Julie Ratcliffe

Effectiveness and cost-effectiveness of three types of physiotherapy used to reduce chronic low back pain disability: a pragmatic randomized trial with economic evaluation.

Study Design. Pragmatic, randomized, assessor blinded, clinical trial with economic analysis. Objective. To compare the effectiveness and cost-effectiveness of three kinds of physiotherapy commonly used to reduce disability in chronic low back pain. Summary of Background Data. Physiotherapy reduces disability in chronic back pain, but there are several forms of physiotherapy and it is unclear which is most effective or cost effective. Methods. A total of 212 patients referred to physiotherapy with chronic low back pain were randomized to receive usual outpatient physiotherapy, spinal stabilization classes, or physiotherapist-led pain management classes. Primary outcome was Roland Disability Questionnaire score 18 months from baseline; secondary measures were pain, health-related quality of life, and time off work. Healthcare costs associated with low back pain and quality-adjusted life years (QALYs) were also measured. Results. A total of 71 participants were assigned to usual outpatient physiotherapy, 72 to spinal stabilization, and 69 to physiotherapist-led pain management. A total of 160 (75%) provided follow-up data at 18 months, showing similar improvements with all interventions: mean (95% confidence intervals) Roland Disability Questionnaire score improved from 11.1 (9.6–12.6) to 6.9 (5.3–8.4) with usual outpatient physiotherapy, 12.8 (11.4−14.2) to 6.8 (4.9–8.6) with spinal stabilization, and 11.5 (9.8–13.1) to 6.5 (4.5–8.6) following pain management classes. Pain, quality of life, and time off work also improved within all groups with no between-group differences. Mean (SD) healthcare costs and QALY gain were £474 (840) and 0.99 (0.27) for individual physiotherapy, £379 (1040) and 0.90 (0.37) for spinal stabilization, and £165 (202) and 1.00 (0.28) for pain management. Conclusions. For chronic low back pain, all three physiotherapy regimens improved disability and other relevant health outcomes, regardless of their content. Physiotherapist-led pain management classes offer a cost-effective alternative to usual outpatient physiotherapy and are associated with less healthcare use. A more widespread adoption of physiotherapist-led pain management could result in considerable cost savings for healthcare providers.

Public preferences for the allocation of donor liver grafts for transplantation

To investigate the nature of public preferences in the allocation of donor liver grafts for transplantation a social conjoint analysis (CA) technique was developed for a questionnaire survey. A convenience sample of academic and non-academic employees of a British University were invited to participate in the survey. Respondents were presented with eight choice situations in which they were asked to allocate 100 donor liver grafts between two groups of 100 individuals in urgent need of a transplant. The groups of individuals differed in terms of the length of time spent waiting, the life years gained following transplantation, age, personal responsibility for their illness and whether they were primary or re-transplant candidates. Only two respondents (0.7%) consistently chose to give all of the donor organs to the group of individuals with the highest expected length of survival whilst seven respondents (2%) exhibited strict egalitarian preferences, allocating equal numbers of donor organs to both groups irrespective of their characteristics. The vast majority of respondents indicated that they would be prepared to sacrifice some gain in the efficiency of the transplantation programme for an increase in equity or fairness in the allocation of donor livers. Using social CA it was possible to establish the relative weight attached to each characteristic in determining individuals allocation decisions.

Time Trade-Off Derived EQ-5D Weights for Australia

BACKGROUND Cost-utility analyses (CUAs) are increasingly common in Australia. The EuroQol five-dimensional (EQ-5D) questionnaire is one of the most widely used generic preference-based instruments for measuring health-related quality of life for the estimation of quality-adjusted life years within a CUA. There is evidence that valuations of health states vary across countries, but Australian weights have not previously been developed. METHODS Conventionally, weights are derived by applying the time trade-off elicitation method to a subset of the EQ-5D health states. Using a larger set of directly valued health states than in previous studies, time trade-off valuations were collected from a representative sample of the Australian general population (n = 417). A range of models were estimated and compared as a basis for generating an Australian algorithm. RESULTS The Australia-specific EQ-5D values generated were similar to those previously produced for a range of other countries, but the number of directly valued states allowed inclusion of more interaction effects, which increased the divergence between Australias algorithm and other algorithms in the literature. CONCLUSION This new algorithm will enable the Australian community values to be reflected in future economic evaluations.

Randomized clinical trial comparing surgery with conservative treatment for uncomplicated varicose veins.

Surgical treatment of medically uncomplicated varicose veins is common, but its clinical effectiveness remains uncertain.

International Comparisons in Valuing EQ-5D Health States: A Review and Analysis

OBJECTIVE To identify the key methodological issues in the construction of population-level EuroQol 5-dimensions (EQ-5D)/time trade-off (TTO) preference elicitation studies. METHOD This study involved three components. The first was to identify existing population-level EQ-5D TTO studies. The second was to illustrate and discuss the key areas of divergence between studies, including the international comparison of tariffs. The third was to portray the relative merits of each of the approaches and to compare the results of studies across countries. RESULTS While most articles report use of the protocol developed in the original UK study, we identified three key areas of divergence in the construction and analysis of surveys. These are the number of health states valued to determine the algorithm for estimating all health states, the approach to valuing states worse than immediate death, and the choice of algorithm. The evidence on international comparisons suggests differences between countries although it is difficult to disentangle differences in cultural attitudes with random error and differences as a result of methodological divergence. CONCLUSIONS Differences in methods may obscure true differences in values between countries. Nevertheless, population-specific valuation sets for countries engaging in economic evaluation would better reflect cultural differences and are therefore more likely to accurately represent societal attitudes.

Is the Nintendo Wii Fit really acceptable to older people?: a discrete choice experiment

BackgroundInteractive video games such as the Nintendo Wii Fit are increasingly used as a therapeutic tool in health and aged care settings however, their acceptability to older people is unclear. The aim of this study was to determine the acceptability of the Nintendo Wii Fit as a therapy tool for hospitalised older people using a discrete choice experiment (DCE) before and after exposure to the intervention.MethodsA DCE was administered to 21 participants in an interview style format prior to, and following several sessions of using the Wii Fit in physiotherapy. The physiotherapist prescribed the Wii Fit activities, supervised and supported the patient during the therapy sessions. Attributes included in the DCE were: mode of therapy (traditional or using the Wii Fit), amount of therapy, cost of therapy program and percentage of recovery made. Data was analysed using conditional (fixed-effects) logistic regression.ResultsPrior to commencing the therapy program participants were most concerned about therapy time (avoiding programs that were too intensive), and the amount of recovery they would make. Following the therapy program, participants were more concerned with the mode of therapy and preferred traditional therapy programs over programs using the Wii Fit.ConclusionsThe usefulness of the Wii Fit as a therapy tool with hospitalised older people is limited not only by the small proportion of older people who are able to use it, but by older peoples preferences for traditional approaches to therapy. Mainstream media portrayals of the popularity of the Wii Fit with older people may not reflect the true acceptability in the older hospitalised population.

HEALTH-RELATED QUALITY OF LIFE FOLLOWING LIVER TRANSPLANTATION

The objectives of this study were to report on the health-related quality of life (QoL) experienced by patients following liver transplantation and to investigate the factors associated with its variation. A questionnaire comprising the SF-36 and EuroQol EQ-5D instruments was sent by post to 147 patients who had received a liver transplant, indicated by a chronic liver disease, in the previous 8 years. The scores of the respondents were compared to population norm scores. The variation in both the SF-36 and EQ-5D scores was explored. Many liver transplant patients experienced most satisfactory QoL levels post- transplantation although, in general terms, the levels were poorer than those seen in the general population. The variation in the post-transplant health-related QoL scores was found to be associated with a number of pre-transplant factors: disease severity (proxied by Child Pugh class), disease duration at the time of transplantation and liver transplant history (whether the patient had received a single or multiple transplants). In making clinical decisions about the use of transplantation for chronic liver diseases, consideration should be given to the key factors likely to affect subsequent health-related QoL.

Valuing Child Health Utility 9D health states with a young adolescent sample: a feasibility study to compare best-worst scaling discrete-choice experiment, standard gamble and time trade-off methods.

QALYs are increasingly being utilized as a health outcome measure to calculate the benefits of new treatments and interventions within cost-utility analyses for economic evaluation. Cost-utility analyses of adolescent-specific treatment programmes are scant in comparison with those reported upon for adults and tend to incorporate the views of clinicians or adults as the main source of preferences. However, it is not clear that the views of adults are in accordance with those of adolescents on this issue. Hence, the treatments and interventions most highly valued by adults may not correspond with those most highly valued by adolescents. Ordinal methods for health state valuation may be more easily understood and interpreted by young adolescent samples than conventional approaches. The availability of young adolescent-specific health state values for the estimation of QALYs will provide new insights into the types of treatment programmes and health services that are most highly valued by young adolescents.The first objective of this study was to assess the feasibility of applying best-worst scaling (BWS) discrete-choice experiment (DCE) methods in a young adolescent sample to value health states defined by the Child Health Utility 9D (CHU9D) instrument, a new generic preference-based measure of health-related quality of life developed specifically for application in young people. The second objective was to compare BWS DCE questions (where respondents are asked to indicate the best and worst attribute for each of a number of health states, presented one at a time) with conventional time trade-off (TTO) and standard gamble (SG) questions in terms of ease of understanding and completeness.A feasibility study sample of consenting young adolescent school children (n = 16) aged 11–13 years participated in a face-to-face interview in which they were asked to indicate the best and worst attribute levels from a series of health states defined by the CHU9D, presented one at a time. Participants were also randomly allocated to receive additional conventional TTO or SG questions and prompted to indicate how difficult they found them to complete.The results indicate that participants were able to readily choose ‘best’ and ‘worst’ dimension levels in each of the CHU9D health states presented to them and provide justification for their choices. Furthermore, when presented with TTO or SG questions and prompted to make comparisons, participants found the BWS DCE task easier to understand and complete.The results of this feasibility study suggest that BWS DCE methods are potentially more readily understood and interpretable by vulnerable populations (e.g. young adolescents). These findings lend support to the potential application of BWS DCE methods to undertake large-scale health state valuation studies directly with young adolescent population samples.

Using willingness to pay to value alternative models of antenatal care

Recent years have seen the development of different models of antenatal care, especially for low risk women. More specifically, there has been a move for more general practitioner and midwifery involvement in such care. Given the current changes that are taking place in the provision of antenatal care, it is becoming increasingly important to carry out economic evaluations of alternative models of care. This paper applies the economic instrument of willingness to pay to assess the benefits of two alternative forms of antenatal care: general practitioner/midwife routine led care versus obstetrician led care. The results suggest a willingness to pay of pounds 2500 for antenatal care, with no significant difference between the types of care provided. It is concluded that before firm policy conclusions can be reached, further studies should be undertaken to address methodological issues around the willingness to pay technique.

A Simulation Modelling Approach to Evaluating Alternative Policies for the Management of the Waiting List for Liver Transplantation

A shortage of donor liver grafts unfortunately results in approximately 10% of patients dying whilst listed for a liver transplant in Europe and the United States. Thus it is imperative that all available organs are used as efficiently as possible. This paper reports upon the application of a simulation modelling approach to assess the impact of several alternative allocation policies upon the cost effectiveness of this technology at one liver transplant centre in the UK. The impact of changes in allocation criteria on the estimated net life expectancy, average net costs and overall cost effectiveness of the transplantation programme were evaluated. The incremental cost effectiveness ratio (ICER) for the base case allocation policy, based upon the time spent on the waiting list (i.e., longest wait first) was £11,557 at 1999 prices. The ICERs associated with an allocation policy based upon age (lowest age first), and an allocation policy based upon the severity of the pre-transplant condition of the patient (with most severely ill patients given a lower priority) were lower than the base case at £10,424 and £9077, respectively. The results of this modelling study suggest that the overall cost effectiveness of the liver transplantation programme could be improved if the current allocation policy were modified to give more weight to the age of the patient and the reduced chances of success of the most severely ill patients.