Cost-effectiveness of timely versus delayed primary total hip replacement in Germany: A social health insurance perspective

Without clinical guideline on the optimal timing for primary total hip replacement (THR), patients often receive the operation with delay. Delaying THR may negatively affect long-term health-related quality of life, but its economic effects are unclear. We evaluated the costs and health benefits of timely primary THR for functionally independent adult patients with end-stage osteoarthritis (OA) compared to non-surgical therapy followed by THR after progression to functional dependence (delayed THR), and non-surgical therapy alone (Medical Therapy), from a German Social Health Insurance (SHI) perspective. Data from hip arthroplasty registers and a systematic review of the published literature were used to populate a tunnel-state modified Markov lifetime model of OA treatment in Germany. A 5% annual discount rate was applied to costs (2013 prices) and health outcomes (Quality Adjusted Life Years, QALY). The expected future average cost of timely THR, delayed THR and medical therapy in women at age 55 were €27,474, €27,083 and €28,263, and QALYs were 20.7, 16.7, and 10.3, respectively. QALY differences were entirely due to health-related quality of life differences. The discounted cost per QALY gained by timely over delayed (median delay of 11 years) THR was €1270 and €1338 in women treated at age 55 and age 65, respectively, and slightly higher than this for men. Timely THR is cost-effective, generating large quality of life benefits for patients at low additional cost to the SHI. With declining healthcare budgets, research is needed to identify the characteristics of those able to benefit the most from timely THR

Common patterns of morbidity and multi-morbidity and their impact on health-related quality of life: evidence from a national survey.

BACKGROUND: There is limited evidence about the impact of specific patterns of multi-morbidity on health-related quality of life (HRQoL) from large samples of adult subjects. METHODS: We used data from the English General Practice Patient Survey 2011-2012. We defined multi-morbidity as the presence of two or more of 12 self-reported conditions or another (unspecified) long-term health problem. We investigated differences in HRQoL (EQ-5D scores) associated with combinations of these conditions after adjusting for age, gender, ethnicity, socio-economic deprivation and the presence of a recent illness or injury. Analyses were based on 831,537 responses from patients aged 18 years or older in 8,254 primary care practices in England. RESULTS: Of respondents, 23 % reported two or more chronic conditions (ranging from 7 % of those under 45 years of age to 51 % of those 65 years or older). Multi-morbidity was more common among women, White individuals and respondents from socio-economically deprived areas. Neurological problems, mental health problems, arthritis and long-term back problem were associated with the greatest HRQoL deficits. The presence of three or more conditions was commonly associated with greater reduction in quality of life than that implied by the sum of the differences associated with the individual conditions. The decline in quality of life associated with an additional condition in people with two and three physical conditions was less for older people than for younger people. Multi-morbidity was associated with a substantially worse HRQoL in diabetes than in other long-term conditions. With the exception of neurological conditions, the presence of a comorbid mental health problem had a more adverse effect on HRQoL than any single comorbid physical condition. CONCLUSION: Patients with multi-morbid diabetes, arthritis, neurological, or long-term mental health problems have significantly lower quality of life than other people. People with long-term health conditions require integrated mental and physical healthcare services

Measurement of health-related quality by multimorbidity groups in primary health care

[EN] Background: Increased life expectancy in Western societies does not necessarily mean better quality of life. To improve resources management, management systems have been set up in health systems to stratify patients according to morbidity, such as Clinical Risk Groups (CRG). The main objective of this study was to evaluate the effect of multimorbidity on health-related quality of life (HRQL) in primary care. Methods: An observational cross-sectional study, based on a representative random sample (n = 306) of adults from a health district (N = 32,667) in east Spain (Valencian Community), was conducted in 2013. Multimorbidity was measured by stratifying the population with the CRG system into nine mean health statuses (MHS). HRQL was assessed by EQ-5D dimensions and the EQ Visual Analogue Scale (EQ VAS). The effect of the CRG system, age and gender on the utility value and VAS was analysed by multiple linear regression. A predictive analysis was run by binary logistic regression with all the sample groups classified according to the CRG system into the five HRQL dimensions by taking the ¿healthy¿ group as a reference. Multivariate logistic regression studied the joint influence of the nine CRG system MHS, age and gender on the five EQ-5D dimensions. Results: Of the 306 subjects, 165 were female (mean age of 53). The most affected dimension was pain/discomfort (53%), followed by anxiety/depression (42%). The EQ-5D utility value and EQ VAS progressively lowered for the MHS with higher morbidity, except for MHS 6, more affected in the five dimensions, save self-care, which exceeded MHS 7 patients who were older, and MHS 8 and 9 patients, whose condition was more serious. The CRG system alone was the variable that best explained health problems in HRQL with 17%, which rose to 21% when associated with female gender. Age explained only 4%. Conclusions: This work demonstrates that the multimorbidity groups obtained by the CRG classification system can be used as an overall indicator of HRQL. These utility values can be employed for health policy decisions based on cost-effectiveness to estimate incremental quality-adjusted life years (QALY) with routinely e-health data. Patients under 65 years with multimorbidity perceived worse HRQL than older patients or disease severity. Knowledge of multimorbidity with a stronger impact can help primary healthcare doctors to pay attention to these population groups.The authors would like to thank the Conselleria de Sanitat Universal i Sanitat Pública of the Generalitat Valenciana (the Regional Valencian Health Government) for providing the study data. We would also like to thank Helen Warbuton for editing the English.Milá-Perseguer, M.; Guadalajara Olmeda, MN.; Vivas-Consuelo, D.; Usó-Talamantes, R. (2019). 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Randomised feasibility trial and embedded qualitative process evaluation of a new intervention to facilitate the involvement of older patients with multimorbidity in decision-making about their healthcare during general practice consultations: the VOLITION study protocol

Background The number of older people with multiple health problems is increasing worldwide. This creates a strain on clinicians and the health service when delivering clinical care to this patient group, who themselves carry a large treatment burden. Despite shared decision-making being acknowledged by healthcare organisations as a priority feature of clinical care, older patients with multimorbidity are less often involved in decision-making when compared with younger patients, with some evidence suggesting associated health inequalities. Interventions aimed at facilitating shared decision-making between doctors and patients are outdated in their assessments of today’s older patient population who need support in prioritising complex care needs in order to maximise quality of life and day-to-day function. Aims To undertake feasibility testing of an intervention (‘VOLITION’) aimed at facilitating the involvement of older patients with more than one long-term health problem in shared decision-making about their healthcare during GP consultations. To inform the design of a fully powered trial to assess intervention effectiveness. Methods This study is a cluster randomised controlled feasibility trial with qualitative process evaluation interviews. Participants are patients, aged 65 years and above with more than one long-term health problem (multimorbidity), and the GPs that they consult with. This study aims to recruit 6 GP practices, 18 GPs and 180 patients. The intervention comprises two components: (i) a half-day training workshop for GPs in shared decision-making; and (ii) a leaflet for patients that facilitate their engagement with shared decision-making. Intervention implementation will take 2 weeks (to complete delivery of both patient and GP components), and follow-up duration will be 12 weeks (from index consultation and commencement of data collection to final case note review and process evaluation interview). The trial will run from 01/01/20 to 31/01/21; 1 year 31 days. Discussion Shared decision-making for older people with multimorbidity in general practice is under-researched. Emerging clinical guidelines advise a patient-centred approach, to reduce treatment burden and focus on quality of life alongside disease control. The systematic development, testing and evaluation of an intervention is warranted and timely. This study will test the feasibility of implementing a new intervention in UK general practice for future evaluation as a part of routine care

Smoking and primary total hip or knee replacement due to osteoarthritis in 54,288 elderly men and women

BACKGROUND The reported association of smoking with risk of undergoing a total joint replacement (TJR) due to osteoarthritis (OA) is not consistent. We evaluated the independent association between smoking and primary TJR in a large cohort. METHODS The electronic records of 54,288 men and women, who were initially recruited for the Second Australian National Blood Pressure study, were linked to the Australian Orthopaedic Association National Joint Replacement Registry to detect total hip replacement (THR) or total knee replacement (TKR) due to osteoarthritis. Competing risk regressions that accounted for the competing risk of death estimated the subhazard ratios for TJR. One-way and probabilistic sensitivity analyses were undertaken to represent uncertainty in the classification of smoking exposure and socioeconomic disadvantage scores. RESULTS An independent inverse association was found between smoking and risk of THR and TKR observed in both men and women. Compared to non-smokers, male and female smokers were respectively 40% and 30% less likely to undergo a TJR. This significant association persisted after controlling for age, co-morbidities, body mass index (BMI), physical exercise, and socioeconomic disadvantage. The overweight and obese were significantly more likely to undergo TJR compared to those with normal weight. A dose–response relationship between BMI and TJR was observed (P < 0.001). Socioeconomic status was not independently associated with risk of either THR or TKR. CONCLUSION The strengths of the inverse association between smoking and TJR, the temporal relationship of the association, together with the consistency in the findings warrant further investigation about the role of smoking in the pathogenesis of osteoarthritis causing TJR.George Mnatzaganian, Philip Ryan, Christopher M Reid, David C Davidson and Janet E Hille

Incorporating equity concerns in cost-effectiveness analyses: A systematic literature review

This is the author accepted manuscript. The final version is available from Springer Verlag via the DOI in this recordIntroduction The aim of this study is to review analytical methods that enable the incorporation of equity concerns within economic evaluation. Methods A systematic search of PubMed, Embase and EconLit was undertaken from database inception to February 2021. The search was designed to identify methodological approaches that are currently employed to evaluate health-related equity impacts in economic evaluation studies of health care interventions. Studies were eligible if they described or elaborated on a formal quantitative method used to integrate equity concerns within economic evaluation studies. Cost-utility, cost-effectiveness, cost-benefit, cost-minimisation and, cost-consequence analyses, as well as health technology appraisal and budget impact analysis, alongside any relevant literature reviews, were included. For each of the identified methods, summaries of the scope of equity considerations covered, the methods employed and their key attributes, data requirements, outcomes, and strengths and weaknesses were provided. A traffic light assessment of the practical suitability of each method was undertaken, alongside a worked example, applying the different methods to evaluate the same decision problem. Finally, the review summarises the typical trade-offs arising in cost-effectiveness analyses and discusses the extent to which the evaluation methods are able to capture these. Results In total, 68 studies were included in the review and methods could broadly be grouped into equity-based weighting (EBW) methods, extended cost-effectiveness analysis (ECEA), distributional cost-effectiveness analysis (DCEA), multi-criteria decision analysis (MCDA), and mathematical programming (MP). EBW and MP methods enable equity consideration through adjustment to incremental cost-effectiveness ratios, whilst equity considerations are represented through financial risk protection (FRP) outcomes in ECEA, social welfare functions (SWFs) in DCEA, and scoring/ranking systems in MCDA. The review identified potential concerns for EBW methods and MCDA with respect to data availability, and EBW methods and MP with respect to explicitly measuring changes in inequality. The only potential concern for ECEA relates to the use of FRP metrics which may not be relevant for all healthcare systems. In contrast, DCEA observed no significant concerns but relies on the use of SWFs which may be unfamiliar to some audiences and requires societal preference elicitation. Consideration of typical cost-effectiveness and equity-related trade-offs highlighted the flexibility of most methods with respect to their ability to capture such trade-offs. Notable exceptions were trade-offs between quality of life and length of life, for which we find DCEA and ECEA unsuitable, and the assessment of lost opportunity costs, for which we find only DCEA and MP to be suitable. The worked example demonstrated that each method is designed with fundamentally different analytical objectives in mind. Conclusions The review emphasises that, not only are some approaches better suited to particular decision problems than others, but also that methods are subject to different practical requirements and that significantly different conclusions can be observed depending on the choice of method and the assumptions made. Further, to fully operationalise these frameworks, there remains a need to develop consensus over the motivation for equity assessment, which should necessarily be informed with stakeholder involvement. Future research of this topic should be a priority, particularly within the context of equity evaluation in health care policy decisions.Dennis and Mereille Gillings Foundatio