Standard Gamble Method Research Articles

Abstract TMP76: Direct Assessment of Health Utilities Among Patients With Intracerebral Hemorrhage Using the Standard Gamble Method

Introduction: EuroQoL-5 Dimension (EQ-5D) is a validated albeit indirect method to derive health utilities (HU). Conversely, Standard Gamble (SG) directly measures patients’ valuation of their health state. We compare in-hospital and day-90 SG Utilities (SGU) among intracerebral hemorrhage (ICH) patients and report a three-way association between SGU, EQ-5D and mRS at day-90. Methods: Primary ICH patients were enrolled in a multisite cohort and underwent in-hospital and day-90 assessments for the mRS, EQ-5D, and SG. SG entails providing patients a choice between their current health state and a hypothetical treatment (a pill) with varying chances of either perfect health or a painless death. Higher SGU (scale 0 - 1) indicates a lower risk-tolerance for death; thus, a higher valuation of one’s health state. Median and interquartile range (IQR) are reported. Logistic regression was used to estimate the likelihood of low SGU (≤ 0.6) and Wilcoxson paired signed rank test compared in-hospital and day-90 SGU. Results: In-hospital and day-90 SG was obtained from 381 and 280 patients respectively (including 236 paired observations). Median (IQR) in-hospital and day-90SGU were 0.85 (0.40-0.98) and 0.98 (0.75-1.00) (p < 0.001). In-hospital SGU were lower with advancing age (p = 0.007), with higher NIHSS and ICH scores (p < 0.001), and with greater treatment intensity. Proxies evaluated lower SGU (p < 0.001). In the adjustedmodel, higher NIHSS and proxy assessments were independently associated with lower SGU, along with an interaction between age and SGU by race (white vs. black) (Figure). Day-90 SGU and mRS were correlated (p < 0.001), however SGU were increasinglyhigher than the EQ-5D HU at higher mRS scores (Figure). Conclusion: Divergence between directly and in-directly assessed HU at high levels of functional disability warrant careful prognostication of ICH outcomes, and should be considered in designing early end-of-life care discussions with families and patients.

Dental health state utilities among dental patients.

To test the efficacy of a dental health state utility measure among a sample of dental patients using the standard gamble (SG) method and to examine its association with two quality of life constructs, namely the Oral Health Impact Profile-14 questionnaire and the global oral health item. A cross-sectional study was conducted with a sample of 202 adult dental patients. Demographic and clinical data were collected. The 14 item oral health impact profile (OHIP-14) and Locker's global rating scale for oral health were administered and a SG utility valuation was carried out. The mean age of the patients was 38.6 ± 14.1 years. The mean SG score was 0.2 ± 0.2. Bivariate and negative binomial regression using the SG score as the outcome variable showed significant associations between SG scores and the OHIP-14 summary scores, global oral health rating values, as well as with age, gender, and nature/severity of the oral problem. The SG method was effective in assessing dental health state utilities in the patient population. Determining patients' risk tolerance through the SG method may lead to greater awareness about factors that could influence their choice of treatment and could help in planning treatment regimens.

Disease severity-based evaluation of utility weights for lung cancer-related health states in Korea

BackgroundUtility weight, a measure of health-related quality of life, is used in disease burden measurements and economic evaluations. In this study, we used the visual analogue scale (VAS) and standard gamble (SG) method to determine the utility weights of lung cancer health states in South Korea from a societal perspective.MethodsSix hypothetical health states for lung cancer or a related health state reflective of disease severity were developed: 1) Stage I, 2) Stage II, 3) Stage IIIa, 4) Stage IIIB, 5) Stage IV, and 6) Pulmonary nodule. The description of each health state description was divided into four parts: diagnosis, symptoms, treatment, and progression and prognosis. A total of 515 representative adult Korean participants used a VAS and SG to evaluate these six health states via face-to-face computer-assisted interviews. The means, standard deviations, and median utility weights of the six health states were estimated by valuation method.ResultsThe two valuation methods of the scenarios yielded the same mean utility rankings. Pulmonary nodule received the highest rank (VAS, 0.66 and SG, 0.83), whereas Stage 4 was assigned the lowest rank (VAS, 0.09 and SG, 0.31). For all health states, the mean utility weights calculated using the SG were greater than those calculated using the VAS. The differences between the utility weights obtained using the two valuation methods ranged from 0.14 (Stage I) to 0.22 (Stage IV). The two approaches tended to yield larger differences for more severe stages.ConclusionsThis study determined utilities for squamous cell lung cancer that will be useful for estimating the burden of lung cancer and for conducting economic evaluations of lung cancer interventions.

Health-related quality of life in patients with uveitis

Background/aimsTo measure health-related quality of life (HRQOL) in patients with uveitis using time trade-off (TTO) and standard gamble (SG) methods of direct utility analysis.MethodsConsecutive patients attending a tertiary referral uveitis...

What utility scores do mental health service users, healthcare professionals and members of the general public attribute to different health states? A co-produced mixed methods online survey.

BackgroundUtility scores are integral to health economics decision-making. Typically, utility scores have not been scored or developed with mental health service users. The aims of this study were to i) collaborate with service users to develop descriptions of five mental health states (psychosis, depression, eating disorder, medication side effects and self-harm); ii) explore feasibility and acceptability of using scenario-based health states in an e-survey; iii) evaluate which utility measures (standard gamble (SG), time trade off (TTO) and rating scale (RS)) are preferred; and iv) determine how different participant groups discriminate between the health scenarios and rank them.Design and methodsThis was a co-produced mixed methods cross-sectional online survey. Utility scores were generated using the SG, TTO and RS methods; difficulty of the completing each method, markers of acceptability and participants’ preference were also assessed.ResultsA total of 119 participants (58%) fully completed the survey. For any given health state, SG consistently generated higher utility scores compared to RS and for some health states higher also than TTO (i.e. SG produces inflated utility scores relative to RS and TTO). Results suggest that different utility measures produce different evaluations of described health states. The TTO was preferred by all participant groups over the SG. The three participant groups scored four (of five) health scenarios comparably. Psychosis scored as the worst health state to live with while medication side-effects were viewed more positively than other scenarios (depression, eating disorders, self-harm) by all participant groups. However, there was a difference in how the depression scenario was scored, with service users giving depression a lower utility score compared to other groups.ConclusionMental health state scenarios used to generate utility scores can be co-produced and are well received by a broad range of participants. Utility valuations using SG, TTO and RS were feasible for use with service users, carers, healthcare professionals and members of the general public. Future studies of utility scores in psychiatry should aim to include mental health service users as both co-investigators and respondents.

Patient preferences for diabetes-related complications in Taiwan

Background: As the prevalence of diabetes mellitus (DM) continues to increase rapidly, there has been a rising need not only to assess the clinical outcomes but also the impact of DM on the health-related quality of life (HRQoL) of affected individuals. Most previous studies have found that having complications is strongly associated with decreased HRQoL in DM patients. As such, it is crucial to measure individuals’ preferences for DM-related complications in order to assess the magnitude of complications’ effect on overall HRQoL. In addition, preference scores are an essential component of cost–utility analyses (CUAs), which studies can incorporate healthcare costs, HRQoL and clinical outcomes of DM into one analysis.Objective: The aims of this study were to assess the preference scores of DM-related complications using both the standard gamble (SG), a choice-based method, and visual analogue scale (VAS), a scaling method. We also aimed to assess several possible factors that might be associated with the preference scores of the complications.Methods: This is a cross-sectional interview-administered survey, and 213 patients with type 2 DM were interviewed. The respondents’ preference scores of eleven DM-related complications were obtained using VAS and SG techniques. Demographic information, clinical characteristics and risk attitudes were also collected to explore factors that may affect patients’ preference scores.Results: Nearly one quarter of participants in Taiwan ranked at least one of the complications worse than death. The mean VAS scores ranged from 0.004 (amputation) to 0.47 (nocturnal hypoglycemia) while the mean adjusted SG scores ranged from 0.30 (blindness) to 0.66 (nocturnal hypoglycemia). There were significant differences in all of the complications’ preference scores depending on risk attitudes.Conclusion: Both the VAS and SG methods were used to elicit the preference scores of DM-related complications, and the preference scores derived could be useful for future cost utility analyses.

Evaluation of options for presenting health-states from PROMIS® item banks for valuation exercises.

Health status descriptive systems based on item response theory (IRT), such as the Patient-Reported Outcomes Measurement Information System (PROMIS®), have item banks to measure domains of health. We developed a method to present such banks for health-state valuation. We evaluated four different presentation approaches: a single item (1S), 2 items presented separately (2S), 2 items presented together (2T), or 5 items presented together (5T). We evaluated these four approaches in three PROMIS item banks (depression, physical function, and sleep disturbance). Adult community members valued health-state descriptions using the visual analog scale and standard gamble methods. We compared the approaches by the range of item bank theta scores captured, participants' assessments of difficulty (1 = very easy to 7 = very hard), and exit interviews. Participants (n = 118) ranged in age from 18 to 71; 63% were female and 54% were white. The 1S approach captured the smallest range of theta scores. A monotonic relationship between theta score and mean standard gamble estimate was found with all approaches except 2S. Across all 3 item banks, mean difficulty assessments were 2.35 (1S), 2.69 (2T), 2.78 (5T), and 2.80 (2S). In exit interviews, participants generally found all four approaches similarly meaningful and realistic. Creating health descriptions by presenting 2 items maximized the range of theta while minimizing difficulty and maintaining a monotonic relationship with utility estimates. We recommend this approach for valuation of IRT-based descriptive systems such as PROMIS.

Abstract WMP87: Comparison of Patient-centered Quality of Life Utilities Using 3 Different Methods Across Modified Rankin Scale Scores - Experience From the ARTSS-2 Trial (Randomized, Multi-center Trial of Argatroban With Recombinant Tissue Plasminogen Activator for Acute Stroke)

Background and Purpose: Although the modified Rankin Score ( mRS ) is broadly used as a measure of stroke outcome, quality of life ( QOL ), expressed in 0-1 numerical utility values (0=death, 1=perfect health), more accurately reflects patients’ value for particular health states. 3 methods for eliciting utility include: visual analog scale ( VAS ), standard gamble ( SG ) and time trade-off ( TTO ). SG, considered the classic method for obtaining utilities, involves making decisions under uncertainty or risk. We hypothesized that utilities from standard gamble ( SG ) would be systematically different than TTO & VAS and utility values would not be linearly associated with mRS scores. Methods: Utilities were elicited from ischemic stroke patients or proxy family members in the ARTSS-2 randomized trial; clinicaltrials.gov/NCT01464788. A societal perspective was performed using TTO (EuroQol-5D) and 2 patient-centered utility methods: VAS, a “feeling thermometer” and the SG. Certified raters blinded to utilities assessed 90-day mRS. Mean utilities were mapped across the mRS. As SG can be cognitively complex, requiring simultaneous assessments of both benefit and harm, patients’ capacity was determined using the validated Assessment of Capacity Evaluation. Only patients demonstrated capacity were able to perform the QOL evaluations. Results: 86 of 90 (96%) patients had utilities at 90-days. Excluding missing and deaths, 70 patients had utilities generated by either the patient (N=48; 70%) or the proxy (N=22; 30%). TTO and VAS utilities declined in a non-linear fashion with increasing mRS. In general, SG utilities were larger and varied the least across mRS (Figure). Conclusions: Patient elicited standard gamble utilities of stroke health states do not appear to correlate with the mRS. Further research is necessary to understand divergence between SG and other methods of QOL elicitation in stroke patients.

Estimation of utility weights for major liver diseases according to disease severity in Korea

BackgroundThe global burden of liver diseases, such as hepatocellular carcinoma and liver cirrhosis, is substantial. In this study, we estimated utility weights of liver disease-related health states in the general population using a visual analogue scale (VAS) and the standard gamble (SG) method.MethodsDepictions of standardized health states related to major liver diseases were developed based on patient education materials and previous publications. To fully reflect disease progression from diagnosis to prognosis, each health state comprised four parts: diagnosis, symptoms, treatment, and progression and prognosis. A total of 407 participants from the Korean general population evaluated the health states using the VAS and SG methods in computer-assisted personal interviews. After excluding illogical responses, mean utility weights were calculated for each health state.ResultsThe utility weights for health states were significantly different according to the existence of inconsistency in general. According to the VAS results, the health state with the highest utility was ‘Chronic hepatitis B virus infection’ (0.64), whereas the health state with the lowest utility was ‘Hepatocellular carcinoma that requires palliative therapy’ (0.17). Similarly, the SG results revealed that the health state with the highest utility was ‘Chronic hepatitis B virus infection’ (0.85), and the health state with the lowest utility was ‘Hepatocellular carcinoma that requires palliative therapy’ (0.40).ConclusionsThe estimated utility weights in this study will be useful to measure the burden of liver diseases and evaluate cost-utility of programs for reducing the burden of liver diseases.

Feasibility, comparability, and reliability of the standard gamble compared with the rating scale and time trade-off techniques in Korean population

The standard gamble (SG) method is the gold standard for valuing health states as a utility, although it is accepted that it is difficult to valuate health states. This study was conducted in order to compare the SG with the rating scale (RS) and time trade-off (TTO) techniques in terms of their feasibility, comparability, and reliability in a valuation survey of the general Korean population. Five-hundred members of the general Korean population were recruited using a multi-stage quota sampling method in Seoul and its surrounding areas, Korea. Respondents evaluated 9 EQ-5D-5L health states using a visual analogue scale (VAS), SG, and TTO during a personal interview. Feasibility was assessed in aspects of the level of difficulty, administration time, and inconsistent responses. Comparability was evaluated using intraclass correlation coefficient (ICC) and the Bland-Altman approach. Test-retest reliability was analyzed using the ICC. Of the three methods, VAS was the easiest and quickest method to respond. The SG method did not differ significantly compared to the TTO method in administration time as well as the level of difficulty. The SG and TTO values were highly correlated (r=0.992), and the average mean difference between the SG and the TTO values was 0.034. The ICCs of the VAS, SG, and TTO scores were 0.906, 0.841, and 0.827, respectively. This study suggests that the SG method compared with the VAS and TTO method was feasible and offered a reliable tool for population-based, health state valuation studies in Korea.

Variation in Preferences of Pregnant Women for Outcomes Related to the Use of Anticoagulants in Pregnancy [16K

INTRODUCTION: Women requiring anticoagulants in pregnancy face increased maternal and fetal risks. The trade-offs women are willing to make to ensure optimal pregnancy outcomes are not known. This study was conducted to compare preferences of pregnant women with and without cardiac disease, for maternal and fetal outcomes resulting from anticoagulant use in pregnancy. METHODS: A cross-sectional study was conducted on pregnant women with cardiac or non-cardiac medical disorder. Study participants were presented with seven vignettes that described a combination of maternal and fetal outcomes related to the use of anticoagulants during pregnancy. Participants were asked to rank these vignettes and assign them with “utility values” (preferences) on a visual analogue scale (VAS), by the standard gamble (SG) and time trade-off (TTO) methods. These were presented on a scale of 0-100 where 0 represented maternal and fetal death, the worst outcome, and 100 represented perfect maternal-fetal health, the best. RESULTS: 90 pregnant women (40 with and 50 without cardiac disease) completed the interviews. The median age was 32 [29-36] years and the median gestational age was 29.5 [22-34.3] weeks. The cardiac and non-cardiac groups had similar demographic characteristics. While no consistent trends were observed with VAS and TTO methods, with SG, women with cardiac disease consistently assigned higher utility values for the seven outcomes as compared with those without cardiac disease. CONCLUSION: Women with cardiac disease value adverse pregnancy outcomes more favorably than non-cardiac patients. Whether this finding is related to risk-taking attitudes among cardiac patients, needs to be further explored.

Preferences of Pregnant Women and Family Members for Health States Arising From Anticoagulant Use in Pregnancy [17N

INTRODUCTION: The aim of this study was to elicit preferences of pregnant women and their family member(s) involved in decision-making, for combined maternal and fetal health-states arising from the use of anticoagulants in pregnancy. METHODS: We conducted a cross-sectional study on pregnant women taking medications for chronic medical disorders and their family member(s). Participants–interviewed separately and together–were presented with seven vignettes representing combined maternal and fetal health-states related to anticoagulant use in pregnancy. They were asked to assign values on a visual analogue scale, by the standard gamble and time trade-off methods. Utility values (preferences) were presented on a scale of 0-100. RESULTS: Fifty-six pregnant women, 43 family members and 40 pairs completed the interviews. The median age was 32.9 years for pregnant women and 37.1 years for family members, and the median gestational age was 28.9 weeks. Regardless of the method used, values obtained from pregnant women were lower than those obtained from family members and combined interviews. There was a wide variation in utility values obtained from the three interviews and using the three methods. Values obtained from the combined interviews had the smallest confidence limits around point estimates. CONCLUSION: This is the first study to determine preferences from pregnant women and family members for combined maternal-fetal health-states. For studies involving pregnancy, utility values that represent the values of both individuals involved in decision-making should probably be used in decision-analysis studies. These findings need prospective validation in different patient populations and different clinical conditions.

Preferences of Pregnant Women for Outcomes Related to Epilepsy and the Use of Antiepileptic Medications in Pregnancy [18N

INTRODUCTION: Women with epilepsy are at risk of higher seizure-frequency in pregnancy and fetal malformations from the use of antiepileptic drugs (AEDs). The trade-offs women are willing to make, to optimize pregnancy outcomes have not been determined. This study elicits preferences of pregnant women with and without epilepsy, for maternal and fetal health states related to epilepsy and the use of AEDs in pregnancy with a view to informing practice and research. METHODS: Cross-sectional study on pregnant women that had epilepsy or another chronic medical disorder requiring medications during pregnancy. Study participants were presented with seven vignettes related to epilepsy and the use of AEDs in pregnancy and asked to assign them values on a visual analogue scale, by the standard gamble and time trade-off methods. Utility values were presented on a scale of 0-100. RESULTS: 52 pregnant women completed the interviews. The median age was 33 (29.5-35) years and the median gestational age was 30 weeks. The epileptic and non-epileptic groups had identical demographic characteristics. Utility values for combined maternal-fetal health states related to epilepsy and the use of AEDs was obtained by three methods, from women with and without epilepsy. There were no differences in utility values obtained between groups regardless of the method used. CONCLUSION: This study provides utility values for combined maternal-fetal health states related to epilepsy and the use of AEDs for use in decision analysis studies and suggests that these preferences could be obtained from pregnant women with any chronic medical disorder taking medications during pregnancy.

Preferences of Pregnant Women With Cardiac Disease for Maternal-Fetal Outcomes Related to Their Pregnancies [20N

INTRODUCTION: The trade-offs pregnant women with cardiac disease are willing to make in order to optimize pregnancy outcomes is undetermined. This study aimed to elicit preferences of these women for maternal and fetal outcomes related to cardiac disease in pregnancy. METHODS: A cross-sectional study was conducted on pregnant women with cardiac disease. participants were then presented with 19 vignettes describing combined maternal and fetal outcomes related to cardiac disease. Maternal outcomes included cardiac events (arrhythmias and cardiac failure), blood clots, a combination of the two and no cardiac events; while fetal outcomes included perfect health, minor or major malformations, small-for-gestational-age (SGA) infants and fetal demise. Participants were asked to assign values to these outcomes on a visual analogue scale (VAS), by the standard gamble (SG) and time trade-off (TTO) methods. Utility values (preferences) for each state obtained from all three methods were presented on a scale of 0-100. RESULTS: 34 pregnant women with cardiac disease completed the interviews. The median age was 31.5 [29-34] years and the median gestational age was 24 [19-35] weeks. Participants did not perceive combinations of maternal cardiac events as more severe than a solitary event. Also, they regarded SGA as more severe outcome than minor congenital malformations, but valued major malformations as bad as fetal demise. CONCLUSION: This study is the first to obtain preferences of pregnant women with cardiac disease for combined maternal and fetal outcomes related to their condition. These preferences should be incorporated in clinical decision-making.

MP22-09 DIAGNOSTIC NEEDLE BIOPSIES IN RENAL MASSES: PATIENT AND PHYSICIAN PERSPECTIVES

You have accessJournal of UrologyKidney Cancer: Epidemiology & Evaluation/Staging I1 Apr 2017MP22-09 DIAGNOSTIC NEEDLE BIOPSIES IN RENAL MASSES: PATIENT AND PHYSICIAN PERSPECTIVES Shay Golan, Paz Lotan, Shlomi Tapiero, Jack Baniel, Andrei Nadu, and Ofer Yossepowitch Shay GolanShay Golan More articles by this author , Paz LotanPaz Lotan More articles by this author , Shlomi TapieroShlomi Tapiero More articles by this author , Jack BanielJack Baniel More articles by this author , Andrei NaduAndrei Nadu More articles by this author , and Ofer YossepowitchOfer Yossepowitch More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.663AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The utility of renal mass biopsies (RMB) in the diagnosis and management of kidney tumors remains debatable. We assessed the patients and urologists preferences in this regard. METHODS Seventy-three patients diagnosed with renal tumors and 59 board-certified urologists were asked to participate in an interview-based study. Decision analysis was quantified using the standard gamble method to determine the minimal accepted accuracy (MAA) at which RMB would be favored as part of the diagnostic process. Clinical and demographic data with potential to affect participants preferences were analyzed. RESULTS At the time of study interview, 56 patients (77%) were referred for kidney surgery and 17 (23%) opted for surveillance. Overall, 59% of the patients were willing to accept some level of inaccuracy (1-20%), whereas 41% would refute a biopsy irrespective of their designated treatment. Anxiety associated with the possibility of missing cancer was the primary determinant (70%) for declining RMB among patients referred for surgery while fear of biopsy-associated complications was the primary reason (58%) to decline RMB among those undergoing surveillance. Having an academic degree was associated with acceptance of a lower accuracy threshold (p=0.03). Of the 59 participating urologists, 39% were reluctant to recommend RMB, primarily because of its inexorable non-diagnostic rate. CONCLUSIONS Most patients and urologists would favor a RMB to facilitate their definitive treatment decision. Diagnostic accuracy of 95% was acceptable by the majority of study participants. The utility of RMB as part of the diagnostic algorithm for renal tumors should be discussed with patients, emphasizing its potential benefits and limitations. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e259-e260 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Shay Golan More articles by this author Paz Lotan More articles by this author Shlomi Tapiero More articles by this author Jack Baniel More articles by this author Andrei Nadu More articles by this author Ofer Yossepowitch More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Estimation of health state utilities in breast cancer.

PurposeThe aim of this study is to determine the utility of breast cancer health states using the standard gamble (SG) and visual analog scale (VAS) methods in the Korean general population.Materials and methodsEight hypothetical breast cancer health states were developed based on patient education material and previous publications. Data from 509 individuals from the Korean general population were used to evaluate breast cancer health states using the VAS and the SG methods, which were obtained via computer-assisted personal interviews. Mean utility values were calculated for each human papillomavirus (HPV)-related health state.ResultsThe rank of health states was identical between two valuation methods. SG values were higher than VAS values in all health states. The utility values derived from SG were 0.801 (noninvasive breast cancer with mastectomy and followed by reconstruction), 0.790 (noninvasive breast cancer with mastectomy only), 0.779 (noninvasive breast cancer with breast-conserving surgery and radiation therapy), 0.731 (invasive breast cancer with surgery, radiation therapy, and/or chemotherapy), 0.610 (locally advanced breast cancer with radical mastectomy with radiation therapy), 0.587 (inoperable locally advanced breast cancer), 0.496 (loco-regional recurrent breast cancer), and 0.352 (metastatic breast cancer).ConclusionOur findings might be useful for economic evaluation of breast cancer screening and interventions in general populations.

Diagnostic Needle Biopsies in Renal Masses: Patient and Physician Perspectives

BackgroundThe utility of renal mass biopsies (RMB) in the diagnosis of kidney tumors remains debatable. ObjectiveTo assess patient and urologist preferences regarding the utilization of RMB. Design, setting, and participantsSeventy-three patients diagnosed with renal tumors and 59 board-certified urologists were asked to participate in an interview-based study. Outcome measurements and statistical analysisUsing the standard gamble method we determined the minimal accepted accuracy at which RMB would be favored as part of the diagnostic process. Clinical and demographic data with potential to affect participants’ preferences were analyzed. Results and limitationsAt the time of the study interview, 56 patients (77%) were referred for kidney surgery and 17 (23%) opted for surveillance. Overall, 59% of the patients accepted some level of inaccuracy (1–20%), whereas 27% refuted a biopsy. Anxiety associated with the possibility of missing cancer was the primary determinant (82%) for declining RMB among patients referred for surgery, while fear of complications was the primary reason (58%) among those undergoing surveillance. Having an academic degree was associated with a lower accuracy threshold (p=0.03). Of the 59 participating urologists, 39% were reluctant to recommend RMB, primarily because of its inexorable nondiagnostic rate. ConclusionsMost patients and urologists would favor RMB to facilitate their definitive treatment decision. Diagnostic accuracy of 95% was acceptable by the majority of study participants. The utility of RMB as part of the diagnostic algorithm for renal tumors should be discussed with patients, emphasizing its potential benefits and limitations. Patient summaryAlthough needle biopsy seems to be an effective tool to differentiate benign from malignant kidney lesions, it is not commonly used. Our study shows that most patients would opt for a biopsy before definitive treatment decision despite its imperfect accuracy. Hence, the option of undergoing renal biopsy should be discussed with all patients diagnosed with small renal tumors.

The Load Model: an alternative to QALY

Background: QALYs are widely used in health economic evaluation, but remain controversial, largely because they do not reflect how many people behave in practice. This paper presents a new conceptual model (Load Model) and illustrates it in comparison with the QALY model.Methods: Load is the average annual weight attributed to morbidity and mortality over a defined period, using weightings based on preference judgements. Morbidity Load is attributed to states of illness, according to their perceived severity. When people are in full health, Load is zero (no morbidity). Death is treated as an event with negative consequences, incurred in the year following death. Deaths may be weighted equally, with a fixed negative weight such as −100, or differ according to the context of death. After death, Load is zero. In a worked example, we use the standard gamble method to obtain a weighting for an illness state, for both Load and QALY models. A judge is indifferent between certainty of 1.5 years’ illness followed by death, or a 50/50 chance of 1.5 years’ full health or 1-year illness, each followed by death. The weightings calculated are applied to a hypothetical life, 72 years in full health followed by 3 years with illness then death, using both models. Three other hypothetical outcomes are also compared.Results: For an example life, the relative size of the morbidity component compared with the mortality component is much higher in the Load model than in the QALY model. When comparing alternative outcomes, there are also substantial differences between the two models.Conclusions: In the Load model the weight of morbidity, relative to mortality, is very different from that in the QALY model. Given the role of the QALYs in economic evaluation, the implications of an alternative, which generates very different results, warrant further exploration.

Willingness to pay for eliminating the risk of being infected by blood-borne diseases in regular replacement treatment for patients with haemophilia

Hemophilia is a set of lifelong bleeding disorders linked to the X chromosome. Standard treatment for patients with severe hemophilia is intensive replacement therapy with intravenous injection of coagulation factor concentrates to prevent spontaneous recurrent joint bleed. In the 1980s, many hemophilia patients were infected with HIV and/or hepatitis C transmitted by plasma derived coagulation factor concentrates. In the future, new pathogens could appear and a risk remains that the current manufacturing methods will not be able to eliminate those. The aim of the study is to estimate the value of eliminating the risk of being infected by blood-borne diseases in the treatment of hemophilia which could provide decision-makers with information on how much resource to spend on this purpose to be in line with societal preferences. Individual preferences for safety were elicited from a sample of 821 individuals from the Swedish general population using a web-based questionnaire. The preferences were estimated using the “chained approach” which combines the contingent valuation (CV) and standard gamble (SG) methods. The respondents were asked (1) to state their willingness-to-pay to avoid a temporary, non-fatal injury presented in a health state derived from the EQ-5D instrument, and (2) to choose between living with this injury with certainty or receive a treatment that could restore the respondent to full health immediately, but which entails a risk of being infected by a fatal, blood-borne disease. A value of a statistical life (VSL) in the context of blood-borne diseases of SEK47 million was calculated by “chaining” the answers to the CV question and SG question, and from the VSL we derived a value of a QALY in the context of blood-borne diseases of SEK2.8 million. Using the current mean annual dose of factor concentrate of 268,000 international units (IU) per patient in Sweden, the value of eliminating the risk of being infected by blood-borne diseases would be SEK1.80 per IU corresponding to a price premium of around 45 %.Published: Online April 2016. In print August 2016.

Development, feasibility, and validity of a computer-based utility assessment tool for measuring asthma-specific health utilities in Malaysia using the standard gamble method

Objectives: To develop and test the feasibility and validity of a computer-based utility assessment tool that used standard gamble (SG) method for measuring asthma-specific health utilities. Methods: A computer-based SG (CBSG) tool was developed using Microsoft® PowerPoint 2007 to value asthma-specific health states in Malaysia. Eight hypothetical health states were considered, including two anchor states (healthy and dead), three chronic (C) states and three temporary (T) states (each numbered 1 through 3, with increasing severity) in addition to the subject's current health state. Twenty adult asthma patients completed the CBSG tool in addition to paper-based Asthma Control Test, three health status measures (EQ-5D, EQ-VAS, and Mini Asthma Quality of Life Questionnaire (MiniAQLQ)), and VAS utility assessment tool. Patients and interviewers rated the difficulty of the VAS and CBSG tools. Correlations between current health state values derived from the various measures were determined. Results: The SG and the VAS received similar difficulty ratings. 17 patients completed the CBSG tool within 30 minutes. The mean utilities determined by the CBSG tool for the T1-T3 asthma health states met the expected logical order of 1>2>3, but those for the C1-C3 states did not. Correlation between current health state values derived from the CBSG tool and other measurement tools was poor. Conclusion: The CBSG tool developed for measuring utilities of asthma health states showed acceptable feasibility and overall validity.