-days. The difference between the highest and lowest ranked treatments predicted by the second model was 7.3 quality-adjusted life-days.

CONCLUSION

When the objective is to maximize life expectancy and quality-adjusted life expectancy, none of the treatments in our analysis were clearly superior.

Methods for measuring temporary health States for cost-utility analyses

A variety of methods are available to measure preferences for temporary health states for cost-utility analyses. The objectives of this review were to summarize the available temporary health-state valuation methods, identify advantages and disadvantages of each, and identify areas for future research. We describe the key aspects of each method and summarize advantages and disadvantages of each method in terms of consistency with QALY theory, relevance to temporary health-state-specific domains, ease of use, time preference, and performance in validation studies. Two broad categories of methods were identified: traditional and adapted. Traditional methods were health status instruments, time trade-off (TTO), and the standard gamble (SG). Methods adapted specifically for temporary health-state valuation were TTO with specified duration of the health state, TTO with a lifespan modification, waiting trade-off, chained approaches for TTO and SG, and sleep trade-off. Advantages and disadvantages vary by method and no 'gold standard' method emerged. Selection of a method to value temporary health states will depend on the relative importance of the following considerations: ability to accurately capture the unique characteristics of the temporary health state, level of respondent burden and cognition, theoretical consistency of elicited preference values with the overall purpose of the study, and resources available for study development and data collection. Further research should focus on evaluating validity, reliability and feasibility of temporary health-state valuation methods.

Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer

CONTEXT

Screening ultrasound may depict small, node-negative breast cancers not seen on mammography.

OBJECTIVE

To compare the diagnostic yield, defined as the proportion of women with positive screen test results and positive reference standard, and performance of screening with ultrasound plus mammography vs mammography alone in women at elevated risk of breast cancer.

DESIGN, SETTING, AND PARTICIPANTS

From April 2004 to February 2006, 2809 women, with at least heterogeneously dense breast tissue in at least 1 quadrant, were recruited from 21 sites to undergo mammographic and physician-performed ultrasonographic examinations in randomized order by a radiologist masked to the other examination results. Reference standard was defined as a combination of pathology and 12-month follow-up and was available for 2637 (96.8%) of the 2725 eligible participants.

MAIN OUTCOME MEASURES

Diagnostic yield, sensitivity, specificity, and diagnostic accuracy (assessed by the area under the receiver operating characteristic curve) of combined mammography plus ultrasound vs mammography alone and the positive predictive value of biopsy recommendations for mammography plus ultrasound vs mammography alone.

RESULTS

Forty participants (41 breasts) were diagnosed with cancer: 8 suspicious on both ultrasound and mammography, 12 on ultrasound alone, 12 on mammography alone, and 8 participants (9 breasts) on neither. The diagnostic yield for mammography was 7.6 per 1000 women screened (20 of 2637) and increased to 11.8 per 1000 (31 of 2637) for combined mammography plus ultrasound; the supplemental yield was 4.2 per 1000 women screened (95% confidence interval [CI], 1.1-7.2 per 1000; P = .003 that supplemental yield is 0). The diagnostic accuracy for mammography was 0.78 (95% CI, 0.67-0.87) and increased to 0.91 (95% CI, 0.84-0.96) for mammography plus ultrasound (P = .003 that difference is 0). Of 12 supplemental cancers detected by ultrasound alone, 11 (92%) were invasive with a median size of 10 mm (range, 5-40 mm; mean [SE], 12.6 [3.0] mm) and 8 of the 9 lesions (89%) reported had negative nodes. The positive predictive value of biopsy recommendation after full diagnostic workup was 19 of 84 for mammography (22.6%; 95% CI, 14.2%-33%), 21 of 235 for ultrasound (8.9%, 95% CI, 5.6%-13.3%), and 31 of 276 for combined mammography plus ultrasound (11.2%; 95% CI. 7.8%-15.6%).

CONCLUSIONS

Adding a single screening ultrasound to mammography will yield an additional 1.1 to 7.2 cancers per 1000 high-risk women, but it will also substantially increase the number of false positives.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00072501.

Identifying the best treatment among common nonsurgical neck pain treatments: a decision analysis

STUDY DESIGN

Decision analysis.

OBJECTIVE

To identify the best treatment for nonspecific neck pain.

SUMMARY OF BACKGROUND DATA

In Canada and the United States, the most commonly prescribed neck pain treatments are nonsteroidal anti-inflammatory drugs (NSAIDs), exercise, and manual therapy. Deciding which treatment is best is difficult because of the trade-offs between beneficial and harmful effects, and because of the uncertainty of these effects.

METHODS

(Quality-adjusted) life expectancy associated with standard NSAIDs, Cox-2 NSAIDs, exercise, mobilization, and manipulation were compared in a decision-analytic model. Estimates of the course of neck pain, background risk of adverse events in the general population, treatment effectiveness and risk, and patient-preferences were input into the model. Assuming equal effectiveness, we conducted a baseline analysis using risk of harm only. We assessed the stability of the baseline results by conducting a second analysis that incorporated effectiveness data from a high-quality randomized trial.

RESULTS

There were no important differences across treatments. The difference between the highest and lowest ranked treatments predicted by the baseline model was 4.5 days of life expectancy and 3.4 quality-adjusted life-days. The difference between the highest and lowest ranked treatments predicted by the second model was 7.3 quality-adjusted life-days.

CONCLUSION

When the objective is to maximize life expectancy and quality-adjusted life expectancy, none of the treatments in our analysis were clearly superior.

Community and patient values for preventing herpes zoster

OBJECTIVES

The US Advisory Committee on Immunization Practices has recently recommended a new vaccine against herpes zoster (shingles) for routine use in adults aged > or =60 years. However, estimates of the cost effectiveness of this vaccine vary widely, in part because of gaps in the data on the value of preventing herpes zoster. Our aims were to (i) generate comprehensive information on the value of preventing a range of outcomes of herpes zoster; (ii) compare these values among community members and patients with shingles and post-herpetic neuralgia (PHN); and (iii) identify clinical and demographic characteristics that explain the variation in these values.

METHODS

Community members drawn from a nationally representative survey research panel (n = 527) completed an Internet-based survey using time trade-off and willingness-to-pay questions to value a series of scenarios that described cases of herpes zoster with varying pain intensities (on a scale of 0 to 10, where 0 represents no pain and 10 represents the worst imaginable pain) and duration (30 days to 1 year). Patients with shingles (n = 382) or PHN (n = 137) [defined as having symptoms for > or =90 days] from two large healthcare systems completed telephone interviews with similar questions to the Internet-based survey and also answered questions about their current experience with herpes zoster. We constructed generalized linear mixed models to evaluate the associations between demographic and clinical characteristics, the length and intensity of the health states and time trade-off and willingness-to-pay values.

RESULTS

In time trade-off questions, community members offered a mean of 89 (95% CI 24, 182) discounted days to avoid the least severe scenario (pain level of 3 for 1 month) and a mean of 162 (95% CI 88, 259) discounted days to avoid the most severe scenario (pain level of 8 for 12 months). Compared with patients with shingles, community members traded more days to avoid low-severity scenarios but similar numbers of days to avoid high-severity scenarios. Compared with patients with PHN, community members traded fewer days to avoid high-severity scenarios. In multivariate analyses, older age was the only characteristic significantly associated with higher time trade-off values. In willingness-to-pay questions, community members offered a mean of $US450 (95% CI 203, 893) to avoid pain of level 3 for 1 month and a mean of $US1384 (95% CI 873, 2050) [year 2005 values] to avoid pain of level 8 for 12 months. Community members traded less money than patients with either shingles or PHN to avoid both low- and high-severity scenarios (p-values <0.05 to <0.001). In multivariate models, male gender, higher income and having experienced shingles or PHN were associated with higher willingness to pay to avoid herpes zoster. When patients were asked to assign a value to avoiding their own case of herpes zoster, those with shingles assigned a mean of 67 days or $US2319, while those with PHN assigned a mean of 206 days or $US18 184. Both the time and monetary value traded were associated with the maximum intensity of the pain the individual had experienced, but neither was associated with the duration of the pain.

CONCLUSIONS

We believe that this study provides the most comprehensive information to date on the value individuals place on preventing herpes zoster, and it includes the only such valuation from nationally representative community members as well as patients with herpes zoster. Community members would trade substantial amounts of time or money to avoid herpes zoster, even in the least severe scenarios. The time trade-off results in this study may differ from those in other studies because of important differences in methods of assessing health utilities. Consideration of both community and patient perspectives is crucial to help decision makers fully determine the implications of their policies now that a vaccine against herpes zoster is available.