Health-related quality of life measured using the EQ-5D-5L: South Australian population norms

BACKGROUND

Although a five level version of the widely-used EuroQol 5 dimensions (EQ-5D) instrument has been developed, population norms are not yet available for Australia to inform the future valuation of health in economic evaluations. The aim of this study was to estimate HrQOL normative values for the EQ-5D-5L preference-based measure in a large, randomly selected, community sample in South Australia.

METHODS

The EQ-5D-5L instrument was included in the 2013 South Australian Health Omnibus Survey, an interviewer-administered, face-to-face, cross-sectional survey. Respondents rated their level of impairment across dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) and global health rating on a visual analogue scale (EQ-VAS). Utility scores were derived using the newly-developed UK general population-based algorithm and relationships between utility and EQ-VAS scores and socio-demographic factors were also explored using multivariate regression analyses.

RESULTS

Ultimately, 2,908 adults participated in the survey (63.4 % participation rate). The mean utility and EQ-VAS scores were 0.91 (95 CI 0.90, 0.91) and 78.55 (95 % CI 77.95, 79.15), respectively. Almost half of respondents reported no problems across all dimensions (42.8 %), whereas only 7.2 % rated their health >90 on the EQ-VAS (100 = the best health you can imagine). Younger age, male gender, longer duration of education, higher annual household income, employment and marriage/de facto relationships were all independent, statistically significant predictors of better health status (p < 0.01) measured with the EQ-VAS. Only age and employment status were associated with higher utility scores, indicating fundamental differences between these measures of health status.

CONCLUSIONS

This is the first Australian study to apply the EQ-5D-5L in a large, community sample. Overall, findings are consistent with EQ-5D-5L utility and VAS scores reported for other countries and indicate that the majority of South Australian adults report themselves in full health. When valuing health in Australian economic evaluations, the utility population norms can be used to estimate HrQOL. More generally, the EQ-VAS score may be a better measure of population health given the smaller ceiling effect and broader coverage of HrQOL dimensions. Further research is recommended to update EQ-5D-5L population norms using the Australian general population specific scoring algorithm once this becomes publically available.

Nevoid basal cell carcinoma syndrome: review of 118 affected individuals

One hundred eighteen cases of nevoid basal cell carcinoma syndrome (NBCCS, Gorlin's syndrome or basal cell nevus syndrome) are presented in this study. In aiming to ascertain all the affected families in Australia, we have examined the largest series to date. Relative frequencies of associated complications are presented and compared with those of the recent English survey by Evans et al. [J Med Genet 30:460-464, 1993]. The frequencies of most manifestations are similar. However, one major difference is that the multiple basal cell carcinomas are manifest from an earlier age in the Australian population, which probably reflects greater exposure to ultraviolet radiation. Of the 64 families ascertained, 37 represented simplex cases, and, accordingly, the apparent new mutation rate is surprisingly high (14-81%) given the lack of impact of NBCCS on reproductive capabilities. There is some evidence to suggest that this may be attributable to anticipation.

Time trade-off derived EQ-5D weights for Australia

BACKGROUND

Cost-utility analyses (CUAs) are increasingly common in Australia. The EuroQol five-dimensional (EQ-5D) questionnaire is one of the most widely used generic preference-based instruments for measuring health-related quality of life for the estimation of quality-adjusted life years within a CUA. There is evidence that valuations of health states vary across countries, but Australian weights have not previously been developed.

METHODS

Conventionally, weights are derived by applying the time trade-off elicitation method to a subset of the EQ-5D health states. Using a larger set of directly valued health states than in previous studies, time trade-off valuations were collected from a representative sample of the Australian general population (n = 417). A range of models were estimated and compared as a basis for generating an Australian algorithm.

RESULTS

The Australia-specific EQ-5D values generated were similar to those previously produced for a range of other countries, but the number of directly valued states allowed inclusion of more interaction effects, which increased the divergence between Australia's algorithm and other algorithms in the literature.

CONCLUSION

This new algorithm will enable the Australian community values to be reflected in future economic evaluations.

Health-related quality of life and health care costs in severe, refractory irritable bowel syndrome

BACKGROUND

The irritable bowel syndrome (IBS) may lead to considerable impairment of health-related quality of life and high health care costs. It is not clear whether these poor outcomes directly result from severe bowel symptoms or reflect a coexisting psychiatric disorder.

OBJECTIVE

To determine whether bowel symptom severity and psychological symptoms directly influence health-related quality of life and health care costs.

DESIGN

Cross-sectional survey.

SETTING

Secondary and tertiary gastroenterology clinics.

PATIENTS

257 patients with severe IBS who did not respond to usual treatments and were recruited for a trial of psychological treatment.

MEASUREMENTS

Predictors were abdominal pain, entries in a diary of 10 IBS symptoms, and measures of psychological symptoms. Outcomes were inability to work, health-related quality of life (measured by Medical Outcomes Survey 36-item short-form questionnaire [SF-36] physical component summary scores), and health care and productivity costs. Predictor and outcome measures were compared by using multiple regression and logistic regression analyses.

RESULTS

Abdominal pain occurred on average 24 days per month and activities were restricted on 145 days of the previous 12 months. The mean (+/-SD) Hamilton depression score was 11.3 +/- 6.1. The SF-36 physical component summary score was low (37.7 +/- 10.6), and the patients had incurred high health care costs ($1743 +/- $2263) over the previous year. Global severity and somatization scores on the Symptom Checklist 90 Revised, abdominal pain, and Hamilton depression scores independently contributed to the physical component score of the SF-36 (adjusted R(2) = 35.2%), but only psychological scores were associated with disability due to ill health. These variables did not accurately predict health care or other costs (adjusted R(2) = 9.3%). History of sexual abuse was not an independent predictor of outcome.

CONCLUSIONS

Both abdominal and psychological symptoms are independently associated with impaired health-related quality of life in patients with severe IBS. Optimal treatment is likely to require a holistic approach. Since health care and loss of productivity costs are not clearly associated with these symptoms, alleviation of them will not necessarily lead to reduced costs.

International comparisons in valuing EQ-5D health states: a review and analysis

OBJECTIVE

To identify the key methodological issues in the construction of population-level EuroQol 5-dimensions (EQ-5D)/time trade-off (TTO) preference elicitation studies.

METHOD

This study involved three components. The first was to identify existing population-level EQ-5D TTO studies. The second was to illustrate and discuss the key areas of divergence between studies, including the international comparison of tariffs. The third was to portray the relative merits of each of the approaches and to compare the results of studies across countries.

RESULTS

While most articles report use of the protocol developed in the original UK study, we identified three key areas of divergence in the construction and analysis of surveys. These are the number of health states valued to determine the algorithm for estimating all health states, the approach to valuing states worse than immediate death, and the choice of algorithm. The evidence on international comparisons suggests differences between countries although it is difficult to disentangle differences in cultural attitudes with random error and differences as a result of methodological divergence.

CONCLUSIONS

Differences in methods may obscure true differences in values between countries. Nevertheless, population-specific valuation sets for countries engaging in economic evaluation would better reflect cultural differences and are therefore more likely to accurately represent societal attitudes.

Measuring and valuing health benefits for economic evaluation in adolescence: an assessment of the practicality and validity of the child health utility 9D in the Australian adolescent population

OBJECTIVES

The Child Health Utility 9D (CHU9D) is a new generic preference-based measure of health-related quality of life developed for children aged 7 to 11 years. There is increasing interest in its potential for application in adolescents, and previous research has demonstrated that it shows good construct validity here. This article further examines its practicality and validity in adolescents by comparing it with KIDSCREEN-10, a short generic measure for assessing children and adolescents' health-related quality of life and well-being.

METHODS

A Web-based survey, including the CHU9D, a general health question, questions on the presence of long-standing illness, disability, or medical conditions, sociodemographic variables, and KIDSCREEN-10, was administered to 961 consenting adolescents. The practicality and face and construct validity of the CHU9D were examined, and the CHU9D and KIDSCREEN-10 were compared in terms of their coverage, correlations between dimensions, and overall scores.

RESULTS

Both measures demonstrated good practicality and validity. The strongest degree of correlation was found with the only dimension in common for the CHU9D and KIDSCREEN (sad). The lowest correlations were found between all the CHU9D dimensions and the "have you had enough time for yourself" dimension of KIDSCREEN-10.

CONCLUSIONS

The findings from this study provide further support for the practicality and validity of the application of the CHU9D in the economic evaluation of adolescent health care and public health programs. Further research to test the psychometric performance of the CHU9D in more diverse clinical samples of adolescents is desirable including tests of reliability.

Effectiveness and cost-effectiveness of three types of physiotherapy used to reduce chronic low back pain disability: a pragmatic randomized trial with economic evaluation

STUDY DESIGN

Pragmatic, randomized, assessor blinded, clinical trial with economic analysis.

OBJECTIVE

To compare the effectiveness and cost-effectiveness of three kinds of physiotherapy commonly used to reduce disability in chronic low back pain.

SUMMARY OF BACKGROUND DATA

Physiotherapy reduces disability in chronic back pain, but there are several forms of physiotherapy and it is unclear which is most effective or cost effective.

METHODS

A total of 212 patients referred to physiotherapy with chronic low back pain were randomized to receive usual outpatient physiotherapy, spinal stabilization classes, or physiotherapist-led pain management classes. Primary outcome was Roland Disability Questionnaire score 18 months from baseline; secondary measures were pain, health-related quality of life, and time off work. Healthcare costs associated with low back pain and quality-adjusted life years (QALYs) were also measured. RESULTS.: A total of 71 participants were assigned to usual outpatient physiotherapy, 72 to spinal stabilization, and 69 to physiotherapist-led pain management. A total of 160 (75%) provided follow-up data at 18 months, showing similar improvements with all interventions: mean (95% confidence intervals) Roland Disability Questionnaire score improved from 11.1 (9.6-12.6) to 6.9 (5.3-8.4) with usual outpatient physiotherapy, 12.8 (11.4-14.2) to 6.8 (4.9-8.6) with spinal stabilization, and 11.5 (9.8-13.1) to 6.5 (4.5-8.6) following pain management classes. Pain, quality of life, and time off work also improved within all groups with no between-group differences. Mean (SD) healthcare costs and QALY gain were pound474 (840) and 0.99 (0.27) for individual physiotherapy, pound379 (1040) and 0.90 (0.37) for spinal stabilization, and pound165 (202) and 1.00 (0.28) for pain management.

CONCLUSIONS

For chronic low back pain, all three physiotherapy regimens improved disability and other relevant health outcomes, regardless of their content. Physiotherapist-led pain management classes offer a cost-effective alternative to usual outpatient physiotherapy and are associated with less healthcare use. A more widespread adoption of physiotherapist-led pain management could result in considerable cost savings for healthcare providers.

Patient navigation across the cancer care continuum: An overview of systematic reviews and emerging literature

Patient navigation is a strategy for overcoming barriers to reduce disparities and to improve access and outcomes. The aim of this umbrella review was to identify, critically appraise, synthesize, and present the best available evidence to inform policy and planning regarding patient navigation across the cancer continuum. Systematic reviews examining navigation in cancer care were identified in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Cumulative Index of Nursing and Allied Health (CINAHL), Epistemonikos, and Prospective Register of Systematic Reviews (PROSPERO) databases and in the gray literature from January 1, 2012, to April 19, 2022. Data were screened, extracted, and appraised independently by two authors. The JBI Critical Appraisal Checklist for Systematic Review and Research Syntheses was used for quality appraisal. Emerging literature up to May 25, 2022, was also explored to capture primary research published beyond the coverage of included systematic reviews. Of the 2062 unique records identified, 61 systematic reviews were included. Fifty-four reviews were quantitative or mixed-methods reviews, reporting on the effectiveness of cancer patient navigation, including 12 reviews reporting costs or cost-effectiveness outcomes. Seven qualitative reviews explored navigation needs, barriers, and experiences. In addition, 53 primary studies published since 2021 were included. Patient navigation is effective in improving participation in cancer screening and reducing the time from screening to diagnosis and from diagnosis to treatment initiation. Emerging evidence suggests that patient navigation improves quality of life and patient satisfaction with care in the survivorship phase and reduces hospital readmission in the active treatment and survivorship care phases. Palliative care data were extremely limited. Economic evaluations from the United States suggest the potential cost-effectiveness of navigation in screening programs.

Longer term clinical and economic benefits of offering acupuncture care to patients with chronic low back pain

OBJECTIVES

To test whether patients with persistent non-specific low back pain, when offered access to traditional acupuncture care alongside conventional primary care, gained more long-term relief from pain than those offered conventional care only, for equal or less cost. Safety and acceptability of acupuncture care to patients, and the heterogeneity of outcomes were also tested.

DESIGN

A pragmatic, two parallel group, randomised controlled trial. Patients in the experimental arm were offered the option of referral to the acupuncture service comprising six acupuncturists. The control group received usual care from their general practitioner (GP). Eligible patients were randomised in a ratio of 2:1 to the offer of acupuncture to allow between-acupuncturist effects to be tested.

SETTING

Three non-NHS acupuncture clinics, with referrals from 39 GPs working in 16 practices in York, UK.

PARTICIPANTS

Patients aged 18-65 years with non-specific low back pain of 4-52 weeks' duration, assessed as suitable for primary care management by their general practitioner.

INTERVENTIONS

The trial protocol allowed up to ten individualised acupuncture treatments per patient. The acupuncturist determined the content and the number of treatments according to patient need.

MAIN OUTCOME MEASURES

The Short Form 36 (SF-36) Bodily Pain dimension (range 0-100 points), assessed at baseline, and 3, 12 and 24 months. The study was powered to detect a 10-point difference between groups at 12 months post-randomisation. Cost--utility analysis was conducted at 24 months using the EuroQoL 5 Dimensions (EQ-5D) and a preference-based single index measure derived from the SF-36 (SF-6D). Secondary outcomes included the McGill Present Pain Index (PPI), Oswestry Pain Disability Index (ODI), all other SF-36 dimensions, medication use, pain-free months in the past year, worry about back pain, satisfaction with care received, and safety and acceptability of acupuncture care.

RESULTS

A total of 159 patients were in the 'acupuncture offer' arm and 80 in the 'usual care' arm. All 159 patients randomised to the offer of acupuncture care chose to receive acupuncture treatment, and received an average of eight acupuncture treatments within the trial. Analysis of covariance, adjusting for baseline score, found an intervention effect of 5.6 points on the SF-36 Pain dimension [95% confidence interval (CI) -1.3 to 12.5] in favour of the acupuncture group at 12 months, and 8 points (95% CI 0.7 to 15.3) at 24 months. No evidence of heterogeneity of effect was found for the different acupuncturists. Patients receiving acupuncture care did not report any serious or life-threatening events. No significant treatment effect was found for any of the SF-36 dimensions other than Pain, or for the PPI or the ODI. Patients receiving acupuncture care reported a significantly greater reduction in worry about their back pain at 12 and 24 months compared with the usual care group. At 24 months, the acupuncture care group was significantly more likely to report 12 months pain free and less likely to report the use of medication for pain relief. The acupuncture service was found to be cost-effective at 24 months; the estimated cost per quality-adjusted (QALY) was 4241 pounds sterling (95% CI 191 pounds sterling to 28,026 pounds sterling) using the SF-6D scoring algorithm based on responses to the SF-36, and 3598 pounds sterling (95% CI 189 pounds sterling to 22,035 pounds sterling) using the EQ-5D health status instrument. The NHS costs were greater in the acupuncture care group than in the usual care group. However, the additional resource use was less than the costs of the acupuncture treatment itself, suggesting that some usual care resource use was offset.

CONCLUSIONS

Traditional acupuncture care delivered in a primary care setting was safe and acceptable to patients with non-specific low back pain. Acupuncture care and usual care were both associated with clinically significant improvement at 12- and 24-month follow-up. Acupuncture care was significantly more effective in reducing bodily pain than usual care at 24-month follow-up. No benefits relating to function or disability were identified. GP referral to a service providing traditional acupuncture care offers a cost-effective intervention for reducing low back pain over a 2-year period. Further research is needed to examine many aspects of this treatment including its impact compared with other possible short-term packages of care (such as massage, chiropractic or physiotherapy), various aspects of cost-effectiveness, value to patients and implementation protocols.

An Australian discrete choice experiment to value eq-5d health states

Conventionally, generic quality-of-life health states, defined within multi-attribute utility instruments, have been valued using a Standard Gamble or a Time Trade-Off. Both are grounded in expected utility theory but impose strong assumptions about the form of the utility function. Preference elicitation tasks for both are complicated, limiting the number of health states that each respondent can value and, therefore, that can be valued overall. The usual approach has been to value a set of the possible health states and impute values for the remainder. Discrete Choice Experiments (DCEs) offer an attractive alternative, allowing investigation of more flexible specifications of the utility function and greater coverage of the response surface. We designed a DCE to obtain values for EQ-5D health states and implemented it in an Australia-representative online panel (n = 1,031). A range of specifications investigating non-linear preferences with respect to time and interactions between EQ-5D levels were estimated using a random-effects probit model. The results provide empirical support for a flexible utility function, including at least some two-factor interactions. We then constructed a preference index such that full health and death were valued at 1 and 0, respectively, to provide a DCE-based algorithm for Australian cost-utility analyses.

Assessing health-related quality of life pre- and post-liver transplantation: a prospective multicenter study

We report on a prospective multicenter study to assess pretransplantation and posttransplantation health-related quality of life (HRQL) of liver transplant recipients. HRQL was assessed at several timepoints using a self-completion questionnaire consisting of the EuroQol instrument (EQ-5D) and the 36-Item Short-Form Health Survey (SF-36) health status profile measure. All individuals selected to receive treatment as part of the UK NHS liver transplantation program at each of six liver transplantation centers in England and Wales during a 2-year period (n = 542) were eligible to be included on the study. An overall response rate of 84% (455 responses) was achieved. A paired comparison of HRQL at listing and 3 months posttransplantation showed statistically significant improvements (P <.05) in all dimensions of the SF-36 (with the exception of Bodily Pain [P =.686]) and the EQ-5D tariff and visual analogue scale (VAS) scores. An analysis of posttransplantation HRQL over time for patients who survived until the end of the study (24 months posttransplantation) showed a statistically significant improvement (P <.05) for all dimensions of the SF-36 (apart from Mental Health [P =.245] and Role-Emotional dimensions [P =.265]) and the EQ-5D VAS and tariff scores. Adjusting for patients who died posttransplantation reduced mean EQ-5D tariff scores substantially, and the change over time in EQ-5D tariff scores was no longer statistically significant (P =.55). Results of regression analysis conducted to assess the importance of patient characteristics and center size on EQ-5D tariff and VAS scores generated posttransplantation indicated there was variation in scores according to patient age and center size.

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

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

Randomised clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial)

OBJECTIVES

To establish the cost-effectiveness of surgery and sclerotherapy for the treatment of varicose veins.

DESIGN

Randomised controlled trials (RCTs) were carried out for conservative treatment, sclerotherapy and surgery for varicose veins. An economic analysis was carried out alongside the randomised trial. Economic modelling was undertaken based on the primary data collection and a literature review (database searches undertaken in April 2000 and updated in March 2001).

SETTING

Primary data collection was from a large district general hospital and a teaching hospital both in England over a 2-year period from January 1999. Cost-effectiveness analysis and economic modelling were carried out using an NHS perspective.

PARTICIPANTS

A total of 1009 patients were recruited.

INTERVENTIONS

Thirty-four patents were randomised in Group 1 (minor varicose veins with no reflux, randomised between conservative treatment and sclerotherapy), 77 in Group 2 (moderate varicose veins with reflux, randomised between surgery and sclerotherapy) and 246 in Group 3 (severe varicose veins with reflux, randomised between conservative treatment and surgery). The remaining 652 patients formed the observational part of the study.

MAIN OUTCOME MEASURES

The cost-effectiveness analysis was based on NHS treatment costs for the 2002--3 financial year, and utilities based on the Short Form 6D (SF-6D) preference-based health measure. For the clinical trial, the outcome measures were health-related quality of life (HRQoL) [Short Form with 36 Items (SF-36), EuroQol quality of life questionnaire (EQ-5D), visual analogue scale (VAS) and standard gamble], symptomatic relief, anatomical extent (for which a new classification was developed and validated), patient satisfaction and the incidence of complications.

RESULTS

Of the RCTs, only the Group 3 trial was large enough to provide clear results. This showed that surgical treatment produced better results than conservative treatment in terms of HRQoL, symptomatic relief, anatomical extent and patient satisfaction. Clinical outcomes of surgery and sclerotherapy showed significant improvement in the extent of varicose veins, symptomatic and HRQoL parameters. Cost-effectiveness analysis based on the Group 3 trial showed that the surgery produced an estimated discounted benefit of 0.054 quality-adjusted life-year (QALY) over a 2-year period, with an additional discounted cost of pound 387.45, giving an incremental cost-effectiveness ratio (ICER) of pound 7175 per QALY. Economic modelling suggested that surgery produced a still greater benefit when considered with a 10-year time horizon, with an ICER of pound 1936 per QALY. Injection sclerotherapy produced an incremental benefit of approximately 0.044 QALY at a cost of pound 155 when compared with conservative treatment, giving an ICER of pound 3500 per QALY. When surgery was compared with sclerotherapy, surgery produced greater benefit with a lower ICER (showing extended dominance).

CONCLUSIONS

Standard surgical treatment of varicose veins by saphenofemoral ligation, stripping and multiple phlebectomies is a clinically effective and cost-effective treatment for varicose veins, with an ICER well below the threshold normally considered appropriate for the funding of treatments within the NHS. Injection sclerotherapy also appears to be cost-effective, but produces less overall benefit, with a higher ICER than surgery for patients with superficial venous reflux. In minor varicose veins without reflux, sclerotherapy is likely to provide a small average benefit with acceptable cost-effectiveness. Research is needed into methods for accurate and acceptable utility evaluations for conditions with relatively minor effect on HRQoL and also for a validated and standardised method of classification for varicose veins.

Randomized clinical trial comparing surgery with conservative treatment for uncomplicated varicose veins

BACKGROUND

Surgical treatment of medically uncomplicated varicose veins is common, but its clinical effectiveness remains uncertain.

METHODS

A randomized clinical trial was carried out at two large acute National Health Service hospitals in different parts of the UK (Sheffield and Exeter). Some 246 patients were recruited from 536 consecutive referrals to vascular outpatient clinics with uncomplicated varicose veins suitable for surgical treatment. Conservative management, consisting of lifestyle advice, was compared with surgical treatment (flush ligation of sites of reflux, stripping of the long saphenous vein and multiple phlebectomies, as appropriate). Changes in health status were measured using the Short Form (SF) 6D and EuroQol (EQ) 5D, quality of life instruments based on SF-36 and EuroQol, complications of treatment, symptomatic measures, anatomical extent of varicose veins and patient satisfaction.

RESULTS

In the first 2 years after treatment there was a significant quality of life benefit for surgery of 0.083 (95 per cent confidence interval (c.i.) 0.005 to 0.16) quality-adjusted life years (QALYs) based on the SF-6D score and 0.13 (95 per cent c.i. 0.016 to 0.25) based on the EQ-5D score. Significant benefits were also seen in symptomatic and anatomical measures.

CONCLUSION

Surgical treatment provides symptomatic relief and significant improvements in quality of life in patients referred to secondary care with uncomplicated varicose veins.

Public preferences for the allocation of donor liver grafts for transplantation

To investigate the nature of public preferences in the allocation of donor liver grafts for transplantation a social conjoint analysis (CA) technique was developed for a questionnaire survey. A convenience sample of academic and non-academic employees of a British University were invited to participate in the survey. Respondents were presented with eight choice situations in which they were asked to allocate 100 donor liver grafts between two groups of 100 individuals in urgent need of a transplant. The groups of individuals differed in terms of the length of time spent waiting, the life years gained following transplantation, age, personal responsibility for their illness and whether they were primary or re-transplant candidates. Only two respondents (0.7%) consistently chose to give all of the donor organs to the group of individuals with the highest expected length of survival whilst seven respondents (2%) exhibited strict egalitarian preferences, allocating equal numbers of donor organs to both groups irrespective of their characteristics. The vast majority of respondents indicated that they would be prepared to sacrifice some gain in the efficiency of the transplantation programme for an increase in equity or fairness in the allocation of donor livers. Using social CA it was possible to establish the relative weight attached to each characteristic in determining individual's allocation decisions.

Valuing SF-6D Health States Using a Discrete Choice Experiment

BACKGROUND

SF-6D utility weights are conventionally produced using a standard gamble (SG). SG-derived weights consistently demonstrate a floor effect not observed with other elicitation techniques. Recent advances in discrete choice methods have allowed estimation of utility weights. The objective was to produce Australian utility weights for the SF-6D and to explore the application of discrete choice experiment (DCE) methods in this context. We hypothesized that weights derived using this method would reflect the largely monotonic construction of the SF-6D.

METHODS

We designed an online DCE and administered it to an Australia-representative online panel (n = 1017). A range of specifications investigating nonlinear preferences with respect to additional life expectancy were estimated using a random-effects probit model. The preferred model was then used to estimate a preference index such that full health and death were valued at 1 and 0, respectively, to provide an algorithm for Australian cost-utility analyses.

RESULTS

Physical functioning, pain, mental health, and vitality were the largest drivers of utility weights. Combining levels to remove illogical orderings did not lead to a poorer model fit. Relative to international SG-derived weights, the range of utility weights was larger with 5% of health states valued below zero.

CONCLUSION

s. DCEs can be used to investigate preferences for health profiles and to estimate utility weights for multi-attribute utility instruments. Australian cost-utility analyses can now use domestic SF-6D weights. The comparability of DCE results to those using other elicitation methods for estimating utility weights for quality-adjusted life-year calculations should be further investigated.

Review of Valuation Methods of Preference-Based Measures of Health for Economic Evaluation in Child and Adolescent Populations: Where are We Now and Where are We Going?

Methods for measuring and valuing health benefits for economic evaluation and health technology assessment in adult populations are well developed. In contrast, methods for assessing interventions for child and adolescent populations lack detailed guidelines, particularly regarding the valuation of health and quality of life in these age groups. This paper critically examines the methodological considerations involved in the valuation of child- and adolescent-specific health-related quality of life by existing preference-based measures. It also describes the methodological choices made in the valuation of existing generic preference-based measures developed with and/or applied in child and adolescent populations: AHUM, AQoL-6D, CHU9D, EQ-5D-Y, HUI2, HUI3, QWB, 16D and 17D. The approaches used to value existing child- and adolescent-specific generic preference-based measures vary considerably. While the choice of whose preferences and which perspective to use is a matter of normative debate and ultimately for decision by reimbursement agencies and policy makers, greater research around these issues would be informative and would enrich these discussions. Research can also inform the other methodological choices required in the valuation of child and adolescent health states. Gaps in research evidence are identified around the impact of the child described in health state valuation exercises undertaken by adults, including the possibility of informed preferences; the appropriateness and acceptability of valuation tasks for adolescents, in particular tasks involving the state 'dead'; anchoring of adolescent preferences; and the generation and use of combined adult and adolescent preferences.

Valuing Child Health Utility 9D health states with a young adolescent sample: a feasibility study to compare best-worst scaling discrete-choice experiment, standard gamble and time trade-off methods

QALYs are increasingly being utilized as a health outcome measure to calculate the benefits of new treatments and interventions within cost-utility analyses for economic evaluation. Cost-utility analyses of adolescent-specific treatment programmes are scant in comparison with those reported upon for adults and tend to incorporate the views of clinicians or adults as the main source of preferences. However, it is not clear that the views of adults are in accordance with those of adolescents on this issue. Hence, the treatments and interventions most highly valued by adults may not correspond with those most highly valued by adolescents. Ordinal methods for health state valuation may be more easily understood and interpreted by young adolescent samples than conventional approaches. The availability of young adolescent-specific health state values for the estimation of QALYs will provide new insights into the types of treatment programmes and health services that are most highly valued by young adolescents. The first objective of this study was to assess the feasibility of applying best-worst scaling (BWS) discrete-choice experiment (DCE) methods in a young adolescent sample to value health states defined by the Child Health Utility 9D (CHU9D) instrument, a new generic preference-based measure of health-related quality of life developed specifically for application in young people. The second objective was to compare BWS DCE questions (where respondents are asked to indicate the best and worst attribute for each of a number of health states, presented one at a time) with conventional time trade-off (TTO) and standard gamble (SG) questions in terms of ease of understanding and completeness. A feasibility study sample of consenting young adolescent school children (n = 16) aged 11-13 years participated in a face-to-face interview in which they were asked to indicate the best and worst attribute levels from a series of health states defined by the CHU9D, presented one at a time. Participants were also randomly allocated to receive additional conventional TTO or SG questions and prompted to indicate how difficult they found them to complete. The results indicate that participants were able to readily choose 'best' and 'worst' dimension levels in each of the CHU9D health states presented to them and provide justification for their choices. Furthermore, when presented with TTO or SG questions and prompted to make comparisons, participants found the BWS DCE task easier to understand and complete. The results of this feasibility study suggest that BWS DCE methods are potentially more readily understood and interpretable by vulnerable populations (e.g. young adolescents). These findings lend support to the potential application of BWS DCE methods to undertake large-scale health state valuation studies directly with young adolescent population samples.

A systematic review of instruments for measuring outcomes in economic evaluation within aged care

BACKGROUND

This paper describes the methods and results of a systematic review to identify instruments used to measure quality of life outcomes in older people. The primary focus of the review was to identify instruments suitable for application with older people within economic evaluations conducted in the aged care sector.

METHODS

Online databases searched were PubMed, Medline, Scopus, and Web of Science, PsycInfo, CINAHL, Embase and Informit. Studies that met the following criteria were included: 1) study population exclusively above 65 years of age 2) measured health status, health related quality of life or quality of life outcomes more broadly through use of an instrument developed for this purpose, 3) used a generic preference based instrument or an older person specific preference based or non-preference based instrument or both, and 4) published in journals in the English language after 2000.

RESULTS

The most commonly applied generic preference based instrument in both the community and residential aged care context was the EuroQol - 5 Dimensions (EQ-5D), followed by the Adult Social Care Outcomes Toolkit (ASCOT) and the Health Utilities Index (HUI2/3). The most widely applied older person specific instrument was the ICEpop CAPability measure for Older people (ICECAP-O) in both community and residential aged care.

CONCLUSION

In the absence of an ideal instrument for incorporating into economic evaluations in the aged care sector, this review recommends the use of a generic preference based measure of health related quality of life such as the EQ-5D to obtain quality adjusted life years, in combination with an instrument that has a broader quality of life focus like the ASCOT, which was designed specifically for evaluating interventions in social care or the ICECAP-O, a capability measure for older people.

A randomised controlled trial of acupuncture care for persistent low back pain: cost effectiveness analysis

OBJECTIVE

To evaluate the cost effectiveness of acupuncture in the management of persistent non-specific low back pain.

DESIGN

Cost effectiveness analysis of a randomised controlled trial.

SETTING

Three private acupuncture clinics and 18 general practices in York, England.

PARTICIPANTS

241 adults aged 18-65 with non-specific low back pain of 4-52 weeks' duration.

INTERVENTIONS

Ten individualised acupuncture treatments over three months from acupuncturists trained in traditional Chinese medicine (n = 160) or usual care only (n = 81).

MAIN OUTCOME MEASURE

Incremental cost per quality adjusted life year (QALY) gained over two years.

RESULTS

Total costs to the United Kingdom's health service during the two year study period were higher on average for the acupuncture group (460 pounds sterling; 673 euros; 859 dollars) than for the usual care group (345 pounds sterling) because of the costs associated with initial treatment. The mean incremental health gain from acupuncture at 12 months was 0.012 QALYs (95% confidence interval -0.033 to 0.058) and at 24 months was 0.027 QALYs (-0.056 to 0.110), leading to a base case estimate of 4241 pounds sterling per QALY gained. This result was robust to sensitivity analysis. The probabilistic sensitivity analysis showed acupuncture to have a more than 90% chance of being cost effective at a pound20 000 cost per QALY threshold.

CONCLUSION

A short course of traditional acupuncture for persistent non-specific low back pain in primary care confers a modest health benefit for minor extra cost to the NHS compared with usual care. Acupuncture care for low back pain seems to be cost effective in the longer term.

TRIAL REGISTRATION

ISRCTN80764175 [controlled-trials.com].

Developing adolescent-specific health state values for economic evaluation: an application of profile case best-worst scaling to the Child Health Utility 9D

BACKGROUND

The way that health is measured and valued is fundamental to economic evaluation. To date, adult health state values have been routinely used in the calculation of QALYs for the economic evaluation of healthcare treatment and preventive programmes, including those targeted at adolescents.

OBJECTIVES

The main objective of this study was to apply profile case best-worst scaling (BWS) discrete-choice experiment (DCE) methods to obtain adolescent-specific values for the Child Health Utility 9D (CHU9D), a new generic preference-based measure of health-related quality of life developed specifically for application in cost-effectiveness analyses of treatments and interventions targeted at young people. A secondary aim was to assess the feasibility of a web-based method of data collection for the valuation of health states defined by the CHU9D.

METHODS

A web-based survey was developed including the CHU9D instrument and a series of BWS DCE questions. Specifically, respondents were asked to indicate the best and worst attribute levels from a series of ten health states defined by the CHU9D, presented one at a time. The survey was administered to a community-based sample of consenting adolescents (n = 590) aged 11-17 years. A conditional logistic regression model was applied to estimate values (part-worth utilities) for each level of the nine attributes relating to the CHU9D. A marginal utility matrix was then estimated to generate an adolescent-specific scoring algorithm on the full health = 1 and dead = 0 scale required for the calculation of QALYs.

RESULTS

The results indicate that participants were able to readily choose 'best' and 'worst' attribute levels for the CHU9D health states. Large differences in value were found between the first and fifth levels (indicating 'no problems' and 'severe problems', respectively) for all nine attributes relating to the CHU9D. In general, there was little differentiation between the middle levels of all attributes indicating only limited additional value for adolescents of moving between these levels. Comparison of the adolescent-specific algorithm and the existing adult scoring algorithm for the CHU9D revealed some significant differences in values for identical health states, which may have important implications for the application of the CHU9D to value adolescent treatment and service programmes particularly for mental health. In general, adolescents appeared to place more weight upon the CHU9D attributes relating to mental health (worried, sad and annoyed) than would be implied by application of the existing algorithm based upon adult values.

CONCLUSION

This study provides preliminary indications that there may be potentially important and systematic differences in the valuations attached to identical health states by adolescents in comparison with adult population groups. The study findings lend support to the potential future application of profile case BWS DCE methods to undertake large-scale health state valuation studies directly with young adolescent population samples and provide support for the feasibility and acceptability of a web-based mode of administration for this purpose.

A prospective study of the adverse effects of midazolam on withdrawal in critically ill children

Fifty-three critically ill infants and children received midazolam as sedation in a regional intensive care unit. Assessment of the level of sedation was carried out at regular intervals on withdrawal of midazolam. Forty-nine patients were fully alert within 4 h of midazolam being stopped. Four patients took from 6 h to 1 week to become fully alert. Four patients had abnormal behaviour highly suggestive of midazolam withdrawal. The onset of abnormal behaviour was within 12 h of discontinuation of midazolam. The duration of the abnormal behaviour ranged from 3 h to 1 week. One child had a paradoxical reaction to midazolam. The overall incidence of adverse effects to midazolam in the patients studied was 17%. No adverse effects were observed in infants; all adverse effects were observed in children. We have shown that it is possible to prospectively study the toxicity of sedatives in critically ill infants and children.

Aboriginal and Torres Strait Islander people's domains of wellbeing: A comprehensive literature review

There are significant health and social disparities between the world's Indigenous and non-Indigenous people on factors likely to influence quality of life (QOL) and wellbeing. However, these disparities in wellbeing are not captured in conventional QOL instruments, as they often do not include dimensions that are likely to be relevant to Indigenous people. The objective of this comprehensive literature review was to identify these wellbeing domains for Aboriginal and Torres Strait Islander people in Australia (hereafter, respectfully referred to collectively as Indigenous Australians). We searched PsycINFO, MEDLINE, Econlit, CINAHL, and Embase (from inception to June 2017, and updated in March 2019), and grey literature sources using keywords relating to adult Indigenous Australians' QOL and wellbeing. From 278 full-text articles assessed for eligibility, 95 were included in a thematic analysis. This synthesis revealed nine broad interconnected wellbeing dimensions: autonomy, empowerment and recognition; family and community; culture, spirituality and identity; Country; basic needs; work, roles and responsibilities; education; physical health; and mental health. The findings suggest domains of wellbeing relevant to and valued by Indigenous Australians that may not be included in existing QOL and wellbeing instruments, domains that may be shared with Indigenous populations globally. This indicates the need for a tailored wellbeing instrument that includes factors relevant to Indigenous Australians. Developing such an instrument will ensure meaningful, culturally-relevant measurement of Indigenous Australians' wellbeing.

An assessment of the construct validity of the CHU9D in the Australian adolescent general population

PURPOSE

To assess the construct validity of the CHU9D in an adolescent general population sample. The CHU9D is a new generic preference-based measure of health-related quality of life developed specifically for application in the economic evaluation of health care treatments and interventions for young people.

METHODS

A web-based survey was developed including the CHU9D and HUI2 instruments and administered to a community-based sample of consenting adolescents (n = 710) aged 11-17 years. The practicality, face and construct validity of the CHU9D was examined. The relationship between the CHU9D and HUI2 instruments was assessed by a comparison of responses to similar dimensions and the utility scores derived from the two instruments.

RESULTS

The CHU9D demonstrated high completion rates. CHU9D was able to discriminate between respondents according to their self-reported general health (Kruskal-Wallis P value <0.001). The mean CHU9D adolescent population utilities were similar to those generated from the HUI2 [Mean (SD) CHU9D utility 0.844 (0.102) and HUI2 utility 0.872 (0.138)], and the intra-class correlation coefficient indicated good levels of agreement overall (ICC = 0.742).

CONCLUSION

The findings from this study provide support for the practicality, face and construct validity of the CHU9D for application with adolescents aged 11-17 years.