Health values of the seriously ill. SUPPORT investigators

Economic evaluation of ceftazidime-avibactam vs. polymyxin B for treatment of hospital-acquired and ventilator-associated bacterial pneumonia

Ventilator-associated pneumonia is one of the most common infections in Intensive Care Units (ICU). It is frequently caused by multidrug-resistant pathogens (including carbapenems) and is an important health issue. It may result in severe clinical consequences, with higher healthcare utilization and high economic burden. Timely and appropriate treatment is key to obtaining better outcomes and allocational efficiency. Currently, the treatment options for carbapenem-resistant pathogen infections are limited, usually based on polymyxin, aminoglycosides, or combination therapy, as well as novel antibiotic therapies including Ceftazidime/Avibactam (CAZ-AVI). CAZ-AVI has shown activity against gram-negative pathogens and is currently used for the treatment of Ventilator-Associated Pneumonia (VAP). To better inform healthcare professionals and help promote a rational use of antibiotic therapy, a cost-effectiveness analysis was conducted to compare the cost-effectiveness of CAZ-AVI versus polymyxin B in ICU patients with VAP from the Brazilian National Supplementary Health Agency perspective over a 5-year time horizon. CAZ-AVI had higher total costs and resulted in more Quality-Adjusted Life Years (QALY) gained when compared with polymyxin B. At a willingness-to-pay threshold of BRL 40,000.00/QALY gained, CAZ-AVI was the cost-effective strategy (ICER: BRL 35,298.65/QALY gained). Nephrotoxicity in patients treated with polymyxin B, hospitalization utility, and treatment duration were the variables that most influenced the results. In the probabilistic sensitivity analysis, CAZ-AVI was cost-effective in 55 %-89 % of the interactions. The evidence suggests that CAZ-AVI results in lower mortality and nephrotoxicity rates, which might have contributed to more QALYs gained and a favorable ICER, despite the higher costs. This study was registered on the Open Science Framework database (Protocol https://doi.org/10.17605/OSF.IO/SP2EJ).

Health State Utility Values: The Implications of Patient versus Community Ratings in Assessing the Value of Care

BackgroundHealth-state utility values (HSUVs) are key inputs into cost-utility analyses. There is debate over whether they are best derived from the community or patients, with concerns raised that community-derived preferences may devalue benefits to ill, elderly, or disabled individuals. This tutorial compares the effects of using patient-derived HSUVs versus community-derived HSUVs on incremental cost-effectiveness ratios (ICERs) and shows their implications for policy.DesignWe review published studies that compared HSUVs derived from patients and the community. We then present equations for the gains in quality-adjusted life-years (QALYs) that would be estimated for an intervention using patient versus community HSUVs and discuss the implications of those QALY gains. We present a numerical example as another way of showing how ICERs change when using patient versus community HSUVs.ResultsPatient HSUVs are generally higher than community HSUVs for severe health states. When an intervention reduces mortality, patient ratings yield more favorable ICERs than do community ratings. However, when the intervention reduces morbidity, patient ratings yield less favorable ICERs. For interventions that reduce both morbidity and mortality, the effect on ICERs of patient versus community HSUVs depends on the relative contribution of each to the resulting QALYs.ConclusionsThe use of patient HSUVs does not consistently favor treatments directed at those patients. Rather, the effect depends on whether the intervention reduces mortality, morbidity, or both. Since most interventions do both, using patient HSUVs has mixed implications for promoting investments for people with illness and disabilities. A nuanced discussion of these issues is necessary to ensure that policy matches the intent of the decision makers.HighlightsThe debate about whether health state utility values (HSUVs) are best derived from patients or the community rests in part on the presumption that using community values devalues interventions for disabled persons or those with chronic diseases.However, we show why the effect of using patient HSUVs depends on whether the intervention in question primarily reduces mortality or morbidity or has substantial effects on both.If the intervention reduces mortality, using patient HSUVs will make the intervention appear more cost-effective than using community HSUVs, but if it reduces morbidity, using patient HSUVs will make the intervention appear less cost-effective.If the intervention reduces both morbidity and mortality, a common situation, the effect of patient versus community HSUVs depends on the relative magnitudes of the gains in quality and length of life.

Relationship of POLST to Hospitalization and ICU Care Among Nursing Home Residents in California

BACKGROUND

Physician Orders for Life Sustaining Treatment (POLST) document instructions for intensity of care based upon patient care preferences. POLST forms generally reflect patients' wishes and dictate subsequent medical care, but it is not known how POLST use and content among nursing home residents is associated with inpatient utilization across a large population.

OBJECTIVE

Evaluate the relationship between POLST use and content with hospital utilization among nursing home residents in California.

DESIGN

Retrospective cohort study using the Minimum Data Set linked to California Section S (POLST documentation), the Medicare Beneficiary Summary File, and Medicare line item claims.

PATIENTS

California nursing home residents with Medicare fee-for-service insurance, 2011-2016.

MAIN MEASURES

Hospitalization, days in the hospital, and days in the intensive care unit (ICU) after adjustment for resident and nursing home characteristics.

KEY RESULTS

The 1,112,834 residents had a completed and signed (valid) POLST containing orders for CPR with Full treatment 29.6% of resident-time (in person-years) and a DNR order with Selective treatment or Comfort care 27.1% of resident-time. Unsigned POLSTs accounted for 11.3% of resident-time. Residents experienced 14 hospitalizations and a mean of 120 hospital days and 37 ICU days per 100 person-years. Residents with a POLST indicating CPR Full treatment had utilization nearly identical to residents without a POLST. A gradient of decreased utilization was related to lower intensity of care orders. Compared to residents without a POLST, residents with a POLST indicating DNR Comfort care spent 56 fewer days in the hospital and 22 fewer days in the ICU per 100 person-years. Unsigned POLST had a weaker and less consistent relationship with hospital utilization.

CONCLUSIONS

Among California NH residents, there is a direct relationship between intensity of care preferences in POLST and hospital utilization. These findings emphasize the importance of a valid POLST capturing informed preferences for nursing home residents.

No Time to Waste: An Appraisal of Value at the End of Life

OBJECTIVES

The use of economic evaluations of end-of-life interventions may be limited by an incomplete appreciation of how patients and society perceive value at end of life. The objective of this study was to evaluate how patients, caregivers, and society value gains in quantity of life and quality of life (QOL) at the end of life. The validity of the assumptions underlying the use of the quality-adjusted life-years (QALY) as a measure of preferences at end of life was also examined.

METHODS

MEDLINE, Embase, CINAHL, PsycINFO, and PubMed were searched from inception to February 22, 2021. Original research studies reporting empirical data on healthcare priority setting at end of life were included. There was no restriction on the use of either quantitative or qualitative methods. Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all included studies. The primary outcomes were the value of gains in quantity of life and the value of gains in QOL at end of life.

RESULTS

A total of 51 studies involving 53 981 participants reported that gains in QOL were generally preferred over quantity of life at the end of life across stakeholder groups. Several violations of the underlying assumptions of the QALY to measure preferences at the end of life were observed.

CONCLUSIONS

Most patients, caregivers, and members of the general public prioritize gains in QOL over marginal gains in life prolongation at the end of life. These findings suggest that policy evaluations of end-of-life interventions should favor those that improve QOL. QALYs may be an inadequate measure of preferences for end-of-life care thereby limiting their use in formal economic evaluations of end-of-life interventions.

Public Insurance Payment Does Not Compensate Hospital Cost for Care of Long-Bone Fractures Requiring Additional Surgery to Promote Union

OBJECTIVES

To quantify the total hospital costs associated with the treatment of lower extremity long-bone fracture aseptic and septic unhealed fracture, to determine if insurance adequately covers these costs, and to examine whether insurance type correlates with barriers to accessing care.

DESIGN

Retrospective cohort study.

SETTING

Academic Level II trauma center.

PATIENTS

All patients undergoing operative treatment of OTA/AO classification 31, 32, 33, 41, 42, and 43 fractures between 2012 and 2020 at a single Level II trauma center with minimum of 1-year follow-up.

MAIN OUTCOME MEASURES

The primary outcome was the total cost of treatment for all hospital-based episodes of care. Distance traveled from primary residence was measured as a surrogate for barriers to care.

RESULTS

One hundred seventeen patients with uncomplicated fracture healing, 82 with aseptic unhealed fracture, and 44 with septic unhealed fracture were included in the final cohort. The median cost of treatment for treatment of septic unhealed fracture was $148,318 [interquartile range(IQR) 87,241-256,928], $45,230 (IQR 31,510-68,030) for treatment of aseptic unhealed fracture, and $33,991 (IQR 25,609-54,590) for uncomplicated fracture healing. The hospital made a profit on all patients with commercial insurance, but lost money on all patients with public insurance. Among patients with unhealed fracture, those with public insurance traveled 4 times further for their care compared with patients with commercial insurance (P = 0.004).

CONCLUSIONS

Septic unhealed fracture of lower extremity long-bone fractures is an outsized burden on the health care system. Public insurance for both septic and aseptic unhealed fracture does not cover hospital costs. The increased distances traveled by our Medi-Cal and Medicare population may reflect the economic disincentive for local hospitals to care for publicly insured patients with unhealed fractures.

LEVEL OF EVIDENCE

Economic Level V. See Instructions for Authors for a complete description of levels of evidence.

Cost-effectiveness analysis of Vaborem in Carbapenem-resistant Enterobacterales (CRE) -Klebsiella pneumoniae infections in Italy

BACKGROUND

Vaborem is a fixed dose combination of vaborbactam and meropenem with potent activity against target Carbapenem-resistant Enterobacterales (CRE) pathogens, optimally developed for Klebsiella pneumoniae carbapenemase (KPC). The study aims to evaluate the cost-effectiveness of Vaborem versus best available therapy (BAT) for the treatment of patients with CRE-KPC associated infections in the Italian setting.

METHODS

A cost-effectiveness analysis was conducted based on a decision tree model that simulates the clinical pathway followed by physicians treating patients with a confirmed CRE-KPC infection in a 5-year time horizon. The Italian National Health System perspective was adopted with a 3% discount rate. The clinical inputs were mostly sourced from the phase 3, randomised, clinical trial (TANGO II). Unit costs were retrieved from the Italian official drug pricing list and legislation, while patient resource use was validated by a national expert. Model outcomes included life years (LYs) and quality adjusted life years (QALYs) gained, incremental costs, incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR). Deterministic and probabilistic sensitivity analyses were also performed.

RESULTS

Vaborem is expected to decrease the burden associated with treatment failure and reduce the need for chronic renal replacement therapy while costs related to drug acquisition and long-term care (due to higher survival) may increase. Treatment with Vaborem versus BAT leads to a gain of 0.475 LYs, 0.384 QALYs, and incremental costs of €3549, resulting in an ICER and ICUR of €7473/LY and €9246/QALY, respectively. Sensitivity analyses proved the robustness of the model and also revealed that the probability of Vaborem being cost-effective reaches 90% when willingness to pay is €15,850/QALY.

CONCLUSIONS

In the Italian setting, the introduction of Vaborem will lead to a substantial increase in the quality of life together with a minimal cost impact, therefore Vaborem is expected to be a cost-effective strategy compared to BAT.

Cost-Effectiveness Analysis of Transcatheter Arterial Embolization Techniques for the Treatment of Gastrointestinal Bleeding in the United States

OBJECTIVES

Gastrointestinal (GI) bleeding is a common medical emergency associated with significant mortality. Transcatheter arterial embolization first was introduced by Rosch et al as an alternative to surgery for upper GI bleeding. The clinical success in patients with GI bleeding treated with transcatheter arterial embolization previously has been reported. However, there are no cost-effectiveness analyses reported to date. Here we report cost-effectiveness analysis of N-butyl 2-cyanoacrylate glue (NBCA) and ethylene-vinyl alcohol copolymer (Onyx) versus coil (gold standard) for treatment of GI bleeding from a healthcare payer perspective.

METHODS

Fixed-effects modeling with a generalized linear mixed method was used in NBCA and coil intervention arms to determine the pooled probabilities of clinical success and mortality with complications with their confidence intervals, while the Clopper-Pearson model was used for Onyx to determine the same parameters. Models were provided by the "Meta-Analysis with R" software package. A decision tree was built for cost-effectiveness analysis, and Microsoft Excel was used for probabilistic sensitivity analysis. The cost-effective option was determined based on the incremental cost-effectiveness ratio and scatter plots of incremental cost versus incremental quality-adjusted life-years.

RESULTS

Comparing scatter plots and incremental cost-effectiveness ratio results, -$1024 and -$1349 per quality-adjusted life-year for Onyx and N-butyl 2-cyanoacrylate glue, respectively, Onyx was the least expensive and most effective intervention.

CONCLUSION

Onyx was the dominant strategy regardless of threshold values. Our analyses provide a framework for researchers to predict the target clinical effectiveness for early-stage TAE interventions and guide resource allocation decisions.

Cost-effectiveness Analysis of Preoperative Screening Strategies for Obstructive Sleep Apnea among Patients Undergoing Elective Inpatient Surgery

Background

Obstructive sleep apnea is underdiagnosed in surgical patients. The cost-effectiveness of obstructive sleep apnea screening is unknown. This study’s objective was to evaluate the cost-effectiveness of preoperative obstructive sleep apnea screening (1) perioperatively and (2) including patients’ remaining lifespans.

Methods

An individual-level Markov model was constructed to simulate the perioperative period and lifespan of patients undergoing inpatient elective surgery. Costs (2016 Canadian dollars) were calculated from the hospital perspective in a single-payer health system. Remaining model parameters were derived from a structured literature search. Candidate strategies included: (1) no screening; (2) STOP-Bang questionnaire alone; (3) STOP-Bang followed by polysomnography (STOP-Bang + polysomnography); and (4) STOP-Bang followed by portable monitor (STOP-Bang + portable monitor). Screen-positive patients (based on STOP-Bang cutoff of at least 3) received postoperative treatment modifications and expedited definitive testing. Effectiveness was expressed as quality-adjusted life month in the perioperative analyses and quality-adjusted life years in the lifetime analyses. The primary outcome was the incremental cost-effectiveness ratio.

Results

In perioperative and lifetime analyses, no screening was least costly and least effective. STOP-Bang + polysomnography was the most effective strategy and was more cost-effective than both STOP-Bang + portable monitor and STOP-Bang alone in both analyses. In perioperative analyses, STOP-Bang + polysomnography was not cost-effective compared to no screening at the $4,167/quality-adjusted life month threshold (incremental cost-effectiveness ratio $52,888/quality-adjusted life month). No screening was favored in more than 90% of iterations in probabilistic sensitivity analyses. In contrast, in lifetime analyses, STOP-Bang + polysomnography was favored compared to no screening at the $50,000/quality-adjusted life year threshold (incremental cost-effectiveness ratio $2,044/quality-adjusted life year). STOP-Bang + polysomnography was favored in most iterations at thresholds above $2,000/quality-adjusted life year in probabilistic sensitivity analyses.

Conclusions

The cost-effectiveness of preoperative obstructive sleep apnea screening differs depending on time horizon. Preoperative screening with STOP-Bang followed by immediate confirmatory testing with polysomnography is cost-effective on the lifetime horizon but not the perioperative horizon. The integration of preoperative screening based on STOP-Bang and polysomnography is a cost-effective means of mitigating the long-term disease burden of obstructive sleep apnea.

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Toward Understanding the Relationship Between Prioritized Values and Preferences for Cardiopulmonary Resuscitation Among Seriously Ill Adults

CONTEXT

Prioritizing among potentially conflicting end-of-life values may help patients discriminate among treatments and allow clinicians to align treatments with values.

OBJECTIVES

To investigate end-of-life values that patients prioritize when facing explicit trade-offs and identify predictors of patients whose values and treatment preferences seem inconsistent.

METHODS

Analysis of surveys from a multi-center cluster-randomized trial of patients with serious illness. Respondents prioritized end-of-life values and identified cardiopulmonary resuscitation (CPR) preferences in two health states.

RESULTS

Of 535 patients, 60% prioritized relief of discomfort over extending life, 17% prioritized extending life over relief of discomfort, and 23% were unsure. Patients prioritizing extending life were most likely to prefer CPR, with 93% preferring CPR in current health and 67% preferring CPR if dependent on others, compared with 69% and 21%, respectively, for patients prioritizing relief of discomfort, and 78% and 33%, respectively, for patients unsure of their prioritized value (P < 0.001 for all comparisons). Among patients prioritizing relief of discomfort, preference for CPR in current health was less likely among older patients (odds ratio 0.958 per year; 95% CI 0.935, 0.981) and more likely with better self-perceived health (odds ratio 1.402 per level of health; 95% CI 1.090, 1.804).

CONCLUSION

Clinicians face challenges as they clarify patient values and align treatments with values. Patients' values predicted CPR preferences, but a substantial proportion of patients expressed CPR preferences that appeared potentially inconsistent with their primary value. Clinicians should question assumptions about relationships between values and CPR preferences. Further research is needed to identify ways to use values to guide treatment decisions.

Cost-effectiveness of ceftazidime-avibactam for treatment of carbapenem-resistant Enterobacteriaceae bacteremia and pneumonia

Background: Ceftazidime/avibactam (CAZ-AVI) may improve outcomes among patients with carbapenem-resistant Enterobacteriaceae (CRE) infections compared to conventional therapies. However, CAZ-AVI's cost-effectiveness is unknown.Methods: We used a decision analytic model to estimate the health and economic consequences of CAZ-AVI-based therapy compared to colistin-based therapy (COL) for a hypothetical cohort of patients with CRE pneumonia or bacteremia over a 5-year horizon. Model inputs were from published sources and included CRE mortality with COL (41%), CAZ-AVI's absolute risk reduction in CRE mortality (23%), daily cost of CAZ-AVI ($926), risk of nephrotoxicity with COL (42%) and probability of discharge to long-term care (LTC) following CRE infection (56%). Outcomes included quality adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICER; $/QALY). 1-way and probabilistic sensitivity analyses were performed and ICERs were compared to willingness to pay standards of $100,000/QALY and $150,000/QALY.Results: In the base case, CAZ-AVI had an ICER of $95,000/QALY. At a $100,000/QALY threshold, results were sensitive to a number of variables including: the probability and cost of LTC, quality of life following CRE infection, CAZ-AVI's absolute risk reduction in mortality, all-cause mortality, daily cost of CAZ-AVI, and healthcare costs after CRE infection. The ICER did not exceed $150,000/QALY after varying all model inputs across a wide range of plausible values. In probabilistic sensitivity analysis, CAZ-AVI was the optimal strategy in 59% and 99% of simulations at $100,000/QALY and $150,000/QALY threshold, respectively.Conclusion: CAZ-AVI is a cost-effective treatment for CRE bacteremia and pneumonia based on accepted willingness to pay standards in the US.

Critical Illness in the Elderly: Review of Pathophysiology of Aging and Outcome of Intensive Care

The goal of this article is to review the literature on age and its influence on the pathophysiology of critical illness, outcome after critical illness, and end of life decision making in critically ill elderly patients. Sources for this review included the MEDLINE database and bibliographies of original articles, reviews, and book chapters. The population is aging and the need for medical care and its costs increase with increasing age. A majority of the elderly lead independent lives, although some need help with various functional activities related to daily living. It is difficult to separate the effects of aging from the effects of the comorbidities that develop with increasing age. The physiologic reserve decreases in the elderly and they may not be able to tolerate a critical injury or illness as well as a younger individual. As the elderlyare usually on multiple medications, they are prone to have more drug interactions and side effects, and need close monitoring of the drugs and adjustment of the dosage. Mortality after a critical illness in the elderly is higher compared to younger patients, and it is more related to the acuity of physiologic disturbance than age alone. The effect of age alone on long-term outcome is not well studied, but individuals with poor functional status and/or increased comorbidities have a poor short-term outcome. Functional status usually deteriorates after critical illness, but the long-term survivors usually recover functional abilities, and they are satisfied with their quality of life. Decision making at the end of life is difficult because of the paucity of data on long-term mortality and quality of life, lack of information about patient wishes, and the uncertainty of the prognosis. Because many elderly patients survive critical illness and may return to their previous lifestyle, age alone should not weigh heavily in end of life decisions. As with other age groups, end of life decisions in the elderly should be made after considering long-term outcomes, patient goals, and the benefits and burdens of life-sustaining technology.

Positive Association between Current Health and Health Values for Hypothetical Disease States

Background: Valuations of hypothetical health state scenarios can be affected by participant characteristics. Methods: The authors interviewed 108 veterans using the visual analogue scale (VAS), standard gamble (SG), time tradeoff (TTO), and willingness to pay (WTP) tomeasure health values for 1) current health and 2) 3 hypothetical health states portrayed in written scenarios describing cervical spondylotic myelopathy (CSM), a degenerative spine condition. They used bivariate rank order and multivariate regression analyses to assess the relationship between CSM values, participants’ characteristics, and participants’ current health values. Results: Participants were predominantly male (89.8%) and Caucasian (75.9%), with a median age of 58.3 years and a median annual income of $15,000. Median values for current health were VAS, 0.75; SG, 0.80; TTO, 0.80; and WTP, $25,000. In the multivariate analysis, higher CSM values were associated with better current health as measured with the SG, TTO, and WTP (for all,P < 0.001); there was no association with VAS values (P = 0.157). Conclusions: Health values for CSM are positively associated with the current health of the study population.

Preferences for Prostate Cancer Outcomes: A Comparison of the Patient Perspective, the General Population Perspective, and a Population at Risk for Prostate Cancer

OBJECTIVE

To collect disease-specific and generic preference values for three populations.

METHODS

Prostate cancer-specific health states were developed with attributes that varied across five health domains: sexual function, urinary function, bowel function, pain, and fear of the future. Men with prostate cancer, men at risk for prostate cancer, and a sample of the general population assigned value to 18 disease-specific health states using standard gamble (SG) methodology. Study participants also completed the Health Utilities Index (HUI) to obtain generic, community-based preference values to capture their current health rating.

RESULTS

A total of 136 participants were enrolled (n = 43 prostate cancer; n = 40 at risk for prostate cancer; n = 49 general population). Mean HUI mark 3 current health ratings: men with prostate cancer 0.75 ± 0.260; men at risk for prostate cancer 0.77 ± 0.238; general population 0.84 ± 0.178. Mean SG preference values ranged from 0.46 to 0.85 among men with prostate cancer, 0.37 to 0.75 among men at risk for prostate cancer, and 0.32 to 0.81 among the general population group.

CONCLUSIONS

In general, preference values for disease-specific health states using the patient perspective were higher than those for the general population. Generic preference values calculated from the HUI were higher than disease-specific preference values calculated from the SG. The higher values calculated from the HUI, from all three perspectives, indicate that a generic measure may not be sensitive enough to capture the disutility of prostate cancer symptoms, specifically sexual dysfunction, urinary dysfunction, and bowel dysfunction, which are being directly measured in the disease-specific health states.

Cost-Effectiveness of Integrating a Clinical Decision Rule and Staged Imaging Protocol for Diagnosis of Appendicitis

OBJECTIVE

To evaluate the cost-effectiveness of a diagnostic protocol for appendicitis in children, the use of a validated clinical decision rule (CDR) and a staged imaging protocol, compared with usual care.

METHODS

We estimated the cost-effectiveness of the three competing strategies using parameters from existing literature as well as a Markov model developed to simulate the effects of exposure to ionizing radiation from a single computed tomography (CT) study in the course of diagnosis. The simulation model was applied to a hypothetical cohort of 100,000 boys and girls, age 10 years, presenting with acute abdominal pain to emergency departments in the United States.

RESULTS

The integrated strategy, the CDR followed by staged imaging, was found to be the most cost-effective approach. Cost savings accrued from the reduction in CT utilization for low-risk patients compared with the other two strategies. The addition of ultrasound (US) to the CDR strategy reduced CT utilization by an additional 10.9%, its main cost advantage, with negligible change in net health benefits from false-negative US results, and associated morbidity or mortality.

CONCLUSIONS

Results suggest that the integration of staged imaging with the CDR for the diagnosis of appendicitis in children is a cost-effective and cost-saving approach. The model estimates a further 10.9% reduction in the number of CTs from the incorporation of US for patients scoring high or medium risk, in excess of the 19.5% reduction estimated in the CDR validation study.

Time Trade-Off as a Measure of Health-Related Quality of Life: Long Bone Nonunions Have a Devastating Impact

BACKGROUND

Long bone nonunions have an important impact on a patient's quality of life. The purpose of this study was to compare long bone nonunions with use of the Time Trade-Off direct measure to compute utility scores and to determine which nonunion anatomic location had the lowest health-related quality of life. The Time Trade-Off assesses the percentage of a patient's remaining life that the patient would be willing to trade for perfect health.

METHODS

Eight hundred and thirty-two consecutive long bone nonunions with Time Trade-Off data were identified and were retrospectively studied from a prospectively collected patient database. Nonunions with infections and those involving the articular portion of the bone were recorded. Time Trade-Off utility scores were obtained for all nonunion cases upon their initial clinical evaluation by a single surgeon specializing in reconstructive trauma.

RESULTS

The mean utility score of our nonunion cohort was 0.68 and it differed significantly by long bone (p = 0.037). Nonunions of the forearm had the lowest utility score (0.54), followed by the clavicle (0.59), femur (0.68), tibia or fibula (0.68), and humerus (0.71). Post hoc tests showed that patients with nonunions of the forearm had significantly lower utility scores (p = 0.031) compared with all other bones.

CONCLUSIONS

Patients diagnosed with a long bone nonunion have a very low health-related quality of life. We found that this single cohort's mean utility score was 0.68. This result is well below that of illnesses such as type-I diabetes mellitus (0.88), stroke (0.81), and acquired immunodeficiency syndrome (0.79). We found that patients with forearm nonunions had the lowest utility scores.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Health state utilities associated with major clinical events in the context of secondary hyperparathyroidism and chronic kidney disease requiring dialysis

BACKGROUND

Patients with chronic kidney disease (CKD) and secondary hyperparathyroidism (SHPT) who require dialysis are at increased risk for cardiovascular events and bone fractures. To assist in economic evaluations, this study aimed to estimate the disutility of these events beyond the impact of CKD and SHPT.

METHODS

A basic one-year health state was developed describing CKD and SHPT requiring dialysis. Further health states added acute events (cardiovascular events, fractures, and surgical procedures) or chronic post-event effects. Acute health states described a year including an event, and chronic health states described a year subsequent to an event. General population participants in Canada completed time trade-off interviews from which utilities were derived. Pairwise comparisons were made between the basic state and event, and between comparable health states.

RESULTS

A total of 199 participants (54.8% female; mean age = 46.3 years) completed interviews. Each health state had ≥130 valuations. The mean (SD) utility of the basic health state was 0.60 (0.34). For acute events, mean utility differences versus the basic state were: myocardial infarction, -0.06; unstable angina, -0.05; peripheral vascular disease (PVD) with amputation, -0.33; PVD without amputation, -0.11; heart failure, -0.14; stroke, -0.30; hip fracture, -0.14; arm fracture, -0.04; parathyroidectomy, +0.02; kidney transplant, +0.06. Disutilities for chronic health states were: stable angina, -0.09; stroke, -0.27; PVD with amputation, -0.30; PVD without amputation, -0.12; heart failure, -0.14.

CONCLUSIONS

Cardiovascular events and fractures were associated with lower utility scores, suggesting a perceived decrease in quality of life beyond the impact of CKD and SHPT.

Quadrimodal distribution of death after trauma suggests that critical injury is a potentially terminal disease

BACKGROUND

Patterns of death after trauma are changing due to advances in critical care. We examined mortality in critically injured patients who survived index hospitalization.

METHODS

Retrospective analysis of adults admitted to a Level-1 trauma center (1/1/2000-12/31/2010) with critical injury was conducted comparing patient characteristics, injury, and resource utilization between those who died during follow-up and survivors.

RESULTS

Of 1,695 critically injured patients, 1,135 (67.0%) were discharged alive. As of 5/1/2012, 977/1,135 (86.0%) remained alive; 75/158 (47.5%) patients who died during follow-up, died in the first year. Patients who died had longer hospital stays (24 vs. 17 days) and ICU LOS (17 vs. 8 days), were more likely to undergo tracheostomies (36% vs. 16%) and gastrostomies (39% vs. 16%) and to be discharged to rehabilitation (76% vs. 63%) or skilled nursing (13% vs. 5.8%) facilities than survivors. In multivariable models, male sex, older age, and longer ICU LOS predicted mortality. Patients with ICU LOS >16 days had 1.66 odds of 1-year mortality vs. those with shorter ICU stays.

CONCLUSIONS

ICU LOS during index hospitalization is associated with post-discharge mortality. Patients with prolonged ICU stays after surviving critical injury may benefit from detailed discussions about goals of care after discharge.

When Life Imitates Art: Surrogate Decision Making at the End of Life

The privileging of the substituted judgment standard as the gold standard for surrogate decision making in law and bioethics has constrained the research agenda in end-of-life decision making. The empirical literature is inundated with a plethora of "Newlywed Game" designs, in which potential patients and potential surrogates respond to hypothetical scenarios to see how often they "get it right." The preoccupation with determining the capacity of surrogates to accurately reproduce the judgments of another makes a number of assumptions that blind scholars to the variables central to understanding how surrogates actually make medical decisions on behalf of another. These assumptions include that patient preferences are knowable, surrogates have adequate and accurate information, time stands still, patients get the surrogates they want, patients want and surrogates utilize substituted judgment criteria, and surrogates are disinterested. This article examines these assumptions and considers the challenges of designing research that makes them problematic.

Health related quality of life in patients in dialysis after renal graft loss and effect of gender

BACKGROUND

An increasing number of dialysis patients have returned to dialysis after renal graft loss, and the transition in disease state could likely be associated with reduced health related quality of life (HRQOL). Furthermore, gender differences in HRQOL have been observed in dialysis and kidney transplanted patients, but whether transition in disease state affects HRQOL differently in respect to gender is not known. The aims of this study were to compare HRQOL in dialysis patients with graft loss to transplant naïve dialysis patients, and to explore possible gender differences.

METHODS

In a cross-sectional study, HRQOL was measured in 301 prevalent dialysis patients using the Kidney Disease and Quality of Life Short Form version 1.3. Adjusted comparisons were made between dialysis patients with previous graft loss and the transplant naïve patients. Multiple linear regression analyses were performed with HRQOL as outcome variables. Interaction analyses using product terms were performed between gender and graft loss. HRQOL was analysed separately in both genders.

RESULTS

Patients with renal graft loss (n = 50) did not experience lower HRQOL than transplant naïve patients after multiple adjustments. Among patients with graft loss, women (n = 23) reported lower HRQOL than men (n = 27) in the items physical function (40 vs. 80, p = 0.006), and effect of kidney disease (49 vs. 67, p = 0.017). Women with graft loss reported impaired kidney-specific HRQOL compared to transplant naïve women (n = 79) in the items effect of kidney disease (50 vs. 72, p = 0.002) and cognitive function (80 vs. 93, p = 0.006), and this observation persisted after multiple adjustments. Such differences were not apparent in the male counterparts.

CONCLUSIONS

Patients who resumed dialysis after renal graft loss did not have lower HRQOL than dialysis patients not previously transplanted. However, losing graft function was associated with reduced HRQOL in females, and important interactions were identified between graft loss and gender. This needs to be further explored in prospective studies.

Cost-effectiveness of preoperative imaging for appendicitis after indeterminate ultrasonography in the second or third trimester of pregnancy

OBJECTIVE

To assess the cost-effectiveness of diagnostic laparoscopy, computed tomography (CT), and magnetic resonance imaging (MRI) after indeterminate ultrasonography in pregnant women with suspected appendicitis.

METHODS

A decision-analytic model was developed to simulate appendicitis during pregnancy taking into consideration the health outcomes for both the pregnant women and developing fetuses. Strategies included diagnostic laparoscopy, CT, and MRI. Outcomes included positive appendectomy, negative appendectomy, maternal perioperative complications, preterm delivery, fetal loss, childhood cancer, lifetime costs, discounted life expectancy, and incremental cost-effectiveness ratios.

RESULTS

Magnetic resonance imaging is the most cost-effective strategy, costing $6,767 per quality-adjusted life-year gained relative to CT, well below the generally accepted $50,000 per quality-adjusted life-year threshold. In a setting where MRI is unavailable, CT is cost-effective even when considering the increased risk of radiation-associated childhood cancer ($560 per quality-adjusted life-year gained relative to diagnostic laparoscopy). Unless the negative appendectomy rate is less than 1%, imaging of any type is more cost-effective than proceeding directly to diagnostic laparoscopy.

CONCLUSIONS

Depending on imaging costs and resource availability, both CT and MRI are potentially cost-effective. The risk of radiation-associated childhood cancer from CT has little effect on population-level outcomes or cost-effectiveness but is a concern for individual patients. For pregnant women with suspected appendicitis, an extremely high level of clinical diagnostic certainty must be reached before proceeding to operation without preoperative imaging.

Preferences of people with advanced heart failure-a structured narrative literature review to inform decision making in the palliative care setting

BACKGROUND AND APPROACH: There is a growing emphasis on the need for high-quality and patient-centered palliative care for patients with heart failure (HF) near end of life. Accordingly, clinicians require adequate knowledge of patient values and preferences, but this topic has been underreported in the HF literature. In response, we conducted a structured narrative review of available evidence regarding patient preferences for HF care near end of life, focusing on circumstances of death, advance care planning, and preferences for specific HF therapies.

RESULTS

Patients had widely varying preferences for sudden ("unaware") death versus a death that was anticipated ("aware"), which would allow time to make arrangements and time with family; preferences influenced their choice of HF therapies. Patients and physicians rarely discussed advance care planning; physicians were rarely aware of resuscitation preferences. Advance care planning discussions rarely included preferences for limiting implantable cardioverter defibrillator use, and patients were often uninformed of the option of implantable cardioverter defibrillator deactivation. A substantial minority of patients strongly preferred improved quality of life versus extended survival, but preferences of individuals could not be easily predicted.

CONCLUSIONS

Current evidence regarding preferences of patients with HF near end of life suggests substantial opportunities for improvement of end-of-life HF care. Most notably, the wide distribution of patient preferences highlights the need to tailor approach to patient wishes, avoiding assumptions of patient wishes. A research agenda and implications for health care provider training are proposed.

Discrepancies in End-of-life Decisions Between Elderly Patients and Their Named Surrogates

Introduction: This study aims to determine the attitudes of Asian elderly patients towards invasive life support measures, the degree of patient-surrogate concordance in end-of-life decision making, the extent to which patients desire autonomy over end-of-life medical decisions, the reasons behind patients’ and surrogates’ decisions, and the main factors influencing patients’ and surrogates’ decision-making processes. We hypothesize that there is significant patient-surrogate discordance in end-of-life decision making in our community. Materials and Methods: The patient and surrogate were presented with a hypothetical scenario in which the patient experienced gradual functional decline in the community before being admitted for life-threatening pneumonia. It was explained that the outcome was likely to be poor even with intensive care and each patient-surrogate pair was subsequently interviewed separately on their opinions of extraordinary life support using a standardised questionnaire. Both parties were blinded to each other’s replies. Results: In total, 30 patients and their surrogate decision-makers were interviewed. Twenty-eight (93.3%) patients and 20 (66.7%) surrogates rejected intensive care. Patient-surrogate concurrence was found in 20 pairs (66.7%). Twenty-four (80.0%) patients desired autonomy over their decision. The patients’ and surrogates’ top reasons for rejecting intensive treatment were treatment-related discomfort, poor prognosis and financial cost. Surrogates’ top reasons for selecting intensive treatment were the hope of recovery, the need to complete final tasks and the sanctity of life. Conclusion: The majority of patients desire autonomy over critical care issues. Relying on the surrogates’ decisions to initiate treatment may result in treatment against patients’ wishes in up to one-third of critically ill elderly patients. Key words: Advanced medical directive, Intensive care

Link between decisions regarding resuscitation and preferences for quality over length of life with heart failure

AIMS

Survival preferences, ascertained from time-trade-off utilities, have not been studied in heart failure patients who designate a 'do not resuscitate' (DNR) status. Therefore, the aim of this study was to determine the association of heart failure patients' resuscitation preferences with survival preferences and mortality in the ESCAPE trial.

METHODS AND RESULTS

We analysed the association of resuscitation orders at 1 month with time-trade-off utilities and 6-month mortality. There were 26 and 349 patients with a DNR order and Full Code order, respectively. DNR patients were older, had more coronary artery disease, hypertension, renal impairment, and poorer exercise capacity than Full Code patients. DNR patients also experienced longer hospitalization and higher 6-month mortality. In multivariate analysis, DNR preference was associated with 10-fold higher odds of willingness to trade survival time (lower time-trade-off utility) in favour of improved quality of life [odds ratio 10.33, 95% confidence interval (CI) 1.65-64.80]. DNR preference was the best predictor of mortality (χ(2) 26.12, P < 0.0001, hazard ratio 6.88, 95% CI 3.28-14.41), despite adjustment for known predictors including brain natriuretic peptide.

CONCLUSIONS

Heart failure patients' requests to forego resuscitation may signify more than simply 'what-if' directives for emergency care. DNR decisions may reflect preferences for intervention to enhance quality rather than prolong survival, which is particularly important as these patients have high early mortality.

Predicting changes in preferences for life-sustaining treatment among patients with advanced chronic organ failure

BACKGROUND

For physicians discussing advance care planning with patients with life-limiting illness, it is important to understand the stability of the patients' preferences for life-sustaining treatments and the factors that predict a change in preferences. Our objectives were to investigate 1-year stability of preferences regarding CPR and mechanical ventilation (MV) for outpatients with advanced COPD, chronic heart failure (CHF), or chronic renal failure (CRF) and to identify predictors of changes in preferences.

METHODS

In this study, 265 clinically stable outpatients with advanced COPD, CHF, or CRF were visited at baseline and every 4 months for 1 year to assess preferences regarding CPR and MV in their current health status. Generalized estimating equations were used to examine the association between change in life-sustaining treatment preferences and several potential predictors, including changes in comorbidities, hospital admissions, generic health status, care dependency, mobility, and symptoms of anxiety or depression.

RESULTS

The 1-year follow-up period was completed by 77.7% of the patients. Preferences regarding CPR or MV changed in 38.3% of the patients during the follow-up period. Changes over time in generic health status, mobility, symptoms of anxiety and depression, and marital status were associated with changes in life-sustaining treatment preferences.

CONCLUSIONS

More than one-third of outpatients with advanced COPD, CHF, or CRF change their preferences regarding CPR and/or MV at least once during 1 year. Regular reevaluation of advance care planning is necessary, in particular when patients experience a change in health status, mobility, symptoms of anxiety or depression, or marital status.

TRIAL REGISTRY

Netherlands National Trial Register; No.: NTR 1552; URL: http://www.trialregister.nl.

Intussusception in children: cost-effectiveness of ultrasound vs diagnostic contrast enema

PURPOSE

The aim of the study was to compare the cost-effectiveness of different imaging strategies for the diagnosis of pediatric intussusception using a decision analytic model.

METHODS

A Markov decision model was constructed to model effects of radiation exposure at the time of intussusception in a hypothetical cohort of 2-year-old children. The 2 strategies compared were ultrasound followed conditionally by contrast enema (US/CE) vs contrast enema (CE) alone. The model simulated short-term and long-term outcomes of the patients, calculating the average quality-adjusted life years (QALYs) and health care costs associated with each arm.

RESULTS

The use of ultrasound as a first-line diagnostic modality would result in a decrease of 79.3 and 59.7 cases of radiation-induced malignancy per 100,000 male and female children evaluated, respectively. For male and female children with intussusception, US/CE was both the most costly initial imaging strategy and the most effective compared with CE. The incremental cost-effectiveness ratios of US/CE to CE was $70,100 (boy) and $92,227 (girl) per quality-adjusted life years gained.

CONCLUSIONS

In a Markov decision model of pediatric acute intussusception, initial US/CE was both the most costly and the most effective strategy.

Family caregivers, patients and physicians: ethical guidance to optimize relationships

Family caregivers play a major role in maximizing the health and quality of life of more than 30 million individuals with acute and chronic illness. Patients depend on family caregivers for assistance with daily activities, managing complex care, navigating the health care system, and communicating with health care professionals. Physical, emotional and financial stress may increase caregiver vulnerability to injury and illness. Geographically distant family caregivers and health professionals in the role of family caregivers may suffer additional burdens. Physician recognition of the value of the caregiver role may contribute to a positive caregiving experience and decrease rates of patient hospitalization and institutionalization. However, physicians may face ethical challenges in partnering with patients and family caregivers while preserving the primacy of the patient-physician relationship. The American College of Physicians in conjunction with ten other professional societies offers ethical guidance to physicians in developing mutually supportive patient-physician-caregiver relationships.

Health-related quality of life in adolescents and young adults with a history of Kawasaki disease

OBJECTIVE

To investigate the health-related quality of life (HRQOL) in adolescents and young adults with Kawasaki disease (KD).

STUDY DESIGN

We conducted a cross-sectional observational study. Patients were eligible for this study when they were > or =16 years of age and had received a diagnosis of KD > or =5 years before the start of this study. The patients were divided in 3 groups according to their coronary status: normal, aneurysms, and giant aneurysms/ischemia. A self-administered questionnaire (Medical Outcome Study Short Form 36) was mailed to the patients to evaluate the HRQOL.

RESULTS

Of 624 total questionnaires mailed, 377 were delivered, and 250 were returned. The response rates of the normal, aneurysm, and giant aneurysms/ischemia groups were 33%, 62%, and 72% of all eligible patients, respectively. All subscale scoress of HRQOL, except vitality and role-emotional (limitations in the usual role activities because of emotional problems) in patients with KD were significantly higher than scores from the national norms.

CONCLUSIONS

The HRQOL of adolescents and young adults with a history of KD is favorable. However, long-term follow-up is necessary, because the general health perceptions of older patients tended to be lower.

Do the 15D scores and time trade-off (TTO) values of hospital patients' own health agree?

Objectives: The aim of this study was to estimate an empirical relationship and degree of agreement between the TTO values of patients’ own health and their 15D scores.

Methods: A total of 863 hospital patients aged 18–93 years filled in the 15D questionnaire to establish their 15D score and valued their present health with TTO. Wilcoxon signed rank test, the Spearman rank correlation coefficient and Tobit models were used to analyze the relation between the 15D and TTO scores.

Results: The null hypothesis of no tendency for one set of scores to be higher or lower than the other set could not be rejected. Apart from dummies for few patients groups, no additional information to the 15D score was found that would have explained significantly the variance in the TTO valuations of patients’ own health. The agreement between these to sets of scores turned out quite good at the aggregate level.

Conclusions: To the extent that mean TTO valuations of patients own health are valid for QALY calculations as they at least theoretically should be, and if experience of health states to be valued counts, the 15D scores are also valid without any transformation in a large group of heterogeneous patients. However, in certain patient groups, the agreement was not as good as overall.

Expectations and outcomes of prolonged mechanical ventilation

OBJECTIVE

To compare prolonged mechanical ventilation decision-makers' expectations for long-term patient outcomes with prospectively observed outcomes and to characterize important elements of the surrogate-physician interaction surrounding prolonged mechanical ventilation provision. Prolonged mechanical ventilation provision is increasing markedly despite poor patient outcomes. Misunderstanding prognosis in the prolonged mechanical ventilation decision-making process could provide an explanation for this phenomenon.

DESIGN

Prospective observational cohort study.

SETTING

Academic medical center.

PATIENTS

A total of 126 patients receiving prolonged mechanical ventilation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Participants were interviewed at the time of tracheostomy placement about their expectations for 1-yr patient survival, functional status, and quality of life. These expectations were then compared with observed 1-yr outcomes measured with validated questionnaires. The 1-yr follow-up was 100%, with the exception of patient death or cognitive inability to complete interviews. At 1 yr, only 11 patients (9%) were alive and independent of major functional status limitations. Most surrogates reported high baseline expectations for 1-yr patient survival (n = 117, 93%), functional status (n = 90, 71%), and quality of life (n = 105, 83%). In contrast, fewer physicians described high expectations for survival (n = 54, 43%), functional status (n = 7, 6%), and quality of life (n = 5, 4%). Surrogate-physician pair concordance in expectations was poor (all kappa = <0.08), as was their accuracy in outcome prediction (range = 23%-44%). Just 33 surrogates (26%) reported that physicians discussed what to expect for patients' likely future survival, general health, and caregiving needs.

CONCLUSIONS

One-year patient outcomes for prolonged mechanical ventilation patients were significantly worse than expected by patients' surrogates and physicians. Lack of prognostication about outcomes, discordance between surrogates and physicians about potential outcomes, and surrogates' unreasonably optimistic expectations seem to be potentially modifiable deficiencies in surrogate-physician interactions.

Preferences for dialysis withdrawal and engagement in advance care planning within a diverse sample of dialysis patients

BACKGROUND AND OBJECTIVES

Rates of dialysis withdrawal are higher among the elderly and lower among Blacks, yet it is unknown whether preferences for withdrawal and engagement in advance care planning also vary by age and race or ethnicity. DESIGN, SETTING, PARTICIPANTS AND METHODS: We recruited 61 participants from two dialysis clinics to complete questionnaires regarding dialysis withdrawal preferences in five different health states. Engagement in advance care planning (end-of-life discussions), completion of advance directives and 'do not resuscitate' or 'do not intubate' (DNR/DNI) orders were ascertained by a questionnaire and from dialysis unit records.

RESULTS

The mean age was 62 +/- 15 years; 38% were Black, 11% were Latino, 34% were White and 16% of participants were Asian. Blacks were less likely to prefer dialysis withdrawal as compared with Whites (odds ratio 0.16, 95% confidence interval 0.03-0.88) and other race/ethnicity groups, and this difference was not explained by age, education, comorbidity and other confounders. In contrast, older age was not associated with preferences for withdrawal. Rates of engagement in end-of-life discussions were higher than for documentation of advance care planning for all age and most race/ethnicity groups. Although younger participants and minorities were generally less likely to document treatment preferences as compared with older patients and Whites, they were not less likely to engage in end-of-life discussions.

CONCLUSIONS

Preferences for withdrawal vary by race/ ethnicity, whereas the pattern of engagement in advance care planning varies by age and race/ethnicity. Knowledge of these differences may be useful for improving communication about end-of-life preferences and in implementing effective advance care planning strategies among diverse haemodialysis patients.

Health values in adolescents with or without inflammatory bowel disease

OBJECTIVE

To examine for differences in and predictors of health value/utility scores in adolescents with or without inflammatory bowel disease (IBD).

STUDY DESIGN

Adolescents with IBD and healthy control subjects were interviewed in an academic health center. We collected sociodemographic data and measured health status, personal, family, and social characteristics, and spiritual well-being. We assessed time tradeoff (TTO) and standard gamble (SG) utility scores for current health. We performed bivariate and multivariable analyses with utility scores used as outcomes.

RESULTS

Sixty-seven patients with IBD and 88 healthy control subjects 11 to 19 years of age participated. Among subjects with IBD, mean (SD) TTO scores were 0.92 (0.17), and mean (SD) SG scores were 0.97 (0.07). Among healthy control subjects, mean (SD) TTO scores were 0.99 (0.03) and mean (SD) SG scores were 0.98 (0.03). TTO scores were significantly lower (P= .001), and SG scores trended lower (P= .065) in patients with IBD when compared with healthy control subjects. In multivariable analyses controlling for IBD status, poorer emotional functioning and spiritual well-being were associated with lower TTO (R(2)=0.17) and lower SG (R(2)=0.22) scores.

CONCLUSION

Direct utility assessment in adolescents with or without IBD is feasible and may be used to assess outcomes. Adolescents with IBD value their health state highly, although less so than healthy control subjects. Emotional functioning and spiritual well-being appear to influence utility scores most strongly.

Affective Forecasting and Advance Care Planning

That sicker people evaluate quality of life in future health status more positively, compared to healthier people, is viewed as an instance of affective forecasting error and explained by Prospect Theory, which holds that two prospects (poor health vs death) are more distinguishable when they are imminent than when distant. In a sample of 230 elderly people, we tested whether life in nine health scenarios would be more acceptable to less healthy individuals than to healthier ones. An interaction between current health status and health scenario supported the relative acceptability of poor-health prospects to sicker individuals, confirming the hypothesis.

Acute appendicitis in young children: cost-effectiveness of US versus CT in diagnosis--a Markov decision analytic model

PURPOSE

To compare the cost-effectiveness of different imaging strategies in the diagnosis of pediatric appendicitis by using a decision analytic model.

MATERIALS AND METHODS

Approval for this retrospective study based on literature review was not required by the institutional Research Ethics Board. A Markov decision model was constructed by using costs, utilities, and probabilities from the literature. The risk of radiation-induced cancer was modeled by using the Biological Effects of Ionizing Radiation VII report, which is based primarily on data from atomic bomb survivors. The three imaging strategies were ultrasonography (US), computed tomography (CT), and US followed by CT if the initial US study was negative. The model simulated the short-term and long-term outcomes of the patients, calculating the average quality-adjusted life span and health care costs.

RESULTS

For a single abdominal CT study in a 5-year-old child, the lifetime risk of radiation-induced cancer would be 26.1 per 100,000 in female and 20.4 per 100,000 in male patients. In the base-case analysis, US followed by CT was the most costly and most effective strategy, CT was the second-most costly and second-most effective strategy, and US was the least costly and least effective strategy. The incremental cost-effectiveness ratios (ICERs) of CT to US and of US followed by CT to US were both well below the societal willingness-to-pay threshold of $50,000 (in U.S. dollars). The ICER of US followed by CT to CT was less than $10,000 in both male and female patients.

CONCLUSION

In a Markov-based decision model of pediatric appendicitis, the most cost-effective method of imaging pediatric appendicitis was to start with a US study and follow each negative US study with a CT examination.

Cost-effectiveness analysis of management strategies for obscure GI bleeding

BACKGROUND AND AIMS

Of patients who are seen with GI hemorrhage, approximately 5% will have a small-bowel source. Management of these patients entails considerable expense. We performed a decision analysis to explore the optimal management strategy for obscure GI hemorrhage.

METHODS

We used a cost-effectiveness analysis to compare no therapy (reference arm) to 5 competing modalities for a 50-year-old patient with obscure overt bleeding: (1) push enteroscopy, (2) intraoperative enteroscopy, (3) angiography, (4) initial anterograde double-balloon enteroscopy (DBE) followed by retrograde DBE if the patient had ongoing bleeding, and (5) small-bowel capsule endoscopy (CE) followed by DBE guided by the CE findings. The model included prevalence rates for small-bowel lesions, sensitivity for each intervention, and the probability of spontaneous bleeding cessation. We examined total costs and quality-adjusted life years (QALY) over a 1-year time period.

RESULTS

An initial DBE was the most cost-effective approach. The no-therapy arm cost $532 and was associated with 0.870 QALYs compared with $2407 and 0.956 QALYs for the DBE approach, which resulted in an incremental cost-effectiveness ratio of $20,833 per QALY gained. Compared to the DBE approach, an initial CE was more costly and less effective. The initial DBE arm resulted in an 86% bleeding cessation rate compared to 76% for the CE arm and 59% for the no-therapy arm. The model results were robust to a wide range of sensitivity analyses.

LIMITATIONS

The short time horizon of the model, because of the lack of long-term data about the natural history of rebleeding from small-intestinal lesions.

CONCLUSIONS

An initial DBE is a cost-effective approach for patients with obscure bleeding. However, capsule-directed DBE may be associated with better long-term outcomes because of the potential for fewer complications and decreased utilization of endoscopic resources.

Choices: a study of preferences for end-of-life treatments in patients with advanced heart failure

BACKGROUND

The purpose of this study is to describe the treatment preferences of patients with heart failure among three distinct treatment options--optimal medical management, oral inotropes or left ventricular device (LVAD) support--to determine if there were differences in preferences between patients with mild heart failure (New York Heart Association [NYHA] Class II) and severe heart failure (NYHA Class IV), and also to determine whether quality of life, perceived severity of symptoms and overall health influenced treatment preferences.

METHODS

We enrolled 91 patients who completed the Minnesota Living with Heart Failure Questionnaire (MLHFQ); visual analog scales for depicting their perceived severity of overall health, dyspnea and fatigue; and a treatment trade-off tool.

RESULTS

The most preferred treatment options were oral inotropes, LVAD and standard medical management. There were no differences in treatment preferences between NYHA II and NYHA IV patients. Patient preferences correlated poorly with MLHFQ, symptom and overall health scores. Although not statistically significant, there was a trend toward patients with worse quality of life and symptom scores preferring more aggressive treatment.

CONCLUSIONS

The results of our study identified two distinct groups of patients: one group preferring treatments that prolonged survival time and another group that favored strategies that improved quality of life but reduced survival time. Treatment preferences were independent of functional or symptom status, suggesting that preferences may be decided early in the course of illness.

The impact of chronic hepatitis B on quality of life: a multinational study of utilities from infected and uninfected persons

OBJECTIVES

Chronic hepatitis B (CHB) is a condition that results in substantial morbidity and mortality worldwide because of progressive liver damage. Investigators undertaking economic evaluations of new therapeutic agents require estimates of health-related quality of life (HRQOL). Recently, evidence has begun to accumulate that differences in cultural backgrounds have a quantifiable impact on perceptions of health. The objective was to elicit utilities for six health states that occur after infection with the hepatitis B virus from infected and uninfected respondents living in jurisdictions with low and with high CHB endemicity.

METHODS

Standard gamble utilities were elicited from hepatitis patients and uninfected respondents using an interviewer-administered survey in the United States, Canada, United Kingdom, Spain, Hong Kong, and mainland China. Generalized linear models were used to the effect on utilities of current health, age and sex, jurisdiction and, for infected respondents, current disease state.

RESULTS

The sample included 534 CHB-infected patients and 600 uninfected respondents. CHB and compensated cirrhosis had a moderate impact on HRQOL with utilities ranging from 0.68 to 0.80. Decompensated cirrhosis and hepatocellular carcinoma had a stronger impact with utilities ranging from 0.35 to 0.41. Significant variation was observed between countries, with both types of respondents in mainland China and Hong Kong reporting systematically lower utilities.

CONCLUSIONS

Health states related to CHB infection have substantial reductions in HRQOL and the utilities reported in this study provide valuable information for comparing new treatment options. The observed intercountry differences suggest that economic evaluations may benefit from country-specific utility estimates. The extent that systematic intercountry differences in utilities hold true for other infectious and chronic diseases remains an open question and has considerable implications for the proper conduct and interpretation of economic evaluations.

Health state valuation in mild to moderate cognitive impairment: feasibility of computer-based, direct patient utility assessment

BACKGROUND

Most patients with dementia will, at some point, need a proxy health care decision maker. It is unknown whether persons with various degrees of cognitive impairment can reliably report their health-related preferences.

METHODS

The authors performed health state valuations (HSVs) of current and hypothetical future health states on 47 pairs of patients with mild to moderate cognitive impairment and their caregivers using computer-based standard gamble, time tradeoff, and rating scale techniques.

RESULTS

Patients' mean (SD) age was 74.6 (9.3) years. About half of the patients were women (48%), as were most caregivers (73%), who were on average younger (mean age= 66.2 years, SD= 12.2). Most participants were white (83%); 17% were African American. The mean (SD) Mini-Mental State Examination (MMSE) score of patients was 24.2 (4.6) of 30. All caregivers and 77% of patients (36/47) completed all 18 components of the HSV exercise. Patients who completed the HSV exercise were slightly younger (mean age [SD]= 74.1 [8.5] v. 75.9 [11.8]; P = 0.569) and had significantly higher MMSE scores (mean score [SD] = 25.0 [4.3] v. 21.4 [4.4]; P = 0.018). Although MMSE scores below 20 did not preclude the completion of all 18 HSV ratings, being classified as having moderate cognitive impairment was associated with a lower likelihood of completing all scenario ratings (44% v. 82%). Patient and caregiver responses showed good consistency across time and across techniques and were logically consistent.

CONCLUSION

Obtaining HSVs for current and hypothetical health states was feasible for most patients with mild cognitive impairment and many with moderate cognitive impairment. HSV assessments were consistent and reasonable.

Rethinking the objectives of decision aids: a call for conceptual clarity

Health decision aids are a potentially valuable adjunct to patient-physician communication and decision making. Although the overarching goal of decision aids--to help patients make informed, preference-sensitive choices--is widely accepted, experts do not agree on the means to achieve this end. In this article, the authors critically examine the theoretical basis and appropriateness of 2 widely accepted criteria used to evaluate decision aids: values clarification and reduction of decisional conflict. First, they argue that although clarifying values is central to decision making under uncertainty, it is not clear that decision aids--as they have been conceived and operationalized so far--can and should be used to achieve this goal. The pursuit of clarifying values, particularly values clarification exercises, raises a number of ethical, methodological, and conceptual issues, and the authors suggest research questions that should be addressed before values clarification is routinely endorsed. Second, the authors argue that the goal of reducing decisional conflict is conceptually untenable and propose that it be eliminated as an objective of decision aids.

Why people refuse to make tradeoffs in person tradeoff elicitations: a matter of perspective?

OBJECTIVE

Person tradeoff (PTO) elicitations assess people's values for health states by asking them to compare the value of treatment programs. For example, people might be asked how many patients need to be cured of health condition X to equal the benefit of curing 100 people of condition Y. However, when faced with PTO elicitations, people frequently refuse to make quantifiable tradeoffs, exhibiting 2 kinds of refusals: 1) They say that 2 treatment programs have equal value, that curing 100 of X is just as good as curing 100 of Y, even if X is a less serious condition than Y, or 2) they say that the 2 programs are incomparable, that millions of people need to be cured of X to be as good as curing 100 of Y. The authors explore whether people would be more willing to make tradeoffs if the focus was changed from trading off groups of patients to choosing the best decision or evaluating treatment benefits.

DESIGN

. Two randomized trials used diverse samples (N=2400) via the Internet to test for the effect of perspective on refusal rates. The authors predicted that perspectives that removed people from decision-making roles would increase their willingness make tradeoffs.

RESULTS

Contrary to expectations, refusal rates increased when people were removed from decision-making roles. In fact, the more pressure put on people to make a decision, the less likely they were to refuse to make tradeoffs.

CONCLUSION

To reduce PTO refusals, it is best to adopt a decision-maker perspective.

Impacto de los cuidados paliativos y perfil clínico del paciente con enfermedad terminal en un área de Medicina Interna

INTRODUCTION

The medical assistance to patients with terminal diseases has been structured with Primary Care and Palliative Care Units as protagonists, and with other specialties as secondary roles. Nevertheless the impact of this group of patients in Internal Medicine areas is unknown. Our objective was to evaluate these parameters in the area of Internal Medicine of a tertiary teaching Hospital.

MATERIAL AND METHODS

Prospective observational study of all patients attended in Internal Medicine areas during June 2003. Patients were stratified in three cohorts (palliative, pluripathologic, and general). Incidence of palliative patients, origin, clinical features, and burden of hospital care in the last 12 months were analyzed. Univariate analysis of the clinical differences between the palliative and the pluripathologic, and general cohorts was performed, using Chi-square, Fisher, ANOVA and post-hoc tests and Kruskal-Wallis test.

RESULTS

52 (53.8% women; mean age 66.5 +/- 15 years) were included from the global study cohort of 339 patients. Incidence of palliative patients was 15.4/100 admissions. The patients were admitted from other specialties (57.6%), Emergency department (27%), and Primary Care (10%). Mean hospital stay was 14.5 (1-150) days, and survival 63.5%. The 68.5% of deceases occurred at home. Patients of palliative cohort, with respect to general cohort had less functional ability at baseline (47.5 vs 95; p < 0.0001), admission (40 vs 75; p < 0.0001), and at discharge (20 vs 75; p < 0.0001), and more functional deterioration during hospital stay (mean fall in Barthel's values at baseline-discharge of 27.5 vs 20 points; p < 0.003). There were no differences in the burden of hospital care in the previous 12 months. With respect to the cohort of pluripathologic patients, palliative patients were younger (66.5 +/- 15 vs 75 +/- 11 years; p = 0.001) and had similar functional limitations at baseline (47.5 vs 45), admission (40 vs 20) and at discharge (20 vs 20).

DISCUSSION

Patients with terminal diseases are prevalent in the clinical setting in areas of internal medicine. These data support the role of the internist in palliative care proceedings, and prompt internists to acquire enough specific abilities to manage competitively these population.

A Markov computer simulation model of the economics of neuromuscular blockade in patients with acute respiratory distress syndrome

Background

Management of acute respiratory distress syndrome (ARDS) in the intensive care unit (ICU) is clinically challenging and costly. Neuromuscular blocking agents may facilitate mechanical ventilation and improve oxygenation, but may result in prolonged recovery of neuromuscular function and acute quadriplegic myopathy syndrome (AQMS). The goal of this study was to address a hypothetical question via computer modeling: Would a reduction in intubation time of 6 hours and/or a reduction in the incidence of AQMS from 25% to 21%, provide enough benefit to justify a drug with an additional expenditure of $267 (the difference in acquisition cost between a generic and brand name neuromuscular blocker)?

Methods

The base case was a 55 year-old man in the ICU with ARDS who receives neuromuscular blockade for 3.5 days. A Markov model was designed with hypothetical patients in 1 of 6 mutually exclusive health states: ICU-intubated, ICU-extubated, hospital ward, long-term care, home, or death, over a period of 6 months. The net monetary benefit was computed.

Results

Our computer simulation modeling predicted the mean cost for ARDS patients receiving standard care for 6 months to be $62,238 (5% – 95% percentiles $42,259 – $83,766), with an overall 6-month mortality of 39%. Assuming a ceiling ratio of $35,000, even if a drug (that cost $267 more) hypothetically reduced AQMS from 25% to 21% and decreased intubation time by 6 hours, the net monetary benefit would only equal $137.

Conclusion

ARDS patients receiving a neuromuscular blocker have a high mortality, and unpredictable outcome, which results in large variability in costs per case. If a patient dies, there is no benefit to any drug that reduces ventilation time or AQMS incidence. A prospective, randomized pharmacoeconomic study of neuromuscular blockers in the ICU to asses AQMS or intubation times is impractical because of the highly variable clinical course of patients with ARDS.

CEU: Advance directives overcoming reluctance and getting them done

Why do less than 10% of healthy adults have them? Why do less than 20% of frail elders have them? If we examine the incentives and the disincentives adults feel to complete advance directives, we can focus our educational efforts for maximal effect and get this important work done.

A clinically based discrete-event simulation of end-stage liver disease and the organ allocation process

BACKGROUND

The optimal allocation of scarce donor livers is a contentious health care issue requiring careful analysis. The objective of this article was to design a biologically based discrete-event simulation to test proposed changes in allocation policies.

METHODS

The authors used data from multiple sources to simulate end-stage liver disease and the complex allocation system. To validate the model, they compared simulation output with historical data.

RESULTS

Simulation outcomes were within 1% to 2% of actual results for measures such as new candidates, donated livers, and transplants by year. The model overestimated the yearly size of the waiting list by 5% in the last year of the simulation and the total number of pretransplant deaths by 10%.

CONCLUSION

The authors created a discrete-event simulation model that represents the biology of end-stage liver disease and the health care organization of transplantation in the United States.

Invariance and inconsistency in utility ratings

PURPOSE

To assess utilities of composite health states for dependence in activities of daily living (ADLs) for invariance (i.e., when subjects provide a utility of 1 for all health states) and order inconsistency (i.e., when subjects order their utilities such that their utility for a combination of ADL dependencies is greater than their utility for any subset of the combination).

METHODS

Each of the 400 subjects, age 65 y and older, enrolled in one of several regional medical centers of the Kaiser Permanente Medical Care Program of Northern California and provided standard-gamble utilities for single ADL dependencies (e.g., bathing, dressing, continence) and for dependence in 8 other combinations of ADL dependencies. For order-inconsistent responses, the authors calculated the maximum magnitude of inconsistency as the maximum difference between the utility for the combined ADL dependence health state and that of its inconsistent subset.

RESULTS

A total of 76 subjects (19%) gave a utility of 1.0 for all health states presented to them; 19 (5%) gave the same utility other than 1.0 for all health states; 130 (33%) gave at least 1 utility < 1.0 and had no order inconsistencies; and 175 (44%) had at least 1 order inconsistency. Invariance was associated with a Mini-Mental Status Examination score < 28.6 (P = 0.01), with education < 12 y (P = 0.004), with race/ethnicity other than non-Hispanic White/Caucasian (P = 0.001), and with shorter time spent on the utility elicitation task (P < 0.0001). Among the inconsistent subjects, 69% had a maximal magnitude of inconsistency that was within 1 standard deviation of the mean utilities. The maximal magnitude of inconsistency was associated with longer time spent on the elicitation task (P < 0.0001) and race/ethnicity other than non-Hispanic White/Caucasian (P = 0.005). The mean (s) utility for dependence in continence among consistent subjects who were not invariant (0.88 [0.24]) was higher than among inconsistent subjects (0.80 [0.27]; P = 0.01).

CONCLUSIONS

Invariance and order inconsistencies in utility ratings for complex health states occur frequently. Utilities of consistent subjects may differ from those of inconsistent subjects. Utility assessments should attempt to measure and report these patterns.

The American Society of Clinical Oncology program to improve end-of-life care

Too few cancer patients have optimal care at the end of life, as measured by unrelieved pain, death in a setting other than home, and uncoordinated care. The American Society of Clinical Oncology (ASCO), as the largest professional society whose members care for most cancer patients in the United States, has begun an initiative to improve end-of-life care. Educational programs for ASCO members have been started at the national level. A Task Force on End of Life Care was created to study the current state of end-of-life care, barriers to improved end-of-life care, and what ASCO can do to improve end-of-life care. A member-wide survey has been completed to assess, from the professional's perspective, the current state of and barriers to end-of-life care. Specific sections of the Task Force will address hospice care, physician- assisted suicide, clinical barriers, economic barriers, research initiatives, educational deficiencies, and quality of care at the end of life. Improvements in end-of-life care can be made if the current deficiencies are noted, barriers ascertained, and specific solutions found. Professional societies have both the interest and responsibility to improve end-of-life care.