Health Utilities for Multiple Sclerosis

PublishedObjectives To estimate health state utility values (HSUVs) for multiple sclerosis (MS) by key demographic and clinical characteristics. Methods Data from a UK prospective, longitudinal, cohort study of people with MS were used for analysis. Patient-reported outcomes on the EuroQol five-dimensional questionnaire (EQ-5D) and the six-dimensional health state short form (SF-6D) (derived from 36-item short form health survey), SF-36 were used to estimate HSUVs by age, sex, MS type, time since diagnosis, disease severity (Expanded Disability Status Scale score), and relapse characteristics. Results The cohort (n = 1,441) (11,778 returned questionnaires) was representative of the UK population with MS. Data indicated that primary and secondary progressive MS were associated with lower HSUVs than relapsing-remitting MS and that HSUVs decreased by disease severity. This was particularly apparent for the EQ-5D, with mean estimates ranging from 0.846 to 0.025 for Expanded Disability Status Scale scores 0 to 8, compared to mean SF-6D estimates ranging from 0.702 to 0.529. Experiencing a relapse in the previous 6 months had a significant impact on HSUVs, with mean decrements of 0.076 for the EQ-5D and 0.052 for the SF-6D. Conclusions These findings demonstrate the negative impact of MS on health-related quality of life, especially as the condition progresses, and indicate the substantial influence of varying features of relapses on HSUVs. This is the first report of SF-6D values for a UK MS population and the first time that EQ-5D data have been presented in such detail for people with MS. The representative nature of the sample means that these data can be used to offer decision makers more precise estimates of the effectiveness and cost-effectiveness of MS treatments.The South West Impact of Multiple Sclerosis (SWIMS) project has been supported through funding from the Multiple Sclerosis Society of Great Britain and Northern Ireland, the Peninsula Medical School Foundation, and the UK National Institute for Health Research (NIHR) Comprehensive Clinical Research Network. This article presents independent research funded by the NIHR. We acknowledge partial funding from the UK NIHR Collaboration for Leadership in Applied Health Research and Care of the South West Peninsula (PenCLAHRC). The views expressed in this publication are those of the author(s) and not necessarily those of the National Health Service, the NIHR, or the Department of Health

Psychosocial characteristics and social networks of suicidal prisoners: towards a model of suicidal behaviour in detention

Prisoners are at increased risk of suicide. Investigation of both individual and environmental risk factors may assist in developing suicide prevention policies for prisoners and other high-risk populations. We conducted a matched case-control interview study with 60 male prisoners who had made near-lethal suicide attempts in prison (cases) and 60 male prisoners who had not (controls). We compared levels of depression, hopelessness, self-esteem, impulsivity, aggression, hostility, childhood abuse, life events (including events occurring in prison), social support, and social networks in univariate and multivariate models. A range of psychosocial factors was associated with near-lethal self-harm in prisoners. Compared with controls, cases reported higher levels of depression, hopelessness, impulsivity, and aggression, and lower levels of self-esteem and social support (all p values <0.001). Adverse life events and criminal history factors were also associated with near-lethal self-harm, especially having a prior prison spell and having been bullied in prison, both of which remained significant in multivariate analyses. The findings support a model of suicidal behaviour in prisoners that incorporates imported vulnerability factors, clinical factors, and prison experiences, and underscores their interaction. Strategies to reduce self-harm and suicide in prisoners should include attention to such factors

Using the Fatigue Severity Scale to inform healthcare decision-making in multiple sclerosis: mapping to three quality-adjusted life-year measures (EQ-5D-3L, SF-6D, MSIS-8D)

This is the author accepted manuscript. The final version is available from BioMed Central via the DOI in this recordBackground:Fatigue has a major influence on the quality of life of people with multiple sclerosis. The Fatigue Severity Scale is a frequently used patient-reported measure of fatigue impact, but does not generate the health state utility values required to inform cost-effectiveness analysis, limiting its applicability within decision-making contexts. The objective of this study was to use statistical mapping methods to convert Fatigue Severity Scale scores to health state utility values from three preference-based measures: the EQ-5D-3L, SF-6D and Multiple Sclerosis Impact Scale-8D. Methods: The relationships between the measures were estimated through regression analysis using cohort data from 1056 people with multiple sclerosis in South West England. Estimation errors were assessed and predictive performance of the best models were tested in a separate sample (n=352). Results: For the EQ-5D and the Multiple Sclerosis Impact Scale-8D, the best performing models used a censored least absolute deviation specification, with Fatigue Severity Scale total score, age and gender as predictors. For the SF-6D, the best performing model used an ordinary least squares specification, with Fatigue Severity Scale total score as the only predictor. Conclusions: Here we present algorithms to convert Fatigue Severity Scales scores into health state utility values based on three preference-based measures. These values may be used to estimate quality adjusted life-years for use in cost-effectiveness analyses and to consider the health-related quality of life of people with multiple sclerosis, thereby informing health policy decisions.Multiple Sclerosis SocietyPenCLAHR

‘Naming and Framing’: The impact of labelling on health state values for multiple sclerosis

This is the author accepted manuscript. The final version is available from SAGE Publications via the DOI in this record.Introduction: Health state valuation is a key input to many economic evaluations that inform resource allocation across competing health care interventions. Empirical evidence has shown that respondents to preference elicitation surveys may value a health state differently if aware of the condition causing it (‘labelling effects’). This study investigates the impact of including a multiple sclerosis (MS) label for valuation of MS health states. Methods: Health state values for MS were elicited using two internet-based surveys in representative samples of the UK population (n=1702; n=1788). In one survey respondents were not informed that health states were caused by MS. The second survey included a condition label for MS. Surveys were identical in all other ways. Health states were described using a MS-specific eight-dimensional classification system (MSIS-8D), and the time trade-off valuation technique was used. Differences between values for labelled and unlabelled states are assessed using descriptive statistics and multivariate regression methods. Results: Adding a MS condition label had a statistically significant effect on mean health state values, resulting in lower values for labelled MS states versus unlabelled states. Data suggests the MS label had a more significant effect on values for less severe states, and no significant effect on values for the most severe states. The inclusion of the MS label had a differential impact across the dimensions of the MSIS-8D. Across the MSIS-8D, predicted values ranged from 0.079-0.883 for unlabelled states, and 0.066-0.861 for labelled states. Conclusions: Differences reported in health state values, using labelled and unlabelled states, demonstrate that condition labels affect the results of valuation studies, and can have important implications in decision-analytic modelling and in economic evaluations.Financial support for this study was provided in part by the Multiple Sclerosis Society of Great Britain and Northern Ireland. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report. C Green and A Hawton acknowledge partial funding from the UK NIHR Collaboration for Leadership in Applied Health Research and Care of the South West Peninsula (PenCLAHRC). The views expressed in this publication are those of the authors and not necessarily those of the Multiple Sclerosis Society, the UK NIHR or the Department of Healt

Health State Values Derived from People with Multiple Sclerosis for a Condition-Specific Preference-Based Measure: Multiple Sclerosis Impact Scale–Eight Dimensions–Patient Version (MSIS-8D-P)

This is the author accepted manuscript. The final version is available from Elsevier via the DOI in this recordObjective: In economic evaluation, health outcomes are commonly quantified using quality-adjusted life-years (QALYs) derived from the preferences of a sample of the general population. It can be argued that this approach ignores the preferences of people with experience of the condition, and that patient preferences have a place in the valuation of health outcomes. Here we report the estimation of a preference-based index for an existing condition-specific preference-based measure for multiple sclerosis (MS), the MSIS-8D, based on the preferences of people with MS. Study design: Internet time trade-off (TTO) survey, eliciting preferences from people with MS. Methods: We elicited preferences from a sample of people with MS (N = 1635) across 169 MSIS-8D health states, using the TTO technique. We fitted ordinary least squares and random effects models to the survey data to estimate values for all health states described by the MSIS-8D. Results: The new patient-derived index (the MSIS-8D-P) provides values ranging from 0.893 for the best possible health state to 0.138 for the worst state. The MSIS-8D-P exhibits good discriminative validity, identifying expected significant differences between groups based on presence/absence of MS, type of MS, and duration since diagnosis. Conclusions: The MSIS-8D-P index of values for MS-specific health states provides an opportunity to estimate QALYs based on patient preferences, for use in economic evaluations of treatments for MS. More broadly, it adds to the methods and data available to consider the health-related quality of life of people with MS to inform resource allocation and individual-level decisions regarding treatments for MS.Financial support for this study was provided in part by the Multiple Sclerosis Society of Great Britain and Northern Ireland. Partial funding was received from the UK National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care of the South West Peninsula (PenCLAHRC) to CG and AH

The efficacy of problem-solving treatments after deliberate self-harm: meta-analysis of randomized controlled trials with respect to depression, hopelessness and improvement in problems

Background. Brief problem-solving therapy is regarded as a pragmatic treatment for deliberate self-harm (DSH) patients. A recent meta-analysis of randomized controlled trials (RCTs) evaluating this approach indicated a trend towards reduced repetition of DSH but the pooled odds ratio was not statistically significant. We have now examined other important outcomes using this procedure, namely depression, hopelessness and improvement in problems. Method. Six trials in which problem-solving therapy was compared with control treatment were identified from an extensive literature review of RCTs of treatments for DSH patients. Data concerning depression, hopelessness and improvement in problems were extracted. Where relevant statistical data (e.g. standard deviations) were missing these were imputed using various statistical methods. Results were pooled using meta-analytical procedures. Results. At follow-up, patients who were offered problem-solving therapy had significantly greater improvement in scores for depression (standardized mean difference =[minus sign]0·36; 95% CI [minus sign]0·61 to [minus sign]0·11) and hopelessness (weighted mean difference =[minus sign]3·2; 95% CI [minus sign]4·0 to [minus sign]2·41), and significantly more reported improvement in their problems (odds ratio = 2·31; 95% CI 1·29 to 4·13), than patients who were in the control treatment groups. Conclusions. Problem-solving therapy for DSH patients appears to produce better results than control treatment with regard to improvement in depression, hopelessness and problems. It is desirable that this finding is confirmed in a large trial, which will also allow adequate testing of the impact of this treatment on repetition of DSH

Suicidal behavior in individuals accused or convicted of child sex abuse or indecent image offenses: systematic review of prevalence and risk factors

Objective An emerging body of research indicates that child sex abuse (CSA) offenders are at high risk of suicide when their offenses come to light and that those accused of accessing indecent images of children (IIOC) are at particular risk. Methods We conducted a systematic review and narrative synthesis on suicide rates and risk factors in this population of offenders. A keyword search of bibliographic databases (PsycINFO, Ovid, MEDLINE, Embase, PILOTS, SCIE, the Cochrane Central Register of Controlled Trials [CENTRAL] and CINAHL) was conducted. Results Eighteen articles were included in the review, with eleven studies meeting criteria for quality assessment. The risk of suicide in perpetrators of CSA and IIOC might be over 100 times that of the general population, although estimates vary widely between studies. Several complex, interlinking factors were identified as associated with risk, including shame, unique demographic characteristics of the offenders, absence of prior criminal contact, and the impact of a criminal investigation. Conclusions The review identified factors that may have practical, clinical, and operational implications in the prevention of suicide in CSA and IIOC perpetrators. Exploring the impact of the investigation itself on suicide risk, including potential operational strategies and clinical input to reduce risk, should be a priority

Does clinical management improve outcomes following self-Harm? Results from the multicentre study of self-harm in England

Background Evidence to guide clinical management of self-harm is sparse, trials have recruited selected samples, and psychological treatments that are suggested in guidelines may not be available in routine practice. Aims To examine how the management that patients receive in hospital relates to subsequent outcome. Methods We identified episodes of self-harm presenting to three UK centres (Derby, Manchester, Oxford) over a 10 year period (2000 to 2009). We used established data collection systems to investigate the relationship between four aspects of management (psychosocial assessment, medical admission, psychiatric admission, referral for specialist mental health follow up) and repetition of self-harm within 12 months, adjusted for differences in baseline demographic and clinical characteristics. Results 35,938 individuals presented with self-harm during the study period. In two of the three centres, receiving a psychosocial assessment was associated with a 40% lower risk of repetition, Hazard Ratios (95% CIs): Centre A 0.99 (0.90–1.09); Centre B 0.59 (0.48–0.74); Centre C 0.59 (0.52–0.68). There was little indication that the apparent protective effects were mediated through referral and follow up arrangements. The association between psychosocial assessment and a reduced risk of repetition appeared to be least evident in those from the most deprived areas. Conclusion These findings add to the growing body of evidence that thorough assessment is central to the management of self-harm, but further work is needed to elucidate the possible mechanisms and explore the effects in different clinical subgroups

Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis

Objective To assess whether lithium has a specific preventive effect for suicide and self harm in people with unipolar and bipolar mood disorders. Design Systematic review and meta-analysis. Data sources Medline, Embase, CINAHL, PsycINFO, CENTRAL, web based clinical trial registries, major textbooks, authors of important papers and other experts in the discipline, and websites of pharmaceutical companies that manufacture lithium or the comparator drugs (up to January 2013). Inclusion criteria Randomised controlled trials comparing lithium with placebo or active drugs in long term treatment for mood disorders. Review methods Two reviewers assessed studies for inclusion and risk of bias and extracted data. The main outcomes were the number of people who completed suicide, engaged in deliberate self harm, and died from any cause. Results 48 randomised controlled trials (6674 participants, 15 comparisons) were included. Lithium was more effective than placebo in reducing the number of suicides (odds ratio 0.13, 95% confidence interval 0.03 to 0.66) and deaths from any cause (0.38, 0.15 to 0.95). No clear benefits were observed for lithium compared with placebo in preventing deliberate self harm (0.60, 0.27 to 1.32). In unipolar depression, lithium was associated with a reduced risk of suicide (0.36, 0.13 to 0.98) and also the number of total deaths (0.13, 0.02 to 0.76) compared with placebo. When lithium was compared with each active individual treatment a statistically significant difference was found only with carbamazepine for deliberate self harm. Lithium tended to be generally better than the other active comparators, with small statistical variation between the results. Conclusions Lithium is an effective treatment for reducing the risk of suicide in people with mood disorders. Lithium may exert its antisuicidal effects by reducing relapse of mood disorder, but additional mechanisms should also be considered because there is some evidence that lithium decreases aggression and possibly impulsivity, which might be another mechanism mediating the antisuicidal effect

Simulation study of magnetic holes at the Earth's collisionless bow shock

Recent observations by the Cluster and Double Star spacecraft at the Earth's bow shock have revealed localized magnetic field and density holes in the solar wind plasma. These structures are characterized by a local depletion of the magnetic field and the plasma density, and by a strong increase of the plasma temperature inside the magnetic and density cavities. Our objective here is to report results of a hybrid-Vlasov simulations of ion-Larmor-radius sized plasma density cavities with parameters that are representative of the high-beta solar wind plasma at the Earth's bow shock. We observe the asymmetric self-steepening and shock-formation of the cavity, and a strong localized temperature increase (by a factor of 5–7) of the plasma due to reflections and shock surfing of the ions against the collisionless shock. Temperature maxima are correlated with density minima, in agreement with Cluster observations. For oblique incidence of the solar wind, we observe efficient acceleration of ions along the magnetic field lines by the shock drift acceleration process