A review of generic preference-based measures of health-related quality of life in visual disorders

Purpose: This review examines generic preference based measures and their ability to reflect health related quality of life in patients with visual disorders. Methods: A systematic search was undertaken to identify clinical studies of patients with visual disorders where health state utility values (HSUVs) were measured and reported. Data were extracted to assess the validity and responsiveness of the measures. A narrative synthesis of the data was undertaken due to the heterogeneity between different studies. Results: There was considerable heterogeneity in the 31 studies identified in terms of patient characteristics, visual disorders and outcomes reported. Vision loss was associated with a reduction in scores across the preference-based measure, but the evidence on validity and responsiveness was mixed. The EQ-5D’s performance differed according to condition, with poor performance in age-related macular degeneration and diabetic retinopathy. The more limited evidence on the HUI-3 found it performed best in differentiating between severity groups of patients with glaucoma, AMD, cataracts and diabetic retinopathy. One study reported data on the SF-6D and showed it was able to differentiate between patients with AMD. Conclusion: The performance of the EQ-5D in visual disorders was mixed. The HUI-3 seemed to perform better in some conditions, but the evidence on this and SF-6D is limited. More head to head comparisons of these three measures are required. The new 5-level version of EQ-5D may do better at the milder end of visual function and there is research being undertaken into adding a vision relevant dimension

Proceed with caution: an economic perspective on the UK's value based pricing proposals

The shift from the Pharmaceutical Pricing Regulation Scheme to Value Based Pricing (VBP) is an important change in the way that medicines will be priced, and consequently, reimbursed in the United Kingdom. Whilst the opportunity to purchase new medicines based on value to society is one that should be welcomed, we should proceed with caution. We highlight ten issues that should be considered relating to innovation, the role and meaning of funding threshold and the adjustments to reflect burden of illness, therapeutic innovation and improvement and wider societal factors. Most importantly, the assessment of value should continue to be based on the characteristics of the displaced activities (e.g. the health produced). To a large extent, all that is changing under VBP are the characteristics being considered; weighted health rather than unweighted health. In addition, we should not totally abandon a cost-utility framework for appraisal just because its current formulation does not match the wider perspective now desired by government

Bridging the gap between methods research and the needs of policy makers: A review of the research priorities of the National Institute for Health and Clinical Excellence

Objectives: The aim of this study was to establish a list of priority topics for methods research to support decision making at the National Institute for Health and Clinical Excellence (NICE). Methods: Potential priorities for methods research topics were identified through a focused literature review, interviews, an email survey, a workshop and a Web-based feedback exercise. Participants were members of the NICE secretariat and its advisory bodies, representatives from academia, industry, and other organizations working closely with NICE. The Web exercise was open to anyone to complete but publicized among the above groups. Results: A list of potential topics was collated. Priorities for further research differed according to the type of respondent and the extent to which they work directly with NICE. Priorities emerging from the group closest to NICE included: methodology for indirect and mixed treatment comparisons; synthesis of qualitative evidence; research relating to the use of quality-adjusted life-years (QALYs) in decision making; methods and empirical research for establishing the cost-effectiveness threshold; and determining how data on the uncertainty of effectiveness and cost-effectiveness data should be taken into account in the decision-making process. Priorities emerging from the broadest group of respondents (through the Web exercise) included: methods for extrapolating beyond evidence observed in trials, methods for capturing benefits not included in the QALY and methods to assess when technologies should be recommended in the context of further evidence gathering. Conclusions: Consideration needs to be given to the needs of those who use the outputs of research for decision making when determining priorities for future methods research.NIHR Medical Research Council

Use of generic and condition-specific measures of health-related quality of life in NICE decision-making: systematic review, statistical modelling and survey.

© Queen’s Printer and Controller of HMSO 2014Background: The National Institute for Health and Care Excellence recommends the use of generic preference-based measures (GPBMs) of health for its Health Technology Assessments (HTAs). However, these data may not be available or appropriate for all health conditions. Objectives: To determine whether GPBMs are appropriate for some key conditions and to explore alternative methods of utility estimation when data from GPBMs are unavailable or inappropriate. Design: The project was conducted in three stages: (1) A systematic review of the psychometric properties of three commonly used GPBMs [EQ-5D, SF-6D and Health Utilities Index Mark 3 (HUI3)] in four broadly defined conditions: visual impairment, hearing impairment, cancer and skin conditions. (2) Potential modelling approaches to ‘map’ EQ-5D values from condition-specific and clinical measures of health [European Organisation for Research and Treatment of Cancer Quality-of-life Questionnaire Core 30 (EORTC QLQ-C30) and Functional Assessment of Cancer Therapy – General Scale (FACT-G)] are compared for predictive ability and goodness of fit using two separate data sets. (3) Three potential extensions to the EQ-5D are developed as ‘bolt-on’ items relating to hearing, tiredness and vision. They are valued using the time trade-off method. A second valuation study is conducted to fully value the EQ-5D with and without the vision bolt-on item in an additional sample of 300 people. Main outcome measures: Comparisons of EQ-5D, SF-6D and HUI3 in four conditions with various generic and condition-specific measures. Mapping functions were estimated between EORTC QLQ-C30 and FACT-G with EQ-5D. Three bolt-ons to the EQ-5D were developed: EQ + hearing/vision/tiredness. A full valuation study was conducted for the EQ + vision. Results: (1) EQ-5D was valid and responsive for skin conditions and most cancers; in vision, its performance varied according to aetiology; and performance was poor for hearing impairments. The HUI3 performed well for hearing and vision disorders. It also performed well in cancers although evidence was limited and there was no evidence in skin conditions. There were limited data for SF-6D in all four conditions and limited evidence on reliability of all instruments. (2) Mapping algorithms were estimated to predict EQ-5D values from alternative cancer-specific measures of health. Response mapping using all the domain scores was the best performing model for the EORTC QLQ-C30. In an exploratory analysis, a limited dependent variable mixture model performed better than an equivalent linear model. In the full analysis for the FACT-G, linear regression using ordinary least squares gave the best predictions followed by the tobit model. (3) The exploratory valuation study found that bolt-on items for vision, hearing and tiredness had a significant impact on values of the health states, but the direction and magnitude of differences depended on the severity of the health state. The vision bolt-on item had a statistically significant impact on EQ-5D health state values and a full valuation model was estimated. Conclusions: EQ-5D performs well in studies of cancer and skin conditions. Mapping techniques provide a solution to predict EQ-5D values where EQ-5D has not been administered. For conditions where EQ-5D was found to be inappropriate, including some vision disorders and for hearing, bolt-ons provide a promising solution. More primary research into the psychometric properties of the generic preference-based measures is required, particularly in cancer and for the assessment of reliability. Further research is needed for the development and valuation of bolt-ons to EQ-5D.UK Medical Research Council (MRC) as part of the MRC-NIHR methodology research programme (reference G0901486

Gender, war and militarism: making and questioning the links

The gender dynamics of militarism have traditionally been seen as straightforward, given the cultural mythologies of warfare and the disciplining of ‘masculinity’ that occurs in the training and use of men's capacity for violence in the armed services. However, women's relation to both war and peace has been varied and complex. It is women who have often been most prominent in working for peace, although there are no necessary links between women and opposition to militarism. In addition, more women than ever are serving in many of today's armies, with feminists rather uncertain on how to relate to this phenomenon. In this article, I explore some of the complexities of applying gender analyses to militarism and peace work in sites of conflict today, looking most closely at the Israeli feminist group, New Profile, and their insistence upon the costs of the militarized nature of Israeli society. They expose the very permeable boundaries between the military and civil society, as violence seeps into the fears and practices of everyday life in Israel. I place their work in the context of broader feminist analysis offered by researchers such as Cynthia Enloe and Cynthia Cockburn, who have for decades been writing about the ‘masculinist’ postures and practices of warfare, as well as the situation of women caught up in them. Finally, I suggest that rethinking the gendered nature of warfare must also encompass the costs of war to men, whose fundamental vulnerability to psychological abuse and physical injury is often downplayed, whether in mainstream accounts of warfare or in more specific gender analysis. Feminists need to pay careful attention to masculinity and its fragmentations in addressing the topic of gender, war and militarism

A Mutation in Amino Acid Permease AAP6 Reduces the Amino Acid Content of the Arabidopsis Sieve Elements but Leaves Aphid Herbivores Unaffected.

The aim of this study was to investigate the role of the amino acid permease gene AAP6 in regulating phloem amino acid composition and then to determine the effects of this altered diet on aphid performance. A genotype of Arabidopsis thaliana (L.) was produced in which the function of the amino acid permease gene AAP6 (At5g49630) was abolished. Plants homozygous for the insertionally inactivated AAP6 gene had a significantly larger mean rosette width than the wild type and a greater number of cauline leaves. Seeds from the aap6 mutant were also significantly larger than those from the wild-type plants. Sieve element (SE) sap was collected by aphid stylectomy and the amino acids derivatized, separated, and quantified using Capillary Electrophoresis with Laser Induced Fluorescence (CE-LIF). In spite of the large variation across samples, the total amino acid concentration of SE sap of the aap6 mutant plants was significantly lower than that of the wild-type plants. The concentrations of lysine, phenylalanine, leucine, and aspartic acid were all significantly lower in concentration in the aap6 mutant plants compared with wild-type plants. This is the first direct demonstration of a physiological role for an amino acid transporter in regulating SE composition in vivo. The amino acid availability in sieve element sap is thought to be the major limiting factor for aphid growth and reproduction. Despite the changes in their diet, the aphid Myzus persicae(Sulzer) displayed only small changes in feeding behaviour on mutant plants when measured using the Electronic Penetration Graph (EPG) technique. Salivation by the aphid into the SE (E1 phase) was increased on mutant plants but there was no significant effect on other feeding EPG behaviours, or in the rate of honeydew production. Consistent with the small effect on aphid feeding behaviour, there was only a small effect of reduced sieve element amino acid concentration on aphid reproduction. The data are discussed in relation to the regulation of phloem composition and the role of phloem amino acids in regulating aphid performance

"It All Ended in an Unsporting Way": Serbian Football and the Disintegration of Yugoslavia, 1989-2006

Part of a wider examination into football during the collapse of Eastern European Communism between 1989 and 1991, this article studies the interplay between Serbian football and politics during the period of Yugoslavia's demise. Research utilizing interviews with individuals directly involved in the Serbian game, in conjunction with contemporary Yugoslav media sources, indicates that football played an important proactive role in the revival of Serbian nationalism. At the same time the Yugoslav conflict, twinned with a complex transition to a market economy, had disastrous consequences for football throughout the territories of the former Yugoslavia. In the years following the hostilities the Serbian game has suffered decline, major financial hardship and continuing terrace violence, resulting in widespread nostalgia for the pre-conflict era

A cost-effectiveness analysis of condom distribution programmes for the prevention of sexually transmitted infections in England

Background Prevention of sexually transmitted infection (STI) incidence in England is a high priority, particularly among young people, men who have sex with men (MSM) and black ethnic minorities. An economic evaluation of condom distribution programmes (CDPs) to reduce STI transmission is presented. Methods An economic model using a Bernoulli process estimated the number of people acquiring an STI as a function of its prevalence, transmission rate, condom use, condom failure rate and number of sexual contacts. Models were developed for young people (13–24 years), black ethnic minorities, MSM and the general English population. Effectiveness evidence came from a recent systematic review. For young people, a CDP was modelled (relative risk for condom use=1.23), along with an exploratory analysis of the impact on unintended pregnancies. For other populations, threshold analyses were used to identify the combination of costs and effect size required to make a programme cost-effective. Results The base case predicted that CDP for all young people in England could avert 5123 STI cases per annum, with an incremental cost–effectiveness ratio of £17 411. In addition, it could avert 118 pregnancies and 82 abortions and save £333 000 in associated costs. Schemes for black ethnic minorities and MSM could also be cost-effective even with relatively high costs and small effect sizes. Conclusion CDPs for young people are likely to be cost-effective or cost-saving. CDPs for other high-risk populations may also be cost-effective if they can increase condom use, since high HIV prevalence in these groups imposes a considerable health and cost burden

Pragmatic intervention for increasing self-directed exercise behaviour and improving important health outcomes in people with multiple sclerosis : a randomised controlled trial

Background: Exercise programmes that can demonstrate evidence of long-lasting clinical effectiveness are needed forpeople with multiple sclerosis (PwMS). Objective: The objective of this study was to assess the effects of a practically implemented exercise programme onself-directed exercise behaviour and important health outcomes in PwMS to nine months of follow-up. Methods: We conducted a parallel-arm, randomised controlled trial: 120 PwMS (Expanded Disability Status Scale (EDSS) 1.0-6.5) randomised to a three-month exercise intervention plus usual care, or usual care only. Two supervised plus one homeexercisesession (weeks 1-6) were followed by one supervised and two home-exercise sessions (weeks 7-12). Cognitivebehaviouraltechniques promoted long-term exercise behaviour change. Outcomes were blindly assessed at baseline and atthree and nine months after randomisation. The primary outcome was self-reported exercise behaviour (Godin Leisure TimeExercise Questionnaire (GLTEQ)). Secondary outcomes included fatigue and health-related quality of life (HRQoL). Results: The intervention increased self-reported exercise (9.6 points; 95% CI: 2.0 to 17.3 points; p = 0.01) andimproved fatigue (p<0.0001) and many HRQoL domains (p≤0.03) at three months. The improvements in emotionalwell-being (p = 0.01), social function (p = 0.004) and overall quality of life (p = 0.001) were sustained for nine months. Conclusion: This pragmatic approach to implementing exercise increases self-reported exercise behaviour, improves fatigue and leads to a sustained enhancement of HRQoL domains in PwMS