Differences In Quality-adjusted Life Expectancy Research Articles

Income-related inequality in quality-adjusted life expectancy in Korea at the national and district levels

BackgroundThe aim of this study was to measure differences in quality-adjusted life expectancy (QALE) by income in Korea at the national and district levels.MethodsMortality rates and EuroQol-5D (EQ-5D) scores were obtained from the National Health Information Database of the National Health Insurance Service and the Korea Community Health Survey, respectively. QALE and differences in QALE among income quintiles were calculated using combined 2008–2014 data for 245 districts in Korea. Correlation analyses were conducted to investigate the associations of neighborhood characteristics with QALE and income gaps therein.ResultsQALE showed a graded pattern of inequality according to income, and increased over time for all levels of income and in both sexes, except for low-income quintiles among women, resulting in a widened inequality in QALE among women. In all 245 districts, pro-rich inequalities in QALE were found in both men and women. Districts with higher QALE and smaller income gaps in QALE were concentrated in metropolitan areas, while districts with lower QALE and larger income gaps in QALE were found in rural areas. QALE and differences in QALE by income showed relatively close correlations with socioeconomic characteristics, but relatively weak correlations with health behaviors, except for smoking and indicators related to medical resources.ConclusionsThis study provides evidence of income-based inequalities in health measured by QALE in all subnational areas in Korea. Furthermore, QALE and differences in QALE by income were closely associated with neighborhood-level socioeconomic characteristics.

Population-Based Estimates of Decreases in Quality-Adjusted Life Expectancy Associated with Unhealthy Body Mass Index.

Being classified as outside the normal range for body mass index (BMI) has been associated with increased risk for chronic health conditions, poor health-related quality of life (HRQOL), and premature death. To assess the impact of BMI on HRQOL and mortality, we compared quality-adjusted life expectancy (QALE) by BMI levels. We obtained HRQOL data from the 1993-2010 Behavioral Risk Factor Surveillance System and life table estimates from the National Center for Health Statistics national mortality files to estimate QALE among U.S. adults by BMI categories: underweight (BMI <18.5 kg/m(2)), normal weight (BMI 18.5-24.9 kg/m(2)), overweight (BMI 25.0-29.9 kg/m(2)), obese (BMI 30.0-34.9 kg/m(2)), and severely obese (BMI ≥35.0 kg/m(2)). In 2010 in the United States, the highest estimated QALE for adults at 18 years of age was 54.1 years for individuals classified as normal weight. The two lowest QALE estimates were for those classified as either underweight (48.9 years) or severely obese (48.2 years). For individuals who were overweight or obese, the QALE estimates fell between those classified as either normal weight (54.1 years) or severely obese (48.2 years). The difference in QALE between adults classified as normal weight and those classified as either overweight or obese was significantly higher among women than among men, irrespective of race/ethnicity. Using population-based data, we found significant differences in QALE loss by BMI category. These findings are valuable for setting national and state targets to reduce health risks associated with severe obesity, and could be used for cost-effectiveness evaluations of weight-reduction interventions.

Impact of depression on quality-adjusted life expectancy (QALE) directly as well as indirectly through suicide.

To estimate quality-adjusted life expectancy (QALE) loss among US adults due to depression and QALE losses associated with the increased risk of suicide attributable to depression. We ascertained depressive symptoms using the eight-item Patient Health Questionnaire (PHQ-8) on the 2006, 2008, and 2010 Behavioral Risk Factor Surveillance System (BRFSS) surveys. We estimated health-related quality of life (HRQOL) scores from BRFSS data (n = 276,442) and constructed life tables from US Compressed Mortality Files to calculate QALE by depression status. QALE loss due to depression is the difference in QALE between depressed and non-depressed adults. QALE loss associated with suicide deaths is the difference between QALE from only those deaths that did not have suicide recorded on the death certificate and QALE from all deaths including those with a suicide recorded on the death certificate. At age 18, QALE was 28.0 more years for depressed adults and 56.8 more years for non-depressed adults, a 28.9-year QALE loss due to depression. For depressed adults, only 0.41 years of QALE loss resulted from deaths by suicide, and only 0.26 years of this loss could be attributed to depression. Depression symptoms lead to a significant burden of disease from both mortality and morbidity as assessed by QALE loss. The 28.9-year QALE loss at age 18 associated with depression markedly exceeds estimates reported elsewhere for stroke (12.4-year loss), heart disease (10.3-year loss), diabetes mellitus (11.1-year loss), hypertension (6.3-year loss), asthma (7.0-year loss), smoking (11.0-year loss), and physical inactivity (8.0-year loss).

The economic burden of disease by industry: Differences in quality-adjusted life years and associated costs.

This study compares differences in quality-adjusted life expectancy across the eight original National Occupational Research Agenda (NORA) industry sectors. Data from the 1997 to 2012 National Health Interview Survey (NHIS) were used to estimate quality-adjusted life years (QALYs) for all workers and by NORA sector. Differences in QALYs were calculated and translated into economic values using estimates of the societal willingness-to-pay per QALY. Mean QALYs across workers was 29.17 years. Among NORA sectors, wholesale, and retail trade workers had the highest average QALYs remaining (35.88), while mining workers had the lowest QALYs (31.4). The economic value of this difference ranges from $604,843 to $1,155,287 per worker depending on the societal willingness-to-pay per QALY. The value of life lost within some industries is very high relative to others. Additional investments in occupational safety, benefits, and health promotion initiatives may reduce these losses, but experimental research is needed to assess the effectiveness of such programs.

Combined Modality Therapy Versus Chemotherapy Alone As an Induction Regimen for Primary CNS Lymphoma: A Cost-Effectiveness Analysis

Abstract 969 Background:Induction therapy for non-HIV, primary CNS lymphoma is centered on high-dose methotrexate (MTX) as the most effective chemotherapeutic agent. Combined modality therapy (CMT) using high-dose MTX and whole brain radiotherapy (WBRT) has improved response rates compared to chemotherapy alone. The trade-off is a significant risk of delayed, treatment-related neurotoxicity (NT), leading to significant morbidity and mortality. This risk of NT is greater in patients over the age of 60. We performed a cost-effectiveness analysis comparing the two strategies and stratified the analysis by age. Our analyses compared quality-adjusted life expectancy (QALY) and incremental cost effectiveness ratio (ICER) with these two strategies. Methods:We developed a Markov decision-analytic model to compare CMT versus chemotherapy alone for a hypothetical cohort of 60 year old patients newly-diagnosed with primary CNS lymphoma. We age-stratified the model to evaluate cohorts of patients <60 and >60 years of age. The model simulates the clinical course of patients over a 5 year time horizon, with the end-points of QALY and ICER. The baseline probabilities used in the model were derived from a systematic review of published studies. Key variables included response, relapse and survival rates with CMT vs. chemotherapy alone, risk of developing NT with each strategy, including severe NT, and the estimated survival once NT develops. The model incorporated data on health state utilities, which were derived from a survey of expert physicians who treat patients with primary CNS lymphoma. Direct and lost productivity costs were collected from a Canadian perspective. Resource utilization was based on guidelines, literature and expert opinion. Cost information was obtained from hospital, provincial and national costing sources, as well as the literature, and presented in 2011 Canadian dollars. Both costs and effects were discounted at 5%. All patients who received chemotherapy alone as induction therapy were assumed to have received salvage radiotherapy upon relapse. The utility of having active disease was assumed to dominate any ill effects from neurotoxicity. The cost of living with neurotoxicity was assumed to be similar to living with Alzheimer’s dementia of comparable severity. Sensitivity analyses were performed for key variables. Results:The quality-adjusted life expectancy was 1.55 quality-adjusted life years (QALYs) for CMT and 1.53 QALYs for chemotherapy alone. The incremental cost-effectiveness ratio for the base case CMT vs. chemotherapy alone was $491,522 per life year gained (LYG). In younger patients <60 years of age, CMT yielded a quality-adjusted life expectancy of 2.44 QALYs, compared to 1.89 QALYs for chemotherapy alone, yielding an expected benefit with CMT of 0.55 QALYs or 6.6 quality-adjusted months. The CMT strategy dominates in younger patients as it is $11,951 less expensive than chemotherapy alone. There was no difference in QALYs between the strategies in the older group. The chemotherapy alone strategy dominates in older patients as it is $11,244 less expensive than CMT. The model was robust to key variables for the younger group. For younger patients, there were no threshold values for cost of CMT, cost of managing severe NT when in CR, and cost of palliation, which would potentially lead to chemotherapy alone being favoured. As well, the model was robust to the plausible ranges in probability of developing NT (base probability: 0.18 at 1yr). It favoured treating younger patients with CMT unless the rate of neurotoxicity was more than 89% at 1yr, a rate not encountered in the published literature. Similarly, for older patients, there were no threshold values for the costs above which lead to CMT being favoured. Conclusion:The preferred induction strategy for younger patients with primary CNS lymphoma appears to be CMT. This strategy minimizes cost, while maximizing life expectancy, and quality adjusted life years. This analysis confirms that the preferred strategy for older patients is chemotherapy alone. The model was robust in sensitivity analyses of key variables tested through the plausible ranges obtained from costing sources and the published literature. Disclosures:No relevant conflicts of interest to declare.

An estimation of the long‐term clinical and economic benefits of insulin lispro in Type 1 diabetes in the UK

AimsTo determine the long-term health economic benefits associated with lispro vs. regular human insulin (RHI) in UK Type 1 diabetic (T1DM) patients using the previously published and validated CORE Diabetes Model.MethodsA literature review designed to capture clinical benefits associated with lispro and T1DM cohort characteristics specific to UK was undertaken. Clinical benefits were derived from a Cochrane meta-analysis. The estimated difference (weighted mean) in glycated haemoglobin (HbA1c) was −0.1% (95% confidence interval −0.2 to 0.0%) for lispro vs. RHI. Severe hypoglycaemia rates for lispro and RHI were 21.8 and 46.1 events per 100 patient years, respectively. Costs and disutilities were accounted for severe hypoglycaemia rates. All costs were accounted in 2007 £UK from a National Health Service (NHS) perspective. Future costs and clinical benefits were discounted at 3.5% annually.ResultsIn the base-case analysis, lispro was projected to be dominant compared with RHI. Lispro was associated with improvements in quality-adjusted life expectancy (QALE) of approximately 0.10 quality-adjusted life years (QALYs) vs. RHI (7.60 vs. 7.50 QALYs). Lifetime direct medical costs per patient were lower with lispro treatment, £70 576 vs. £72 529. Severe hypoglycaemia rates were the key driver in terms of differences in QALE and lifetime costs. Sensitivity analyses with assumptions around time horizon, discounting rates and benefits in terms of glycaemic control or hypoglycaemic event rates revealed that lispro remained dominant.ConclusionsOur findings suggest that lispro is likely to improve QALE, reduce frequency of diabetes-related complications and lifetime medical costs compared with RHI.

Composite measures for hospital quality using quality‐adjusted life years

Developing clinically meaningful summary measures of health-care quality is key to inferring quality of care. Current summary measures use a number of different approaches to weight their individual measures but rarely use weights based on clinical 'importance'. Such an approach would help to focus quality improvement efforts on areas likely to have the largest impact on health outcomes. Using coronary artery bypass graft (CABG) surgery as a case study, we weight and combine 11 process, complication, and survival measures to summarize differences in quality-adjusted life expectancy 1 year following surgery for a sample of hospitals. We use a fully Bayesian analysis to estimate 1-year survival outcomes using a hierarchical exponential survival model. We then estimate the expected utility of the year following surgery for each patient using complication probabilities fitted from hierarchical models and utility values from the literature. We estimate quality-adjusted life years (QALYs) for each hospital as the utility-weighted average 1-year survival probability and then estimate 'incremental QALYs' by taking the difference in QALYs for each hospital relative to a comparison group that reflects the average performance of all hospitals in the state. We illustrate our framework by estimating incremental QALYs for 14 hospitals performing CABG surgery in Massachusetts in 2003 and find that a composite measure based on QALYs can change the classification of quality outliers relative to conventional mortality measures.

Gender differences in quality-adjusted life expectancy: Results from the National Health Interview Survey

Gender differences in quality-adjusted life expectancy: Results from the National Health Interview Survey

Patient attitudes regarding treatment-related erectile dysfunction at time of early detection of prostate cancer

To assess potency rate and patient attitudes regarding erectile dysfunction. A multiple choice, self-administered questionnaire distributed to 750 men undergoing testing for early detection of prostate cancer was used. Overall, 33.9% of patients reported either partial or complete lack of erections and 31.1% were not sexually active or active less than once per month. Furthermore, 55.4% would be affected or very affected by lack of erections and 73.6% chose definitive treatment despite a 50% chance of erectile dysfunction. Finally, 47.4% found such treatment-induced erectile dysfunction to be an important or very important problem. When asked to ascribe a quantity of life or period of time that they would be willing to sacrifice to preserve sexual function following treatment, only 15.2% of patients were able to do so, but no consensus could be reached regarding its value. Reported differences in quality-adjusted life expectancy when screening was compared to no screening and definitive therapy was compared to expectant management are marginal. Therefore, close attention to seemingly minor variables such as existing impotence rate, attitude regarding erectile dysfunction, and willingness to undergo therapy despite its inherent morbidity may substantially reduce or even reverse this reported disadvantage.

Management of infants at risk for occult bacteremia: A decision analysis

Because febrile infants with no obvious source of bacterial infection may have bacteremia, and because bacteremia is difficult to diagnose on clinical grounds, we used decision analysis to evaluate whether such infants should be treated with antibiotics, tested further, or sent home. Using a simple decision tree, we found that the decision to give empiric antibiotic treatment is the decision of choice. The difference in quality-adjusted life expectancy between the "best" and "worst" decisions was only 11 days. However, this difference translated to prevention of death or permanent disability in 60 cases per 100,000 febrile children. Further, empiric treatment remained the best management alternative unless the probability of bacteremia was less than 1.4% (less than any published prevalence), or the efficacy of treatment was less than 21%. Our analysis demonstrated that a test with far greater sensitivity than leukocyte count or other tests currently in use is needed to justify testing rather than treating empirically. Further, an enormous patient population would be needed to find a difference of both clinical and statistical significance between treated and untreated patients in a controlled trial. In the absence of such trials, we recommend blood culture and empiric antibiotic treatment of all infants at risk for occult bacteremia.