The social value of a QALY : raising the bar or barring the raise?

Background: Since the inception of the National Institute for Health and Clinical Excellence (NICE) in England, there have been questions about the empirical basis for the cost-per-QALY threshold used by NICE and whether QALYs gained by different beneficiaries of health care should be weighted equally. The Social Value of a QALY (SVQ) project, reported in this paper, was commissioned to address these two questions. The results of SVQ were released during a time of considerable debate about the NICE threshold, and authors with differing perspectives have drawn on the SVQ results to support their cases. As these discussions continue, and given the selective use of results by those involved, it is important, therefore, not only to present a summary overview of SVQ, but also for those who conducted the research to contribute to the debate as to its implications for NICE. Discussion: The issue of the threshold was addressed in two ways: first, by combining, via a set of models, the current UK Value of a Prevented Fatality (used in transport policy) with data on fatality age, life expectancy and age-related quality of life; and, second, via a survey designed to test the feasibility of combining respondents’ answers to willingness to pay and health state utility questions to arrive at values of a QALY. Modelling resulted in values of £10,000-£70,000 per QALY. Via survey research, most methods of aggregating the data resulted in values of a QALY of £18,000-£40,000, although others resulted in implausibly high values. An additional survey, addressing the issue of weighting QALYs, used two methods, one indicating that QALYs should not be weighted and the other that greater weight could be given to QALYs gained by some groups. Summary: Although we conducted only a feasibility study and a modelling exercise, neither present compelling evidence for moving the NICE threshold up or down. Some preliminary evidence would indicate it could be moved up for some types of QALY and down for others. While many members of the public appear to be open to the possibility of using somewhat different QALY weights for different groups of beneficiaries, we do not yet have any secure evidence base for introducing such a system

Crop Updates 2002 - Geraldton

This session covers twenty seven papers from different authors: 1. Taking the Why out of Wyalkatchem – the new widely adapted wheat variety, Steve Penny Jr, Department of Agriculture 2. Future wheat varieties, Robin Wilson, Iain Barclay,Robyn McLean, Robert Loughman, Jenny Garlinge, Bill Lambe, Neil Venn and Peter Clarke Department of Agriculture 3. Maximising wheat variety performance through agronomic management, Wal Anderson, Raffaele Del Cima, James Bee, Darshan Sharma, Sheena Lyon, Melaine Kupsch, Mohammad Amjad, Pam Burgess, Veronika Reck, Brenda Shackley, Ray Tugwell, Bindi Webb and Steve Penny Jr Department of Agriculture 4. Cereal rust update 2002 – a new stem rust on Camm wheat, Robert Loughman1and Robert Park2 1Department of Agriculture, 2University of Sydney 5. Influence of nutrition and environmental factors on seed vigour in wheat, Darshan Sharma, Wal Anderson and Daya Patabendige, Department of Agriculture 6. Cereal aphids and direct feeding damage to cereals, Phil Michael, Department of Agriculture 7. A decision support system for control of aphids and BYDV in cereal crops, Debbie Thackray, Jenny Hawkes and Roger Jones, Department of Agriculture and Centre for Legumes in Mediterranean Agriculture 8. Summary of 2001 weather and seasonal prospects for 2002, David Stephens, Department of Agriculture 9. Towards a management package for grain protein in lupins, Bob French, Senior Research Officer, Department of Agriculture 10. Lupin genotypes respond differently to potash, Bob French and Laurie Wahlsten, Senior Research Officer and Technical Officer, Department of Agriculture 11. Time of harvest for improved seed yield of pulses, G. Riethmuller and B. French, Department of Agriculture 12. Comparing the phosphorus requirement of field pea and wheat, M. Bolland and P. White, Department of Agriculture Western Australia 13. Field pea variety evaluation, T. Khan, Department of Agriculture Western Australia 14. Diamondback moth (DBM) in canola, Kevin Walden, Department of Agriculture 15. WA blackleg resistance ratings on canola varieties for 2002, Ravjit Khangura, Martin J. Barbetti and Graham Walton, Department of Agriculture 16. The effect of single or multiple spray treatments on the control of Diamondback moth (Plutella xylostella) and yield of canola at Wongan Hills, Françoise Berlandier, Paul Carmody and Christiaan Valentine, Department of Agriculture 17. Perennial pastures in annual cropping systems: Lucerne and beyond, Roy Latta and Keith Devenish, Department of Agriculture 18. Nutrition in 2002: Decisions to be made as a result of last season, Bill Bowden,Department of Agriculture 19. Profitability of deep banding lime, Michael O\u27Connell, Chris Gazey and David Gartner, Department of Agriculture 20. Economic comparisons of farming systems for the medium rainfall northern sandplain, Caroline Peek and David Rogers, Department of Agriculture 21. The use of Twist Fungus as a biosecurity measure against Annual Ryegrass Toxicity (ARGT), Greg Shea, GrainGuard Coordinator and George Yan, Biological and Resource Technology 22. Major outcomes from IWM demonstration sites, Alexandra Douglas, Department of Agriculture 23. Understanding the weed seed bank life of important agricultural weeds, Sally Peltzer and Paul Matson, Department of Agriculture 24. Seeding rate, row spacing and herbicides for weed control, David Minkey, Department of Agriculture 25. Improving weed control in grazed pastures using legumes with low palatability, Clinton Revell and Giles Glasson, Department of Agriculture, Dean Thomas, Faculty of Agriculture, University of Western Australia 26. Group F resistant wild radish: What’s new? Aik Cheam1, Siew Lee1and Mike Clarke2, 1Department of Agriculture WA, 2Aventis Crop Science 27. Knockdown herbicides do not reliably kill small grass weeds, Peter Newman and Glenn Adam, Department of Agricultur

Study design and methods of the BoTULS trial: a randomised controlled trial to evaluate the clinical effect and cost effectiveness of treating upper limb spasticity due to stroke with botulinum toxin type A

Background Following a stroke, 55–75% of patients experience upper limb problems in the longer term. Upper limb spasticity may cause pain, deformity and reduced function, affecting mood and independence. Botulinum toxin is used increasingly to treat focal spasticity, but its impact on upper limb function after stroke is unclear. The aim of this study is to evaluate the clinical and cost effectiveness of botulinum toxin type A plus an upper limb therapy programme in the treatment of post stroke upper limb spasticity. Methods Trial design : A multi-centre open label parallel group randomised controlled trial and economic evaluation. Participants : Adults with upper limb spasticity at the shoulder, elbow, wrist or hand and reduced upper limb function due to stroke more than 1 month previously. Interventions : Botulinum toxin type A plus upper limb therapy (intervention group) or upper limb therapy alone (control group). Outcomes : Outcome assessments are undertaken at 1, 3 and 12 months. The primary outcome is upper limb function one month after study entry measured by the Action Research Arm Test (ARAT). Secondary outcomes include: spasticity (Modified Ashworth Scale); grip strength; dexterity (Nine Hole Peg Test); disability (Barthel Activities of Daily Living Index); quality of life (Stroke Impact Scale, Euroqol EQ-5D) and attainment of patient-selected goals (Canadian Occupational Performance Measure). Health and social services resource use, adverse events, use of other antispasticity treatments and patient views on the treatment will be compared. Participants are clinically reassessed at 3, 6 and 9 months to determine the need for repeat botulinum toxin type A and/or therapy. Randomisation : A web based central independent randomisation service. Blinding : Outcome assessments are undertaken by an assessor who is blinded to the randomisation group. Sample size : 332 participants provide 80% power to detect a 15% difference in treatment successes between intervention and control groups. Treatment success is defined as improvement of 3 points for those with a baseline ARAT of 0–3 and 6 points for those with ARAT of 4–56

Genomic investigations of unexplained acute hepatitis in children

Since its first identification in Scotland, over 1,000 cases of unexplained paediatric hepatitis in children have been reported worldwide, including 278 cases in the UK1. Here we report an investigation of 38 cases, 66 age-matched immunocompetent controls and 21 immunocompromised comparator participants, using a combination of genomic, transcriptomic, proteomic and immunohistochemical methods. We detected high levels of adeno-associated virus 2 (AAV2) DNA in the liver, blood, plasma or stool from 27 of 28 cases. We found low levels of adenovirus (HAdV) and human herpesvirus 6B (HHV-6B) in 23 of 31 and 16 of 23, respectively, of the cases tested. By contrast, AAV2 was infrequently detected and at low titre in the blood or the liver from control children with HAdV, even when profoundly immunosuppressed. AAV2, HAdV and HHV-6 phylogeny excluded the emergence of novel strains in cases. Histological analyses of explanted livers showed enrichment for T cells and B lineage cells. Proteomic comparison of liver tissue from cases and healthy controls identified increased expression of HLA class 2, immunoglobulin variable regions and complement proteins. HAdV and AAV2 proteins were not detected in the livers. Instead, we identified AAV2 DNA complexes reflecting both HAdV-mediated and HHV-6B-mediated replication. We hypothesize that high levels of abnormal AAV2 replication products aided by HAdV and, in severe cases, HHV-6B may have triggered immune-mediated hepatic disease in genetically and immunologically predisposed children

Do ordering effects matter in willingness-to-pay studies of health care?

Willingness-to-pay studies are increasingly being used in the evaluation of health care programmes. However, there are methodological issues that need to be resolved before the potential of willingness-to-pay can be fully exploited as a tool for the economic evaluation of health care programmes. Of particular methodological interest are the consequences of varying the order in which willingness-to-pay questions are presented to respondents in contingent valuation studies. This paper examines the possibility of ordering effects in willingness-to-pay studies in health care. That is, when asking willingness-to-pay questions about three health care programmes within a single survey, does the order the programmes are presented have an impact on the reported willingness-to-pay? Ordering effects are observed in the ranking of the programmes, in the proportion of zero values reported and in the WTP for one of the programmes. The results suggest that the best explanation for the ordering effects is one of fading glow, whereby the first programme in any sequence captures much of the utility associated with giving

Crop Updates 2002 - Geraldton

This session covers twenty seven papers from different authors: 1. Taking the Why out of Wyalkatchem – the new widely adapted wheat variety, Steve Penny Jr, Department of Agriculture 2. Future wheat varieties, Robin Wilson, Iain Barclay,Robyn McLean, Robert Loughman, Jenny Garlinge, Bill Lambe, Neil Venn and Peter Clarke Department of Agriculture 3. Maximising wheat variety performance through agronomic management, Wal Anderson, Raffaele Del Cima, James Bee, Darshan Sharma, Sheena Lyon, Melaine Kupsch, Mohammad Amjad, Pam Burgess, Veronika Reck, Brenda Shackley, Ray Tugwell, Bindi Webb and Steve Penny Jr Department of Agriculture 4. Cereal rust update 2002 – a new stem rust on Camm wheat, Robert Loughman1and Robert Park2 1Department of Agriculture, 2University of Sydney 5. Influence of nutrition and environmental factors on seed vigour in wheat, Darshan Sharma, Wal Anderson and Daya Patabendige, Department of Agriculture 6. Cereal aphids and direct feeding damage to cereals, Phil Michael, Department of Agriculture 7. A decision support system for control of aphids and BYDV in cereal crops, Debbie Thackray, Jenny Hawkes and Roger Jones, Department of Agriculture and Centre for Legumes in Mediterranean Agriculture 8. Summary of 2001 weather and seasonal prospects for 2002, David Stephens, Department of Agriculture 9. Towards a management package for grain protein in lupins, Bob French, Senior Research Officer, Department of Agriculture 10. Lupin genotypes respond differently to potash, Bob French and Laurie Wahlsten, Senior Research Officer and Technical Officer, Department of Agriculture 11. Time of harvest for improved seed yield of pulses, G. Riethmuller and B. French, Department of Agriculture 12. Comparing the phosphorus requirement of field pea and wheat, M. Bolland and P. White, Department of Agriculture Western Australia 13. Field pea variety evaluation, T. Khan, Department of Agriculture Western Australia 14. Diamondback moth (DBM) in canola, Kevin Walden, Department of Agriculture 15. WA blackleg resistance ratings on canola varieties for 2002, Ravjit Khangura, Martin J. Barbetti and Graham Walton, Department of Agriculture 16. The effect of single or multiple spray treatments on the control of Diamondback moth (Plutella xylostella) and yield of canola at Wongan Hills, Françoise Berlandier, Paul Carmody and Christiaan Valentine, Department of Agriculture 17. Perennial pastures in annual cropping systems: Lucerne and beyond, Roy Latta and Keith Devenish, Department of Agriculture 18. Nutrition in 2002: Decisions to be made as a result of last season, Bill Bowden,Department of Agriculture 19. Profitability of deep banding lime, Michael O\u27Connell, Chris Gazey and David Gartner, Department of Agriculture 20. Economic comparisons of farming systems for the medium rainfall northern sandplain, Caroline Peek and David Rogers, Department of Agriculture 21. The use of Twist Fungus as a biosecurity measure against Annual Ryegrass Toxicity (ARGT), Greg Shea, GrainGuard Coordinator and George Yan, Biological and Resource Technology 22. Major outcomes from IWM demonstration sites, Alexandra Douglas, Department of Agriculture 23. Understanding the weed seed bank life of important agricultural weeds, Sally Peltzer and Paul Matson, Department of Agriculture 24. Seeding rate, row spacing and herbicides for weed control, David Minkey, Department of Agriculture 25. Improving weed control in grazed pastures using legumes with low palatability, Clinton Revell and Giles Glasson, Department of Agriculture, Dean Thomas, Faculty of Agriculture, University of Western Australia 26. Group F resistant wild radish: What’s new? Aik Cheam1, Siew Lee1and Mike Clarke2, 1Department of Agriculture WA, 2Aventis Crop Science 27. Knockdown herbicides do not reliably kill small grass weeds, Peter Newman and Glenn Adam, Department of Agricultur