Annie Hawton

The impact of social isolation on the health status and health-related quality of life of older people

PurposeTo investigate for socially isolated older people, and older people at risk of social isolation: (1) health status and health-related quality of life (HRQL); (2) the relationship between social isolation and health status/HRQL; (3) the relationship between two alternative measures of health status/HRQL.MethodsOlder people at risk of social isolation (n = 393) completed the EQ-5D and the SF-12. Multiple regression analyses were performed to examine the relationship between levels of social isolation and health status/HRQL, controlling for demographic/clinical characteristics. The agreement between EQ-5D and SF-6D (SF-12) scores was explored using descriptive psychometric techniques.ResultsHealth status and health state values were much lower than UK general population age-matched norms. After controlling for depression, physical co-morbidities, age, gender, living alone status, employment and accommodation, social isolation was significantly associated, to a degree that was clinically relevant, with EQ-5D DSI, SF-6D (SF-12) and SF-12 MCS scores. The potential for ceiling effects on the EQ-5D with this population was identified.ConclusionThis work highlights the burden that social isolation may have on the health and well-being of older people. The potential HRQL gains from addressing social isolation may be considerable, with those at risk of social isolation also a key target group.

An evaluation of the effectiveness of a community mentoring service for socially isolated older people: a controlled trial

BackgroundSocial isolation affects a significant proportion of older people and is associated with poor health outcomes. The current evidence base regarding the effectiveness of interventions targeting social isolation is poor, and the potential utility of mentoring for this purpose has not previously been rigorously evaluated. The purpose of this study was to examine the effectiveness of a community-based mentoring service for improving mental health, social engagement and physical health for socially isolated older people.MethodsThis prospective controlled trial compared a sample of mentoring service clients (intervention group) with a matched control group recruited through general practice. One hundred and ninety five participants from each group were matched on mental wellbeing and social activity scores. Assessments were conducted at baseline and at six month follow-up. The primary outcome was the Short Form Health Survey v2 (SF-12) mental health component score (MCS). Secondary outcomes included the SF-12 physical health component score (PCS), EuroQol EQ-5D, Geriatric Depression Score (GDS-10), social activity, social support and morbidities.ResultsWe found no evidence that mentoring was beneficial across a wide range of participant outcomes measuring health status, social activity and depression. No statistically significant between-group differences were observed at follow-up in the primary outcome (p = 0.48) and in most secondary outcomes. Identifying suitable matched pairs of intervention and control group participants proved challenging.ConclusionsThe results of this trial provide no substantial evidence supporting the use of community mentoring as an effective means of alleviating social isolation in older people. Further evidence is needed on the effectiveness of community-based interventions targeting social isolation. When using non-randomised designs, there are considerable challenges in the recruitment of suitable matches from a community sample.Trial registrationSCIE Research Register for Social Care 105923

Using the Multiple Sclerosis Impact Scale to Estimate Health State Utility Values: Mapping from the MSIS-29, Version 2, to the EQ-5D and the SF-6D

OBJECTIVES The 29-item Multiple Sclerosis Impact Scale (MSIS-29) is a psychometrically validated patient-reported outcome measure increasingly used in trials of treatments for multiple sclerosis. However, it is non-preference-based and not amenable for use across policy decision-making contexts. Our objective was to statistically map from the MSIS-29, version 2, to the EuroQol five-dimension (EQ-5D) and the six-dimension health state short form (derived from short form 36 health survey) (SF-6D) to estimate algorithms for use in cost-effectiveness analyses. METHODS The relationships between MSIS-29, version 2, and EQ-5D and SF-6D scores were estimated by using data from a cohort of people with multiple sclerosis in South West England (n=672). Six ordinary least squares (OLS), Tobit, and censored least adjusted deviation (CLAD) regression analyses were conducted on estimation samples, including the use of subscale and item scores, squared and interaction terms, and demographics. Algorithms from models with the smallest estimation errors (mean absolute error [MAE], root mean square error [RMSE], normalized RMSE) were then assessed by using separate validation samples. RESULTS Tobit and CLAD. For the EQ-5D, the OLS models including subscale squared terms, and item scores and demographics performed comparably (MAE 0.147, RMSE 0.202 and MAE 0.147, RMSE 0.203, respectively), and estimated scores well up to 3 years post-baseline. Estimation errors for the SF-6D were smaller (OLS model including squared terms: MAE 0.058, RMSE 0.073; OLS model using item scores and demographics: MAE 0.059, RMSE 0.08), and the errors for poorer health states found with the EQ-5D were less pronounced. CONCLUSIONS We have provided algorithms for the estimation of health state utility values, both the EQ-5D and SF-6D, from scores on the MSIS-29, version 2. Further research is now needed to determine how these algorithms perform in practical decision-making contexts, when compared with observed EQ-5D and SF-6D values.

The use of multiple sclerosis condition-specific measures to inform health policy decision-making: mapping from the MSWS-12 to the EQ-5D.

Background: Walking impairment has a major influence on the quality of life of people with multiple sclerosis (MS). The Multiple Sclerosis Walking Scale (MSWS-12) assesses the impact of MS on walking ability from the patient’s perspective, but in its current form, is not amenable for use in many policy decision-making settings. Objectives: Statistical ‘mapping’ methods were used to convert MSWS-12 scores to EQ-5D health state values. Methods: The relationship between the measures was estimated using cohort data from people with MS in South West England. Regression analyses were conducted, estimation errors assessed, and predictive performance of the best models tested using longitudinal data. Results: Model performance was in line with that of other mapping studies, with the best-performing models being an ordinary least squares (OLS) model using MSWS-12 item scores, and an OLS model using the total MSWS-12 score and its squared term. Conclusions: A process has been described whereby data from a patient-reported outcome measure (MSWS-12) can be converted to (EQ-5D) health state values. These values may be used to consider the health-related quality of life of people with MS, to estimate quality adjusted life-years for use in effectiveness and cost-effectiveness analyses, and to inform health policy decisions.

Multiple sclerosis: relapses, resource use, and costs

BackgroundRelapses can have a major impact on the lives of people with multiple sclerosis (MS), and yet relapse-related healthcare costs have received little attention. This has limited cost-effectiveness analyses of treatments for MS and hampered decision-making regarding the funding of MS healthcare services.ObjectiveTo describe health/social care resource use and costs according to the frequency, severity, and endurance of MS relapses.MethodsData from the prospective, longitudinal UK South West Impact of Multiple Sclerosis cohort were used. A total of 11,800 questionnaires from 1441 people with MS were available, including data on relapses, contacts with health/social care professionals, and other MS-related resource use.ResultsThe mean (SD) 6-monthly MS-related health/social care cost for individuals who reported a relapse was £519 (£949), compared to £229 (£366) for those who had not did report a relapse. Care costs varied widely dependent on the characteristics of the relapse. The mean (SD) cost when a relapse was not treated with steroids was £381 (£780), whilst the equivalent cost was £3579 (£1727) when a relapse resulted in hospitalization.ConclusionsThe impact of relapses on health and social care resources and costs differs according to their frequency, length, and severity. The data provided here can be used in cost-effectiveness analyses and to inform decision-making regarding healthcare provision for people with this condition.

Health Utilities for Multiple Sclerosis.

OBJECTIVES 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.

Statistical Alchemy: Conceptual Validity and Mapping to Generate Health State Utility Values

Mapping between non-preference- and preference-based health-related quality-of-life instruments has become a common technique for estimating health state utility values for use in economic evaluations. Despite the increased use of mapped health state utility estimates in health technology assessment and economic evaluation, the methods for deriving them have not been fully justified. Recent guidelines aim to standardise reporting of the methods used to map between instruments but do not address fundamental concerns in the underlying conceptual model. Current mapping methods ignore the important conceptual issues that arise when extrapolating results from potentially unrelated measures. At the crux of the mapping problem is a question of validity; because one instrument can be used to predict the scores on another, does this mean that the same preference for health is being measured in actual and estimated health state utility values? We refer to this as conceptual validity. This paper aims to (1) explain the idea of conceptual validity in mapping and its implications; (2) consider the consequences of poor conceptual validity when mapping for decision making in the context of healthcare resource allocation; and (3) offer some preliminary suggestions for improving conceptual validity in mapping.

“Naming and Framing”: The Impact of Labeling on Health State Values for Multiple Sclerosis:

Introduction. Health state valuation is a key input in many economic evaluations that inform resource allocation across competing healthcare interventions. Empirical evidence has shown that, in preference elicitation surveys, respondents may value a health state differently if they are aware of the condition causing it (‘labeling 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 labeled and unlabeled states were 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 labeled MS states v. unlabeled states. The data suggest that 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 to 0.883 for unlabeled states, and 0.066 to 0.861 for labeled states. Conclusion. Differences reported in health state values, using labeled and unlabeled states, demonstrate that condition labels affect the results of valuation studies, and can have important implications in decision-analytic modelling and in economic evaluations.

Implementing a patient-initiated review system for people with rheumatoid arthritis: a prospective, comparative service evaluation

RATIONALE, AIMS AND OBJECTIVES The management of rheumatoid arthritis (RA) usually entails regular hospital reviews with a specialist often when the patient is well rather than during a period of exacerbation. An alternative approach where patients initiate appointments when they need them can improve patient satisfaction and resource use whilst being safe. This service evaluation reports a system-wide implementation of a patient-initiated review appointment system called Direct Access (DA) for people with RA. The aim was to establish the impact on patient satisfaction of the new system versus usual care as well as evaluate the implementation processes. METHODS As all patients could not start on the new system at once, in order to manage the implementation, patients were randomly allocated to DA or to usual care. Instead of regular follow-up appointments, DA comprised an education session and access to a nurse-led telephone advice line where appointments could be accessed within two weeks. Usual care comprised routine follow-ups with the specialist. Data were collected on patient satisfaction, service use and outcomes of any contact to the advice line. RESULTS Three hundred and eleven patients with RA were assessed as being suitable for DA. In terms of patient satisfaction, between-group differences were found in favour of DA for accessibility and convenience, ease of contacting the nurse and overall satisfaction with the service. Self-reported visits to the general practitioner were also significantly lower. DA resulted in a greater number of telephone contacts (incidence rate ratio = 1.69; 95% confidence interval 1.07 to 2.68). Hospital costs of the two different service models were similar. Mean waiting time for an appointment was 10.8 days CONCLUSION This service evaluation found that DA could be implemented and it demonstrated patient benefit in a real-world setting. Further research establishing the broader cost-consequences across the whole patient pathway would add to our findings.

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)

OBJECTIVE 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.