What is the relationship between the minimally important difference and health state utility values? The case of the SF-6D

Health-related quality of life of adults with spinal muscular atrophy: insights from a nationwide patient registry in Germany

PURPOSE

Spinal muscular atrophy (SMA) is a rare, autosomal-recessive disease characterized by progressive muscular atrophy and weakness resulting in substantial disability and short life expectancy. The objective of this cross-sectional study was to assess health-related quality of life (HRQoL) of adults with SMA in Germany in the era of disease-modifying therapy.

METHODS

Adults with SMA were recruited via the German national TREAT-NMD SMA patient registry. HRQoL was measured using the EQ-5D-5L, the Health Utilities Index Mark III (HUI), and the Short Form (36) Health Survey (SF-36). Estimates were stratified by current best motor function of the lower limb and trunk (i.e., non-sitter, sitter, and walker) and SMA type (i.e., type I, II, and III).

RESULTS

A total of 82 adults with SMA (mean age: 42 years, 51% female) self-completed the study questionnaire. The mean EQ-5D-5L utility was estimated at 0.5135 (range across subgroups: 0.31-0.99), mean EQ-VAS at 69.71 (64.67-90.00), mean HUI-derived utility at 0.3171 ( - 0.02-0.96), mean SF-6D utility at 0.6308 (0.58-0.65), and mean SF-36 Physical Component Summary and Mental Health Component Summary scores at 33.78 (9.92-53.10) and 53.49 (21.02-72.25), respectively.

CONCLUSIONS

We show that adults with SMA experience considerable impairment across a wide range of health dimensions, including mobility, dexterity, pain, and emotional well-being. However, our results exhibit non-trivial variability across clinical subgroups and HRQoL measures. These data contribute to our understanding of the subjective impact of living with a severely debilitating neuromuscular disease, such as SMA.

Association between Quality of Life and Visual Acuity in a Randomized Clinical Trial of Patients with Uveitis Taking Antimetabolites

PURPOSE

To evaluate how changes in visual acuity are associated with changes in quality of life (QoL) among patients with non-infectious uveitis taking antimetabolites.

METHODS

This secondary analysis of the multicenter First-line Antimetabolites as Steroid-sparing Treatment (FAST) Uveitis Trial involves 216 participants randomized to methotrexate or mycophenolate mofetil. Vision-related (NEI-VFQ and IND-VFQ) and health-related (PCS and MCS SF-36v2) QoL and visual acuity were measured at baseline and 6-month primary endpoint.

RESULTS

Visual acuity was significantly associated and correlated with all QoL measures (Spearman correlation coefficients = 0.5, 0.5, 0.3, and 0.4 for NEI-VFQ, IND-VFQ, SF-36v2 MCS and PCS, respectively). All observed changes in QoL met or exceeded the minimal clinically important difference definition on each scale. Treatment group was not significantly associated with any QoL measure.

CONCLUSION

By adding insight beyond visual acuity, QoL provides a more comprehensive picture of the patient experience during uveitis treatment.Abbreviations and Acronyms: QoL = quality of life; VR-QoL = vision-related quality of life; HR-QoL = health-related quality of life; FAST = First-line Antimetabolites as Corticosteroid Sparing Treatment; NEI-VFQ = National Eye Institute Visual Functioning Questionnaire; IND-VFQ = Indian Visual Functioning Questionnaire; SF-36v2 = Medical Outcomes Study 36-Item Short Form Survey; PCS = physical component score; MCS = mental component score; 95% CI = 95% confidence interval; MCID = minimal clinically important difference.

Health-related quality of life during the COVID-19 pandemic: The impact of restrictive measures using data from two Dutch population-based cohort studies

OBJECTIVES

We describe health-related quality of life during the COVID-19 pandemic in the general Dutch population and correlations with restrictive measures.

METHODS

Data were obtained from 18-85 year-old participants of two population-based cohort studies (February 2021-July 2022): PIENTER Corona (n = 8,019) and VASCO (n = 45,413). Per cohort, mean scores of mental and physical health and health utility from the SF-12 were calculated by age group, sex and presence of a medical risk condition. Spearman correlations with stringency of measures were calculated.

RESULTS

Both cohorts showed comparable results. Participants <30 years had lowest health utility and mental health score, and highest physical health score. Health utility and mental health score increased with age (up to 79 years), while physical health score decreased with age. Women and participants with a medical risk condition scored lower than their counterparts. Fluctuations were small over time but most pronounced among participants <60 years, and correlated weakly, but mostly positively with measure stringency.

CONCLUSIONS

During the Dutch COVID-19 epidemic, health utility and mental health scores were lower and fluctuated strongest among young adults compared to older adults. In our study population, age, sex and presence of a medical risk condition seemed to have more impact on health scores than stringency of COVID-19 non-pharmaceutical interventions.

Bathing Adaptations in the Homes of Older Adults (BATH-OUT-2): study protocol for a randomised controlled trial, economic evaluation and process evaluation

BACKGROUND

The onset of disability in bathing is particularly important for older adults as it can be rapidly followed by disability in other daily activities; this may represent a judicious time point for intervention in order to improve health, well-being and associated quality of life. An important environmental and preventative intervention is housing adaptation, but there are often lengthy waiting times for statutory provision. In this randomised controlled trial (RCT), we aim to evaluate the effectiveness and cost-effectiveness of bathing adaptations compared to no adaptations and to explore the factors associated with routine and expedited implementation of bathing adaptations.

METHODS

BATH-OUT-2 is a multicentre, two-arm, parallel-group RCT. Adults aged 60 and over who are referred to their local authority for an accessible level access shower will be randomised, using pairwise randomisation, 1:1, to receive either an expedited provision of an accessible shower via the local authority or a usual care control waiting list. Participants will be followed up for a maximum of 12 months and will receive up to four follow-ups in this duration. The primary outcome will be the participant's physical well-being, assessed by the Physical Component Summary score of the Short Form-36 (SF-36), 4 weeks after the intervention group receives the accessible shower. The secondary outcomes include the Mental Component Summary score of the SF-36, self-reported falls, health and social care resource use, health-related quality of life (EQ-5D-5L), social care-related quality of life (Adult Social Care Outcomes Toolkit (ASCOT)), fear of falling (Short Falls Efficacy Scale), independence in bathing (Barthel Index bathing question), independence in daily activities (Barthel Index) and perceived difficulty in bathing (0-100 scale). A mixed-methods process evaluation will comprise interviews with stakeholders and a survey of local authorities with social care responsibilities in England.

DISCUSSION

The BATH-OUT-2 trial is designed so that the findings will inform future decisions regarding the provision of bathing adaptations for older adults. This trial has the potential to highlight, and then reduce, health inequalities associated with waiting times for bathing adaptations and to influence policies for older adults.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN48563324. Prospectively registered on 09/04/2021.

Health-related quality of life and experience measures, to assess patients' experiences of peripheral intravenous catheters: a secondary data analysis

BACKGROUND

Peripheral intravenous catheters (PIVCs) are essential for successful administration of intravenous treatments. However, insertion failure and PIVC complications are common and negatively impact patients' health-outcomes and experiences. We aimed to assess whether generic (not condition-specific) quality of life and experience measures were suitable for assessing outcomes and experiences of patients with PIVCs.

METHODS

We undertook a secondary analysis of data collected on three existing instruments within a large randomised controlled trial, conducted at two adult tertiary hospitals in Queensland, Australia. Instruments included the EuroQol Five Dimension - Five Level (EQ5D-5L), the Functional Assessment of Chronic Illness Therapy - Treatment Satisfaction - General measure (FACIT-TS-G, eight items), and the Australian Hospital Patient Experience Question Set (AHPEQS, 12 items). Responses were compared against two clinical PIVC outcomes of interest: all-cause failure and multiple insertion attempts. Classic descriptives were reported for ceiling and floor effects. Regression analyses examined validity (discrimination). Standardised response mean and effect size (ES) assessed responsiveness (EQ5D-5L, only).

RESULTS

In total, 685 participants completed the EQ5D-5L at insertion and 526 at removal. The FACIT-TS-G was completed by 264 and the AHPEQS by 262 participants. Two FACIT-TS-G items and one AHPEQS item demonstrated ceiling effect. Instruments overall demonstrated poor discrimination, however, all-cause PIVC failure was significantly associated with several individual items in the instruments (e.g., AHPEQS, 'unexpected physical and emotional harm'). EQ5D-5L demonstrated trivial (ES < 0.20) responsiveness.

CONCLUSIONS

Initial investigation of an existing health-related quality of life measure (EQ5D-5L) and two patient-reported experience measures (FACIT-TS-G; AHPEQS) suggest they are inadequate (as a summary measure) to assess outcomes and experiences for patients with PIVCs. Reliable instruments are urgently needed to inform quality improvement and benchmark standards of care.

Surgical correction of the genital hiatus at the time of sacrocolpopexy - a 7-year Markov analysis: a cost-effectiveness analysis

INTRODUCTION AND HYPOTHESIS

To perform a cost-effectiveness analysis of concurrent posterior repair performed at the time of laparoscopic hysterectomy with sacrocolpopexy over a 7-year time period. We hypothesize it is not cost-effective to perform a posterior colporrhaphy.

METHODS

We used TreeAge Pro® to construct a decision model with Markov modeling to compare sacrocolpopexy with and without concurrent posterior repair (SCP and SCP+PR) over a time horizon of 7 years. Outcomes included probability and costs associated with prolapse recurrence, prolapse retreatment, and complications including rectal injury, rectovaginal hematoma requiring reoperation, and postoperative dyspareunia. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) calculated as ∆ costs /∆ effectiveness and the willingness to pay (WTP) was set at $100,000/QALY.

RESULTS

Our model showed that SCP was the dominant strategy, with lower costs (-$ 2681.06) and higher effectiveness (+0.10) compared to SCP+PR over the 7-year period. In two-way sensitivity analyses, we varied the probability of prolapse recurrence after both strategies. Our conclusions would only change if the probability of recurrence after SCP was at least 29.7% higher than after SCP+PR. When varying the probabilities of dyspareunia for both strategies, SCP+PR only became the dominant strategy if the probability of dyspareunia for SCP+PR was lower than the rate of SCP alone.

CONCLUSIONS

In this 7-year Markov cost-effectiveness analysis, SCP without concurrent PR was the dominant strategy. SCP+PR costs more with lower effectiveness than SCP alone, due to higher surgical cost of SCP+PR and higher probability of dyspareunia after SCP+PR.

Characterization of quality of life among individuals with current treated, untreated, and past alcohol use disorder

Background: Understanding health-related quality of life (HRQOL) among those who seek treatment for their alcohol use disorder (AUD) and those not seeking AUD treatment is critical to decreasing morbidity and mortality, yet HRQOL in these groups has been little characterized.Objectives: Characterize HRQOL among those who meet diagnostic criteria for AUD, both receiving and not receiving treatment.Methods: This analysis used the NESARC-III database (n = 36,309; female = 56.3%), a nationally representative survey of US adults, to compare four groups: those treated for current AUD; those untreated for current AUD; those with past AUD only; and those who never met criteria for AUD. Multiple regression analysis was used to account for differences in sociodemographic and other behavioral factors across these groups. HRQOL was operationalized using annual quality-adjusted life years (QALYs).Results: Patients treated for past-year AUD had a deficit of 0.07 QALYs/year compared to those who never met criteria for AUD (P < .001). They retained a still clinically meaningful 0.03 QALYs/year deficit after controlling for concomitant psychiatric disorders and other behavioral health factors (P < .001). Those with past-year untreated AUD or past AUD had a near-zero difference in QALYs compared with those who never met criteria for AUD.Conclusion: These findings suggest that previously-reported differences in HRQOL associated with AUD may be due to the problems of the relatively small sub-group who seek treatment. Clinicians seeking to treat those with currently untreated AUD may do better to focus on the latent potential health effects of AUD instead of current HRQOL concerns.

Rationale and protocol for a safety, tolerability and feasibility randomized, parallel group, double-blind, placebo-controlled, pilot study of a novel ketone ester targeting frailty via immunometabolic geroscience mechanisms

Background

Frailty is a geriatric syndrome characterized by chronic inflammation and metabolic insufficiency that creates vulnerability to poor outcomes with aging. We hypothesize that geroscience interventions, which target mechanisms of aging, could ameliorate frailty. Metabolites such as ketone bodies are candidate geroscience interventions, having pleiotropic effects on inflammo-metabolic aging mechanisms. Ketone esters (KEs) induce ketosis without dietary changes, but KEs have not been studied in an older adult population. Our long-term goal is to examine if KEs modulate geroscience mechanisms and clinical outcomes relevant to frailty in older adults.

Objectives

The primary objective of this randomized, placebo-controlled, double-blinded, parallel-group, pilot trial is to determine tolerability of 12-weeks of KE ingestion in a generalizable population of older adults (≥ 65 years). Secondary outcomes include safety and acute blood ketone kinetics. Exploratory outcomes include physical function, cognitive function, quality of life, aging biomarkers and inflammatory measures.

Methods

Community-dwelling adults who are independent in activities of daily living, with no unstable acute medical conditions (n=30) will be recruited. The study intervention is a KE or a taste, appearance, and calorie matched placebo beverage. Initially, acute 4-hour ketone kinetics after 12.5g or 25g of KE consumption will be assessed. After collection of baseline safety, functional, and biological measurements, subjects will randomly be allocated to consume KE 25g or placebo once daily for 12-weeks. Questionnaires will assess tolerability daily for 2-weeks, and then via phone interview at bi-monthly intervals. Safety assessments will be repeated at week 4. All measures will be repeated at week 12.

Conclusion

This study will evaluate feasibility, tolerability, and safety of KE consumption in older adults and provide exploratory data across a range of geroscience-related endpoints. This data will inform design of larger trials to rigorously test KE effects on geroscience mechanisms and clinical outcomes relevant to frailty.

Cost-effectiveness of somatrogon in the Spanish pediatric population with growth hormone deficiency

OBJECTIVE

To analyze the cost-effectiveness of weekly somatrogon compared to daily growth hormones (GH-d) in the pediatric population of Spain with growth hormone deficiency (GHD).

METHODS

Markov model with two states (patients with or without GH-d or somatrogon treatment) in prepubertal children (3 to 11 years and 3 to 12 years in girls and boys, respectively) with GHD in isolation or as part of multiple pituitary hormone deficiency and without previous treatment, from the perspective of the National Health System. The simulation of the economic model ends at the age of 18. The costs of hormones and monitoring were obtained from Spanish sources. The utilities were obtained from the literature. Spanish clinical experts validated the assumptions of the model.

RESULTS

In the deterministic analysis, somatrogon would be cost-effective, compared to GH-d, with a cost per QALY (quality-adjusted life year) gained of €19,259 and a clinically relevant QALY gain (0.336). This result was confirmed in deterministic sensitivity analyses. According to the probabilistic analysis, somatrogon would be the dominant treatment, with a 61% probability of a willingness to pay of €25,000 per QALY gained.

CONCLUSION

Compared to GH-d, somatrogon is cost-effective in the Spanish pediatric population with GHD.

Resurrecting Multiattribute Utility Function: Developing a Value Set for Health Utility for Glaucoma

OBJECTIVES

This study aimed to develop a scoring function to calculate health utilities for health states described by the Health Utility for Glaucoma (HUG-5) based on the preferences of the general population in the United States.

METHODS

Preferences for HUG-5 health states were elicited using the standard gamble and visual analog scale through an online survey. Quota-based sampling was used to recruit a representative sample of the US general population in terms of age, sex, and race. A multiple attribute disutility function (MADUF) approach was adopted to derive scoring for the HUG-5. Model fit was assessed using mean absolute error associated with 5 HUG-5 marker health states that describe mild/moderate and severe glaucoma.

RESULTS

Of 634 respondents completing the tasks, 416 were included in the estimation of the MADUF; 260 respondents (63%) considered worst possible HUG-5 health state better than death. The preferred scoring function generates the utilities ranging from 0.05 (worst HUG-5 health state) to 1 (best HUG-5 health state). The correlation between mean elicited and estimated values for marker states was strong (R² = 0.97) with mean absolute error = 0.11.

CONCLUSIONS

The MADUF for HUG-5 is used to measure health utilities on the scale of perfect health and death, which can be used to estimate quality-adjusted life-years for economic evaluations of glaucoma interventions.

Sex Differences in Presentation and Surgical Outcomes From a Prospective Multicenter Chronic Rhinosinusitis Study

OBJECTIVE

Despite extensive research into chronic rhinosinusitis (CRS) epidemiology, presentation, and outcomes, there is scant knowledge on sex-specific differences. The objective of this study was to identify differences between male and female patients with CRS in baseline disease severity at presentation, choice for surgery vs continued medical treatment, and postoperative response.

STUDY DESIGN

We evaluated data on demographic and health characteristics, clinical objective disease measures, and sinus-specific and general health patient-reported outcome measures.

SETTING

Secondary analysis of prospective multicenter outcome study.

METHODS

Comparison of cohort characteristics and baseline and postoperative measures was performed with a t test, chi-square test of independence, or Fisher exact test. Within-subject improvement was compared between sexes with a linear mixed model.

RESULTS

Females reported worse quality of life on presentation and postsurgery, despite experiencing less severe disease by standard clinical measures. Overall, females and males showed similar within-subject improvement after surgery. However, certain quality of life domains and disease measures showed sex-specific improvement. Females demonstrated greater within-subject improvement in SF6D-derived health utility and the SNOT-22 ear and facial, psychological, and sleep subdomains, although this did not reach statistical significance for the overall cohort.

CONCLUSION

Incorporating data on sex-specific differences may be important to personalize CRS treatment decision making. The discordance between patient-reported and clinical measures in CRS has been demonstrated in other pathologies and appears to be exaggerated by sex. Biological and psychological bases for sex-specific differences in CRS manifestations are an intriguing topic for further research.

Higher diet quality is associated with short and long-term benefits on SF-6D health state utilities: a 5-year cohort study in an international sample of people with multiple sclerosis

BACKGROUND/PURPOSE

Health state utilities (HSU) are a subjective measure of an individual's health-related quality of life (HRQoL), adjusted by societal or patient relative preference weights for living in different states of health-related quality of life (HRQoL), derived from patient-reported responses to multi-attribute utility instrument (MAUI), and can be used as inputs for cost-utility analyses and in clinical assessment. This research assessed associations of diet with subsequent HSU in a large international cohort of people living with multiple sclerosis (MS), a progressive autoimmune condition of the central nervous system.

METHODS

HSUs were generated from responses to Short-Form Six-Dimension (SF-6D) MAUI, and quality-of-the-diet by Diet Habits Questionnaire (DHQ). Cross-sectional, and short- and long-term prospective associations of DHQ with HSU evaluated by linear regression at 2.5- and 5-years. Pooled prospective associations between DHQ and HSU evaluated using linear and quantile regression. Analyses adjusted for relevant demographic and clinical covariates.

RESULTS

Among 839 participants, baseline DHQ scores showed short- and long-term associations with subsequent HSU, each 10-unit increase in total DHQ score associated with 0.008-0.012 higher HSU (out of 1.00). These associations were dose-dependent, those in the top two quartiles of baseline DHQ scores having 0.01-0.03 higher HSU at follow-up, 0.03 being the threshold for a minimally clinically important difference. Fat, fiber, and fruit/vegetable DHQ subscores were most strongly and consistently associated with better HSU outcomes. However, baseline meat and dairy consumption were associated with 0.01-0.02 lower HSU at subsequent follow-up.

CONCLUSIONS

A higher quality-of-the-diet showed robust prospective relationships with higher HSUs 2.5- and 5-years later, substantiating previous cross-sectional relationships in this cohort. Subject to replication, these results suggest interventions to improve the quality-of-the-diet may be effective to improve HRQoL in people living with MS.

How gambling problems relate to health and wellbeing in Australian households: Evidence from the Household Income and Labour Dynamics of Australia Survey

Gambling harms can impact the health and wellbeing of both individuals who gamble and those close to them. While harms occur across a spectrum of gambling risk levels, most research is conducted on people close to those gamblers who have severe problems. This study examined the health and wellbeing of people living with gamblers across the entire spectrum of gambling risk levels, via secondary analysis of the nationally-representative Household Income and Labour Dynamics in Australia Survey (HILDA). The subsample of interest comprised 13,698 respondents without a gambling problem of their own, aged between 15 and 84, and who lived in households where all residents completed the Problem Gambling Severity Index (PGSI). Health and wellbeing were measured via the SF-6D, the SF-36, and subjective wellbeing measures. Compared to those living in non-problem gambling households, participants living in problem-gambling households reported significantly lower mean SF-6D scores, lower scores on the SF-36 mental health domain, and significantly less satisfaction with both their financial situation and with feeling part of their local community. Participants living in moderate-risk gambling households also reported less satisfaction with their financial situation than those in non-problem gambling households. Conclusions: The results indicate that measurable impacts to the health and wellbeing of those living with gamblers occur predominantly at the more severe end of the risk level spectrum, except for financial dissatisfaction, which is also evident in those residing with gamblers categorised as moderate-risk.

Cost-effectiveness of cladribine tablets and dimethyl fumarate in the treatment of relapsing remitting multiple sclerosis in Spain

Aim: To analyze the cost-effectiveness of treatment of relapsing remitting multiple sclerosis (RRMS) with cladribine tablets (CladT) and dimethyl fumarate (DMF) from the perspective of the Spanish National Health System (NHS). Methods: A probabilistic Markov model (second-order Monte Carlo simulation) with a 10-year time horizon and annual Markov cycles was performed. Results: CladT was the dominant treatment, with lower costs (-74,741 € [95% CI: -67,247; -85,661 €]) and greater effectiveness (0.1920 [95% CI: -0.1659; 0.2173] QALY) per patient, compared with DMF. CladT had a 95.1% probability of being cost-effective and a 94.1% chance of being dominant compared with DMF. Conclusion: CladT is the dominant treatment (lower costs, with more QALYs) compared with DMF in the treatment of RRMS in Spain.

Racial and Ethnic Disparity in Preference-Weighted Quality of Life: Findings from the Selenium and Vitamin E Cancer Prevention Trial

Differences in preference-weighted health-related quality of life (HRQOL) scores by race/ethnicity may be due to social factors. Here, Short-Form Six-Dimension (SF-6D) scores are analyzed among men in a prostate cancer prevention trial to explore such differences. Selenium and vitamin E cancer prevention trial participants who completed the SF-6D at baseline, and in at least 1 of follow-up years 1, 3, and 5 were included. This study compared mean SF-6D scores across race/ethnicity at each point using a linear mixed model controlling for demographic and clinical characteristics. At baseline, 9691 men were eligible for analysis, of whom 7556 (78%) were non-Hispanic White, 1592 (16.4%) were non-Hispanic Black, and 543 (5.6%) were Hispanic. Hispanic and White participants had higher unadjusted mean SF-6D scores than Black participants at every time point (P < 0.05), while white participants had lower mean scores than Hispanic participants at every time point after baseline (P < 0.05). After adjusting for covariates, statistically significant differences in HRQOL among the 3 groups persisted. Hispanic participants had higher preference scores than White participants by 0.073 (P < 0.001), 0.075 (P < 0.001), and 0.040 (P < 0.001) in follow-up years 1, 3, and 5, respectively. Black participants had lower scores than White participants by 0.009 (P = 0.004) and 0.008 (P = 0.02) in follow-up years 1 and 3, respectively. The results suggest there is a preference-weighted HRQOL difference by race/ethnicity that cannot be explained by social and clinical variables alone. Understanding how individuals belonging to different racial/ethnic categories view their own HRQOL is necessary for culturally competent care and cost-effectiveness analyses.

A non-randomised controlled study to assess the effectiveness of a new proactive multidisciplinary care intervention for older people living with frailty

Background

Integrated care may improve outcomes for older people living with frailty. We aimed to assess the effectiveness of a new, anticipatory, multidisciplinary care service in improving the wellbeing and quality of life (QoL) of older people living with severe frailty.

Methods

A community-based non-randomised controlled study. Participants (≥65 years, electronic Frailty Index ≥0.36) received either the new integrated care service plus usual care, or usual care alone. Data collection was at three time points: baseline, 2-4 weeks, and 10-14 weeks. The primary outcome was patient wellbeing (symptoms and other concerns) at 2-4 weeks, measured using the Integrated Palliative care Outcome Scale (IPOS); the secondary outcome was QoL, measured using EQ-5D-5L. To test duration of effect and safety, wellbeing and QoL were also measured at 10-14 weeks. Descriptive statistics were used to characterise and compare intervention and control groups (eligible but had not accessed the new service), with t-test, Chi-Square, or Mann-Whitney U tests (as appropriate) to test differences at each time point. Generalised linear modelling, with propensity score matching, was used for further group comparisons. Data were analysed using STATA v17.

Results

199 intervention and 54 control participants were recruited. At baseline, intervention and control groups were similar in age, gender, ethnicity, living status, and body mass index, but not functional status or area deprivation score. At 2-4 weeks, wellbeing had improved in the intervention group but worsened in the control (median IPOS -5 versus 2, p<0.001). QoL improved in the intervention group but was unchanged in the control (median EQ-5D-5L 0.12, versus 0.00, p<0.001). After adjusting for age, gender, and living status, the intervention group had an average total IPOS score reduction at 2-4 weeks of 6.34 (95% CI: -9.01: -4.26, p<0.05); this improvement was sustained, with an average total IPOS score reduction at 10-14 weeks of 6.36 (95% CI: -8.91:-3.80, p<0.05). After propensity score matching based on functional status/area deprivation, modelling showed similar results, with a reduction in IPOS score at 2-4 weeks in the intervention group of 7.88 (95% CI: -12.80: -2.96, p<0.001).

Conclusions

Our findings suggest that the new, anticipatory, multidisciplinary care service may have improved the overall wellbeing and quality of life of older people living with frailty at 2-4 weeks and the improvement in wellbeing was sustained at three months.

Ethics approval

NHS Research Ethics Committee 18/YH/0470 and IRAS-250981.

Trial registration

The trial was retrospectively registered at the International Standard Randomised Controlled Trial Number (ISRCTN) registry (registration date: 01/08/2022, registration number: ISRCTN10613839).

Catquest-9SF questionnaire: Validation in a Greek-speaking population using Rasch analysis

PURPOSE

The Catquest-9SF questionnaire is a tool measuring visual disability and vision-related limitation in patients' daily activities. The primary objective of this study was the validation of Catquest-9SF in a Greek-speaking cataract population.

METHODS

The questionnaire was translated into Greek and translated back into English. A pre-final Greek version was formed and tested by 10 Greek-English bilingual participants and by the translation team, and the final version was produced. Patients scheduled for cataract surgery completed the questionnaire preoperatively and postoperatively. Rasch analysis was performed for the assessment of the Catquest-9SF psychometric properties, including response category ordering, item fit statistics, principal components analysis, precision, differential item functioning and targeting for preoperative and postoperative data collectively.

RESULTS

A total of 100 (55 men, 45 women, mean age = 71.94±6.63) cataract patients completed the Greek version of Catquest-9SF questionnaire preoperatively and postoperatively. Rasch analysis showed a significant improvement in the median person Rasch score from -1.49 preoperatively to -4.71 logits postoperatively, while the effect size was 1.3. Unidimensionality was confirmed since infit and outfit mean square values varied between 0.66 and 1.37. Rasch analysis showed good precision and separation ability (Person Separation Index of 3.28, and Person Reliability of 0.92). Four response categories were found for all items. The item-person means difference was -1.83 logits. The difference between preoperative and postoperative Catquest-9SF logit score was positively correlated with preoperative Catquest-9SF logit score (coeff. = 0.798, p<0.0001) and negatively correlated with postoperative spherical equivalent (coeff. = -0.825, p = 0.011).

CONCLUSION

The Greek version of Catquest-9SF proved to be reliable, valid, unidimensional and responsive to changes after cataract surgery presenting good psychometric properties for cataract patients. Some postoperative mistargeting was found indicating that the tasks were easily performed by respondents after cataract surgery.

TRIAL REGISTRATION

NCT05323526 -retrospectively registered.

Interventions for improving mobility after hip fracture surgery in adults

BACKGROUND

Improving mobility outcomes after hip fracture is key to recovery. Possible strategies include gait training, exercise and muscle stimulation. This is an update of a Cochrane Review last published in 2011.

OBJECTIVES

To evaluate the effects (benefits and harms) of interventions aimed at improving mobility and physical functioning after hip fracture surgery in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, trial registers and reference lists, to March 2021.

SELECTION CRITERIA

All randomised or quasi-randomised trials assessing mobility strategies after hip fracture surgery. Eligible strategies aimed to improve mobility and included care programmes, exercise (gait, balance and functional training, resistance/strength training, endurance, flexibility, three-dimensional (3D) exercise and general physical activity) or muscle stimulation. Intervention was compared with usual care (in-hospital) or with usual care, no intervention, sham exercise or social visit (post-hospital).

DATA COLLECTION AND ANALYSIS

Members of the review author team independently selected trials for inclusion, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. We used the assessment time point closest to four months for in-hospital studies, and the time point closest to the end of the intervention for post-hospital studies. Critical outcomes were mobility, walking speed, functioning, health-related quality of life, mortality, adverse effects and return to living at pre-fracture residence.

MAIN RESULTS

We included 40 randomised controlled trials (RCTs) with 4059 participants from 17 countries. On average, participants were 80 years old and 80% were women. The median number of study participants was 81 and all trials had unclear or high risk of bias for one or more domains. Most trials excluded people with cognitive impairment (70%), immobility and/or medical conditions affecting mobility (72%). In-hospital setting, mobility strategy versus control Eighteen trials (1433 participants) compared mobility strategies with control (usual care) in hospitals. Overall, such strategies may lead to a moderate, clinically-meaningful increase in mobility (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.10 to 0.96; 7 studies, 507 participants; low-certainty evidence) and a small, clinically meaningful improvement in walking speed (CI crosses zero so does not rule out a lack of effect (SMD 0.16, 95% CI -0.05 to 0.37; 6 studies, 360 participants; moderate-certainty evidence). Mobility strategies may make little or no difference to short-term (risk ratio (RR) 1.06, 95% CI 0.48 to 2.30; 6 studies, 489 participants; low-certainty evidence) or long-term mortality (RR 1.22, 95% CI 0.48 to 3.12; 2 studies, 133 participants; low-certainty evidence), adverse events measured by hospital re-admission (RR 0.70, 95% CI 0.44 to 1.11; 4 studies, 322 participants; low-certainty evidence), or return to pre-fracture residence (RR 1.07, 95% CI 0.73 to 1.56; 2 studies, 240 participants; low-certainty evidence). We are uncertain whether mobility strategies improve functioning or health-related quality of life as the certainty of evidence was very low. Gait, balance and functional training probably causes a moderate improvement in mobility (SMD 0.57, 95% CI 0.07 to 1.06; 6 studies, 463 participants; moderate-certainty evidence). There was little or no difference in effects on mobility for resistance training. No studies of other types of exercise or electrical stimulation reported mobility outcomes. Post-hospital setting, mobility strategy versus control Twenty-two trials (2626 participants) compared mobility strategies with control (usual care, no intervention, sham exercise or social visit) in the post-hospital setting. Mobility strategies lead to a small, clinically meaningful increase in mobility (SMD 0.32, 95% CI 0.11 to 0.54; 7 studies, 761 participants; high-certainty evidence) and a small, clinically meaningful improvement in walking speed compared to control (SMD 0.16, 95% CI 0.04 to 0.29; 14 studies, 1067 participants; high-certainty evidence). Mobility strategies lead to a small, non-clinically meaningful increase in functioning (SMD 0.23, 95% CI 0.10 to 0.36; 9 studies, 936 participants; high-certainty evidence), and probably lead to a slight increase in quality of life that may not be clinically meaningful (SMD 0.14, 95% CI -0.00 to 0.29; 10 studies, 785 participants; moderate-certainty evidence). Mobility strategies probably make little or no difference to short-term mortality (RR 1.01, 95% CI 0.49 to 2.06; 8 studies, 737 participants; moderate-certainty evidence). Mobility strategies may make little or no difference to long-term mortality (RR 0.73, 95% CI 0.39 to 1.37; 4 studies, 588 participants; low-certainty evidence) or adverse events measured by hospital re-admission (95% CI includes a large reduction and large increase, RR 0.86, 95% CI 0.52 to 1.42; 2 studies, 206 participants; low-certainty evidence). Training involving gait, balance and functional exercise leads to a small, clinically meaningful increase in mobility (SMD 0.20, 95% CI 0.05 to 0.36; 5 studies, 621 participants; high-certainty evidence), while training classified as being primarily resistance or strength exercise may lead to a clinically meaningful increase in mobility measured using distance walked in six minutes (mean difference (MD) 55.65, 95% CI 28.58 to 82.72; 3 studies, 198 participants; low-certainty evidence). Training involving multiple intervention components probably leads to a substantial, clinically meaningful increase in mobility (SMD 0.94, 95% CI 0.53 to 1.34; 2 studies, 104 participants; moderate-certainty evidence). We are uncertain of the effect of aerobic training on mobility (very low-certainty evidence). No studies of other types of exercise or electrical stimulation reported mobility outcomes.

AUTHORS' CONCLUSIONS

Interventions targeting improvement in mobility after hip fracture may cause clinically meaningful improvement in mobility and walking speed in hospital and post-hospital settings, compared with conventional care. Interventions that include training of gait, balance and functional tasks are particularly effective. There was little or no between-group difference in the number of adverse events reported. Future trials should include long-term follow-up and economic outcomes, determine the relative impact of different types of exercise and establish effectiveness in emerging economies.

No Difference in Quality-Of-Life Outcomes in the First 7 Years Following Primary Total Knee Arthroplasty Performed Using Computer Navigation Versus Conventional Referencing: A Propensity Score-Matched Analysis

BACKGROUND

Computer navigation techniques can potentially improve both the accuracy and precision of prosthesis implantation in total knee arthroplasty (TKA) but its impact on quality-of-life outcomes following surgery remains unestablished.

METHODS

An institutional arthroplasty registry was queried to identify patients with TKA performed between January 1, 2007 and December 31, 2019. Propensity score matching based on demographical, medical, and surgical variables was used to match computer-navigated to conventionally referenced cases. The primary outcomes were Veterans RAND 12 Item Health Survey scores (VR-12 PCS and MCS), Short Form 6 Dimension utility values (SF-6D), and quality-adjusted life years (QALYs) in the first 7 years following surgery.

RESULTS

A total of 629 computer-navigated TKAs were successfully matched to 1,351 conventional TKAs. The VR-12 PCS improved by a mean of 12.75 and 11.94 points in computer-navigated and conventional cases at 12-month follow-up (P = .25) and the VR-12 MCS by 6.91 and 5.93 points (P = .25), respectively. The mean VR-12 PCS improvement at 7-year follow-up (34.4% of the original matched cohort) for navigated and conventional cases was 13.00 and 12.92 points (P = .96) and for the VR-12 MCS was 4.83 and 6.30 points (P = .47), respectively. The mean improvement in the SF-6D utility score was 0.164 and 0.149 points at 12 months (P = .11) and at 7 years was 0.115 and 0.123 points (P = .69), respectively. Computer-navigated cases accumulated 0.809 QALYs in the first 7 years, compared to 0.875 QALYs in conventionally referenced cases (P = .65). There were no differences in these outcomes among a subgroup analysis of obese patients (body mass index ≥ 30 kg/m²).

CONCLUSION

The use of computer navigation did not provide an incremental benefit to quality-of-life outcomes at a mean of 2.9 years following primary TKA performed for osteoarthritis when compared to conventional referencing techniques.

Evaluating Distance Bias in Chronic Rhinosinusitis Outcomes

Importance

The distance traveled by patients for medical care is associated with patient outcomes (ie, distance bias) and is a limitation in outcomes research. However, to date, distance bias has not been examined in rhinologic studies.

Objective

To evaluate the association of distance traveled by a cohort of patients with chronic rhinosinusitis with baseline disease severity and treatment outcomes.

Design, Setting, and Participants

A total of 505 patients with chronic rhinosinusitis were prospectively enrolled in a multi-institutional, cross-sectional study in academic tertiary care centers between April 2011 and January 2020. Participants self-selected continued appropriate medical therapy or endoscopic sinus surgery. The 22-item Sinonasal Outcome Test (SNOT-22) and Medical Outcomes Study Short Form 6-D (SF-6D) health utility value scores were recorded at enrollment and follow-up. Data on the distances traveled by patients to the medical centers, based on residence zip codes, and medical comorbid conditions were collected.

Exposures

Distance traveled by patient to obtain rhinologic care.

Main Outcomes and Measures

SNOT-22 and SF-6D scores. Scores for SNOT-22 range from 0 to 110; and for SF-6D, from 0.0 to 1.0. Higher SNOT-22 total scores indicate worse overall symptom severity. Higher SF-6D scores indicate better overall health utility; 1.0 represents perfect health and 0.0 represents death.

Results

The median age for the 505 participants was 56.0 years (IQR, 41.0-64.0 years), 261 were men (51.7%), 457 were White (90.5%), and 13 were Hispanic or Latino (2.6%). These categories were collected according to criteria described and required by the National Institutes of Health and therefore do not equal the entire cohort. Patients traveled a median distance of 31.6 miles (50.6 km) (IQR, 12.2-114.5 miles [19.5-183.2 km]). Baseline (r = 0.00; 95% CI, 0.00-0.18) and posttreatment (r = 0.01; 95% CI, -0.07 to 0.10) SNOT-22 scores, as well as baseline (r = -0.12; 95% CI, -0.21 to -0.04) and posttreatment (r = 0.07; 95% CI, -0.02 to 0.16) SF-6D scores, were not associated with distance. There was no clinically meaningful correlation between distance traveled and mean comorbidity burden. Nevertheless, patients with a history of endoscopic sinus surgery were more likely to travel longer distances to obtain care (Cliff delta = 0.28; 95% CI, 0.19-0.38).

Conclusions and Relevance

Although this cross-sectional study found that some patients appear more willing to travel longer distances for chronic rhinosinusitis care, results suggest that distance traveled to academic tertiary care centers was not associated with disease severity, outcomes, or comorbidity burden. These findings argue for greater generalizability of study results across various cohorts independent of distance traveled to obtain rhinologic care.

Trial Registration

ClinicalTrials.gov Identifier: NCT02720653.

Cumulative comorbidity burden does not worsen outcomes in management of chronic rhinosinusitis

BACKGROUND

The impact of multiple coexisting medical comorbidities on treatment outcomes in chronic rhinosinusitis (CRS) is unknown. In this study we sought to evaluate the effect of comorbidities on sinonasal quality of life (QOL) and general health utility values by utilizing the Functional Comorbidity Index (FCI) in CRS patients.

METHODS

Patients with CRS were prospectively enrolled in a cross-sectional study of medical and surgical therapies. The 22-item Sino-Nasal Outcome Test (SNOT-22) and Medical Outcomes Study Short-Form 6D (SF-6D) scores were recorded at enrollment and 6-month follow-up; Lund-Kennedy endoscopy and Lund-Mackay computed tomography scores were recorded at enrollment. The FCI was calculated using the electronic medical record. The impact of cumulative comorbidity burden on baseline and posttreatment outcomes was assessed using univariate and bivariate correlations.

RESULTS

A total of 428 participants with CRS were included. The average (mean standard ± deviation) FCI score was 3.03 ± 2.28 (range, 0-12). Significant linear correlations were identified between increasing FCI score and baseline SNOT-22 and SF-6D scores (R = 0.166, p = 0.001 and R = -0.245, p < 0.001, respectively). There was no correlation between FCI and change in SNOT-22 or SF-6D scores after CRS treatment (R = 0.066, p = 0.17 and R = -0.087, p = 0.074, respectively). Achievement of a minimally clinically important difference was also independent of FCI.

CONCLUSION

Although cumulative comorbidity burden, as measured by FCI, is associated with worse baseline SNOT-22 and SF-6D scores, it does not appear to limit posttreatment improvement in either outcome measure. On average, patients with high comorbidity burden report substantial improvement in both QOL and health utility after CRS treatment, similar to those with fewer comorbidities.

Impact of elevated BMI and types of comorbid conditions on health-related quality of life in a nationally representative US sample

OBJECTIVE

Elevated BMI is associated with multiple chronic conditions including diabetes and CVD. Patients with overweight or obesity may also suffer from comorbidities not directly related to the pathophysiology of elevated BMI. The current study sought to determine the impact of BMI and different types of chronic conditions on health-related quality of life (HRQoL) outcomes.

DESIGN

Six weight categories by BMI were identified: underweight, normal weight, overweight, Class-I obesity, Class-II obesity and Class-III obesity. Twenty chronic conditions were considered and categorised as elevated BMI-related (concordant) or -unrelated (discordant) conditions. HRQoL outcomes were measured using Short Form-6 Dimensions (SF-6D). Multivariable regression models were performed to examine the impact of type, number of comorbid conditions and BMI categories on SF-6D scores.

SETTING

Medical Expenditure Panel Survey (2013-2015).

PARTICIPANTS

Nationally representative sample of US population; 18 years or older (n 58 960).

RESULTS

Of the sample, 1·7 %, 32·9 %, 34·0 % and 31·4 % were classified as underweight, normal weight, overweight and obese, respectively. The SF-6D scores were significantly decreased across all obesity classes, with the largest reduction in Class-III obesity (0·033; P < 0·001). Additionally, individuals with obesity having one or more concordant or discordant comorbidities further reduced SF-6D scores between 0·031 and 0·148 (P-values < 0·001) or between 0·080 and 0·212 (P-values < 0·001), respectively.

CONCLUSIONS

Individuals with obesity had a significant reduction in HRQoL outcomes compared to those with normal BMI. Importantly, discordant comorbidity resulted in greater reduction in HRQoL outcomes compared to concordant comorbidity in subjects with elevated BMI.

Changing lung function and associated health-related quality-of-life: A five-year cohort study of Malawian adults

BACKGROUND

In Sub-Saharan Africa cross-sectional studies report a high prevalence of abnormal lung function indicative of chronic respiratory disease. The natural history and health impact of this abnormal lung function in low-and middle-income countries is largely unknown.

METHODS

A cohort of 1481 adults representative of rural Chikwawa in Malawi were recruited in 2014 and followed-up in 2019. Respiratory symptoms and health-related quality of life (HRQoL) were quantified. Lung function was measured by spirometry.

FINDINGS

1232 (83%) adults participated; spirometry was available for 1082 (73%). Mean (SD) age 49.5 (17.0) years, 278(23%) had ever smoked, and 724 (59%) were women. Forced expiratory volume in one second (FEV₁) declined by 53.4 ml/year (95% CI: 49.0, 57.8) and forced vital capacity (FVC) by 45.2 ml/year (95% CI: 39.2, 50.5) . Chronic airflow obstruction increased from 9.5% (7.6, 11.6%) in 2014 to 17.5% (15.3, 19.9%) in 2019. There was no change in diagnosed asthma or in spirometry consistent with asthma or restriction. Rate of FEV₁ decline was not associated with diagnosed Chronic obstructive pulmonary disease (COPD), asthma, or spirometry consistent with asthma, COPD, or restriction. HRQoL was adversely associated with respiratory symptoms (dyspnoea, wheeze, cough), previous tuberculosis, declining FEV₁ and spirometry consistent with asthma or restriction. These differences exceeded the minimally important difference.

INTERPRETATION

In this cohort, the increasing prevalence of COPD is associated with the high rate of FEV₁ decline and lung function deficits present before recruitment. Respiratory symptoms and sub-optimal lung function are independently associated with reduced HRQoL.

Botulinum toxin injections as salvage therapy is beneficial for management of patellofemoral pain syndrome

Purpose

Patellofemoral pain syndrome (PFPS) is a common pathology usually presenting with anterior or retropatellar pain. It is associated with a relative imbalance between the vastus medialis oblique (VMO) and the vastus lateralis (VL) muscles. This can lead to considerable morbidity and reduced quality of life (QOL). This study aims to assess the long-term functional outcome of PFPS treated with VL muscle botulinum toxin A (BoNT-A) injection.

Materials and methods

A retrospective review was performed on 26 consecutive patients (31 knees) with a mean age of 50.1 years (± 19.7 years) who were treated with BoNT-A injections to the VL muscle followed by physiotherapy between 2008 and 2015. Pre- and post-treatment pain levels (numerical rating scale, NRS), QOL (SF-6D), and functional scores (Kujala and Lysholm questionnaires) were measured. Demographics, physical therapy compliance, previous surgeries, perioperative complications, and patient satisfaction levels were collected.

Results

The mean follow-up time was 58.8 ± 36.4 months. There were significant improvements in all the examined domains. The average pain score (NRS) decreased from 7.6 to 3.2 (P < 0.01), and the Kujala, Lysholm, and SF-6D scores improved from 58.9 to 82.7 (P < 0.001), 56.2 to 83.2 (P < 0.001), and 0.6 to 0.8 (P < 0.001), respectively. Similar delta improvement was achieved irrespective of gender, age, compliance to post-treatment physical therapy, or coexisting osteoarthritis. Patients who presented with a worse pre-treatment clinical status achieved greater improvement. Prior to BoNT-A intervention, 16 patients (18 knees) were scheduled for surgery, of whom 12 (75%, 13 knees) did not require further surgical intervention at the last follow-up.

Conclusions

A single intervention of BoNT-A injections to the VL muscle combined with physiotherapy is beneficial for the treatment of patients with persistent PFPS.

Level III evidence

Retrospective cohort study.

Minimal clinically important differences in SF-36 global score: Current value in orthopedic oncology

The SF-36 is widely used to evaluate the health-related quality of life (HRQoL) of patients with musculoskeletal tumors. Instead of typical methods, calculating the SF-36 Global Score has recently become an increasingly common reporting approach. However, numerical changes lack clear clinical relevance. The minimal clinically important difference (MCID) is useful for interpreting changes in functional scores by defining the smallest change patients may perceive as clinically meaningful. The aim of this study is to determine the MCID of the SF-36 Global Score in orthopedic oncology patients, which has not been reported to date. Three-hundred ten patients who underwent surgery and completed two surveys during postoperative follow-up were reviewed. The two most common methods for calculating the SF-36 Global Score were used: (1) anchor-based methods and receiver operating characteristic analysis based on one-half of the SD of change score and standard error of measurement at baseline and; (2) distribution-based methods. Using anchor-based methods, the MCIDs of SF-36 Global Scores #1 and #2 were 2.7 (area under the curve [AUC] = 0.85) and 2.5 (AUC = 0.79) for improvement, and -1.5 (AUC = 0.81) and -0.6 (AUC = 0.83) for deterioration, respectively. Using distribution-based methods, the MCIDs of SF-36 Global Scores #1 and #2 were 4.1 and 4.4 by half SD, and 4.1 and 4.5 by standard error of measurement, respectively. Our findings provide benchmark values, which can serve as a reference for future studies in musculoskeletal tumor patients using the SF-36 Global Score as a single measure for HRQoL.

Health-related quality of life deviations from population norms in patients with lumbar radiculopathy: associations with pain, pain cognitions, and endogenous nociceptive modulation

PURPOSE

The primary goal of this study was to compare the health-related quality of life (HRQoL) of people with lumbar radiculopathy to age- and sex-adjusted population norms. Additionally, it aimed to explore the associations between the HRQoL difference scores and measures related to pain cognitions, pain intensity, and endogenous nociceptive modulation.

METHODS

Using answers from the Short Form 36-item Health Survey and UK population norms, SF-6D difference scores were calculated. A one-sample t test was used to assess the SF-6D difference scores. Univariate and multivariate regression analyses were used to assess the associations between SF-6D difference scores and pain intensity [Visual Analogue Scale (VAS) for back and leg pain], pain cognitions [Pain Catastrophizing Scale (PCS), Tampa Scale for Kinesiophobia (TSK), Pain Vigilance and Awareness Questionnaire (PVAQ)], and correlates for endogenous nociceptive modulation using quantitative sensory testing.

RESULTS

One hundred and twenty people with lumbar radiculopathy scheduled for surgery were included in this study. The mean SF-6D difference score of - 0.26 [SD = 0.09] was found to be significantly less than 0 [95%CI: - 0.27 to - 0.24]. Univariate analyses showed a significant influence from PCS, TSK, and PVAQ on the SF-6D difference scores. The final multivariate regression model included PCS and PVAQ, with only PCS maintaining a statistically significant regression coefficient [b = - 0.002; 95% CI: - 0.004 to - 0.001].

CONCLUSION

People diagnosed with lumbar radiculopathy report significantly lower HRQoL scores when compared with age- and sex-adjusted UK norm values. Even though all examined pain cognitions were found to have a significant association, pain catastrophizing showed the most significant relation to the SF-6D difference scores.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier No. NCT02630732. Date of registration: November 25, 2015.

Health State Utility Values for Type 2 Diabetes and Related Complications in East and Southeast Asia: A Systematic Review and Meta-Analysis

OBJECTIVES

East and Southeast Asia has the greatest burden of diabetes in the world. We sought to derive a reference set of utility values for type 2 diabetes without complication and disutility (utility decrement) values for important diabetes-related complications to better inform economic evaluation.

METHODS

A systematic review to identify utility values for diabetes and related complications reported in East and Southeast Asia. We searched MEDLINE (OVID) from inception to May 26, 2020 for utility values elicited using direct and indirect methods. Identified studies were assessed for quality based on the National Institute of Health and Care Excellence guidelines. Utility and disutility estimates were pooled by meta-analyses with subgroup analyses to evaluate differences by nationality and valuation instrument. (PROSPERO: CRD42020191075).

RESULTS

We identified 17 studies for the systematic review from a total of 13 035 studies in the initial search, of which 13 studies met the quality criteria for inclusion in the meta-analyses. The pooled utility value for diabetes without complication was 0.88 (95% CI 0.83-0.93), with the pooled utility decrement for associated complications ranged from 0.00 (for excess BMI) to 0.18 (for amputation). The utility values were consistently more conservative than previous estimates derived in Western populations. Utility decrements were comparable for SF-6D and EQ-5D valuation instruments and for Chinese and other Asian groups.

CONCLUSIONS

A reference set of pooled disutility and utility values for type 2 diabetes and its complications in East and Southeast Asian populations yielded more conservative estimates than Western populations.

A feasibility cluster randomised controlled trial of a paramedic-administered breathlessness management intervention for acute-on-chronic breathlessness (BREATHE)

Chronic breathlessness, persistent and disabling despite optimal treatment of underlying causes, is a prevalent and frightening symptom and is associated with many emergency presentations and admission to hospital. Breathlessness management techniques used by paramedics may reduce the need for conveyance to hospital. The Breathlessness RElief AT HomE study (BREATHE) aims to explore the feasibility of conducting a definitive cluster randomised controlled trial (cRCT) for people with acute-on-chronic breathlessness who have called an ambulance, to evaluate the effectiveness and cost-effectiveness of a paramedic-administered non-pharmacological breathlessness intervention.

The trial is a mixed-methods feasibility cRCT. Eight paramedics will be randomised 1:1 to deliver either the BREATHE intervention in addition to usual care or usual care alone at call-outs for acute-on-chronic breathlessness. Sixty participants will be recruited to provide access to routine data relating to the index call-out with optional follow-up questionnaires at 14 days, 1 month and 6 months. An in-depth interview will be conducted with a subgroup. Feasibility outcomes relating to recruitment, data quality (especially candidate primary outcomes), and intervention acceptability and fidelity will be collected as well as providing data to estimate a sample size for a definitive trial.

Yorkshire and The Humber–Sheffield Research Ethics Committee approved the trial protocol (19/YH/0314). The study results will inform progression to, or not, and design of a main trial according to predetermined stop-go criteria. Findings will be disseminated to relevant stakeholders and submitted for publication in a peer-reviewed journal.

Acute-on-chronic breathlessness initiates many emergency presentations. The BREATHE protocol describes a feasibility, cluster randomised controlled trial of a paramedic breathlessness management intervention.https://bit.ly/2LZg72w

Health- and Vision-Related Quality of Life in a Randomized Controlled Trial Comparing Methotrexate and Mycophenolate Mofetil for Uveitis

PURPOSE

To evaluate changes in health-related and vision-related quality of life (VRQoL) among patients with noninfectious uveitis who were treated with antimetabolites.

DESIGN

Secondary analysis of a randomized controlled trial.

PARTICIPANTS

Patients with noninfectious uveitis from India, the United States, Australia, Saudi Arabia, and Mexico.

METHODS

From 2013 through 2017, 216 participants were randomized to receive 25 mg weekly oral methotrexate or 1.5 g twice daily oral mycophenolate mofetil. Median changes in quality of life (QoL) were measured using Wilcoxon signed-rank tests, and differences between treatment groups were measured using linear mixed models, adjusting for baseline QoL score, age, gender, and site. Among Indian patients, VRQoL scores from a general scale (the National Eye Institute Visual Function Questionnaire [NEI-VFQ]) and a culturally specific scale (the Indian Visual Function Questionnaire [IND-VFQ]) were compared using Pearson correlation tests.

MAIN OUTCOME MEASURES

Vision-related QoL (NEI-VFQ and IND-VFQ) and health-related QoL (HRQoL; physical component score [PCS] and mental component score [MCS] of the Medical Outcomes Study 36-Item Short Form Survey [SF-36v2]) were measured at baseline, the primary end point (6 months or treatment failure before 6 months), and the secondary end point (12 months or treatment failure between 6 and 12 months).

RESULTS

Among 193 participants who reached the primary end point, VRQoL increased from baseline by a median of 12.0 points (interquartile range [IQR], 1.0-26.1, NEI-VFQ scale), physical HRQoL increased by a median of 3.6 points (IQR, -1.4 to 14.9, PCS SF-36v2), and mental HRQoL increased by a median of 3.0 points (IQR, -3.7 to 11.9, MCS SF-36v2). These improvements in NEI-VFQ, SF-36v2 PCS, and SF-36v2 MCS scores all were significant (P < 0.01). The linear mixed models showed that QoL did not differ between treatment groups for each QoL assessment (NEI-VFQ, IND-VFQ, PCS SF-36v2, and MCS SF-36v2; P > 0.05 for all). The NEI-VFQ and IND-VFQ scores for Indian participants were correlated highly at baseline and the primary and secondary end points (correlation coefficients, 0.87, 0.80, and 0.90, respectively).

CONCLUSIONS

Among patients treated with methotrexate or mycophenolate mofetil for uveitis, VRQoL and HRQoL improved significantly over the course of 1 year and did not differ by treatment allocation. These findings suggest that antimetabolites could improve overall patient well-being and daily functioning.

Evaluation of the cost-utility of a prescription digital therapeutic for the treatment of opioid use disorder

Background: The opioid epidemic continues to generate a significant mental and physical health burden on patients, and claims the life of almost 150 Americans daily. Making matters worse, an increase in relapses and/or opioid-related deaths has been reported in more than 40 U.S. states since the start of the COVID-19 pandemic. Opioid use disorder (OUD) is one of the single most expensive disorders in the United States, generating average medical costs of $60B from just 2 million Americans diagnosed with the disorder. In commercial use since 2019, reSET-O is a non-drug, prescription digital therapeutic (PDT) that delivers evidence-based neurobehavioral treatment for OUD and helps overcome the barriers associated with access to care, stigma, and social distancing. Although shown to be cost effective and efficacious in clinical trials and real-world evidence studies, respectively, information on its value for money from a health utilities and cost per quality-adjusted life-year is needed to inform policy discussions.Objectives: To evaluate the impact of reSET-O on health utilities and assess its overall cost per quality-adjusted life year (QALY) gained vs. treatment-as-usual (TAU).Methods: Decision analytic model comparing reSET-O plus TAU to TAU alone (i.e. buprenorphine, face-to-face counseling, and contingency management) over 12 weeks. Clinical effectiveness data (abstinence and health utility) were obtained from a clinical trial, and resource utilization and cost data were adapted from a recent claims data analysis to reflect less frequent face-to-face counseling with the therapeutic.Results: The addition of reSET-O to TAU decreases total health care costs by -$131 and resulted in post-treatment utility values within population norms, with a corresponding gain of 0.003 QALYs. reSET-O when used adjunctively to TAU was economically dominant (less costly, more effective) vs. TAU alone.Conclusion: reSET-O is an economically-dominant adjunctive treatment for OUD and is associated with an overall reduction in total incremental cost vs TAU.

Utility estimations of health states of older Australian women with atrial fibrillation using SF-6D

PURPOSE

To estimate SF-6D utility scores for older women with atrial fibrillation (AF); calculate and compare mean utility scores for women with AF with various demographic, health behaviours, and clinical characteristics; and develop a multivariable regression model to determine factors associated with SF-6D utility scores.

METHODS

This study evaluated N = 1432 women diagnosed with AF from 2000 to 2015 of the old cohort (born 1921-26) of the Australian Longitudinal Study on Women's Health (ALSWH) who remained alive for at least 12 months post first recorded AF diagnosis. Self-reported data on demographics, health behaviours, health conditions, and SF-36 were obtained from the ALSWH surveys, corresponding to within three years of the date of the first record of AF diagnosis. Linked Pharmaceutical Benefits Scheme (PBS) data determined the use of oral anticoagulants and comorbid conditions, included in CHA₂DS₂-VA (Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes, Stroke or TIA, Vascular disease and Age 65-74 years) score calculation, were assessed using state-based hospital admissions data. Utility scores were calculated for every woman from their SF-36 responses using the SF-6D algorithm with Australian population norms. Mean utility scores were then calculated for women with various demographic, health behaviours, and clinical characteristics. Ordinary Least Square (OLS) regression modelling was performed to determine factors associated with these utility scores. Two different scenarios were used for the analysis: (1) complete-case, for women with complete data on all the SF-36 items required to estimate SF-6D (N = 584 women), and (2) Multiple Imputation (MI) for missing data, applied to missing values on SF-36 items (N = 1432 women). MI scenario was included to gauge the potential bias when using complete data only.

RESULTS

The mean health utility was estimated to be 0.638 ± 0.119 for the complete dataset and 0.642 ± 0.120 for the dataset where missing values were handled using MI. Using the MI technique, living in regional and remote areas ([Formula: see text]) and the use of oral anticoagulants ([Formula: see text] were positively associated with health utility compared to living in major cities and no use of anticoagulants, respectively. Difficulty to manage on available income [Formula: see text], no/low physical activity [Formula: see text], disability [Formula: see text], history of stroke ([Formula: see text] and history of arthritis [Formula: see text] were negatively associated with health utility.

CONCLUSION

This study presents health utility estimates for older women with AF. These estimates can be used in future clinical and economic research. The study also highlights better health utilities for women living in regional and remote areas, which requires further exploration.

A Multicenter, Longitudinal Cohort Study of Cryptococcosis in Human Immunodeficiency Virus-negative People in the United States

BACKGROUND

Cryptococcosis is increasingly recognized in people without human immunodeficiency virus (HIV).

METHODS

A multicenter, prospective cohort study was performed in 25 US centers. Consenting patients were prospectively followed for ≤2 years. Neurological morbidities were assessed with longitudinal event depiction and functional scores (Montreal Cognitive Assessment [MoCA]). Risks of death were analyzed using Cox regression.

RESULTS

One hundred forty-five subjects were enrolled. Most were male (95; 65.5%) and had immunosuppression (120; 82.8%), including solid organ transplant (SOT; 33.8%), autoimmunity (15.9%), and hematologic malignancies (11.7%). Disease involved the central nervous system (CNS) in 71 subjects (49%). Fever was uncommon, documented in 40 (27.8%) subjects, and absence was associated with diagnostic delay (mean: 48.2 vs 16.5 days; P = .007). Abnormal MoCA scores (<26) were predictive of CNS disease; low scores (<22) were associated with poor long-term cognition. Longitudinal event depiction demonstrated frequent complications in people with CNS disease; 25 subjects (35.2%) required >1 lumbar puncture and 8 (11.3%) required ventriculostomies. In multivariable models, older age (>60 years) was associated with higher risks of death (hazard ratio [HR], 2.14; 95% confidence interval [CI], 1.05-4.38; P = .036), and lower risks were noted with underlying hematologic malignancy (HR, 0.29; 95% CI, 0.09-0.98; P = .05) and prior SOT (HR, 0.153; 95% CI, 0.05-0.44; P = .001).

CONCLUSIONS

Despite aggressive antifungal therapies, outcomes of CNS cryptococcosis in people without HIV are characterized by substantial long-term neurological sequelae. Studies are needed to understand mechanism(s) of cognitive decline and to enable better treatment algorithms.

Analysis of SF-6D Health State Utility Scores: Is Beta Regression Appropriate?

Background: Typically, modeling of health-related quality of life data is often troublesome since its distribution is positively or negatively skewed, spikes at zero or one, bounded and heteroscedasticity. Objectives: In the present paper, we aim to investigate whether Bayesian beta regression is appropriate for analyzing the SF-6D health state utility scores and respondent characteristics. Methods: A sample of 126 Lebanese members from the American University of Beirut valued 49 health states defined by the SF-6D using the standard gamble technique. Three different models were fitted for SF-6D via Bayesian Markov chain Monte Carlo (MCMC) simulation methods. These comprised a beta regression, random effects and random effects with covariates. Results from applying the three Bayesian beta regression models were reported and compared based on their predictive ability to previously used linear regression models, using mean prediction error (MPE), root mean squared error (RMSE) and deviance information criterion (DIC). Results: For the three different approaches, the beta regression model was found to perform better than the normal regression model under all criteria used. The beta regression with random effects model performs best, with MPE (0.084), RMSE (0.058) and DIC (−1621). Compared to the traditionally linear regression model, the beta regression provided better predictions of observed values in the entire learning sample and in an out-of-sample validation. Conclusions: Beta regression provides a flexible approach to modeling health state values. It also accounted for the boundedness and heteroscedasticity of the SF-6D index scores. Further research is encouraged.

Systematic literature review of humanistic and economic burdens of chronic rhinosinusitis with nasal polyposis

OBJECTIVES

We conducted a systematic literature review (SLR) of randomized controlled trials and real-world evidence (RWE) studies to determine the humanistic (e.g. health-related/disease-specific quality of life [QOL]) and economic (e.g. direct and indirect costs) burdens of chronic rhinosinusitis with nasal polyposis (CRSwNP).

METHODS

The SLR adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Embase, MEDLINE and Evidence-Based Medicine Reviews databases were searched using OVID. Relevant studies involving adult patients with CRSwNP published between 1 January 2008 and 16 February 2019 were included, with relevant conference abstracts from 1 January 2017, onward.

RESULTS

Sino-Nasal Outcomes Test (SNOT)-22 was the most frequently used disease-specific health-related QOL/patient-reported outcomes instrument for patients with CRSwNP. Baseline SNOT-22 scores ranged from 25 to 73 for surgical candidates and from 14 to 56 for medically managed patients with CRSwNP. Mean baseline EuroQol-5 Dimensions (EQ-5D) index for patients with CRSwNP ranged from 0.81 to 0.86, and mean baseline Short Form-6 Dimensions (SF-6D) ranged from 0.67 to 0.75. Three months (EQ-5D) and 5 years (SF-6D) post-endoscopic sinus surgery (ESS), rates increased from 0.81 to 0.89 and from 0.69 to 0.80, respectively. One year post-diagnosis, patients with CRSwNP had significantly more systemic prescriptions, underwent significantly more medical procedures, demonstrated greater health care resource utilization and had significantly greater mean health care costs compared with matched controls (all p < .001). Overall, for patients with initial ESS, CRSwNP was associated with higher disease-related expenditures compared with CRS without nasal polyposis (NP), even for patients who did not undergo revision surgery.

CONCLUSIONS

This SLR identified substantial humanistic burden among surgery candidates. RWE shows that surgeries were used to treat relatively more severe CRSwNP patients as recommended by guidelines. Patient QOL is improved significantly after surgery; however, there is a lack of evidence on patients with revision surgery. Surgery is also associated with higher costs, and the presence of NP was a predictor of revision surgery. Patients with CRSwNP demonstrate greater health care resource utilization and costs compared to those with CRS without NP. Costs associated with different severity of CRSwNP and revision surgery need to be assessed further.

Exploring the consistency of the SF-6Dv2 in a breast cancer population

Background: Short-Form Six-Dimension version 2 (SF-6Dv2) is a multi-attribute utility instrument that can be used in combination with the SF-36v2 (SF-6Dv2_SF-36) or as an independent instrument in two forms: six questions (SF-6Dv2_ind-6) and 10 questions (SF-6Dv2_ind-10). The purpose of this research was to assess the consistency between the results of the SF-6Dv2_ind-6 and the SF-6Dv2_SF-36 in patients with breast cancer.Research design and methods: This cross-sectional study was carried out on 418 patients with breast cancer. The degree of agreement between the descriptive systems of instruments was calculated using Spearman's correlation coefficient, global consistency index (GCI), and identically classified index (ICI).Results: The average size of the Spearman's correlation coefficients between the descriptive systems of instruments was higher than 0.5. The results of the GCI revealed that the level of agreement between dimensions of the two instruments had a mean of 64.9 (range 32.45-86.8). The SF-6Dv2_SF-36 generates statistically higher values than does the SF-6Dv2_ind-6, and mean difference between the two instruments was 0.087 for model 3 and 0.027 for model 10.Conclusions: This study provided evidence that the SF-6Dv2_SF-36 and the SF-6Dv2_ind-6 may produce different answers from patients with breast cancer and lead to a small difference in utility values.

A systematic review and meta-analysis of health state utility values for osteoarthritis-related conditions

BACKGROUND

Health state utility values (HSUVs) are a key input in health economic modelling but HSUVs of people with osteoarthritis (OA)-related conditions have not been systematically reviewed and meta-analysed.

OBJECTIVE

To systematically review and meta-analyse the HSUVs for people with OA.

METHODS

Searches within health economic/biomedical databases were performed to identify eligible studies reporting OA-related HSUVs. Data on study design, participant characteristics, affected OA joint sites, treatment type, HSUV elicitation method, considered health states, and the reported HSUVs were extracted. HSUVs for people with knee, hip and mixed OA in pre- and post-treatment populations were meta-analysed using random effects models.

RESULTS

One-hundred and fifty-one studies were included in the systematic review, and 88 in meta-analyses. Of 151 studies, 56% were conducted in Europe, 75% were in people with knee and/or hip OA and 79% were based on the EQ-5D. The pooled mean (95% confidence interval [CI]) baseline HSUVs for knee OA core interventions, medication, injection and primary surgery treatments were 0.64 (0.61-0.66), 0.56 (0.45-0.68), 0.58 (0.50-0.66) and 0.52 (0.49-0.55), respectively. These were 0.71 (0.59-0.84) for hip OA core interventions and 0.52 (0.49-0.56) for hip OA primary surgery. For all knee OA treatments and hip OA primary surgery, pooled HSUVs were significantly higher in the post- than the pre- treatment populations.

CONCLUSION

This study provides a comprehensive summary of OA-related HSUVs and generates a HSUVs database for people with different affected OA joint sites undergoing different treatments to guide HSUV choices in future health economic modelling of OA interventions.

The relationship between consumption of animal products and expenditure levels with Quality of Life Scores (SF-36) by veterinary students in Turkey

ABSTRACT The present study aimed to calculate the quality of life scores (Short Form-36) of veterinary students in Turkey and review their scores with regards to different socio-demographic characteristics. A total of 1211 students studying veterinary medicine in 26 different faculties in Turkey were selected by stratified sampling method and were asked questions concerning their consumption of and expenditures on foods of animal origin using the SF-36 questionnaire between October and December 2018. Significant differences were found between SF-36 components in terms of year level, gender, accommodation status, income level, and level of expenditures on foods and foods of animal origin (P<0.01). With the increase in the size of the budget set aside for animal products, the scores in the domains of physical functioning, vitality, mental health, pain, and general health perception also enhanced, and statistically significant differences were found (P<0.01). The low quality of life scores of the veterinary students can be improved by increasing their income level and consumption of foods of animal origin. This will ensure that they are energetic and have the desired level of mental and general health perceptions.

Health state utilities for economic evaluation of bariatric surgery: A comprehensive systematic review and meta-analysis

Health state utilities (HSUs) are health economic metrics that capture and assess health-related quality of life (HRQoL). They are essential in health-economic evaluations when calculating quality-adjusted life years. We investigated published studies reporting bariatric surgery-related HSUs elicited through direct or indirect (multiattribute utility instrument [MAUI]) patient-reported methods (PROSPERO registration number: CRD42019131725). Mean HSUs for different time points and HSU changes over time (where feasible) were meta-analysed using random-effects models. Of the 950 potentially relevant identified studies, n = 28 (2004-2018) qualified for data extraction, with n = 85 unique HSUs elicited mainly from the EQ-5D (88%). Most (75%) studies were published after 2013. The follow-up duration varied between studies and was often limited to 12 months. The pooled mean HSU was 0.72 (0.67-0.76) at baseline/presurgery (n = 18) and 0.84 (0.79-0.89) one-year postsurgery (n = 11), indicating a 0.11 (0.09-0.14) utility unit increment. EQ-5D showed the similar results. This positive difference can be partially explained by BMI and/or co-morbidities status improvement. This study provides a valuable summary of HSUs to future bariatric surgery-related cost-utility models. However, more well-designed higher-quality bariatric-related HSU studies are expected for future reviews to improve the available evidence. We suggest that researchers select an MAUI that is preferentially sensitive to the study population.

Health-Related Quality of Life as Measured by the 12-Item Short-Form Survey Among Adults With Community-Acquired Bacterial Pneumonia who Received Either Lefamulin or Moxifloxacin in 2 Phase III Randomized, Double-Blind, Double-Dummy Clinical Trials

Background

Interest in patient-reported outcomes (PROs) as part of benefit–risk assessment for new drug approvals is increasing. Lefamulin is the first intravenous (IV) and oral pleuromutilin antibiotic for treatment of adults with community-acquired bacterial pneumonia (CABP). Assessment of health-related quality of life (HRQoL) was prospectively incorporated in its CABP trials (Lefamulin Evaluation Against Pneumonia [LEAP] 1 and 2) via the 12-Item Short-Form Survey (SF-12), a widely used PRO that measures general health status in 8 domains.

Methods

HRQoL was evaluated by SF-12 at baseline and test of cure (TOC; 5–10 days after the last study drug dose) in patients who received lefamulin or moxifloxacin in LEAP 1 (IV/oral treatment) and LEAP 2 (oral-only treatment). SF-12 outcomes included the 8 domains, physical component and mental component summary scores, and the Short-Form Six-Dimension health utility score.

Results

Analysis included 1215 patients (lefamulin: n = 607; moxifloxacin: n = 608). At baseline, all mean SF-12 scores in both treatment groups were well below the United States reference mean. Clinically meaningful and significant improvements from baseline to TOC were observed in all SF-12 scores. No significant differences in mean score improvements from baseline to TOC between treatment groups were observed. SF-12 score improvements at TOC across predefined subgroups were comparable between treatment groups.

Conclusions

Results indicate that adults with CABP experienced comparable HRQoL improvements with lefamulin relative to moxifloxacin, and treatment with either agent resulted in returns to population norm HRQoL levels. These data suggest that lefamulin is a potential alternative to moxifloxacin for treatment of adults with CABP.

Critical consideration of assessment methods for clinically significant changes of mental distress after psycho-oncological interventions

OBJECTIVES

Considering the heterogeneity of cancer entities and the associated disease progression, personalized care of patients is increasingly emphasized in psycho-oncology. This individualization makes the use of measurements of individual clinically significant change important when studying the efficacy and effectiveness of psycho-oncological care. Two conceptualizations for the measurement of clinical significance are critically contrasted in this study: the Reliable Change Index (RCI) and the Minimal Important Difference (MID) method.

METHODS

In total, 2,121 cancer patients participated in the study and a subsample of 708 patients was reassessed about 4 months later. Psychological distress was measured using the Hospital Anxiety and Depression Scale. We evaluated two measures of clinical significance (RCI, MID) by comparing the respective numbers of improved, unimproved, and deteriorated patients.

RESULTS

Individually significant changes were observed with both methods; however, determined rates of improvement differed substantially: MID (66.67%) and RCI (48.23%). Most importantly, according to MID, 17.93% of patients were identified as being improved, although their respective improvements were not statistically significant and thus unreliable.

CONCLUSIONS

The benefits of RCI outweigh MID, and therefore, the RCI is recommended as a measure to assess change.

Exhalation delivery system with fluticasone improves quality of life and health status: pooled analysis of phase 3 trials NAVIGATE I and II

Background

Chronic rhinosinusitis with or without nasal polyps (CRSwNP/CRSsNP) seriously impairs health‐related quality of life (HRQoL). This analysis describes the impact of the exhalation delivery system with fluticasone (EDS‐FLU) on HRQoL, assessed by the 36‐item Short‐Form Health Survey version 2 (SF‐36v2), and on utilities, assessed via the Short‐Form 6‐Dimension (SF‐6D), in patients with CRSwNP.

Methods

Post hoc analysis of pooled randomized clinical trial data (NAVIGATE I and II; N = 643) to examine change from baseline in SF‐36v2 and SF‐6D at end‐of‐double‐blind (EODB: 16 weeks) and end‐of‐open‐label (EOOL: 24 weeks; following 8 weeks of open‐label treatment) for EDS‐FLU vs placebo (EDS‐PBO). Baseline characteristics predictive of change in SF‐36 and SF‐6D scores were assessed.

Results

Mean baseline SF‐36v2 scores were below population norms. At EODB, mean improvement was greater for all SF‐36v2 domain and component scores with EDS‐FLU (range: 2.9 [physical functioning] to 5.11 [bodily pain {BP}]) vs EDS‐PBO (range: 0.81 [mental health] to 2.87 [BP]) (each comparison p < 0.01); physical and mental component score improvements within the EDS‐FLU group exceeded the minimal clinically important difference (MCID). Clinically meaningful and statistically significant improvements in SF‐6D utility scores were seen in EDS‐FLU–treated patients compared to EDS‐PBO–treated patients (0.058 vs 0.023, respectively, p < 0.001). At EOOL, SF‐36v2 and SF‐6D mean scores were at or above population norms, with clinically meaningful and statistically significant improvements from baseline.

Conclusion

In this pooled analysis of 2 large pivotal EDS‐FLU trials, health domain and health utilities improvements were significantly greater with EDS‐FLU than EDS‐PBO and were comparable to population norms.

How is the minimal clinically important difference established in health-related quality of life instruments? Review of anchors and methods

Background

The aim of this systematic review is to describe the different types of anchors and statistical methods used in estimating the Minimal Clinically Important Difference (MCID) for Health-Related Quality of Life (HRQoL) instruments.

Methods

PubMed and Google scholar were searched for English and French language studies published from 2010 to 2018 using selected keywords. We included original articles (reviews, meta-analysis, commentaries and research letters were not considered) that described anchors and statistical methods used to estimate the MCID in HRQoL instruments.

Results

Forty-seven papers satisfied the inclusion criteria. The MCID was estimated for 6 generic and 18 disease-specific instruments. Most studies in our review used anchor-based methods (n = 41), either alone or in combination with distribution-based methods. The most common applied anchors were non-clinical, from the viewpoint of patients. Different statistical methods for anchor-based methods were applied and the Change Difference (CD) was the most used one. Most distributional methods included 0.2 standard deviations (SD), 0.3 SD, 0.5 SD and 1 standard error of measurement (SEM). MCID values were very variable depending on methods applied, and also on clinical context of the study.

Conclusion

Multiple anchors and methods were applied in the included studies, which lead to different estimations of MCID. Using several methods enables to assess the robustness of the results. This corresponds to a sensitivity analysis of the methods. Close collaboration between statisticians and clinicians is recommended to integrate an agreement regarding the appropriate method to determine MCID for a specific context.

Efficacy and Safety of Surgery for Mild Degenerative Cervical Myelopathy: Results of the AOSpine North America and International Prospective Multicenter Studies

BACKGROUND

There is controversy over the optimal treatment strategy for patients with mild degenerative cervical myelopathy (DCM).

OBJECTIVE

To evaluate the degree of impairment in baseline quality of life as compared to population norms, as well as functional, disability, and quality of life outcomes following surgery in a prospective cohort of mild DCM patients undergoing surgical decompression.

METHODS

We identified patients with mild DCM (modified Japanese Orthopaedic Association [mJOA] 15 to 17) enrolled in the prospective, multicenter AOSpine CSM-NA or CSM-I trials. Baseline quality of life Short Form-36 version 2 (SF-36v2) was compared to population norms by the standardized mean difference (SMD). Outcomes, including functional status (mJOA, Nurick grade), disability (NDI [Neck Disability Index]), and quality of life (SF-36v2), were evaluated at baseline and 6 mo, 1 yr, and 2 yr after surgery. Postoperative complications within 30 d of surgery were monitored.

RESULTS

One hundred ninety-three patients met eligibility criteria. Mean age was 52.4 yr. There were 67 females (34.7%). Patients had significant impairment in all domains of the SF-36v2 compared to population norms, greatest for Social Functioning (SMD –2.33), Physical Functioning (SMD –2.31), and Mental Health (SMD –2.30). A significant improvement in mean score from baseline to 2-yr follow-up was observed for all major outcome measures, including mJOA (0.87, P < .01), Nurick grade (–1.13, P < .01), NDI (–12.97, P < .01), and SF-36v2 Physical Component Summary (PCS) (5.75, P < .01) and Mental Component Summary (MCS) (6.93, P < .01). The rate of complication was low.

CONCLUSION

Mild DCM is associated with significant impairment in quality of life. Surgery results in significant gains in functional status, level of disability, and quality of life.

Self-reported Health is Related to Body Height and Waist Circumference in Rural Indigenous and Urbanised Latin-American Populations

Body height is a life-history component. It involves important costs for its expression and maintenance, which may originate trade-offs on other costly components such as reproduction or immunity. Although previous evidence has supported the idea that human height could be a sexually selected trait, the explanatory mechanisms that underlie this selection are poorly understood. Despite extensive studies on the association between height and attractiveness, the role of immunity in linking this relation is scarcely studied, particularly in non-Western populations. Here, we tested whether human height is related to health measured by self-perception, and relevant nutritional and health anthropometric indicators in three Latin-American populations that widely differ in socioeconomic and ecological conditions: two urbanised populations from Bogota (Colombia) and Mexico City (Mexico), and one isolated indigenous population (Me'Phaa, Mexico). Results showed that self-reported health is best predicted by an interaction between height and waist circumference: the presumed benefits of being taller are waist-dependent, and affect taller people more than shorter individuals. If health and genetic quality cues play an important role in human mate-choice, and height and waist interact to signal health, its evolutionary consequences, including cognitive and behavioural effects, should be addressed in future research.

Health Impairment From Nasal Airway Obstruction and Changes in Health Utility Values From Septorhinoplasty

Importance

The association of nasal airway obstruction with health is significant, and the health care resources utilized in open septorhinoplasty need to be included in health economic analyses.

Objectives

To describe the association of nasal airway obstruction and subsequent open septorhinoplasty with patient health.

Design, Setting, and Participants

A prospective case series study was conducted from September 30, 2009, to October 29, 2015, at 2 tertiary rhinologic centers in Sydney, Australia, among 144 consecutive adult patients (age, ≥18 years) with nasal airway obstruction from septal and nasal valve disorders.

Interventions

Open septorhinoplasty.

Main Outcomes and Measures

Patients were assessed before undergoing open septorhinoplasty and then 6 months after the procedure. Health utility values (HUVs) were derived from the 36-Item Short Form Health Survey. Nasal obstruction severity was also measured using the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire and the Sino-Nasal Outcome Test 22 questionnaires.

Results

A total of 144 patients (85 women and 59 men; mean [SD] age, 38 [13] years) were assessed. The baseline mean (SD) HUV for patients in this study was 0.72 (0.09), which was below the weighted mean (SD) Australian norm of 0.81 (0.22). After open septorhinoplasty, the mean (SD) HUV improved to 0.78 (0.12) (P < .001). Improvements in HUV were associated with changes in disease-specific patient-reported outcome measures, including Nasal Obstruction Symptom Evaluation scores (r = -0.48; P = .01) and Sino-Nasal Outcome Test 22 scores (r = -0.68; P = .01).

Conclusions and Relevance

Patients with nasal airway obstruction reported baseline HUVs that were lower than the Australian norm and similar to those in individuals with chronic diseases with significant health expenditure. There was a clinically and statistically significant improvement in HUVs after open septorhinoplasty that was associated with a reduction in Nasal Obstruction Symptom Evaluation and Sino-Nasal Outcome Test 22 scores. Outcomes from this study may be used for health economic analyses of the benefit associated with open septorhinoplasty.

Level of Evidence

4.

Pre-consultation biopsychosocial data from patients admitted for management at pain centers in Norway

Background and aims

A bio-psycho-social approach has been recommended in multidisciplinary pain clinics, and in Norway patients with severe chronic nonmalignant pain (CNMP, defined as pain that has persisted for more than 3 months) might be treated at a regional multidisciplinary pain center. The specific aims of this study were (1) to describe characteristics of a sample of outpatients referred and accepted for treatment/management to three regional multidisciplinary pain centers in Norway, (2) to examine patient differences between the centers and (3) to study associations between symptom scores (insomnia, fatigue, depression, anxiety) and patient characteristics.

Methods

Patients, aged 17 years or older with CNMP admitted to and given a date for first consultation at one of three tertiary, multidisciplinary pain centers: St. Olavs Hospital Trondheim University Hospital (STO), Haukeland University Hospital (HUS) and University Hospital of North Norway (UNN), were included in the study. Data on demographics, physical activity, characteristics of pain, previous traumatic events, social network, Insomnia Severity Index (ISI), Chalder Fatigue Questionnaire (CFQ), Hopkins Symptom Checklist-25 (HSCL-25) and SF-36v2® were retrieved from the local quality registry at each pain center.

Results

Data from 1563 patients [mean age 42 (SD 15) years and 63% females] were available for analyses. Average years with pain were 9.3 (SD 9.1). Primary education as highest level of education was reported by 20%, being actively working/student/military by 32%, and no physical activity by 31%. Further, 48% reported widespread pain, 61% reported being exposed to serious life event(s), and 77% reported having a close friend to talk to. Non-worker status, no physical activity, lack of social network, reports of being exposed to serious life event(s) and widespread pain were all characteristics repeatedly associated with clinically high symptom scores. No significant differences between the centers were found in the proportions of patients reporting fatigue nor mean levels of insomnia symptoms. However, the proportion of patients reporting symptoms of anxiety and depression was a little lower at UNN compared with STO and HUS.

Conclusions

Analyses of registry data from three tertiary multidisciplinary pain centers in Norway support previous findings from other registry studies regarding patient characterized: A large proportion being women, many years of pain, low employment rate, low physical activity rate, and a large proportion reporting previous traumatic event(s). Characteristics such as non-work participation, no physical activity, lack of social network, have been exposed to serious life event(s), and chronic widespread pain were all associated with high clinical score levels of insomnia, fatigue, and mental distress. Health related quality of life was low compared to what has been reported for a general population and a range of other patient groups.

Implications

The findings of this study indicate that physical activity and work participation might be two important factors to address in the rehabilitation of patients with chronic non-malignant pain. Future studies should also explore whether pre consultation self-reported data might give direction to rehabilitation modalities.

Co-Morbidities and Sex Differences in Long-Term Quality-of-Life Outcomes among Patients with and without Diabetes after Total Knee Replacement: Five-Year Data from Registry Study

Improved understanding of quality-of-life (QoL) outcomes can provide valuable information on intervention effectiveness and guide better patient care. The aim of this study was to examine whether QoL trajectories differ between patients with and without diabetes and identify to what extent patient characteristics are related to poor QoL outcomes after total joint replacement (TKR). Multilevel modelling was used to analyse long-term QoL patterns of patients undergoing TKR between 2006 and 2011. Patient-reported QoL at baseline and up to 5 years post-surgery were included. Of the 1553 TKR patients, one-fifth (n = 319) had diabetes. Despite there being no significant differences in QoL at baseline, patients with diabetes consistently reported lower QoL (on average by 0.028, p < 0.001) and did not improve to the same level as patients without the disease following surgery. Compared to males, females had significantly lower QoL (by 0.03, p < 0.001). Other baseline patient characteristics associated with important differences in QoL included presence of respiratory disease and mental health disorder. Patients with diabetes exhibit significantly poorer QoL compared to patients without diabetes, particularly among females. Knowledge of risk factors that impact on QoL can be useful for clinicians in identifying characteristics related to poor QoL outcomes and be used to guide patient-centered care.