Valuing EQ-5D-Y: the current state of play

BACKGROUND

For nearly a decade, value sets for the EQ-5D-Y were not available, reflecting challenges in valuing child HRQoL. A methodological research programme led to publication of a valuation protocol in 2020, which was rapidly taken up by local study teams. By the end of 2022, between 11 and 17 EQ-5D-Y value sets will be available, more than for any other child HRQoL measure. It is timely to review the experience of those using the protocol to identify early learnings and remaining issues where more research is needed.

METHODS

In June 2021, the EuroQol Group organised a three-day workshop, bringing together all those involved in EQ-5D-Y value set studies and related methodological research concerning EQ-5D-Y and valuation. Workshop discussions were captured by note taking and recording all sessions and online chat. A narrative summary of all sessions was produced and synthesised to identify points of agreement and aspects of methods where uncertainty remains.

RESULTS

There was broad agreement that DCE is working well as the principal valuation method. However, the most appropriate means of anchoring the latent scale values produced by DCE remains unclear. Some studies have deviated from the protocol by extending the number of states included in TTO tasks, to better support modelling of DCE and TTO. There is ongoing discussion about the relative merits of alternative variants of TTO and other methods for anchoring. Very few studies have consulted with local end-users to gauge the acceptability of methods used to value EQ-5D-Y.

CONCLUSIONS

Priority areas for research include testing alternative methods for anchoring DCE data; exploring the preferences of adolescents; and scale differences in values for EQ-5D-Y and adult EQ-5D states, and implications of such differences for the use of EQ-5D-Y values in HTA. Given the normative elements of the protocol, engaging with HTA bodies and other local users should be the first step for all future value set studies. Value sets undertaken to date are for the three-level EQ-5D-Y. However, the issues discussed in this paper are equally relevant to valuation of the five-level version of EQ-5D-Y; indeed, similar challenges are encountered valuing any measure of child HRQoL.

Psychotic experiences in a mental health clinic sample: implications for suicidality, multimorbidity and functioning

BACKGROUND

Recent community-based research has suggested that psychotic experiences act as markers of severity of psychopathology. There has, however, been a lack of clinic-based research. We wished to investigate, in a clinical sample of adolescents referred to a state-funded mental health service, the prevalence of (attenuated or frank) psychotic experiences and the relationship with (i) affective, anxiety and behavioural disorders, (ii) multimorbid psychopathology, (iii) global functioning, and (iv) suicidal behaviour.

METHOD

The investigation was a clinical case-clinical control study using semi-structured research diagnostic psychiatric assessments in 108 patients newly referred to state adolescent mental health services.

RESULTS

Psychotic experiences were prevalent in a wide range of (non-psychotic) disorders but were strong markers of risk in particular for multimorbid psychopathology (Z = 3.44, p = 0.001). Young people with psychopathology who reported psychotic experiences demonstrated significantly poorer socio-occupational functioning than young people with psychopathology who did not report psychotic experiences, which was not explained by multimorbidity. Psychotic experiences were strong markers of risk for suicidal behaviour. Stratified analyses showed that there was a greatly increased odds of suicide attempts in patients with a major depressive disorder [odds ratio (OR) 8.89, 95% confidence interval (CI) 1.59-49.83], anxiety disorder (OR 15.4, 95% CI 1.85-127.94) or behavioural disorder (OR 3.13, 95% CI 1.11-8.79) who also had psychotic experiences compared with patients who did not report psychotic experiences.

CONCLUSIONS

Psychotic experiences (attenuated or frank) are an important but under-recognized marker of risk for severe psychopathology, including multimorbidity, poor functioning and suicidal behaviour in young people who present to mental health services.

Understanding the effects on HR-QoL of treatment for overactive bladder: a detailed analysis of EQ-5D clinical trial data for mirabegron

BACKGROUND

Analysis of EQ-5D data often focuses on changes in utility, ignoring valuable information from other parts of the instrument. The objective was to explore how the utility index, EQ-5D profile, and EQ-VAS captured change in clinical trials of mirabegron, a new treatment for overactive bladder (OAB).

DATA

Data were pooled from three phase III clinical trials that investigated the efficacy and safety of mirabegron vs placebo. Tolterodine ER 4 mg was included as an active control in one study: (1) placebo, mirabegron 50 mg and 100 mg, and tolterodine 4 mg ER; (2) placebo, mirabegron 50 mg and 100 mg; (3) placebo, and mirabegron 25 mg and 50 mg. Data were collected at baseline, week 4, 8, and 12.

METHODS

Analyses were performed on full analysis and modified intention to treat (ITT) data sets using UK utilities. Analysis controlled for relevant patient characteristics. Analysis of Covariance identified changes from baseline at each time point in utilities and EQ-VAS. Areas Under the Curve were estimated to summarize inter-temporal differences in effect. EQ-5D profile data were analysed using the Paretian Classification of Health Change.

RESULTS

In modified ITT analyses, mirabegron 50 mg was superior to tolterodine 4 mg in changes from baseline utilities after 12 weeks (p < 0.05); similarly, AUC results showed mirabegron 50 mg to be superior to tolterodine (p < 0.05) and placebo (p < 0.05) with the benefit already apparent at 4 weeks (p < 0.05). EQ-VAS more consistently indicated superior outcomes: all three mirabegron doses showed statistically significant greater effectiveness compared to tolterodine at 12 weeks. Individual EQ-5D dimensions and the overall profile showed no significant differences between study arms.

CONCLUSION

Mirabegron showed quicker and superior improvement in HR-QoL compared to tolterodine 4 mg ER. A limitation of the study is that EQ-5D was a secondary outcome in the pivotal trials, which were not powered to measure differences on EQ-5D.

Prevalence of psychotic symptoms in childhood and adolescence: a systematic review and meta-analysis of population-based studies

BACKGROUND

Psychotic symptoms occur more frequently in the general population than psychotic disorder and index risk for psychopathology. Multiple studies have reported on the prevalence of these symptoms using self-report questionnaires or clinical interviews but there is a lack of consensus about the prevalence of psychotic symptoms among children and adolescents.

METHOD

We conducted a systematic review of all published literature on psychotic symptom prevalence in two age groups, children aged 9-12 years and adolescents aged 13-18 years, searching through electronic databases PubMed, Ovid Medline, PsycINFO and EMBASE up to June 2011, and extracted prevalence rates.

RESULTS

We identified 19 population studies that reported on psychotic symptom prevalence among children and adolescents. The median prevalence of psychotic symptoms was 17% among children aged 9-12 years and 7.5% among adolescents aged 13-18 years.

CONCLUSIONS

Psychotic symptoms are relatively common in young people, especially in childhood. Prevalence is higher in younger (9-12 years) compared to older (13-18 years) children.

The delivery of orthodontic care in New Zealand. Part II: Analysis of a census of dentists

Part I of this study reported the level and distribution of the supply of specialist orthodontic services in New Zealand. This paper focuses on the amount and variety of orthodontic services supplied by dentists. A questionnaire sent to all dentists in New Zealand sought information on the amount and type of orthodontic treatment carried out between 1 July 1998 and 30 June 1999. The reply rate was 80.9 percent. The majority of dentists carried out some form of orthodontic treatment, predominantly of a minor nature. A small number provided significant amounts of treatment, both simple and complex. The majority of orthodontic treatment and the majority of comprehensive fixed-appliance treatment were undertaken by orthodontists. One-quarter of all orthodontic patients in New Zealand were treated by dentists, irrespective of the complexity of treatment. Nearly a fifth of all full fixed upper and lower appliances, and nearly a third of all single-arch fixed appliances were placed by dentists during the study period. In general, male dentists, dentists over the age of 40, those who had attended an orthodontic continuing education course in the previous 5 years, and those who referred fewer patients to an orthodontist carried out more procedures, including those of a complex nature; they also had a higher average active orthodontic patient load. Wanting to be more or less busy had little influence on the amount or complexity of treatment performed. Dentists in regions with a low supply of specialist orthodontic services provided more comprehensive fixed appliance treatment and had a higher orthodontic patient load. However, the presence or absence of an orthodontist in an urban area seemed to have little impact on the complexity of treatment or the orthodontic patient load of dentists. Despite fewer orthodontists in secondary and minor urban areas, dentists in these areas did not have a higher orthodontic patient load, but carried out a wider range of procedures and more complex procedures than those in main urban areas.

The delivery of orthodontic care in New Zealand. Part I: Analysis of a census of orthodontists

A two-part study was undertaken to determine the supply of orthodontic services in New Zealand. Part I focuses on services supplied by specialist orthodontists. A companion paper will describe the amount and characteristics of orthodontic services supplied by dentists. All orthodontists in New Zealand in 1999 were surveyed to provide information on practice location and days practiced in 1996 (the year of the last population Census), and the amount and type of orthodontic treatment carried out in the year 1 July 1998 to 30 June 1999. The response rate was 78.9 percent. Data from 1996 were used to establish and quantify the location and distribution of orthodontists in New Zealand, and their spatial relationship to 12-year-olds and 10- to 14-year-olds using Geographic Information Systems. The information from 1998-1999 was used to determine the amount and variety of services provided by orthodontists and the makeup of their patient base. Nearly two-thirds of orthodontists had a branch practice. Over 50 percent of the 10- to 14-year-old population resided within 5 km of an orthodontist, and nearly three-quarters within 10 km. Disparities between regions existed in the supply of specialist orthodontic services. The catchment areas of main urban areas had more than three times the supply of orthodontists to 12-year-olds than did the secondary and minor urban areas combined. The mean average active patient load was 371, and the mean number of full upper and lower fixed appliances placed was 130.3 during the year of the study. Nearly half of all patients had been referred from dentists, approximately one-quarter were self-referred, and a quarter had been referred by dental therapists. Adults comprised 12.1 percent of the patient load of orthodontists; 60 percent were female.

Economic evaluation of a community based exercise programme to prevent falls

OBJECTIVE

To assess the incremental costs and cost effectiveness of implementing a home based muscle strengthening and balance retraining programme that reduced falls and injuries in older women.

DESIGN

An economic evaluation carried out within a randomised controlled trial with two years of follow up. Participants were individually prescribed an exercise programme (exercise group, n=116) or received usual care and social visits (control group, n=117).

SETTING

17 general practices in Dunedin, New Zealand.

PARTICIPANTS

Women aged 80 years and older living in the community and invited by their general practitioner to take part.

MAIN OUTCOME MEASURES

Number of falls and injuries related to falls, costs of implementing the intervention, healthcare service costs resulting from falls and total healthcare service costs during the trial. Cost effectiveness was measured as the incremental cost of implementing the exercise programme per fall event prevented.

MAIN RESULTS

27% of total hospital costs during the trial were related to falls. However, there were no significant differences in health service costs between the two groups. Implementing the exercise programme for one and two years respectively cost $314 and $265 (1995 New Zealand dollars) per fall prevented, and $457 and $426 per fall resulting in a moderate or serious injury prevented.

CONCLUSIONS

The costs resulting from falls make up a substantial proportion of the hospital costs for older people. Despite a reduction in falls as a result of this home exercise programme there was no significant reduction in healthcare costs. However, the results reported will provide information on the cost effectiveness of the programme for those making decisions on falls prevention strategies.

Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 2: Controlled trial in multiple centres

OBJECTIVES

To assess the effectiveness of trained nurses based in general practices individually prescribing a home exercise programme to reduce falls and injuries in elderly people and to estimate the cost effectiveness of the programme.

DESIGN

Controlled trial with one year's follow up.

SETTING

32 general practices in seven southern New Zealand centres.

PARTICIPANTS

450 women and men aged 80 years and older.

INTERVENTION

330 participants received the exercise programme (exercise centres) and 120 received usual care (control centres); 87% (371 of 426) completed the trial.

MAIN OUTCOME MEASURES

Number of falls, number of injuries resulting from falls, costs of implementing the programme, and hospital costs as a result of falls.

RESULTS

Falls were reduced by 30% in the exercise centres (incidence rate ratio 0.70, 95% confidence interval 0.59 to 0.84). The programme was equally effective in men and women. The programme cost $NZ418 (121 pound sterling) (at 1998 prices) per person to deliver for one year or $NZ1519 (441 pound sterling) per fall prevented. Fewer participants had falls resulting in injuries, but there was no difference in the number who had serious injuries and no difference in hospital costs resulting from falls in exercise centres compared with control centres.

CONCLUSIONS

An individually tailored exercise programme, delivered by trained nurses from within general practices, was effective in reducing falls in three different centres. This strategy should be combined with other successful interventions to form part of home programmes to prevent falls in elderly people.

Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial

OBJECTIVES

To assess the effectiveness of a trained district nurse individually prescribing a home based exercise programme to reduce falls and injuries in elderly people and to estimate the cost effectiveness of the programme.

DESIGN

Randomised controlled trial with one year's follow up.

SETTING

Community health service at a New Zealand hospital.

PARTICIPANTS

240 women and men aged 75 years and older.

INTERVENTION

121 participants received the exercise programme (exercise group) and 119 received usual care (control group); 90% (211 of 233) completed the trial.

MAIN OUTCOME MEASURES

Number of falls, number of injuries resulting from falls, costs of implementing the programme, and hospital costs as a result of falls.

RESULTS

Falls were reduced by 46% (incidence rate ratio 0.54, 95% confidence interval 0.32 to 0.90). Five hospital admissions were due to injuries caused by falls in the control group and none in the exercise group. The programme cost $NZ1803 (523 pound sterling) (at 1998 prices) per fall prevented for delivering the programme and $NZ155 per fall prevented when hospital costs averted were considered.

CONCLUSION

A home exercise programme, previously shown to be successful when delivered by a physiotherapist, was also effective in reducing falls when delivered by a trained nurse from within a home health service. Serious injuries and hospital admissions due to falls were also reduced. The programme was cost effective in participants aged 80 years and older compared with younger participants.

Variations in self-reported health status: results from a New Zealand survey

AIMS

To report measures of the self-reported health of a sample of the New Zealand adult population elicited using the EuroQol Group's EQ-5D questionnaire, and to investigate variations in these measures, according to respondents' socio-demographic characteristics.

METHODS

Personal health status questions were included in a self-completed postal questionnaire mailed to a non-stratified sample of 3000 New Zealanders, selected at random from the electoral roll. 1350 questionnaires were completed and returned. Each respondent rated their health on the five EQ-5D dimensions- mobility, self care, usual activities, pain/discomfort and anxiety/depression- and assigned a global score to their profile.

RESULTS

Pain/discomfort was the most commonly experienced health problem, with 41% of all respondents and 63% of over-70 year olds reporting moderate or extreme problems. Just 4.5% of respondents reported problems with self-care. Respondents were more likely to report problems on each of the five dimensions and to have a lower global score if they smoked, if they were unemployed, a houseworker or retiree, and if their education did not continue past the minimum school leaving-age, or they did not have a degree or equivalent qualification. Problems on all dimensions were more common the older the respondent, and the global score was lower for over-70 year olds than for younger people. Neither the global score nor the incidence of problems on any of the dimensions was related to sex or ethnicity.

CONCLUSIONS

The EQ-5D is a potentially useful instrument for monitoring health in the New Zealand context. Further research to explore its validity and reliability, particularly for Maori, would be valuable.

Priority-setting in New Zealand: translating principles into practice

In May 1998 the New Zealand Health Funding Authority released a discussion paper which proposed a principles-based approach to setting purchasing priorities that incorporates the economic methods of programme budgeting and marginal analysis, and cost-utility analysis. The principles upon which the process was to be based are effectiveness, cost, equity of health outcomes, Maori health and acceptability. This essay describes and critiques issues associated with translating the principles into practice, most particularly the proposed methods for evaluating the effectiveness and measuring the cost of services. It is argued that the proposals make an important contribution towards the development of a method for prioritizing services which challenges our thinking about those services and their goals, and which is systematic, explicit, and transparent. The shift towards 'thinking at the margin' and systematically reviewing the value for money of competing claims on resources is likely to improve the quality of decision-making compared with the status quo. This does not imply that prioritization can, or should, be undertaken by means of any simple formula. Any prioritization process should always be guided by informed judgement. The approach is more appropriate for some services than for others. Key methodological issues that need further consideration include the choice of instrument for measuring health gains, the identification of marginal services, how to combine qualitative and quantitative information, and how to ensure consistency across different levels of decision-making.

The cost-effectiveness of introducing a varicella vaccine to the New Zealand immunisation schedule

This study examined the cost-effectiveness of adding a varicella vaccine to an existing childhood immunisation schedule relative to a counterfactual where the varicella vaccine is available on a user-pays basis (the current New Zealand situation). The costs and consequences of chickenpox in an annual cohort of 57,200, 15-month old children were simulated for a 30-year period. The cohort simulation design captures the 'phasing-in' effects of routine varicella vaccination on the population. From a health care payer's perspective (medical costs only) every dollar invested in a vaccination programme would return NZ $0.67. However, from a societal point of view (which includes the value of work-loss), a vaccination programme would return NZ $2.79 for every dollar invested. To implement a varicella vaccination programme covering 80% of 15-month old children in New Zealand would add more than NZ $1 million in net direct (health care) costs each year. However, the indirect cost savings from reduced losses of work-time exceed NZ $2 million annually. The net average health care cost per child vaccinated over the 30-year modelling period was $54 whereas the cost-savings from work-loss averted averaged $101 per child vaccinated. Total cost-savings to society of $47 per child vaccinated, on average, could be gained from a vaccination programme. The finding that the addition to vaccination costs resulting from a routine programme (including the cost of complications from the vaccine) were greater than the offsetting health care cost savings from reduced incidence of chickenpox were robust to a sensitivity analysis on all assumptions within plausible ranges. Overall cost-effectiveness estimates were most sensitive to assumptions regarding lost work-time, the discount rate, and the price and efficacy of the vaccine. Estimates were relatively insensitive to changes in assumptions regarding health care utilisation.

The horizontal equity of health care in New Zealand

OBJECTIVE

Given that 'equal access for equal need' is a clearly articulated goal of the New Zealand public health system, this study is an attempt to determine if access to public health care services in New Zealand is, for people of equal health need, independent of income.

METHOD

Information on health status, income and health service utilisation for just over 6,000 New Zealanders was obtained from the national Household Health Survey 1992-93. Using standardised expenditure concentration curves and a concentration index, the distribution of health service use by individuals in different income groups, as a proxy for access, was illustrated and quantified.

RESULTS

The results suggest either appropriate or slightly excess use of services by the poor given their estimated health need. Due to analytical problems caused by data deficiencies, these results must be regarded as tentative.

CONCLUSION

For the period under study, no evidence was found to indicate significant access barriers to publicly funded health care for people on different incomes. This study has served to demonstrate one approach to measuring inequality and analysing the relationship between inequality and inequity. Given the reforms to the health sector since 1993, ongoing monitoring of equity of access to health care services is essential.

IMPLICATIONS

Given the income-related disparities in health that do exist, the public health community should endeavour to develop techniques to monitor the delivery of publicly funded health care to ensure that further inequity is not borne by the poor.

Valuing quality of life: results for New Zealand health professionals

AIMS

To illustrate the means by which health state preferences, which are required in the calculation of QALYs, may be generated. To elicit health state values from a sample of New Zealand health professionals, and to compare these with those evident from a sample of health professionals and of the general population overseas.

METHODS

This research employed a questionnaire (EQ-5D) developed by the EuroQol group which elicits preferences for health states described in terms of three levels within each of five dimensions of health-related quality of life. This questionnaire was administered to groups of students enrolled in a postgraduate Diploma of Public Health course in Auckland (1993-1995), Wellington and Dunedin (1993-1998), and Christchurch (1993-1997).

RESULTS

The health state preferences for the New Zealand sample are similar to those evident for samples of health professionals in Sweden and, to a lesser extent, those evident from a sample of the English general public.

CONCLUSIONS

The EQ-5D represents a means of readily eliciting health state preferences in the form required to facilitate cost utility analysis. Further research is required in New Zealand to generate a "tariff of health state preferences from the general public across all health states and to explore hypotheses specific to New Zealand, including the possibility that there may be significant differences between Maori and non-Maori with regards to health state preferences.