Pirjo Räsänen

Effectiveness of hip or knee replacement surgery in terms of quality-adjusted life years and costs

Background Concurrent head-to-head comparisons of healthcare interventions regarding cost-utility are rare. The concept of favorable cost-effectiveness of total hip or knee arthroplasty is thus inadequately verified. Patients and methods In a trial involving several thousand patients from 10 medical specialties, 223 patients who were enrolled for hip or knee replacement surgery were asked to fill in the 15D health-related quality of life (HRQoL) survey before and after operation. Results Mean (SD) HRQoL score (on a 0–1 scale) increased in primary hip replacement patients (n = 96) from 0.81 (0.084) preoperatively to 0.86 (0.12) at 12 months (p < 0.001). In revision hip replacement (n = 24) the corresponding scores were 0.81 (0.086) and 0.82 (0.097) respectively (p = 0.4), and in knee replacement (n = 103) the scores were 0.81 (0.093) and 0.84 (0.11) respectively (p < 0.001). Of 15 health dimensions, there were statistically significant improvements in moving, usual activities, discomfort and symptoms, distress, and vitality in both primary replacement groups. Mean cost per quality-adjusted life year (QALY) gained during a 1-year period was € 6,710 for primary hip replacement, € 52,274 for revision hip replacement, and € 13,995 for primary knee replacement. Interpretation Hip and knee replacement both improve HRQoL. The cost per QALY gained from knee replacement is twice that gained from hip replacement.

The HTA Core Model: A novel method for producing and reporting health technology assessments

OBJECTIVES The aim of this study was to develop and test a generic framework to enable international collaboration for producing and sharing results of health technology assessments (HTAs). METHODS Ten international teams constructed the HTA Core Model, dividing information contained in a comprehensive HTA into standardized pieces, the assessment elements. Each element contains a generic issue that is translated into practical research questions while performing an assessment. Elements were described in detail in element cards. Two pilot assessments, designated as Core HTAs were also produced. The Model and Core HTAs were both validated. Guidance on the use of the HTA Core Model was compiled into a Handbook. RESULTS The HTA Core Model considers health technologies through nine domains. Two applications of the Model were developed, one for medical and surgical interventions and another for diagnostic technologies. Two Core HTAs were produced in parallel with developing the model, providing the first real-life testing of the Model and input for further development. The results of formal validation and public feedback were primarily positive. Development needs were also identified and considered. An online Handbook is available. CONCLUSIONS The HTA Core Model is a novel approach to HTA. It enables effective international production and sharing of HTA results in a structured format. The face validity of the Model was confirmed during the project, but further testing and refining are needed to ensure optimal usefulness and user-friendliness. Core HTAs are intended to serve as a basis for local HTA reports. Core HTAs do not contain recommendations on technology use.

Dysphonia and dysphagia after anterior cervical decompression

OBJECT In this paper, the authors investigate the effects of anterior cervical decompression (ACD) on swallowing and vocal function. METHODS The study comprised 114 patients who underwent ACD. The early group (50 patients) was examined immediately pre- and postoperatively, and the late group (64 patients) was examined at only 3 to 9 months postoperatively. Fifty age- and sex-matched patients from the Department of Otorhinolaryngology-Head and Neck Surgery who had not been intubated in the previous 5 years were used as a control group. All patients in the early and control groups were examined by a laryngologist; patients in the late group were examined by a laryngologist and a neurosurgeon. Videolaryngostroboscopy was performed in all members of the patient and control groups, and the function of the ninth through 12th cranial nerves were clinically evaluated. Data were collected concerning swallowing, voice quality, surgery results, and health-related quality of life. Patients with persistent dysphonia were referred for phoniatric evaluation and laryngeal electromyography (EMG). Those with persistent dysphagia underwent transoral endoscopic evaluation of swallowing function and videofluorography. RESULTS Sixty percent of patients in the early group reported dysphonia and 69% reported dysphagia at the immediate postoperative visit. Unilateral vocal fold paresis occurred in 12%. The prevalence of both dysphonia and dysphagia decreased in both groups 3 to 9 months postoperatively. All six patients with vocal fold paresis in the early group recovered, and in the late group there were two cases of vocal fold paresis. The results of laryngeal EMG were abnormal in 14 of 16 patients with persistent dysphonia. Neither intraoperative factors nor age or sex had any effect on the occurrence of dysphonia, dysphagia, or vocal fold paresis. Most patients were satisfied with the surgical outcome. CONCLUSIONS Dysphonia, dysphagia, and vocal fold paresis are common but usually transient complications of ACD. Recurrent laryngeal nerve damage detected by EMG is not rare. Pre-and postoperative laryngeal examination of ACD patients should be considered.

Health-related quality of life in patients with common rheumatic diseases referred to a university clinic

The aim of the present study was to assess the health-related quality of life (HRQoL) in patients with common rheumatic diseases referred to a rheumatology clinic and to compare it to the HRQoL of the general population. All patients with a new referral to the Department of Rheumatology of the Helsinki University Central Hospital were asked to participate in the study during the period from May 2002 to April 2003. A total of 295 patients with various rheumatic diseases were included in the analysis: 99 patients with rheumatoid arthritis (RA), 47 with arthralgia and fibromyalgia, 43 with other chronic arthritis (spondyloarthritis, psoriatic arthritis, enteropathic arthritis), 44 with osteoarthritis (OA), 22 with active reactive arthritis (ReA), 17 with systemic rheumatic diseases, 9 adults with juvenile idiopathic arthritis (JIA) and 14 with other diagnoses. HRQoL was measured by a disease specific instrument, the Stanford health assessment questionnaire (HAQ) and by a generic instrument, 15D. The mean baseline 15D score of the 295 included patients (0.822, SD 0.114) was significantly lower than of the general population (0.903, SD 0.098). Patients with OA and chronic arthritis reported the poorest HRQoL scores (both 0.810 on a 0–1 scale). In patients with RA and ReA the 15D score improved in a statistically significant and clinically important manner during the 8-month follow-up. Discomfort and symptoms caused by the disease were alleviated in a statistically significant manner in patients with RA as well as in those with arthralgia and fibromyalgia, chronic arthritis, ReA and systemic rheumatic diseases. HAQ score improved significantly in patients with RA, arthralgia and fibromyalgia, and ReA. The HRQoL of patients with common rheumatic diseases at referral to rheumatology clinic is significantly lower than the HRQoL of age-standardized general population. The most affected patients are those with OA, chronic arthritis and RA. A significant improvement in HRQoL with conventional interventions was achieved in patients with RA and ReA.

Cost-utility of routine cataract surgery.

BackgroundIf decisions on health care spending are to be as rational and objective as possible, knowledge on cost-effectiveness of routine care is essential. Our aim, therefore, was to evaluate the cost-utility of routine cataract surgery in a real-world setting.MethodsProspective assessment of health-related quality of life (HRQoL) of patients undergoing cataract surgery. 219 patients (mean (SD) age 71 (11) years) entering cataract surgery (in 87 only first eye operated, in 73 both eyes operated, in 59 first eye had been operated earlier) filled in the 15D HRQoL questionnaire before and six months after operation. Direct hospital costs were obtained from a clinical patient administration database and cost-utility analysis performed from the perspective of the secondary care provider extrapolating benefits of surgery to the remaining statistical life-expectancy of the patients.ResultsMean (SD) utility score (on a 0–1 scale) increased statistically insignificantly from 0.82 (0.13) to 0.83 (0.14). Of the 15 dimensions of the HRQoL instrument, only seeing improved significantly after operation. Mean utility score improved statistically significantly only in patients reporting significant or major preoperative seeing problems. Of the subgroups, only those whose both eyes were operated during follow-up showed a statistically significant (p < 0.001) improvement. Cost per quality-adjusted life year (QALY) gained was €5128 for patients whose both eyes were operated and €8212 for patients with only one eye operated during the 6-month follow-up. In patients whose first eye had been operated earlier mean HRQoL deteriorated after surgery precluding the establishment of the cost per QALY.ConclusionMean utility gain after routine cataract surgery in a real-world setting was relatively small and confined mostly to patients whose both eyes were operated. The cost of cataract surgery per quality-adjusted life year gained was much higher than previously reported and associated with considerable uncertainty.

Cost of a quality-adjusted life year in liver transplantation: the influence of the indication and the model for end-stage liver disease score.

Cost issues in liver transplantation (LT) have received increasing attention, but the cost‐utility is rarely calculated. We compared costs per quality‐adjusted life year (QALY) from the time of placement on the LT waiting list to 1 year after transplantation for 252 LT patients and to 5 years after transplantation for 81 patients. We performed separate calculations for chronic liver disease (CLD), acute liver failure (ALF), and different Model for End‐Stage Liver Disease (MELD) scores. For the estimation of QALYs, the health‐related quality of life was measured with the 15D instrument. The median costs and QALYs after LT were €141,768 and 0.895 for 1 year and €177,618 and 3.960 for 5 years, respectively. The costs of the first year were 80% of the 5‐year costs. The main cost during years 2 to 5 was immunosuppression drugs (59% of the annual costs). The cost/QALY ratio improved from €158,400/QALY at 1 year to €44,854/QALY at 5 years, and the ratio was more beneficial for CLD patients (€42,500/QALY) versus ALF patients (€63,957/QALY) and for patients with low MELD scores versus patients with high MELD scores. Although patients with CLD and MELD scores > 25 demonstrated markedly higher 5‐year costs (€228,434) than patients with MELD scores < 15 (€169,541), the cost/QALY difference was less pronounced (€59,894/QALY and €41,769/QALY, respectively). The cost/QALY ratio for LT appears favorable, but it is dependent on the assessed time period and the severity of the liver disease. Liver Transpl 17:1333–1343, 2011.

Cost-effectiveness of interventions based on physical exercise in the treatment of various diseases: A systematic literature review

OBJECTIVES The aim of this study was to review studies reporting cost-effectiveness of exercise-based interventions in treatment of various diseases. METHODS Systematic literature search using several databases. Abstracts initially screened independently by two authors, full-text articles again evaluated by two authors, who decided whether an article should be included. Included were scientifically valid articles describing controlled studies that included an exercise-based intervention in the treatment of an established medical condition, and also reported on the cost-effectiveness of the intervention, or its effect on the utilization of health services. Quality was assessed with an established approach. RESULTS A total of 914 articles were identified, of them 151 were obtained for closer review. Sixty-five articles describing sixty-one studies were included. Most (82 percent) were randomized trials. Twenty-eight studies dealt with musculoskeletal disorders, fifteen with cardiology, four with rheumatic diseases, four with pulmonary diseases, three with urinary incontinence, and two with vascular disorders. There was one study each in the fields of oncology, chronic fatigue, endocrinology, psychiatry, and neurology. Exercise interventions in musculoskeletal disorders were deemed to be cost-effective in 54 percent, in cardiology in 60 percent, and in rheumatic diseases in 75 percent of the cases. There was some evidence that exercise might be cost-effective in intermittent claudication, breast cancer patients, diabetes, and schizophrenia. CONCLUSIONS The number of studies assessing cost-effectiveness of exercise interventions in various diseases is still limited. The results show large variation but suggest that some exercise interventions can be cost-effective. Most convincing evidence was found for rehabilitation of cardiac and back pain patients; however, even in these cases, the evidence was partly contradictory.

Testing the HTA Core Model: Experiences from two pilot projects

OBJECTIVES The aim of this study was to analyze and describe process and outcomes of two pilot assessments based on the HTA Core Model, discuss the applicability of the model, and explore areas of development. METHODS Data were gathered from HTA Core Model and pilot Core HTA documents, their validation feedback, questionnaires to investigators, meeting minutes, emails, and discussions in the coordinating team meetings in the Finnish Office for Health Technology Assessment (FINOHTA). RESULTS The elementary structure of the HTA Core Model proved useful in preparing HTAs. Clear scoping and good coordination in timing and distribution of work would probably help improve applicability and avoid duplication of work. CONCLUSIONS The HTA Core Model can be developed into a platform that enables and encourages true HTA collaboration in terms of distribution of work and maximum utilization of a common pool of structured HTA information for national HTA reports.

Cost analysis and health-related quality of life of home and self-care satellite haemodialysis

BACKGROUND Home haemodialysis (HHD) and self-care satellite dialyses (SHD) have been suggested to offer significant benefits over conventional in-centre haemodialysis. However, little is known about differences between these two modalities. The purpose of the study was to analyse costs and health-related quality of life (HRQoL) of HHD and SHD. METHODS On 15 October 2004, a total of 65 patients attended self-care haemodialysis in the area. Of those patients, 33 were on HHD and 32 on SHD. Cost data were collected from those study patients who were on dialysis the whole calendar year 2004 (23/33 HHD and 28/32 SHD patients). HRQoL was measured by the generic 15D instrument. The questionnaire was administered to all the study patients. A total of 23/33 of HHD and 24/32 of SHD patients returned the questionnaire. RESULTS Direct medical costs of dialysis and hospital treatment were higher in HHD (31 834 +/- 6046 EUR/year, mean +/- SD) than in SHD (27 528 +/- 4325), P < 0.005. By contrast, travel costs were lower in HHD (426 +/- 743 EUR/year) than in SHD (5228 +/- 4236), P < 0.001. Costs of pharmaceuticals did not differ significantly. There was no significant difference in the total costs between HHD and SHD (38 477 +/- 7685 and 39 781 +/- 10 226 EUR/year), P = not significant. There were no significant differences in the total 15D score or in the 15 dimensions of the 15D instrument between home and satellite patients. CONCLUSIONS HHD and SHD are, from the patients perspective, equally effective in providing health. Although there were significant differences in the distribution of costs (which needs to be taken into account when evaluating different treatment strategies), total costs were similar. However, in the HHD setting, patients had on average more and longer sessions. Patient preference should be the main decisive factor when choosing between home or satellite haemodialysis.

Cost-utility of Treatment of Bulimia Nervosa

OBJECTIVE The costs of treating eating disorders are high. Our objective was to perform a cost-utility analysis of treatment of bulimia nervosa. METHOD 72 patients entering treatment of bulimia nervosa (ICD-10 diagnosis) completed the 15D health-related quality of life (HRQoL) questionnaire and the Eating Disorder Inventory (EDI) before and 6 months after the start of treatment. Quality-adjusted life years (QALYs) gained were calculated and cost-utility was assessed within the time horizon of 10 years. RESULTS Baseline HRQoL was severely impaired in the patients. As a consequence of treatment, mean HRQoL improved clinically and statistically significantly. The cost per QALY gained varied from €1,455 to €16,481 (from €4,428 to €19,663 discounted at 5%) depending on the assumptions used in the analysis. DISCUSSION HRQoL of bulimia nervosa patients is severely impaired, but treatment has a clear positive effect on HRQoL. The cost per QALY gained is comparable to many other treatments.