Construct validity of the interview Time Trade-Off and computer Time Trade-Off in patients with rheumatoid arthritis: A cross-sectional observational pilot study

Background\ud The Time Trade-Off (TTO) is a widely used instrument for valuing preference-based health-related quality of life (HRQoL). The TTO reveals preferences for own current health (‘utilities’) on a scale anchored between death (0) and perfect health (1). Limited information on the external validity of the TTO is available. Aim of this pilot study was to examine the construct validity of both an interview TTO and a computer-based TTO in patients with rheumatoid arthritis (RA).\ud \ud Methods\ud Thirty patients visiting the outpatient rheumatology clinic participated. Construct validity was assessed by measuring convergent and discriminative validity. Convergent validity was assessed by calculating Spearman’s correlations between the utilities obtained from the TTOs and pain, general health (rating scales), health-related quality of life (SF-36 and SF-6D) and functional status (HAQ-DI). Discriminative power of both TTO measures was determined by comparing median utilities between worse and better health outcomes.\ud \ud Results\ud Correlations of both TTO measures with HRQoL, general health, pain and functional status were poor (absolute values ranging from .05 to .26). Both TTOs appeared to have no discriminative value among groups of RA patients who had a worse or better health status defined by six health outcome measures. About one-third of respondents were zero-traders on each of the TTO measures. After excluding zero-traders from analysis, the correlations improved considerably.\ud \ud Conclusions\ud Both the interview TTO and computer TTO showed poor construct validity in RA patients when using measures of HRQol, general health, pain and functional status as reference measures. Possibly, the validity of the TTO improves when using an anchor that is more realistic to RA patients than the anchor ‘death’

Moving beyond a limited follow-up in cost-effectiveness analyses of behavioral interventions

Background Cost-effectiveness analyses of behavioral interventions typically use a dichotomous outcome criterion. However, achieving behavioral change is a complex process involving several steps towards a change in behavior. Delayed effects may occur after an intervention period ends, which can lead to underestimation of these interventions. To account for such delayed effects, intermediate outcomes of behavioral change may be used in cost-effectiveness analyses. The aim of this study is to model cognitive parameters of behavioral change into a cost-effectiveness model of a behavioral intervention. Methods The cost-effectiveness analysis (CEA) of an existing dataset from an RCT in which an high-intensity smoking cessation intervention was compared with a medium-intensity intervention, was re-analyzed by modeling the stages of change of the Transtheoretical Model of behavioral change. Probabilities were obtained from the dataset and literature and a sensitivity analysis was performed. Results In the original CEA over the first 12 months, the high-intensity intervention dominated in approximately 58% of the cases. After modeling the cognitive parameters to a future 2nd year of follow-up, this was the case in approximately 79%. Conclusion This study showed that modeling of future behavioral change in CEA of a behavioral intervention further strengthened the results of the standard CEA. Ultimately, modeling future behavioral change could have important consequences for health policy development in general and the adoption of behavioral interventions in particular

The Uptake and Impact of a Personal Health Record for Patients with Type 2 Diabetes Mellitus in Primary Care: a research protocol for a backward and forward evaluation

A Personal Health Record (PHR) is a promising technology for improving the quality of chronic disease management. Despite the efforts that have been made in a research project to develop a PHR for patients with type 2 diabetes mellitus in primary care (e-Vita), differences have been reported between the number of registered users in the participating primary practices. To gain insight into the factors that influence the implementation of the PHR into daily health care processes and into the possibilities to improve the content, interviews have been conducted with participating primary practice nurses and other stakeholders in the research project. A first impression of the interviews indicated that in many cases, the low impact of the PHR is due to a lack of information about the purpose, content and use of the syste

Exploring Outcomes to Consider in Economic Evaluations of Health Promotion Programs: What Broader Non-Health Outcomes Matter Most?

Background Attention is increasing on the consideration of broader non-health outcomes in economic evaluations. It is unknown which non-health outcomes are valued as most relevant in the context of health promotion. The present study fills this gap by investigating the relative importance of non-health outcomes in a health promotion context. Method We investigated the relative importance of ten non-health outcomes of health promotion programs not commonly captured in QALYs. Preferences were elicited from a sample of the Dutch general public (N = 549) by means of a ranking task. These preferences were analyzed using Borda scores and rank-ordered logit models. Results The relative order of preference (from most to least important) was: self-confidence, insights into own (un)healthy behavior, perceived life control, knowledge about a certain health problem, social support, relaxation, better educational achievements, increased labor participation and work productivity, social participation, and a reduction in criminal behavior. The weight given to a particular non-health outcome was affected by the demographic variables age, gender, income, and education. Furthermore, in an open question, respondents mentioned a number of other relevant non-health outcomes, which we classified into outcomes relevant for the individual, the direct social environment, and for society as a whole. Conclusion The study provides valuable insights in the non-health outcomes that are considered as most important by the Dutch general population. Ideally, researchers should include the most important non-health outcomes in economic evaluations of health promotio

Worst-case future scenarios of patients with rheumatoid arthritis: a cross-sectional study

Objective. The time trade-off is a health-related quality of life instrument that measures valuations for health states (utilities) by asking patients to value their health state anchored on a scale between death (0) and perfect health (1). Dying earlier is not perceived as a realistic worst-case consequence of the disease by RA patients. Of the previous focus groups study on RA patients, five worst-case future scenarios emerged. The aim of this study was to examine which potential worst-case scenario was the most appropriate for RA patients to use in utility calculation. \ud \ud Methods. In a cross-sectional study of 74 consecutive RA patients visiting the rheumatology outpatient clinic, participants were presented with descriptions of the five worst-case future scenarios. In pairwise comparisons, patients had to choose the scenario that would be the worst to experience. The worst-case future scenario was defined by the scenario that was chosen by a significantly greater proportion of participants than could be expected based on chance (20%). Therefore, analysis based on a single fraction () was used and 95% CI was calculated. \ud \ud Results. The scenario being dependent on others was chosen most often as the worst to experience [by 35% of participants (95% CI 24%, 46%)] and significantly more often than could be expected based on chance ( = 0.35, z = 6.45, P = 0.00). \ud \ud Conclusion. The scenario being dependent on others is likely to be the most appropriate worst-case future scenario for RA patients. Using an alternative anchor could improve the validity and responsiveness of the time trade-off in RA patients

Productivity loss due to absenteeism and presenteeism by different instruments in patients with RA and subjects without RA

Objectives. To explore the impact of at-work productivity loss on the total productivity cost by different instruments in patients recently diagnosed with RA and controls without RA. \ud \ud Methods. Cross-sectional data were collected from outpatients with RA between December 2007 and February 2008. The control group was formed by subjects without RA matched on age and gender. Absenteeism and presenteeism were estimated by the Quantity and Quality (QQ) Questionnaire, Work Productivity and Activity Impairment Questionnaire General Health V2.0 (WPAI-GH) and Health and Labor Questionnaire (HLQ) questionnaires. Differences between groups were tested by Mann–Whitney U-test. Costs were valued by the human capital approach. \ud \ud Results. Data were available from 62 patients with a paid job and 61 controls. QQ- and WPAI-GH scores of presenteeism were moderately correlated (r = 0.61) while the HLQ presenteeism score correlated poorly with the other instruments (r = 0.34). The contribution of presenteeism on total productivity costs was estimated at ∼70% in the RA group. The mean costs per person per week due to presenteeism varied between €79 and €318 per week in the RA group, dependent on the instrument used. The costs due to presenteeism were about two to four times higher in the RA group compared with the control group. \ud \ud Conclusion. This study indicates that the impact of presenteeism on the total productivity costs in patients with RA is high. However, work productivity in individuals without RA was not optimal either, which implies a risk of overestimation of cost when a normal score is not taken into account. Finally, different presenteeism instruments lead to different results

The Added Value of Log File Analyses of the use of a Personal Health Record for Patients with Type 2 Diabetes Mellitus: Preliminary Results

The electronic personal health record (PHR) is a promising technology for improving the quality of chronic disease management. Until now, evaluations of such systems have provided only little insight into why a particular outcome occurred. The aim of this study is to gain insight into the navigation process (what functionalities are used, and in what sequence) of e-Vita, a PHR for patients with type 2 diabetes mellitus (T2DM), to increase the efficiency of the system and improve the long-term adherence. Log data of the first visits in the first 6 weeks after the release of a renewed version of e-Vita were analyzed to identify the usage patterns that emerge when users explore a new application. After receiving the invitation, 28% of all registered users visited e-Vita. In total, 70 unique usage patterns could be identified. When users visited the education service first, 93% of all users ended their session. Most users visited either 1 or 5 or more services during their first session, but the distribution of the routes was diffuse. In conclusion, log file analyses can provide valuable prompts for improving the system design of a PHR. In this way, the match between the system and its users and the long-term adherence has the potential to increas

Intensive exercise therapy after hospitalization in patients with rheumatic diseases is more effective at limited extra costs: results from the DAPPER study

Purpose:\ud To estimate the cost utility and cost effectiveness of intensive exercise therapy (IET) compared to usual care (UC) in patients with Rheumatoid Arthritis (RA) and polyarticular Osteoarthritis (OA) recovering after hospitalization. \ud \ud Methods:\ud RA and OA patients (n = 114) who were admitted to the hospital because of active disease or for arthroplasty of hip or knee were randomly assigned to receive either a 3 week intensive training intervention directly following discharge in a dedicated convalescence institute or usual care. Quality adjusted life years (QALYs) were derived from the Short Form 6d (SF-6D) scores and visual analog scale (VAS) rating personal health. Outcome expressed as functional ability was calculated according to the Health Assessment Questionnaire (HAQ), the McMaster Toronto Arthritis Patient Preference Interview (MACTAR) and the Escola Paulista de Medicina - Range of Motion scale (EPM-ROM). Patients were followed for one year. Costs were reported from societal perspective. Differences in costs as well as Incremental Cost Effectiveness Ratios (ICERs) were estimated and 95% confidence intervals (CI) were calculated using double-sided bootstrapping.\ud \ud Results:\ud The data of 85 (50 intervention and 35 controls) of the 114 patients (75%) could be used for analysis. QALYs in both groups were similar according to the SF-6D but were in favour of IET according to the VAS-score personal health (6 month difference -1.05 QALYs; 95% CI -2.06 to -0.04). Functional ability was similar according to the HAQ, but in favour of the intensive training group according to the EPM-ROM (6 month difference 0.89; 95% CI 0.2 to 1.58) and MACTAR (6 month difference -6.0; 95% CI -10.3 to -0.5). After one year of follow-up no statistically significant differences between the groups were found. The increase per patient in total costs from societal perspective was estimated at € 804 (CI -€ 2,595 to € 3,996) after 6 months of follow-up. The resulting ICERs were € 8,398 per QALY according to the VAS-score (CI -€ 16,025 to € 23,032 per QALY); € 6,534 per EPM-ROM score point (CI -€ 9,996 to € 16,714) and € 799 per MACTAR point (CI -€ 2,432 to € 3,196).\ud \ud Conclusion:\ud After 6 months of follow-up IET was associated with slightly more costs and better effectiveness compared to UC. This underscores the general preference for intensive convalescence treatment over usual care for patients with rheumatic diseases recovering after hospitalization