A parent-child dyad approach to the assessment of health status and health-related quality of life in children with asthma

Economic evaluations of medical devices in paediatrics: a systematic review and a quality appraisal of the literature

BACKGROUND

Although economic evaluations (EEs) have been increasingly applied to medical devices, little discussion has been conducted on how the different health realities of specific populations may impact the application of methods and the ensuing results. This is particularly relevant for pediatric populations, as most EEs on devices are conducted in adults, with specific aspects related to the uniqueness of child health often being overlooked. This study provides a review of the published EEs on devices used in paediatrics, assessing the quality of reporting, and summarising methodological challenges.

METHODS

A systematic literature search was performed to identify peer-reviewed publications on the economic value of devices used in paediatrics in the form of full EEs (comparing both costs and consequences of two or more devices). After the removal of duplicates, article titles and abstracts were screened. The remaining full-text articles were retrieved and assessed for inclusion. In-vitro diagnostic devices were not considered in this review. Study descriptive and methodological characteristics were extracted using a structured template. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklist was used to assess the quality of reporting. A narrative synthesis of the results was conducted followed by a critical discussion on the main challenges found in the literature.

RESULTS

39 full EEs were eligible for review. Most studies were conducted in high-income countries (67%) and focused on high-risk therapeutic devices (72%). Studies comprised 25 cost-utility analyses, 13 cost-effectiveness analyses and 1 cost-benefit analysis. Most of the studies considered a lifetime horizon (41%) and a health system perspective (36%). Compliance with the CHEERS 2022 items varied among the studies.

CONCLUSIONS

Despite the scant body of evidence on EEs focusing on devices in paediatrics results highlight the need to improve the quality of reporting and advance methods that can explicitly incorporate the multiple impacts related to the use of devices with distinct characteristics, as well as consider specific child health realities. The design of innovative participatory approaches and instruments for measuring outcomes meaningful to children and their families should be sought in future research.

Understanding UK public views on normative decisions made to value health-related quality of life in children: A qualitative study

Developing methodology for measuring and valuing child health-related quality of life (HRQoL) is a priority for health technology agencies. One aspect of this is normative decisions that are made in child HRQoL valuation. This qualitative study aimed to better understand adult public opinion on the normative questions of whose preferences to elicit (adults, children, or both) and from which perspective (who should be imagined living in impaired health), when valuing child HRQoL. Opinions of the adult UK public (N = 32) were solicited using online semi-structured focus groups, featuring a breadth of age, sex, ethnicities, and responsibility for children under 18 years. Participants were provided with bespoke informational material on health state valuation and were probed for their views. Arguments for and against different positions were discussed. Data was analysed using framework analysis. Participants demonstrated near-to-universal agreement that children should be involved in valuation in some form, yet this should differ depending on age or maturity. There was strong support for approaches combining involvement from children and adults (e.g., their parents), especially for younger children. There was little intuitive support for the 'taxpayer argument' for asking taxpaying adults. In the context of greater involvement of children in valuation, most participants supported using an 'own' perspective. Most participants thought that valuation study participants should know the exercise is about valuing child health states for ethical reasons. Informed views from the UK public on who should be asked and with what perspective when valuing child HRQoL appear to differ from normative positions previously advocated by some health economists, such as prioritising the preferences of taxpaying adults. In contrast, the results suggest including adults and children in valuation, with the proviso that the children are of an appropriate age and level of maturity, and that an own perspective is used wherever possible.

Finalising the administration of co-SSPedi, a dyad approach to symptom screening for paediatric patients receiving cancer treatments

OBJECTIVES

Symptom Screening in Pediatrics Tool (SSPedi) is a validated self-report symptom screening tool for patients with cancer 8-18 years of age. Co-SSPedi is a novel dyad approach in which both child and parent complete SSPedi together. The objective was to finalise the approach to co-SSPedi administration with instruction that is easy to understand, resulting in dyads completing co-SSPedi correctly.

METHOD

We enrolled child and parent dyads, who understood English and where children (4-18 years) had cancer or were hematopoietic stem cell transplantation recipients. We provided each dyad with instruction on how to complete co-SSPedi together. Mixed methods were used to determine how easy or hard the instruction was to understand. Two raters adjudicated if co-SSPedi was completed correctly. Dyads were enrolled in cohorts of 12 evenly divided by age (4-7, 8-10, 11-14 and 15-18 years).

RESULTS

We enrolled 5 cohorts of 12 dyads, resulting in 60 dyads. Following verbal instruction provided in the first cohort, we identified the need for written instruction emphasising children should wait for parent response prior to entering scores. The instruction was iteratively refined based on qualitative feedback until the fifth cohort, where all 12 dyads found the instruction easy to understand and completed co-SSPedi correctly.

CONCLUSIONS

We developed a standard approach to dyad symptom screening named co-SSPedi with instruction that is easy to understand, resulting in correct co-SSPedi completion. Future efforts should focus on co-SSPedi validation and understanding how co-SSPedi scores compare to self- or proxy-reported symptom reporting.

Systematic Review of the Psychometric Performance of Generic Childhood Multi-attribute Utility Instruments

BACKGROUND

Childhood multi-attribute utility instruments (MAUIs) can be used to measure health utilities in children (aged ≤ 18 years) for economic evaluation. Systematic review methods can generate a psychometric evidence base that informs their selection for application. Previous reviews focused on limited sets of MAUIs and psychometric properties, and only on evidence from studies that directly aimed to conduct psychometric assessments.

OBJECTIVE

This study aimed to conduct a systematic review of psychometric evidence for generic childhood MAUIs and to meet three objectives: (1) create a comprehensive catalogue of evaluated psychometric evidence; (2) identify psychometric evidence gaps; and (3) summarise the psychometric assessment methods and performance by property.

METHODS

A review protocol was registered with the Prospective Register of Systematic Reviews (PROSPERO; CRD42021295959); reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guideline. The searches covered seven academic databases, and included studies that provided psychometric evidence for one or more of the following generic childhood MAUIs designed to be accompanied by a preference-based value set (any language version): 16D, 17D, AHUM, AQoL-6D, CH-6D, CHSCS-PS, CHU9D, EQ-5D-Y-3L, EQ-5D-Y-5L, HUI2, HUI3, IQI, QWB, and TANDI; used data derived from general and/or clinical childhood populations and from children and/or proxy respondents; and were published in English. The review included 'direct studies' that aimed to assess psychometric properties and 'indirect studies' that generated psychometric evidence without this explicit aim. Eighteen properties were evaluated using a four-part criteria rating developed from established standards in the literature. Data syntheses identified psychometric evidence gaps and summarised the psychometric assessment methods/results by property.

RESULTS

Overall, 372 studies were included, generating a catalogue of 2153 criteria rating outputs across 14 instruments covering all properties except predictive validity. The number of outputs varied markedly by instrument and property, ranging from 1 for IQI to 623 for HUI3, and from zero for predictive validity to 500 for known-group validity. The more recently developed instruments targeting preschool children (CHSCS-PS, IQI, TANDI) have greater evidence gaps (lack of any evidence) than longer established instruments such as EQ-5D-Y, HUI2/3, and CHU9D. The gaps were prominent for reliability (test-retest, inter-proxy-rater, inter-modal, internal consistency) and proxy-child agreement. The inclusion of indirect studies (n = 209 studies; n = 900 outputs) increased the number of properties with at least one output of acceptable performance. Common methodological issues in psychometric assessment were identified, e.g., lack of reference measures to help interpret associations and changes. No instrument consistently outperformed others across all properties.

CONCLUSION

This review provides comprehensive evidence on the psychometric performance of generic childhood MAUIs. It assists analysts involved in cost-effectiveness-based evaluation to select instruments based on the application-specific minimum standards of scientific rigour. The identified evidence gaps and methodological issues also motivate and inform future psychometric studies and their methods, particularly those assessing reliability, proxy-child agreement, and MAUIs targeting preschool children.

Psychometric Properties of Generic Preference-Weighted Measures for Children and Adolescents: A Systematic Review

INTRODUCTION

Preference-weighted measures (PWMs)-also referred to as preference-based measures in the literature-of health status/health-related quality of life plays an essential role in estimating quality-adjusted life-years (QALY) for use in economic evaluations of healthcare products and interventions. However, as PWMs are first and foremost intended to accurately reflect respondent health status, they should ideally demonstrate good psychometric properties for the population in question. This study aimed to systematically review published evidence on the measurement properties of commonly used PWMs for children and adolescents.

METHODS

Three electronic databases (PubMed, Medline, and PsycINFO) were searched for articles assessing the psychometric properties (content validity, construct validity-including convergent validity and known-group validity, test-retest reliability, and responsiveness) of the PWMs of interest (AQoL-6D, CHU9D, HUI2, HUI3, and EQ-5D-Y). The COsensus-based Standards for the selection of health Measurement INstruments methodology (COSMIN) guidelines were used to assess (a) the methodological quality of the studies included and (b) the psychometric performance of the instruments covered. Data were analysed overall as well as by population (country and disease group) and perspective (self-report or proxy-report). The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42021277296).

RESULTS

In total, 53 articles were included in this systematic review. Health Utilities Index (HUI) was tested only in patient populations, CHU9D was most frequently tested in general population samples, while EQ-5D-Y was tested in both populations. Overall, there was high-quality evidence supporting sufficient construct validity for all instruments except AQoL-6D. Evidence supporting test-retest and responsiveness was scarce. There was high-quality evidence supporting sufficient responsiveness of HUI2 and HUI3, and inconsistent test-retest reliability of CHU9D and EQ-5D-Y. Evidence for content validity was minimal and therefore not extracted and synthesized for any PWMs.

CONCLUSION

This review provides updated evidence on the measurement properties of existing generic PWMs for children and adolescents. High-quality evidence for all relevant psychometric properties and across a range of populations was not available for any of the instruments included, indicating that further work is needed in this direction. This study has identified some of the most noticeable evidence gaps for each of the individual measures. Users can use this information to guide their decision on the choice of PWM to administer.

Are We Agreed? Self- Versus Proxy-Reporting of Paediatric Health-Related Quality of Life (HRQoL) Using Generic Preference-Based Measures: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of this study was to examine the level of agreement between self- and proxy-reporting of health-related quality of life (HRQoL) in children (under 18 years of age) using generic preference-based measures.

METHODS

A systematic review of primary studies that reported agreement statistics for self and proxy assessments of overall and/or dimension-level paediatric HRQoL using generic preference-based measures was conducted. Where available, data on intraclass correlation coefficients (ICCs) were extracted to summarise overall agreement levels, and Cohen's kappa was used to describe agreement across domains. A meta-analysis was also performed to synthesise studies and estimate the level of agreement between self- and proxy-reported paediatric overall and domain-level HRQoL.

RESULTS

Of the 30 studies included, 25 reported inter-rater agreement for overall utilities, while 17 reported domain-specific agreement. Seven generic preference-based measures were identified as having been applied: Health Utilities Index (HUI) Mark 2 and 3, EQ-5D measures, Child Health Utility 9 Dimensions (CHU9D), and the Quality of Well-Being (QWB) scale. A total of 45 dyad samples were included, with a total pooled sample of 3084 children and 3300 proxies. Most of the identified studies reported a poor inter-rater agreement for the overall HRQoL using ICCs. In contrast to more observable HRQoL domains relating to physical health and functioning, the inter-rater agreement was low for psychosocial-related domains, e.g., 'emotion' and 'cognition' attributes of both HUI2 and HUI3, and 'feeling worried, sad, or unhappy' and 'having pain or discomfort' domains of the EQ-5D. Parents demonstrated a higher level of agreement with children relative to health professionals. Child self- and proxy-reports of HRQoL showed lower agreement in cancer-related studies than in non-cancer-related studies. The overall ICC from the meta-analysis was estimated to be 0.49 (95% confidence interval 0.34-0.61) with poor inter-rater agreement.

CONCLUSION

This study provides evidence from a systematic review of studies reporting dyad assessments to demonstrate the discrepancies in inter-rater agreement between child and proxy reporting of overall and domain-level paediatric HRQoL using generic preference-based measures. Further research to drive the inclusion of children in self-reporting their own HRQoL wherever possible and limiting the reliance on proxy reporting of children's HRQoL is warranted.

The Impact of a Family-Based Assessment and Intervention Healthy Lifestyle Programme on Health Knowledge and Beliefs of Children with Obesity and Their Families

Objective: To determine the impact of a family-based assessment-and-intervention healthy lifestyle programme on health knowledge and beliefs of children and families affected by obesity. Second, to compare the health knowledge of the programme cohort to those of a national cohort in Aotearoa/New Zealand (NZ). Design: This mixed-methods study collected health knowledge and health belief data in a questionnaire at baseline and 12-, 24-, and 60-month follow-up assessments. Health knowledge over time was compared with baseline knowledge and with data from a nationally representative survey. A data-driven subsumption approach was used to analyse open-text responses to health belief questions across the study period. Setting: Taranaki region, a mixed urban−rural setting in NZ. Participants: Participants (caregiver/child dyads) from the Whānau Pakari randomised trial. Results: A greater proportion of the cohort correctly categorised foods and drinks as healthy or unhealthy at 12 months compared to baseline for most questionnaire items. Retention of this health knowledge was evident at 24- and 60-month follow-ups. More than twice as many participants correctly reported physical activity recommendations at follow-up compared to baseline (p < 0.001). Health knowledge of participants was similar to the national survey cohort at baseline, but surpassed it at 12 and 24 months. Participant beliefs around healthy lifestyles related to physical functioning, mental and emotional wellbeing, and enhancement of appearance, and gained greater depth and detail over time. Conclusions: This study demonstrates the important role that community-level healthy lifestyle programmes can have in knowledge-sharing and health promotion.

Protocol for the implementation evaluation of an integrated paediatric and primary care model: Strengthening Care for Children (SC4C)

INTRODUCTION

Implementation evaluations provide insight into how interventions are delivered across varying contexts and why interventions work in some contexts and not in others. This manuscript outlines a detailed protocol of an implementation evaluation embedded in a stepped-wedge cluster randomised controlled trial of a model of care, Strengthening Care for Children (SC4C), that integrates paediatric care in general practice. The purpose of this manuscript is to describe the pragmatic methods that will be used to capture implementation evaluation process and outcome data within this trial.

METHODS AND ANALYSIS

Our implementation evaluation will use a mixed methods design, with data collected in the intervention arm of the SC4C trial guided by a logic model developed using the Consolidated Framework for Implementation Research (CFIR) and Proctor and colleague's taxonomy of implementation outcomes. Data collection will be via questionnaires and semistructured interviews with general practitioners, paediatricians, general practice administrative staff and children and families. Each of the 21 general practices recruited into the study will be described in terms of staffing, patient throughput and location, in addition to the nuanced inner and outer contexts, use of the intervention and its acceptability. We will quantify implementation effectiveness in each general practice clinic using the CFIR validated scoring system. Importantly, we have embedded data collection post intervention to enable assessment of the sustainable adoption of the intervention. An inductive approach to the analysis of qualitative data will identify additional emerging themes that may not be covered by the formal frameworks underpinning our analysis.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Royal Children's Hospital Ethics Committee in August 2020 (HREC: 65955). Results will be submitted for publication in peer-reviewed journals and presented at relevant conferences.

TRIAL REGISTRATION NUMBER

Australia New Zealand Clinical Trials Registry 12620001299998 on 1 December 2020.

Agreement between parent-proxy and child self-report in pediatric hypermobile Ehlers-Danlos syndrome

Hypermobile Ehlers-Danlos syndrome (hEDS) is a common disorder in children and adolescents that negatively impacts health-related quality of life (HRQOL). It can include chronic pain, fatigue, autonomic dysfunction, and mood problems. The objective of this study was to examine levels of agreement between children and parents in the setting of hEDS and HRQOL. Individuals with hEDS, ages 10-20 years, and their parents were recruited to complete a series of surveys. Instruments included pediatric quality of life generic and multidimensional fatigue scales, Functional Disability Index, Pain-Frequency-Severity-Duration scale, Brief Illness Perception Questionnaire, and Herth Hope Index. Agreement on each measure was evaluated using statistical calculations. Thirty-six parent-child dyads completed the surveys. There were no significant differences between the means of parent and child scores. There was moderate to strong agreement on all survey scores. However, the proportion of dyads with disagreement was relatively high for each individual score. Eighteen dyads disagreed on at least half of the surveys. Body mass index centile and child perception of cognitive fatigue most strongly predicted disagreement in total HRQOL score. Proxy-reporters for children and adolescents with hEDS may agree with their child on average. However, due to significant frequency of clinically important disagreement, information from both children and their parents should be sought whenever possible.

Dyadic Predictors of Child Body Shame in a Polish and Italian Sample

The present study aimed at assessing the predictors (related to the functioning of a parent-child dyad) of child body shame. Therefore, in the main analysis we examined relationships among child body shame, child perfectionism, child body dissatisfaction, parent body shame, parent perfectionism, and parent body dissatisfaction. In our main hypothesis we assumed that higher levels of the abovementioned parent functioning-related variables would be associated with higher child body shame after accounting for the effects of the foregoing child functioning-related variables. The analysis finally included complete data from 420 participants, i.e., a 115 Polish and 95 Italian parent-child dyad. Participants completed: (a) child: the Objectified Body Consciousness Scale for Youth, the Child-Adolescent Perfectionism Scale, the Children's Body Image Scale/the Figure Rating Scale; (b) parent: the Objectified Body Consciousness Scale, the Frost Multidimensional Perfectionism Scale, and the Contour Drawing Rating Scale. The results of a correlational analysis show that in both the Polish and Italian samples, the higher the level of child body shame, the higher the level of the following variables: child perfectionism, child body dissatisfaction, parent perfectionism, and parent body dissatisfaction. Interestingly, the only insignificant relationship in both samples is the association between body shame in both members of the child-parent dyad. Moreover, all steps of the regressions were significant in both Polish and Italian samples. It turned out that only in the Italian sample were all predictors significantly associated with a child's body shame (in the Polish sample there was no significant association between child's body shame and parent's perfectionism). To sum up, the above studies show the importance of considering the functioning of the parent-child dyad in understanding child body shame. These findings suggest that parents' attitudes toward their bodies and their beliefs about an ideal self should be taken into account when planning interventions to improve children's and adolescents' attitudes toward their bodies. This is so because it is possible for children to internalize their parents' beliefs about how to look and how critical one should be of themselves, which can result in strong body shame when they are not perfect enough against the internalized ideal. Therefore, it is also necessary to make parents aware that children's attitude toward their body is often a reflection of parents' attitude toward the body.

EQ-5D-Y-3L and EQ-5D-Y-5L proxy report: psychometric performance and agreement with self-report

BACKGROUND

Self-report is the standard for measuring people's health-related quality of life (HRQoL), including children. However, in certain circumstances children cannot report their own health. For this reason, children's HRQoL measures often provide both a self-report and a proxy-report form. It is not clear whether the measurement properties will be the same for these two forms. We investigated whether it would be beneficial to extend the classification system of the EQ-5D-Y proxy questionnaire from 3 to 5 response levels. The agreement between self-report and proxy-report was assessed for both EQ-5D-Y measures.

METHODS

The study included 286 pediatric patients and their caregivers as proxies. At three consecutive measurements-baseline, test-retest and follow-up-the proxies assessed the child's HRQoL using the EQ-5D-Y-3L, EQ-5D-Y-5L, the PedsQL Generic, and matched disease-specific instruments. The proxy versions of EQ-5D-Y-3L and EQ-5D-Y-5L were compared in terms of feasibility, distribution properties, convergent validity, test-retest and responsiveness. Agreement between both EQ-5D-Y proxy versions to their respective self-report versions was assessed at baseline and follow-up.

RESULTS

The proportion of missing responses was 1% for the EQ-5D-Y-3L and 1.4% for the EQ-5D-Y-5L. The frequency of health state with no problems in all dimensions (11111) was slightly lower for the EQ-5D-Y-5L (21.3% vs 16.7%). Regarding the convergent validity with the PedsQL and disease-specific measures, the proxy versions of EQ-5D-Y-3L and EQ-5D-Y-5L had similar magnitudes of associations between similar dimensions. The means of test-retest coefficients between the two versions of the EQ-5D-Y proxy were comparable (0.83 vs. 0.84). Regarding reported improved conditions, responsiveness of the EQ-5D-Y-5L proxy (26.6-54.1%) was higher than that of the EQ-5D-Y-3L proxy (20.7-46.4%). Except for acutely ill patients, agreement between the EQ-5D-Y-5L proxy and self-reports was at least moderate.

CONCLUSIONS

Extending the number of levels of the proxy version of EQ-5D-Y can improve the classification accuracy and the ability to detect health changes over time. The level structure of EQ-5D-Y-5L was associated with a closer agreement between proxy and self-report. The study findings support extending the EQ-5D-Y descriptive system from 3 to 5 levels when administered by a proxy, which is often the case in the pediatric population.

An Assessment of the Validity and Reliability of the Pediatric Child Health Utility 9D in Children with Inflammatory Bowel Disease

Health utilities relevant to children are lacking, compromising health funding and policy decisions for children. The Child Health Utility 9D (CHU9D) is a recently developed preference-based health utility instrument designed for use in children. The objective was to examine the validity of the CHU9D in a cohort of 285 Canadian children aged 6.5 to 18 years of age with Crohn’s disease (CD) and ulcerative colitis (UC), (collectively inflammatory bowel disease (IBD)). The correlation and agreement between paired CHU9D and Health Utility Index (HUI) assessments were determined with Spearman coefficients and Bland–Altman levels of agreement. Total and domain utilities were calculated for the CHU9D using Australian adult and youth tariffs. Algorithms for HUI2 and HUI3 were used. Domain correlations were determined between domains with expected overlap between instruments. In CD and in UC, correlations between CHU9D, HUI2, and HUI3 utilities ranged between 0.62 to 0.67 and 0.67 to 0.69, respectively (p < 0.05). CHU9D utilities were lower using youth tariffs compared to adult tariffs. A large range in health utilities suggested a heterogeneous quality of life. The CHU9D is a good option for preference-based utility measurement in pediatric IBD. Additional research is required to derive pediatric tariffs to conduct economic evaluation in children.

Measuring child functioning: Assessing correlation and agreement between caregiver and child responses at the Iganga-Mayuge health and demographic surveillance site in Uganda

INTRODUCTION

Empirical data is scare on assessment of concordance between caregiver-child responses on child functioning.

OBJECTIVE

To assess correlation and agreement between children (11-17 years old) and their caregivers' responses to the UNICEF/Washington Group Child Functioning Module (CFM) at the Iganga-Mayuge Health and Demographic Surveillance Site (IM-HDSS) in Uganda.

METHODS

CFM with 24-questions corresponding to 13 domains of functioning was administered to children between 11 and 17 years of age and their caregivers. Descriptive analyses of the child/caregiver responses were conducted. Correlation and agreement between caregiver and child responses were assessed.

RESULTS

Of the 217 caregiver/child pairs eligible for this study, 181 pairs agreed to participate (83.4%). The mean age of children was 13.9 ± 1.9 years, and 56.4% were males. Cronbach's alpha was 0.892 and 0.886 for the caregiver and child versions of CFM respectively, showing good internal consistency in both. There was a significant overall agreement between mean score of caregiver (5.36 ± 5.63 out of 39) and child (5.45 ± 5.34) pairs. Spearman's rank correlation between the pairs was 0.806 (strong positive correlation). Bland-Altman plots for CFM scores showed greater agreement between caregiver and child at lower scores. Percentage agreement between the pairs for overall disability was greater for mild (83.53%) and moderate (79.37%) categories as compared to the severe (66.67%) category. There was substantial agreement (kappa 0.623) for overall disability between the pairs.

CONCLUSION

This study indicates that there is significant correlation and agreement between self-reported caregiver-child pair responses, opening the way for considering children as CFM respondents, when possible.

EQ-5D-Y Value Set for Slovenia

BACKGROUND

A value set for the EuroQoL 5-Dimensions (EQ-5D)-Y in Slovenia is not yet available, making the calculation of quality-adjusted life-years (QALYs) for children and adolescents using this generic instrument impossible.

OBJECTIVE

The main objective of our study was to obtain adult preferences towards EQ-5D-Y health states in Slovenia, following the EQ-5D-Y-3L international valuation protocol. The adults were asked to take the perspective of a hypothetical 10-year-old child.

METHOD

A sample of 1074 adults in Slovenia completed an online discrete-choice experiment (DCE) survey on EQ-5D-Y health states. The latent scale issue was addressed by obtaining the value of the anchor (33333) with 200 composite time trade-off (cTTO) interviews. A mixed (random coefficients) logit model was used to estimate the value set.

RESULTS

All the estimated coefficients of the mixed logit model were statistically significant at the 1% level and had an expected negative sign. The most important health dimension in EQ-5D-Y is pain/discomfort, followed by anxiety/depression, usual activities, and mobility, with self-care being the least important health dimension.

CONCLUSIONS

The study addresses an important research gap and presents the EQ-5D-Y value set for Slovenia. At the time of writing, no published value sets are available for the EQ-5D-Y-3L appropriate for use in QALY calculations, making this value set the first EQ-5D-Y value set in the world.

A Review of the Psychometric Performance of Selected Child and Adolescent Preference-Based Measures Used to Produce Utilities for Child and Adolescent Health

OBJECTIVE

This review examined the psychometric performance of 4 generic child- and adolescent-specific preference-based measures that can be used to produce utilities for child and adolescent health.

METHODS

A systematic search was undertaken to identify studies reporting the psychometric performance of the Child Health Utility (CHU9D), EQ-5D-Y (3L or 5L), and Health Utilities Index Mark 2 (HUI2) or Mark 3 (HUI3) in children and/or adolescents. Data were extracted to assess known-group validity, convergent validity, responsiveness, reliability, acceptability, and feasibility. Data were extracted separately for the dimensions and utility index where this was reported.

RESULTS

The review included 76 studies (CHU9D n = 12, EQ-5D-Y-3L n = 20, HUI2 n = 26,HUI3 n = 43), which varied considerably across conditions and sample size. EQ-5D-Y-3L had the largest amount of evidence of good psychometric performance in proportion to the number of studies examining performance. The majority of the evidence related to EQ-5D-Y-3L was based on dimensions. CHU9D was assessed in fewer studies, but the majority of studies found evidence of good psychometric performance. Evidence for HUI2 and HUI3 was more mixed, but the studies were more limited in sample size and statistical power, which was likely to have affected performance.

CONCLUSIONS

The heterogeneity of published studies means that the evidence is based on studies across a range of countries, populations and conditions, using different study designs, different languages, different value sets and different statistical techniques. Evidence for CHU9D in particular is based on a limited number of studies. The findings raise concerns about the comparability of self-report and proxy-report responses to generate utility values for children and adolescents.

SF-6Dv2 preference value set for health utility in food allergy

BACKGROUND

The lack of a value set allowing the calculation of QALY is an important limitation when establishing the value of emerging therapies to treat food allergy. The aim of this study was to develop a Short-Form Six-Dimension version 2 (SF-6Dv2) preference value set for the calculation of health utility from the Canadian food-allergic population.

METHODS

Two hundred ninety-five parents of patients aged 0-17 years old and 154 patients aged 12 years old and above with food allergy were recruited in clinic and online. Participants were asked to complete a self-administered online questionnaire including generic health-related quality of life questionnaires. Various health states described by the SF-6Dv2 were valued with time-trade-off and discrete choice experiments. Data from elicitation techniques were combined using the hybrid regression model.

RESULTS

A total of 241 parents and 125 patients performed 3904 time-trade-off and 5112 discrete choice experiments. Utility decrements were estimated for each level of each SF-6Dv2 dimension. Utility values calculated based on the validated preference set were in average 0.15 lower (95%CI: 0.12-0.18) and were poorly correlated (R²  = 0.46) with those derived from the EQ-5D-5L generic questionnaire in the same cohort.

CONCLUSION

A representative preference value set for patients with food allergy was determined using the SF-6Dv2 generic questionnaire. This adapted preference set will contribute to improve the validity of future utility estimates in this population for the appraisal of upcoming potentially impactful but sometimes costly therapies.

A Review of the Methods Used to Generate Utility Values in NICE Technology Assessments for Children and Adolescents

OBJECTIVE

This review summarizes and critically examines methods used to generate utilities for child and adolescent health states in previous National Institute for Health and Care Excellence (NICE) technology assessments (TA) and highly specialized technology (HST) evaluations.

METHODS

We identified all NICE TA and HST evaluations in which the licensed indication for the technology included people younger than 18 and included in the review all evaluations using a cost-utility analysis.

RESULTS

The review includes 40 TA and HST evaluations. Most assessments generated utility values with the EQ-5D scored using the adult version of the EQ-5D either exclusively (n = 16) or alongside other utility measures and direct elicitation methods of patient own utility (n = 17), although 7 did not use the EQ-5D. Eight assessments used both the EQ-5D child- and adolescent-specific preference-based measures: Health Utilities Index Mark 2 (n = 6), child- and adolescent-specific preference-based measure for atopic dermatitis (n = 1), and youth version of the EQ-5D (EQ-5D-Y) valued using the adult EQ-5D value set (n = 1) or generated using mapping and valued using the adult EQ-5D value set (n = 2). Some cost-utility analyses used age adjustment (utility subtractions, weights, and published mapping formulae) from the adult EQ-5D UK population norms to reflect the general population or disease-free health for children and adolescents (n = 9), and 1 assessment assumed full health (utility value of 1).

CONCLUSION

The review found limited use of child and adolescent population-specific measures to generate health state utility values for children and adolescents in NICE technology assessments. Often assessments involve the use of an adult-specific measure to reflect the health of children.

Discordance between pediatric self-report and parent proxy-report symptom scores and creation of a dyad symptom screening tool (co-SSPedi)

Symptom Screening in Pediatrics Tool (SSPedi) (age 8-18 years) and mini-SSPedi (age 4-7 years) can be used to self-report and proxy-report bothersome symptoms in pediatric patients receiving cancer treatments. There are limitations of sole child self-report or proxy-report. An approach in which children and parents complete symptom reports together may be useful. The aim of our study was to describe discordance between child self-report and parent proxy-report symptom scores, and to determine how these scores compare to an approach in which reporting is performed together (co-SSPedi). Children and parents completed SSPedi or mini-SSPedi separately. Discordant symptoms were shared with respondents and discussed. Next, the dyad completed co-SSPedi together and were asked which approach they preferred. Discordance was evaluated for each symptom and was defined as a difference of at least 2 points on an ordinal scale ranging from 0 (not at all bothered) to 4 (extremely bothered). Of the 48 enrolled dyads (children, median age, 10.8 years; 54.2% male), 41 (85.4%) had discordance in at least one symptom. There was no clear pattern in discordance by age group. When a dyad approach was used, more co-SSPedi scores agreed with the original child self-report scores (59 dyads, 56.2%) compared to original parent proxy-report scores (15 dyads, 14.3%) for discordant symptoms. Forty-three (89.6%) dyads preferred to complete SSPedi together. Future work should evaluate the psychometric properties of co-SSPedi.

Mind the (inter-rater) gap. An investigation of self-reported versus proxy-reported assessments in the derivation of childhood utility values for economic evaluation: A systematic review

PURPOSE

Evidence surrounding utilities for health states, derived either directly from the application of preference-based valuation methods or indirectly from the application of preference-based quality of life instruments, is increasingly being utilised to inform the cost-effectiveness of child health interventions. Proxy (parent or health professional) assessments are common in this area. This study sought to investigate the degree of convergence in childhood utilities generated directly or indirectly within dyad child and proxy assessments.

METHODS

A systematic literature review was conducted following PRISMA guidelines. A comprehensive literature search strategy conducted across six search engines (PubMed, Embase, Web of Science, PsychoINFO, EconLit, CINAHL and Cochrane Library). Original peer-reviewed articles that reported utilities derived directly or indirectly using simultaneous dyad child and proxy assessments were extracted. Mean and median utilities, correlation coefficients and levels of agreement were extracted, catalogued and assessed.

RESULTS

A total of 35 studies that reported utilities for two or more respondent types were identified. Of these, 29 studies reported dyad childhood self-report and proxy utilities whilst six studies reported levels of agreement and/or correlations only without documenting overall utilities. Proxy assessment was most often conducted by parents with the HUI3 representing the most commonly applied instrument across a range of health conditions. The utilities derived from child and parent proxy assessment were bidirectional with parental proxies tending to underestimate and health professional proxies tending to overestimate relative to child self-reports. Inter-rater agreement between child self-reports and parent-proxy reports were poorer for more subjective attributes (cognition, emotion and pain), relative to physical attributes (mobility, self-care, speech, vision) of health-related quality of life.

CONCLUSIONS

Childhood utilities derived from children or proxies are not interchangeable. The choice of self or proxy assessor may have potentially significant implications for economic evaluations of child health interventions.

The relationship between parental attitudes and children's alcohol use: a systematic review and meta-analysis

AIMS

The main aim of this study was to assess the relationship between parental attitudes towards children's alcohol use and their child's alcohol use. Secondary aims included assessing the relationship between attitudes reported by parents and those perceived by children, and between perceived parental attitudes and children's alcohol use.

METHODS

Meta-analysis of studies reporting on the associations between parental attitudes towards children's alcohol use and children's self-reported alcohol use. Published, peer-reviewed cross-sectional and longitudinal studies were identified from the following databases up to April 2018: Medline, PsycINFO, EMBASE, Scopus and Web of Science. Quality assessment was performed by using guidelines developed by Hayden, Cote & Bombardier. Pooled effect sizes were calculated by using random-effects meta-analyses, if there were at least two studies that could be included per analysis. Of 7471 articles screened, 29 were included comprising data from 16 477 children and 15 229 parents.

RESULTS

Less restrictive parental attitudes towards children's alcohol use were related to higher rates of alcohol use initiation [odds ratio (OR) = 1.45, 95% confidence interval (CI) = 1.17-1.80], alcohol use frequency (OR = 1.52, 95% CI = 1.24-1.86) and drunkenness (OR = 1.58, 95% CI = 1.35-1.85) among children. Less perceived restrictive parental attitudes were related to higher alcohol use frequency (OR = 1.76, 95% CI = 1.29-2.40). Perceived parental attitudes were not clearly related to alcohol use initiation. Parent-reported attitudes and perceived parental attitudes were weakly positively correlated (r = 0.27, P = ≤ 0.001). The strength of the relationship between parental attitudes and children's alcohol use frequency attenuated with children's age. Study design, sample size, study location and levels of alcohol use frequency did not have a detectable effect on the relationship.

CONCLUSIONS

Less restrictive parental attitudes towards children's alcohol use are associated with increases in children's alcohol use onset, alcohol use frequency and drunkenness. Children's perception of less restrictive parental attitudes is associated with children's alcohol use.

Impact of shared decision making on asthma quality of life and asthma control among children

OBJECTIVE

Few studies have examined the effectiveness of shared decision making (SDM) in clinical practice. This study evaluated the impact of SDM on quality of life and symptom control in children with asthma.

METHODS

We conducted a prospective 3-year study in six community-based practices serving a low-income patient population. Practices received training on SDM using an evidence-based toolkit. Patients aged 2-17 with a diagnosis of asthma were identified from scheduling and billing data. At approximate 6-month intervals, patients completed a survey consisting of the Mini Pediatric Asthma Quality of Life Questionnaire (range 1-7) and the control domain of the Pediatric Asthma Therapy Assessment Questionnaire (range 0-7). We used propensity scores to match 46 children receiving SDM to 46 children receiving usual care with decision support. Included children had completed a baseline survey and at least one follow-up survey. Random coefficient models incorporated repeated measures to assess the effect of SDM on asthma quality of life and asthma control.

RESULTS

The sample was primarily of non-White patients (94.6%) with Medicaid insurance (92.4%). Receipt of SDM using an evidence-based toolkit was associated with higher asthma quality of life [mean difference 0.9; 95% confidence interval (CI) 0.4-1.4] and fewer asthma control problems (mean difference -0.9; 95% CI -1.6--0.2) compared to usual care with decision support.

CONCLUSIONS

Implementation of SDM within clinical practices using a standardized toolkit is associated with improved asthma quality of life and asthma control for low-income children with asthma when compared to usual care with decision support.

Perceptions of Healthy Eating Among Hispanic Parent-Child Dyads

Limited research exists exploring the perceptions of healthy and unhealthy eating among Hispanic families, yet understanding their perceptions could inform public health practice with regard to nutrition and obesity prevention. This study conducted an exploratory analysis of interview data collected from 25 parent-child dyads as part of a program evaluation to learn more about both parent and child beliefs and practices regarding healthy eating, and in particular fruit and vegetable consumption. Families described an incomplete knowledge regarding healthy eating, specifically how to increase fruit and vegetable consumption, and the benefits of healthy eating as well as risks of unhealthy eating. Parents in particular seemed to identify many of the foods to avoid but were unclear about healthier alternatives. Children focused more on the benefits of healthy eating, while parents spoke more about the risks of unhealthy eating and the challenges of eating vegetables, particularly among families where child weight was also raised as a concern.

Preference-based measures to obtain health state utility values for use in economic evaluations with child-based populations: a review and UK-based focus group assessment of patient and parent choices

Background

No current guidance is available in the UK on the choice of preference-based measure (PBM) that should be used in obtaining health-related quality of life from children. The aim of this study is to review the current usage of PBMs for obtaining health state utility values in child and adolescent populations, and to obtain information on patient and parent–proxy respondent preferences in completing PBMs in the UK.

Methods

A literature review was conducted to determine which instrument is most frequently used for child-based economic evaluations and whether child or proxy responses are used. Instruments were compared on dimensions, severity levels, elicitation and valuation methods, availability of value sets and validation studies, and the range of utility values generated. Additionally, a series of focus groups of parents and young people (11–20 years) were convened to determine patient and proxy preferences.

Results

Five PBMs suitable for child populations were identified, although only the Health Utilities Index 2 (HUI2) and Child Heath Utility 9D (CHU-9D) have UK value sets. 45 papers used PBMs in this population, but many used non-child-specific PBMs. Most respondents were parent proxies, even in adolescent populations. Reported missing data ranged from 0.5 to 49.3%. The focus groups reported their experiences with the EQ-5D-Y and CHU-9D. Both the young persons’ group and parent/proxy groups felt that the CHU-9D was more comprehensive but may be harder for a proxy to complete. Some younger children had difficulty understanding the CHU-9D questions, but the young persons’ group nonetheless preferred responding directly.

Conclusion

The use of PBMs in child populations is increasing, but many studies use PBMs that do not have appropriate value sets. Parent proxies are the most common respondents, but the focus group responses suggest it would be preferred, and may be more informative, for older children to self-report or for child–parent dyads to respond.

Electronic supplementary material

The online version of this article (10.1007/s11136-018-1831-6) contains supplementary material, which is available to authorized users.

General and Disease-specific Scales in Children with Asthma and their Parents

OBJECTIVE

To investigate and compare the efficiency of general and disease-specific life quality scales in children with asthma.

METHODS

Children with asthma, and their parents completed the Childhood Asthma Control Test (C-ACT), Pediatric Asthma Quality of Life Questionnaire (PAQLQ), Pediatric Quality of Life Inventory (PedsQL), and also underwent spirometry.

RESULTS

82 children (55 males) with a median (IQR) age of 10.1 (8.9-10.5) years were included. C-ACT, PAQLQ and PedsQL child scores were significantly higher in children with controlled asthma.

CONCLUSION

Quality of life in children, assessed using disease- specific quality of life measures, is better for children with good asthma control.

A Review of the Development and Application of Generic Multi-Attribute Utility Instruments for Paediatric Populations

Multi-attribute utility instruments (MAUIs) are increasingly being used as a means of quantifying utility for the calculation of quality-adjusted life-years within the context of cost utility analysis. Traditionally, MAUIs have been developed and applied in adult populations. However, increasingly, researchers in health economics and other disciplines are recognising the importance of the measurement and valuation of health in both children and adolescents. Presently, there are nine generic MAUIs available internationally that have been used in paediatric populations: the Quality of Well-Being Scale (QWB), the Health Utility Index Mark 2 (HUI2), the HUI3, the Sixteen-dimensional measure of health-related quality of life (HRQoL) (16D), the Seventeen-dimensional measure of HRQoL (17D), the Assessment of Quality of Life 6-Dimension (AQoL-6D) Adolescent, the Child Health Utility 9D (CHU9D), the EQ-5D Youth version (EQ-5D-Y) and the Adolescent Health Utility Measure (AHUM). This paper critically reviews the development and application of the above nine MAUIs and discusses the specific challenges of health utility measurement in children and adolescents. Areas for further research relating to the development and application of generic MAUIs in paediatric populations are highlighted.

Assessing the Health-Related Quality of Life of Australian Adolescents: An Empirical Comparison of the Child Health Utility 9D and EQ-5D-Y Instruments

OBJECTIVES

To examine the performance of two recently developed preference-based instruments-the Child Health Utility 9D (CHU9D) and the EuroQol five-dimensional questionnaire Youth version (EQ-5D-Y)-in assessing the health-related quality of life (HRQOL) of Australian adolescents.

METHODS

An online survey including the CHU9D and the EQ-5D-Y, self-reported health status, and a series of sociodemographic questions was developed for administration to a community-based sample of adolescents (aged 11-17 years). Individual responses to both instruments were translated into utilities using scoring algorithms derived from the Australian adult general population.

RESULTS

A total of 2020 adolescents completed the online survey. The mean ± SD utilities of the CHU9D and the EQ-5D-Y were very similar (0.82 ± 0.13 and 0.83 ± 0.19, respectively), and the intraclass correlation coefficient (0.80) suggested good levels of agreement. Both instruments were able to discriminate according to varying levels of self-reported health status (P < 0.001). Although exhibiting good levels of agreement overall, some wide divergences were apparent at an individual level.

CONCLUSIONS

The study results are encouraging and illustrate the potential for both the CHU9D and the EQ-5D-Y to be more widely used for measuring and valuing the HRQOL of adolescent populations in Australia and internationally. Generating adolescent-specific scoring algorithms pertaining to each instrument and an empirical comparison of the resulting utilities is a natural next step. More evidence is required from the application of the CHU9D and the EQ-5D-Y in specific patient groups in adolescent health settings to inform the choice of instrument for measuring and valuing the HRQOL for the economic evaluation of adolescent health care treatments and services.

Mapping EQ-5D utility scores from the PedsQL™ generic core scales

PURPOSE

The Pediatric Quality of Life Inventory™ (PedsQL™) General Core Scales (GCS) were designed to provide a modular approach to measuring health-related quality of life in healthy children, as well as those with acute and chronic health conditions, across the broadest, empirically feasible, age groups (2-18 years). Currently, it is not possible to estimate health utilities based on the PedsQL™ GCS, either directly or indirectly. This paper assesses different mapping methods for estimating EQ-5D health utilities from PedsQL™ GCS responses.

METHODS

This study is based on data from a cross-sectional survey conducted in four secondary schools in England amongst children aged 11-15 years. We estimate models using both direct and response mapping approaches to predict EQ-5D health utilities and responses. The mean squared error (MSE) and mean absolute error (MAE) were used to assess the predictive accuracy of the models. The models were internally validated on an estimation dataset that included complete PedsQL™ GCS and EQ-5D scores for 559 respondents. Validation was also performed making use of separate data for 337 respondents.

RESULTS

Ordinary least squares (OLS) models that used the PedsQL™ GCS subscale scores, their squared terms and interactions (with and without age and gender) to predict EQ-5D health utilities had the best prediction accuracy. In the external validation sample, the OLS model with age and gender had a MSE (MAE) of 0.036 (0.115) compared with a MSE (MAE) of 0.036 (0.114) for the OLS model without age and gender. However, both models generated higher prediction errors for children in poorer health states (EQ-5D utility score <0.6). The response mapping models encountered some estimation problems because of insufficient data for some of the response levels.

CONCLUSION

Our mapping algorithms provide an empirical basis for estimating health utilities in childhood when EQ-5D data are not available; they can be used to inform future economic evaluations of paediatric interventions. They are likely to be robust for populations comparable to our own (children aged 11-15 years in attendance at secondary school). The performance of these algorithms in childhood populations, which differ according to age or clinical characteristics to our own, remains to be evaluated.

Parent-child agreement on health-related quality of life (HRQOL): a longitudinal study

Background

Few studies have evaluated changes on parent–child agreement in HRQOL over time. The objectives of the study were to assess parent–child agreement on child’s HRQOL in a 3-year longitudinal study, and to identify factors associated with possible disagreement.

Methods

A sample of Spanish children/adolescents aged 8–18 years and their parents both completed the KIDSCREEN-27 questionnaire. Data on age, gender, family socioeconomic status (SES), and mental health (Strengths and Difficulties Questionnaire, SDQ) was also collected at baseline (2003), and again after 3 years (2006). Changes in family composition were collected at follow-up. Agreement was assessed through intraclass correlation coefficient (ICC), and Bland and Altman plots. Generalizing Estimating Equation (GEE) models were built to analyze factors associated with parent–child disagreement.

Results

A total of 418 parent–child pairs were analyzed. At baseline the level of agreement on HRQOL was low to moderate and it was related to the level of HRQOL reported. Physical well-being at baseline showed the highest level of parent–child agreement (ICC=0.59; 0.53-0.65) while less “observable” dimensions presented lower levels of agreement, (i.e. Psychological well-being: ICC= 0.46; 0.38-0.53). Agreement parent–child was lower at follow-up. Some interactions were found between rater and child’s age; with increasing age, child scored lower than parents on Parents relationships and Autonomy (Beta [B] -0.47; -0.71 / -0.23) and the KIDSCREEN-10 (−0.49; -0.73 /-0.25).

Conclusions

Parent–child agreement on child’s HRQOL is moderate to low and tends to diminish with children age. Measuring HRQOL of children/adolescents mainly in healthy population samples might require direct self-assessments.

Pediatric patient-reported outcome instruments for research to support medical product labeling: report of the ISPOR PRO good research practices for the assessment of children and adolescents task force

BACKGROUND

Patient-reported outcome (PRO) instruments for children and adolescents are often included in clinical trials with the intention of collecting data to support claims in a medical product label.

OBJECTIVE

The purpose of the current task force report is to recommend good practices for pediatric PRO research that is conducted to inform regulatory decision making and support claims made in medical product labeling. The recommendations are based on the consensus of an interdisciplinary group of researchers who were assembled for a task force associated with the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). In those areas in which supporting evidence is limited or in which general principles may not apply to every situation, this task force report identifies factors to consider when making decisions about the design and use of pediatric PRO instruments, while highlighting issues that require further research.

GOOD RESEARCH PRACTICES

Five good research practices are discussed: 1) Consider developmental differences and determine age-based criteria for PRO administration: Four age groups are discussed on the basis of previous research (<5 years old, 5-7 years, 8-11 years, and 12-18 years). These age groups are recommended as a starting point when making decisions, but they will not fit all PRO instruments or the developmental stage of every child. Specific age ranges should be determined individually for each population and PRO instrument. 2) Establish content validity of pediatric PRO instruments: This section discusses the advantages of using children as content experts, as well as strategies for concept elicitation and cognitive interviews with children. 3) Determine whether an informant-reported outcome instrument is necessary: The distinction between two types of informant-reported measures (proxy vs. observational) is discussed, and recommendations are provided. 4) Ensure that the instrument is designed and formatted appropriately for the target age group. Factors to consider include health-related vocabulary, reading level, response scales, recall period, length of instrument, pictorial representations, formatting details, administration approaches, and electronic data collection (ePRO). 5) Consider cross-cultural issues.

CONCLUSIONS

Additional research is needed to provide methodological guidance for future studies, especially for studies involving young children and parents' observational reports. As PRO data are increasingly used to support pediatric labeling claims, there will be more information regarding the standards by which these instruments will be judged. The use of PRO instruments in clinical trials and regulatory submissions will help ensure that children's experience of disease and treatment are accurately represented and considered in regulatory decisions.