Sex, benevolence and willingness to pay for screening

Purpose: We report the findings of a contingent valuation survey of health care services, designed to illuminate self-interest and benevolence on the part of one sex for the other. Design/methodology/approach: In a constructed scenario, men and women recorded how much they would be willing to contribute to each of three different types of cancer screening, one of which would be available only to members of the opposite sex. Findings: Over two-thirds of individuals, amongst whom men were more heavily represented, chose an identical contingent valuation for all three services. Amongst those who nominated dissimilar values, a willingness to contribute to own-sex screening coupled with an unwillingness to contribute to opposite-sex screening was more common amongst women than amongst men. Both sexes valued own-sex screening more highly than opposite-sex screening yet, compared with men, women were prepared to offer proportionately less for the latter relative to the former. In an associated person trade-off task, women were considerably less likely than men to choose opposite-sex screening at the expense of a type from which they could benefit personally. Originality/value: To date, very little research has been undertaken on differential responses to health valuation of care provision by sex. The results suggest a degree of asymmetry between the sexes, with respect to self-interest and benevolence

An introduction to the methods of decision-analytic modelling used in economic evaluations for Dermatologists

Economic evaluations are used to identify which health treatments or preventions, offer the most effective use of resources, or value for money. This is achieved by identifying, measuring and valuing the inputs and outcomes of alternative interventions. These evaluations are often conducted alongside clinical trials, however these trials may end before the outcomes of economic interest have been observed and measured. An alternative to within trial economic evaluation is to use decision modelling, which can model the cost‐effectiveness of interventions over an extended time period. This paper aims to provide an overview for clinicians of the different modelling techniques used within health economic evaluations and to introduce methods for critical appraisal. The most common modelling approaches, and their associated strengths and weaknesses, were discussed. Alongside this, practical examples specific to dermatology were given. These examples include studies where the model chosen or the methods used may not have been the most appropriate. Methods for critical appraisal were also highlighted. Common modelling approaches include Decision Trees, Markov Cohort, extensions to the Markov model (Monte Carlo Simulation), and Discrete Event Simulation models. Items of the Philips Checklist were discussed in the context of performing critical appraisal. Health economic decision models are multi‐faceted and can often be complex. Full critical appraisal requires clinicians’ unique knowledge, which is complementary to the knowledge of health economists

Estimating loss in quality of life associated with asthma-related crisis events (ESQUARE): a cohort, observational study

Background: Evidence of quality of life implications of asthma attacks are limited,particularly when measured on a utility scale, which enables calculating Quality-Adjusted Life-Years (QALYs) and comparisons with other health conditions andservices. Therefore, this study sought to estimate the utility loss associated with anasthma-related crisis event (accident and emergency (A&E) attendance or hospitaladmission).Methods: Participants were recruited in a cohort study from A&E and hospitaladmissions at three UK hospitals. They completed the EuroQol-5 Dimensions 5-Level(EQ-5D-5L), Asthma Quality of Life Questionnaire (AQLQ), Time trade-off (TTO), andpeak flow and symptom diary over 8 weeks, where three different methods (EQ-5D-5L,AQLQ, and TTO), were used to estimate utilities. The mean difference between twotime points were estimated using the Wilcoxon signed rank test.Results: From baseline to week 8, mean increases (95% CI) were estimated to be0.086 (0.019-0.153), 0.154 (0.112-0.196) and 0.132 (0.063-0.201) for EQ-5D-5L, AQL-5D (preference-based measure derived from AQLQ), and TTO respectively over 8weeks (p<0.01).Conclusion: Asthma crisis events are estimated to be associated with a mean utilityloss of between 0.086 and 0.132. The utility decrement can be used to assign valuesto asthma-related crisis events, which can enhance economic evaluations

The construct validity and responsiveness of the EQ-5D-5L, AQL-5D and a bespoke TTO in acute asthmatics

Purpose: Measuring quality of life in acute asthmatics is challenging, especially when asthma attacks can occur sporadically. Several questionnaires can be used to measure quality of life in this patient group; however, psychometric testing is limited on questionnaires that can be used to estimate Quality Adjusted Life years. The objective of this study is to assess the construct validity (convergent and discriminative validity) and responsiveness of the EuroQol-5-Dimensions 5-Level (EQ-5D-5L), Asthma Quality of Life Utility Index-5 Dimensions (AQL-5D) and Time Trade-Off (TTO) in acute asthma patients. Methods: Data from a prospective cohort study were used to test the validity and responsiveness of the EQ-5D-5L, AQL-5D and TTO in asthma patients who were recruited from UK accident & emergency departments or hospital wards. The spearman’s rank correlation coefficient, the Kruskal–Wallis test statistic and the standardized response mean were used to test for convergent validity, discriminative validity and responsiveness, respectively. Results: One hundred and twenty-one participants were included in the available case analysis. The EQ-5D-5L and AQL-5D showed moderate to strong correlations for convergent validity at baseline, week 4 and week 8. The AQL-5D and TTO showed moderate correlations at week 4 and week 8. No statistical significance was observed for discriminative validity at baseline. Both the EQ-5D-5L and the AQL-5D also showed that they were sensitive to change for the recovery responses. Conclusions: The EQ-5D-5L and AQL-5D showed stronger construct validity and responsiveness compared to the TTO. Therefore, both the EQ-5D-5L and AQL-5D should be considered for use in future economic evaluations

Effectiveness of an educational intervention for general practice teams to deliver problem focused therapy for insomnia: pilot cluster randomised trial

Introduction Sleep problems are common leading to physical and psychosocial morbidity and impaired quality of life. Sufferers often seek help from primary care and receive advice or hypnotic drugs which are ineffective long term. Cognitive behavioural therapy for insomnia (CBTi) is effective but is not widely used in general practice. We conducted a pilot study to test procedures and collect information in preparation for a larger definitive trial to measure effectiveness and cost-effectiveness of an educational intervention for general practitioners and primary care nurses a to deliver problem focused therapy to adults Methods This was a pilot cluster randomised controlled trial. General practices were randomised to an educational intervention (2x2 hours) for problem focused therapy which comprised assessment (of secondary causes, severity and using sleep diaries) and modified CBTi compared with usual care (sleep hygiene advice and hypnotic drugs). We recruited patients with sleep problems due to lifestyle causes, pain or mild to moderate depression or anxiety and Pittsburgh Sleep Quality Index (PSQI≥4). The primary outcome was PSQI and secondary outcomes including Insomnia Severity Index (ISI), Epworth Sleepiness Scale, Beck Depression Inventory and PSYCHLOPS were measured at 0, 4, 8 and 13 weeks. Intervention fidelity was evaluated using telephone interviews of participating practitioners and patients. Results Out of 64 participants recruited, 37 completed the trial. Analysis was conducted masked to treatment allocation. We used a mixed effects model to test for overall change and whether the intervention affected the rate of change over time. There was significant dropout during the pilot study, mainly due to delays in recruitment. We detected neither an overall change over time (PSQI score increase per week 0.06 (95%CI -0.03 to 0.16) nor differential change between intervention and control groups 0.10 (-0.03 to 0.23) although the study was not powered to detect such a change. Conclusion This pilot study confirmed that it was feasible to undertake a trial of education for primary care clinicians to deliver problem focused therapy for insomnia in general practice but also exposed problems with study recruitment, dropout, and intervention fidelity which should be addressed in the design of a full trial

Barriers and facilitators to model replication within health economics

Objective: Model replication is important as it enables researchers to check research integrity, transparency and, potentially, to inform the model conceptualisation process when developing a new or updated model. The aim of this study was to evaluate the replicability of published decision analytic models, and to identify the barriers and facilitators to replication. Methods: Replication attempts of five published economic modelling studies were made. The replications were conducted using only publicly available information within the manuscripts and supplementary materials. The replicator attempted to reproduce the key results detailed in the paper, for example the total cost, total outcomes and if applicable, the incremental cost effectiveness ratio reported. Whilst a replication attempt was not explicitly defined as a success or failure, the replicated results were compared in terms of percentage difference to the original results. Results: In conducting the replication attempts, common barriers and facilitators emerged. For the majority of the case studies, the replicator needed to make additional assumptions when recreating the model. This was often exacerbated by conflicting information being presented in the text and the tables. Across the case studies, the variation between original and replicated results ranged from -4.54% to 108.00% for costs and -3.81% to 0.40% for outcomes. Conclusion: This study demonstrates that whilst models may appear to be comprehensively reported, it is often not enough to facilitate a precise replication. Further work is needed to understand how to improve model transparency and in turn to increase the chances of replication, thus ensuring future usability

Measurement properties of quality-of-life measurement instruments for infants, children and adolescents with eczema: a systematic review

Background: Quality of life (QoL) is one of the core outcome domains identified by the Harmonising Outcome Measures for Eczema (HOME) initiative to be assessed in every eczema trial. There is uncertainty about the most appropriate QoL instrument to measure this domain in infants, children and adolescents. Objectives: To systematically evaluate the measurement properties of existing measurement instruments developed and/or validated for the measurement of QoL in infants, children and adolescents with eczema. Methods: A systematic literature search in PubMed and EMBASE, complemented by a thorough hand search of reference lists, retrieved studies on measurement properties of eczema QoL instruments for infants, children and adolescents. For all eligible studies, we judged the adequacy of the measurement properties and the methodological study quality with the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. Results from different studies were summarized in a best evidence synthesis and formed the basis to assign four degrees of recommendation. Results: 17 articles, 3 of which were found by hand search, were included. These 17 articles reported on 24 instruments. No instrument can be recommended for use in all eczema trials because none fulfilled all required adequacy criteria. With adequate internal consistency, reliability and hypothesis testing, the US version of the Childhood Atopic Dermatitis Impact Scale (CADIS), a proxy-reported instrument, has the potential to be recommended depending on the results of further validation studies. All other instruments, including all self-reported ones, lacked significant validation data. Conclusions: Currently, no QoL instrument for infants, children and adolescents with eczema can be highly recommended. Future validation research should primarily focus on the CADIS, but also attempt to broaden the evidence base for the validity of self-reported instruments

Health state utility data in Cystic Fibrosis: A systematic review

Introduction: Cystic fibrosis (CF) is a life-limiting, hereditable condition, with the highest prevalence in Europe. CF treatments have led to improvements in clinical symptoms, disease management and decelerated disease progression. However, little is known about the health state utility (HSU) associated with CF disease states, adverse events, and changes in disease severity. Although HSU data have contributed to existing health economic modelling studies, a lack of such data have been highlighted. This systematic review aims to provide a summary of HSU-related research in CF and highlight related research gaps. Methods: Online searches were performed in six databases and studies in any of the following categories were included: (1) estimation of HSUs in CF; (2) mapping studies between patient-reported outcome measures (PROMs) and HSUs; (3) economic evaluations on the management of CF that report primary HSU data; and (4) any CF clinical trial that reported HSU as an outcome. Results: A total of 17 studies were reviewed, of which 12 provided HSU values for specific CF populations. The remaining five articles provided HSU data that were broken down by CF relevant health states, including lung transplantations, pulmonary exacerbation (PEx) events and forced expiratory volume in 1 s (FEV 1). Conclusion: Current HSU data in CF are limited and there is considerable scope for further research, both in providing HSU values for CF and in investigating methods for HSU elicitation/evaluation in CF populations

Clinical and cost effectiveness of a multi-professional medication reviews in care homes (CAREMED)

Objectives With 70% of care home residents experiencing a medication error every day in the UK, better multi‐professional working between medical practitioners, pharmacists and care homes was recommended. The aim of this study was to determine the effectiveness (falls reduction) and cost‐effectiveness, of a multi‐professional medication review (MPMR) service in care homes for older people. Method A total of care homes in the East of England were cluster randomised to ‘usual care’ or two multi‐professional (General practitioner, clinical pharmacist and care homes staff) medication reviews during the 12‐month trial period. Target recruitment was 900 residents with 10% assumed loss to follow‐up. Co‐primary outcome measures were number of falls and potentially inappropriate prescribing assessed by the Screening Tool of Older Persons Prescriptions. Key findings A total of 826 care home residents were recruited with 324 lost to follow‐up for at least one primary outcome measure. The mean number of falls per resident per annum was 3.3 for intervention and 3.0 for control (P = 0.947). Each resident was found to be prescribed 0.69 (intervention) and 0.85 (control) potentially inappropriate medicines after 12 months (P = 0.046). No significant difference identified in emergency hospital admissions or deaths. Estimated unadjusted incremental mean cost per resident was £374.26 higher in the intervention group. Conclusions In line with other medication review based interventions in care homes, two MPMRs improved medication appropriateness but failed to demonstrate improvements in clinical outcomes. From a health system perspective costs where estimated to increase overall and therefore a different model of medicines management is required

A multicentre randomised controlled trial of day hospital-based falls prevention programme for a screened population of community-dwelling older people at high risk of falls

Objective: to determine the clinical effectiveness of a day hospital-delivered multifactorial falls prevention programme, for community-dwelling older people at high risk of future falls identified through a screening process