Lynda McKenzie

The use of QALYs in health care decision making.

This paper seeks to highlight some of the critical issues concerning the use of the Quality Adjusted Life Years (QALYs) to measure the outcome of health care choices, in decisions related to both individual patient care and social resource allocation. Much of the support for the QALY is based on its simplicity as a tool for resolving complex choices. However, it may be the case that the QALY is not sufficiently refined or robust, failing perhaps to take into account some of the critical factors which affect preferences over different health care scenarios.

Mapping the EORTC QLQ C-30 onto the EQ-5D instrument: the potential to estimate QALYs without generic preference data.

OBJECTIVES The aim of this article is to map the European Organization for Research and Treatment of Cancer (EORTC) QLQ C-30 onto the EQ-5D measure to enable the estimation of health state values based on the EORTC QLQ C-30 data. The EORTC QLQ C-30 is of interest because it is the most commonly used instrument to measure the quality of life of cancer patients. METHODS Regression analysis is used to establish the relationship between the two instruments. The performance of the model is assessed in terms of how well the responses to the EORTC QLQ C-30 predict the EQ-5D responses for a separate data set. RESULTS The results showed that the model explaining EQ-5D values predicted well. All of the actual values were within the 95% confidence intervals of the predicted values. More importantly, predicted difference in quality-adjusted life-years (QALYs) between the arms of the trial was almost identical to the actual difference. CONCLUSION There is potential to estimate EQ-5D values using responses to the disease-specific EORTC QLQ C-30 measure of quality of life. Such potential implies that in studies that do not include disease-specific measures, it might still be possible to estimate QALYs.

Symptom-based outcome measures for asthma: the use of discrete choice methods to assess patient preferences.

This paper reports on an application of discrete choice modelling to the measurement of patient preferences over asthma symptoms. A sample of patients with moderate to severe asthma was asked to choose between a series of pairs of scenarios characterised by different combinations of asthma symptoms. Their responses were analysed using a random effects ordered probit model. The results implied that patients weighted some symptoms more highly than others. Discrete choice modelling proved to be a useful approach for developing preference based outcome measures, although the results show how, in contexts where preferences over health care outcomes based on symptoms or some measure of health status are involved, a conventional linear additive model may not always be suitable.

Tackling Alcohol Misuse Purchasing Patterns Affected by Minimum Pricing for Alcohol

BackgroundAlcohol consumption is associated with a range of health and social harms that increase with the level of consumption. Policy makers are interested in effective and cost-effective interventions to reduce alcohol consumption and associated harms. Economic theory and research evidence demonstrate that increasing price is effective at the population level. Price interventions that target heavier consumers of alcohol may be more effective at reducing alcohol-related harms with less impact on moderate consumers. Minimum pricing per unit of alcohol has been proposed on this basis but concerns have been expressed that ‘moderate drinkers of modest means’ will be unfairly penalized. If those on low incomes are disproportionately affected by a policy that removes very cheap alcohol from the market, the policy could be regressive. The effect on households’ budgets will depend on who currently purchases cheaper products and the extent to which the resulting changes in prices will impact on their demand for alcohol. This paper focuses on the first of these points.ObjectiveThis paper aims to identify patterns of purchasing of cheap off-trade alcohol products, focusing on income and the level of all alcohol purchased.MethodThree years (2006–08) of UK household survey data were used. The Expenditure and Food Survey provides comprehensive 2-week data on household expenditure. Regression analyses were used to investigate the relationships between the purchase of cheap off-trade alcohol, household income levels and whether the household level of alcohol purchasing is categorized as moderate, hazardous or harmful, while controlling for other household and non-household characteristics. Predicted probabilities and quantities for cheap alcohol purchasing patterns were generated for all households.ResultsThe descriptive statistics and regression analyses indicate that low-income households are not the predominant purchasers of any alcohol or even of cheap alcohol. Of those who do purchase off-trade alcohol, the lowest income households are the most likely to purchase cheap alcohol. However, when combined with the fact that the lowest income households are the least likely to purchase any off-trade alcohol, they have the lowest probability of purchasing cheap off-trade alcohol at the population level. Moderate purchasing households in all income quintiles are the group predicted as least likely to purchase cheap alcohol. The predicted average quantity of low-cost off-trade alcohol reveals similar patterns.ConclusionThe results suggest that heavier household purchasers of alcohol are most likely to be affected by the introduction of a ‘minimum price per unit of alcohol’ policy. When we focus only on those households that purchase off-trade alcohol, lower income households are the most likely to be affected. However, minimum pricing in the UK is unlikely to be significantly regressive when the effects are considered for the whole population, including those households that do not purchase any off-trade alcohol. Minimum pricing will affect the minority of low-income households that purchase off-trade alcohol and, within this group, those most likely to be affected are households purchasing at a harmful level.

A randomised controlled trial of a tailored multifaceted strategy to promote implementation of a clinical guideline on induced abortion care

Objective  To evaluate the effectiveness and efficiency of a tailored multifaceted strategy, delivered by a national clinical effectiveness programme, to implement a guideline on induced abortion.

Head and neck cancer assessment by flexible endoscopy and telemedicine

We have conducted a feasibility study to establish whether ENT tele-endoscopy would be a suitable method of service delivery for patients who live in the Shetland Islands. Ten clinics were conducted over a period of 17 months using ISDN-based videoconferencing at a bandwidth of 384 kbit/s. A total of 42 patients were seen in Aberdeen via videoconferencing for a head and neck cancer assessment. Feasibility was confirmed after the first 20 patients, following positive feedback from all concerned and the absence of any significant clinical or technical problems. A total of 42 journeys was avoided, each journey saving 123 kg CO2 per person. A preliminary cost analysis showed that the threshold at which tele-ENT became cheaper than travel was a workload of 35 patients/year. The actual workload during the pilot study was 29 patients/year. A national telemedicine service for the initial assessment of potential malignancy has the potential to reduce unnecessary transfers to specialist centres, with accompanying reductions in carbon emissions.

Metal on metal hip resurfacing arthroplasty

This paper explores the cost utility of metalon-metal hip resurfacing arthroplasty (MOM) as an alternative intervention to total hip replacement or ‘watchful waiting’ for patients with advanced hip disease. Early implant failure among younger and more active elderly patients can mean that the use of total hip replacement (THR) is delayed, with patients managed through ‘watchful waiting’, a combination of pain control and other non-surgical interventions. Information on costs is combined with evidence on effectiveness from a systematic review in a Markov model in order to estimate the incremental cost per quality adjusted life year (QALY) of MOM relative to THR and ‘watchful waiting’.

Costs and benefits of tele-endoscopy clinics in a remote location

We assessed the cost and benefits of tele-endoscopy clinics in a remote location in Scotland. Before the introduction of a tele-endoscopy service, patients whose symptoms suggested possible cancer of the airways had to travel to the mainland (to Aberdeen) to receive an endoscopy. The costs of staff, capital, disposables and travel were estimated for the tele-endoscopy clinic and for the conventional, mainland clinic. The benefits of the two types of clinic were estimated from a sample of the general public using a survey method called the discrete choice experiment. The average cost per patient was lower for the tele-endoscopy clinic (£353) than for the mainland clinic (£381). This was true if more than 27 patients were seen per year. Assuming equal waiting times, individuals preferred the tele-endoscopy clinic to the mainland clinic. The net benefits were larger for tele-endoscopy clinics as long as the additional waiting time was not longer than four weeks. Tele-endoscopy clinics in Shetland are an efficient alternative to conventional practice. The results are sensitive to both economies of scale and scope. The model can readily be applied to mainland communities outside the main population centres in Scotland.