Impact of screening for breast cancer in high-risk women on health-related quality of life

The effectiveness of intensive surveillance in women at high risk for breast cancer due to a familial or genetic predisposition is uncertain and is currently being evaluated in a Dutch magnetic resonance imaging (MRI) screening (MRISC) study, in which annual imaging consists of mammography and MRI. Unfavourable side effects on health-related quality of life may arise from this screening process. We examined the short-term effects of screening for breast cancer in high-risk women on generic health-related quality of life and distress. A total of 519 participants in the MRISC study were asked to complete generic health-status questionnaires (SF-36, EQ-5D) as well as additional questionnaires for distress and items relating to breast cancer screening, at three different time points around screening. The study population showed significantly better generic health-related quality of life scores compared to age-/sex-adjusted reference scores from the general population. Neither generic health-related quality of life scores nor distress scores among the study sample (n=334) showed significant changes over time. The impact of the screening process on generic health status did not differ between risk categories. Relatively more women reported mammography as quite to very painful (30.1%) compared to MRI. Anxiety was experienced by 37% of the women undergoing MRI. We conclude that screening for breast cancer in high-risk women does not have an unfavourable impact on short-term generic health-related quality of life and general distress. In this study, high-risk women who opted for regular breast cancer screening had a better health status than women from the general population.

Including the quality-of-life effects in the evaluation of prostate cancer screening: expert opinions revisited?

OBJECTIVE

To apply the general empirical framework for estimating utilities in cost-utility analysis (CUA) of population-based prostate cancer screening, including an assessment of empirical health status with a classifying measure (e.g. the EQ-5D) and linking these descriptions to utility estimates using the standard preference-based algorithm, combining them with the appropriate duration into quality-adjusted life years, and sensitivity analysis.

MATERIALS AND METHODS

Empirical studies to describe and value the health status effects of prostate cancer screening have been ongoing within the Rotterdam centre of the European Randomised Study on Screening for Prostate Cancer since 1995. The results of these studies, including the screening, the primary treatment phase and advanced disease, will be used in estimating utilities for cost-utility analysis.

RESULTS

Estimation of cost-utility of population-based prostate cancer screening with the results of the three empirical health status studies yielded partly counterintuitive results, underestimating the unfavourable health status effects that are inevitably associated with prostate cancer screening. This may be caused by other than health effects of the screening itself ('process effects') and adaptive changes in perception of their situation in patients after curative primary treatment ('response shift'), among other elements.

CONCLUSIONS

These results prompted us to reconsider the suitability of the general framework of CUA for screening programmes. Possible directions for solutions are indicated.

Distribution and determinants of health and work status in a comprehensive population of injury patients

BACKGROUND

Insight into the distribution and determinants of both short- and long-term disability can be used to prioritize the development of prevention policies and to improve trauma care. We report on a large follow-up study in a comprehensive population of injury patients.

METHODS

We fielded a postal questionnaire in a stratified sample of 4,639 nonhospitalized and hospitalized injury patients aged 15 years and older, at 2, 5, and 9 months after injury. We gathered sociodemographic information, data on functional outcome with a generic instrument for health status measurement (EuroQol EQ-5D+) and data on work absence.

RESULTS

The response rates were 39%, 75%, and 68% after 2, 5, and 9 months, respectively. The reported data were adjusted for response bias and stratification. The 2-month health status of nonhospitalized patients was comparable to the general population's health when measured by the EQ-5D summary score, although considerable prevalence of restrictions in usual activities (24.0%) and pain and discomfort (34.8%) were reported. Hospitalized patients reported higher prevalences of disability in all health domains. Their mean EQ-5D summary score increased from 0.62 at 2 months to 0.74 at 5 months but remained below the population norm at 9 months, particularly for patients with a long hospital stay. Patients with injuries of the spinal cord and vertebral column, hip fracture, and other lower extremity fractures reported the worst health status, also when adjusted for age, sex, and educational level. Age, sex, type of injury, length of stay, educational level, motor vehicle injury, medical operation, intensive care unit admission, and number of injuries were all significant predictors of functioning. Nonhospitalized and hospitalized injury patients lost on average 5.2 and 72.1 work days, respectively. Of nonhospitalized patients, 5% had not yet returned to work after 2 months, and 39%, 20%, and 10% of hospitalized patients had not yet returned to work after 2, 5, and 9 months, respectively. In a multivariate regression analysis, length of stay, type of injury, level of education, and intensive care unit admission appeared to be significant predictors of absence duration and return to work.

CONCLUSION

Injury is a major source of disease burden and work absence. Both hospitalized and nonhospitalized patients contribute significantly to this burden.

Feasibility and reliability of a mailed questionnaire to obtain visual analogue scale valuations for health states defined by the Health Utilities Index Mark 3

To establish the generalizability (external validity) of the Health Utilities Index Mark 3 (HUI3) as a single-summary score generic outcome measure in numerous countries/subgroups (including children), repeated studies of community preferences should be performed in various settings. In performing multiple HUI3 studies, a mailed questionnaire approach, if feasible and reliable, might be substituted for oral interviews. In the present study, we assessed the feasibility and reliability of a mailed questionnaire approach originally developed for the EQ-5D, for the purpose of collecting Visual Analogue Scale (VAS) valuations from parents as surrogate responders for 65 pediatric HUI3 health states and for the state of being dead. Untransformed mean VAS scores of the health states and scores converted into preliminary Standard Gamble (SG)-utilities were compared with Canadian and French multiattribute utility estimates. A random sample of 1920 parents of schoolchildren (aged 4 to 13) received a mailed questionnaire. Each parent was asked to rate 6 HUI3 health states on a 0 to 100 VAS. Response was 70%. Mean completion time was 20 minutes (SD 9). The questionnaire was rated difficult by only 9%. The current format was, however, inappropriate for valuing the state of being dead. Interrater reliability of health state valuations was.87. Spearman's rank correlations, Pearson-R correlations and intra class correlation coefficients (ICCs) between untransformed VAS valuations and Canadian/French utility estimates were > or =.87. However, preliminary SG-utilities showed diminished ICCs (.71 to.72). The data support the feasibility and reliability of mailed HUI3 valuation questionnaires to a considerable extent, but further methodological studies regarding other formats and different populations are recommended.

Levels of disability in major depression: findings from the Netherlands Mental Health Survey and Incidence Study (NEMESIS)

BACKGROUND

Information on the distribution of disability associated with major depression (MD) across different groups of patients is of interest to health policy and planning. We examined the associations of severity and type (a single or recurrent episode) of MD with disability in a Dutch general population sample.

METHODS

We used data from the first wave (1996) of the Netherlands Mental Health Survey and Incidence Study (NEMESIS). MD 'severity' and 'type' were diagnosed with the help of the Composite International Diagnostic Interview according to DSM-III-R criteria. SF-36 scores, days ill in bed and days absent from work were taken as indicators of disability. The differences in these variables were studied by means of variance and regression analysis.

RESULTS

Recurrent MD was found not to be associated with more disability than single episode MD. Higher 'severity' classes were associated with more disability. However, the degree of disability between 'moderate' and 'severe' MD differed only very slightly. The difference in disability between non-depressed and mildly depressed individuals had a larger effect than between each successive pair of 'severity' classes.

CONCLUSIONS

Three groups of MD can be distinguished based on the associated degree of disability: 'mild', 'moderate to severe' and 'severe with psychotic features'. In the future, these groups can be used to describe the distribution of disability in the depressed population. The marked difference between 'mild' MD and no MD suggests that 'mild' cases should be considered relevant.

Measuring disease specific quality of life in localized prostate cancer: the Dutch experience

OBJECTIVE

We aimed at developing and testing a Dutch health-related quality of life measure for localized prostate cancer patients.

METHODS

Scales on urinary and bowel function and bother from the UCLA Prostate Cancer Index (PCI) underwent formal linguistic and cultural translation. PCI sexual scales were replaced by an existing Dutch sexual activities module (SAc). After qualitative pilot testing 389 patients with localized prostate cancer (mean age 67 +/- 7 years) completed the measure before and at 2 time points after primary treatment. Psychometric properties (feasibility, score distribution, reliability, construct validity and responsiveness to change) of the new instrument were analyzed.

RESULTS

Response rates ranged from 93% at baseline to 87% after treatment. Urinary and bowel function scales showed Cronbach's alphas >0.7. Urinary function and bother, and bowel function and bother were significantly correlated. Pre- vs. post-prostatectomy effect sizes were >0.9 only for urinary scales; while pre- vs. post-radiotherapy effect sizes were >0.75 only for bowel scales. Six months after baseline erectile dysfunction was reported by 64% of respondents, either as a problem in sexual activity or as a reason for not being sexually active.

CONCLUSION

The Dutch PCI and SAc performed well in men treated for early stage prostate cancer.

Cost-utility analysis of patient care in children with meningeal signs

OBJECTIVES

We designed a model of diagnostic and therapeutic interventions applied in children with meningeal signs. Using this model, we determined in a cost-utility analysis the consequences for society of different diagnostic strategies in terms of quality-adjusted life-years (QALYs) and costs.

METHODS

Data were used from 360 children (0.1-15 years) visiting the pediatric emergency department of the Sophia Children's Hospital Rotterdam, The Netherlands (1988-98) with meningeal signs. Model inputs included probabilities of meningitis and adverse outcome, QALYs for years lived with long-term sequelae, and costs of tests and treatments. Mean outcome measures were costs and effects of diagnostic and therapeutic interventions in children suspected of bacterial meningitis, key determinants of the model outcomes, and evaluation of alternative diagnostic strategies and two vaccination programs in an analysis.

RESULTS

The population comprised 99 children with bacterial meningitis (adverse outcome in 10), 36 with serious other bacterial infections, and 225 with self-limiting diseases. Key determinants were the risk of bacterial meningitis or sequelae, costs of treatment, and long-term morbidity. Minimizing lumbar punctures and empirical treatments using a diagnostic decision rule, without missing a single case of meningitis, was a dominant strategy to actual practice. Vaccination strategies of Streptococcus pneumoniae and Neisseria meningitidis resulted in our model in incremental cost-utility ratios of 401,965 Euro dollar ([symbol: see text])/QALY and [symbol: see text]22,635/QALY, respectively.

CONCLUSIONS

Costs of long-term morbidity of bacterial meningitis largely outweigh diagnostic and treatment costs. Modeling interventions in children at risk of bacterial meningitis should include long-term consequences in terms of costs and QALYs.

Reliability and validity of the child health questionnaire-child form (CHQ-CF87) in a Dutch adolescent population

Feasibility, reliability, and discriminative validity of the cross-culturally adapted Dutch version of the originally US child health questionnaire-child form (CHQ-CF87), an 87-item generic pediatric health-related quality of life instrument, were assessed. The success criterion in this first evaluation was the equivalence of psychometric properties of the adapted and the original CHQ. A total of 466 schoolchildren (9-17 years) were invited to complete the questionnaire in the classroom. Test-retest reliability was measured after 14 days in a subgroup (n = 71). Response was 96%. Four scales had ceiling effects (>50%), as was reported in an Australian study. Cronbach alpha-values were adequate (>0.70), except for 'physical functioning' (0.56). Test-retest correlations, not previously reported, were not statistically significant for two CHQ-scales, whereas average retest scores indicated better health for five scales (p < 0.01). The CHQ scales discriminated significantly (p < 0.01) between children without (n = 281) and children with two or more self-reported chronic diseases (n = 59). This is in correspondence with US and Australian reports.

CONCLUSIONS

The current data support application of the Dutch CHQ-CF in predominantly healthy populations, e.g. in school settings. Given the limitations of this study and some less favorable results (score distributions, internal consistency, test-retest reliability), further evaluation of the CHQ-CF is recommended, preferably by analyses of item performance and scale validity in international data sets that include varied clinical subgroups.

The EQ-5D and the Health Utilities Index for permanent sequelae after meningitis: a head-to-head comparison

Framed in a study on the cost-effectiveness of different diagnostic strategies regarding children with meningeal signs, this study evaluated the quality weights for permanent sequelae after childhood bacterial meningitis obtained with two different classification instruments: the EQ-5D, and Health Utilities Index (HUI). A panel of 28 pediatricians classified seven standardized descriptions of patients with permanent sequelae after bacterial meningitis according to the EQ-5D and HUI classification system. Quality weights for each classification were calculated using the EQ-5D and HUI standard scoring algorithms. HUI Mark 3 quality weights were substantially lower than the EQ-5D for all descriptions (mean difference 0.11; 95% CI: 0.08-0.14). Mean Kendall W for agreement of the ranking order between EQ-5D and HUI Mark 3 was 0.90. The EQ-5D and HUI resulted in different absolute quality weights, in particular for states associated with "deafness" and "mental retardation." Due to their performance differences, the HUI may be preferable to EQ-5D in studies focussed on "sensation" (hearing, vision, speech) or "cognition." These differences proved not to be relevant in the present cost-utility study of diagnostic strategies to rule out bacterial meningitis, as such consequences were at the distal end of the decision tree. This may be different in a cost-utility analysis of therapeutic strategies. Hence, sensitivity analysis to quality weights is recommended.

Cross-national comparability of burden of disease estimates: the European Disability Weights Project

OBJECTIVE

To investigate the sources of cross-national variation in disability-adjusted life-years (DALYs) in the European Disability Weights Project.

METHODS

Disability weights for 15 disease stages were derived empirically in five countries by means of a standardized procedure and the cross-national differences in visual analogue scale (VAS) scores were analysed. For each country the burden of dementia in women, used as an illustrative example, was estimated in DALYs. An analysis was performed of the relative effects of cross-national variations in demography, epidemiology and disability weights on DALY estimates.

FINDINGS

Cross-national comparison of VAS scores showed almost identical ranking orders. After standardization for population size and age structure of the populations, the DALY rates per 100000 women ranged from 1050 in France to 1404 in the Netherlands. Because of uncertainties in the epidemiological data, the extent to which these differences reflected true variation between countries was difficult to estimate. The use of European rather than country-specific disability weights did not lead to a significant change in the burden of disease estimates for dementia.

CONCLUSIONS

Sound epidemiological data are the first requirement for burden of disease estimation and relevant between-countries comparisons. DALY estimates for dementia were relatively insensitive to differences in disability weights between European countries.

Health-related quality of life and cost-effectiveness studies in the European randomised study of screening for prostate cancer and the US Prostate, Lung, Colon and Ovary trial

Decisions on policies for screening for prostate cancer require that information upon health-related quality of life (HRQL) and cost-effectiveness (CE) be available, as the lead time for some of the cases detected by screening will be very long and detriments in quality of life could have a major impact on the subjects remaining life-span. A framework within which both HRQL and cost-effectiveness of prostate cancer screening can be assessed is presented. Studies of both are ongoing in the European Randomised Study of screening for prostate cancer and the US Prostate, Lung, Colon and Ovary trial. Preliminary information confirms that it is important to study screened subjects and controls, and not to assume that inferences derived from study of prostate cancer outside screening trials can be extrapolated to the trials. However, it will require prolonged study to enable the overall effects on quality of life, and on cost-effectiveness to be determined. Such studies are ongoing for the two trials.

Sexual functioning in patients with localized prostate cancer awaiting treatment

This article evaluates current sexual functioning in patients with prostate cancer who are awaiting treatment. One-hundred fifty-eight patients filled out a 15-item questionnaire regarding current sexual functioning. Median age was 67 years. Sixty percent reported to have spontaneous erections at least once a week, and 37% reported a good firmness. Thirty-five percent reported that during sexual activity they had no difficulty in getting erections, and 33% reported that they had no difficulty in maintaining an erection. After diagnosis, all patients reported a decrease in sexual interest, activity, and pleasure. Diagnosis of prostate cancer does have an impact on sexual functioning, therefore sexual counseling prior to treatment is advised.

Health-related quality-of-life effects of radical prostatectomy and primary radiotherapy for screen-detected or clinically diagnosed localized prostate cancer

PURPOSE

The current study was undertaken within the framework of a screening trial to compare the health-related quality-of-life (HRQOL) outcomes of two primary treatment modalities for localized prostate cancer: radical prostatectomy and external-beam radiotherapy.

PATIENTS AND METHODS

We conducted a prospective longitudinal cohort study among 278 patients with early screen-detected (59%) or clinically diagnosed (41%) prostate cancer using both generic and disease-specific HRQOL measures (SF-36, UCLA Prostate Cancer Index [urinary and bowel modules] and items relating to sexual functioning) at three points in time: t1 (baseline), t2 (6 months later), and t3 (12 months after t1).

RESULTS

Questionnaires were completed by 88% to 93% of all initially enrolled patients. Patients referred for primary radiotherapy were significantly older than prostatectomy patients (63 v 68 years, P <.01). Analyses (adjusted for age and pretreatment level of functioning) revealed poorer levels of generic HRQOL after radiotherapy. Prostatectomy patients reported significantly higher (P <.01) posttreatment incidences of urinary incontinence (39% to 49%) and erectile dysfunction (80% to 91%) than radiotherapy patients (respectively, 6% to 7% and 41% to 55%). Bowel problems (urgency) affected 30% to 35% of the radiotherapy group versus 6% to 7% of the prostatectomy group (P <.01). Patients with screen-detected and clinically diagnosed cancer reported similar posttreatment HRQOL.

CONCLUSION

Prostatectomy and radiotherapy differed in the type of HRQOL impairment. Because the HRQOL effects may be valued differently at the individual level, patients should be made fully aware of the potential benefits and adverse consequences of therapies for early prostate cancer. Differences in posttreatment HRQOL were not related to the method of cancer detection.

Health-related quality of life in patients with screen-detected versus clinically diagnosed prostate cancer preceding primary treatment

BACKGROUND

The purpose of this study was to evaluate baseline health-related quality of life (HRQOL) in patients with localized prostate cancer before primary treatment (radical prostatectomy or radiotherapy).

METHODS

Two hundred patients with newly diagnosed localized (screen-detected or clinically diagnosed) prostate cancer completed HRQOL questionnaires (generic and disease-specific measures). Clinical data were collected from patients' medical records in four Rotterdam hospitals.

RESULTS

Screen-detected tumors were of more favorable stages and grades than clinically diagnosed ones. The diagnostic groups did not differ significantly in bowel and sexual functioning. Differences were found in urinary functioning, favoring patients with screen-detected tumors of T2-T3 stages. Patients with screen-detected T2 cancer reported better generic HRQOL (physical aspects) than the clinical group, but HRQOL of the latter group was similar to the population norm. Radiotherapy patients were significantly older and had more comorbidity than subjects referred to prostatectomy. Urinary, bowel, and sexual problems were uncommon. Older (> 65 years) radiotherapy patients appeared to be less sexually active. Radiotherapy patients also reported poorer levels of generic HRQOL.

CONCLUSIONS

Screen-detected prostate cancer patients presented with more favorable cancer stage and grade. HRQOL was related to both the tumor stage and the detection method. Pre-treatment HRQOL differences between prostatectomy and radiotherapy patients were associated neither with tumor characteristics nor with the detection method. Baseline differences in HRQOL should be taken into account when evaluating post-treatment HRQOL.

Why do men refuse or attend population-based screening for prostate cancer?

BACKGROUND

The aims of this study were to investigate the motives for refusing or attending population-based screening for prostate cancer, in relation to various background characteristics.

METHODS

The present study is part of the European Randomized Study of Screening for Prostate Cancer (ERSPC), and took place in 1995-1996. Men aged 55-75 years were invited using the Rotterdam population registry (100 per cent coverage), of whom 42 per cent gave written informed consent. These men were randomized to receive either determination of prostate specific antigen (PSA), digital rectal examination (DRE), transrectal ultrasound (TRUS) and biopsy on indication (screening group), or no screening (control group). To 626 consecutive men of the screening group a questionnaire was sent before the screening. To 500 randomly selected refusers (no written informed consent) a similar questionnaire was sent, followed by two reminders. In both refusers and attenders we addressed motives, knowledge of prostate cancer, attitudes towards screening, background characteristics and urological complaints (American Urological Association symptom index, AUA7).

RESULTS

Response rates for questionnaires were 48 per cent in refusers and 99 per cent in attenders. Main reported motives for refusing were absence of urological complaints (57 per cent) and anticipated pain or discomfort (18 per cent). Main reported motives for attending were personal benefit (82 per cent), contribution to science (49 per cent) and presence of urological complaints (25 per cent). Compared with attenders, refusers were slightly and significantly older, less often married and had a lower level of education; they had less knowledge about prostate cancer and a less positive attitude towards screening; they had worse general health but fewer urological complaints (AUA7 median 2 versus 4, p < 0.001).

CONCLUSION

In refusing or attending population-based prostate cancer screening, urological complaints but also knowledge, attitudes and sociodemographic factors seem to play a role. Therefore, the approach of the general population should be carefully considered.

A national burden of disease calculation: Dutch disability-adjusted life-years. Dutch Burden of Disease Group

OBJECTIVES

This study estimated the burden of disease due to 48 major causes in the Netherlands in 1994 in disability-adjusted life-years (DALYs), using national epidemiologic data and disability weights, and explored associated problems and uncertainties.

METHODS

We combined data from Dutch vital statistics, registrations, and surveys with Dutch disability weights to calculate disease-specific health loss in DALYs, which are the sum of years of life lost (YLLs) and years lived with disability (YLDs) weighted for severity.

RESULTS

YLLs were primarily lost by cardiovascular diseases and cancers, while YLDs were mostly lost by mental disorders and a range of chronic somatic disorders (such as chronic nonspecific lung disease and diabetes). These 4 diagnostic groups caused approximately equal numbers of DALYs. Sensitivity analysis calls for improving the accuracy of the epidemiologic data in connection with disability weights, especially for mild and frequent diseases.

CONCLUSIONS

The DALY approach appeared to be feasible at a national Western European level and produced interpretable results, comparable to results from the Global Burden of Disease Study for the Established Market Economies. Suggestions for improving the methodology and its applicability are presented.

Estimating parametric relationships between health description and health valuation with an application to the EuroQol EQ-5D

Generic health status measures classify patients into different health states. For example, the EQ-5D descriptive system developed by the EuroQol Group classifies patients into 243 health states. Empirical values for the health states are available for only a selection (mostly 12 to 45) of these health states. Several parametric relationships between the descriptive system and the known values can be formulated to estimate the values for the unrecorded health states. This paper describes several of these modeling exercises in a comprehensible way, using the EQ-5D as an illustration. It is shown that the estimation task does not depend on the meaning of the values, but does depend on the selection of the empirically valued health states and the assumptions about the relationship between these values and the descriptive system.

The effect of adding a cognitive dimension to the EuroQol multiattribute health-status classification system

A methodological study was conducted to examine the effect of extending a frequently used simple multiattribute health-status classification system by adding a cognitive dimension. The EQ-5D questionnaire is a generic instrument to value health, developed by the EuroQol Group. The EQ-5D defines health according to five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. We defined 18 different health states according to the standard EQ-5D classification. A second set of health states was constructed similar to the first, except for the addition of a cognitive dimension (EQ-5D+C). Valuations of both sets of health states were statistically analyzed to detect the effect of the additional dimension. The cognitive dimension generated systematically different values compared with the standard EQ-5D version, whereas the content validity improved. Both systems evoked equally reliable values. Analyses showed that a simple additive model to predict summary values for health states was not optimal for both systems. Although there is a current lack of consensus regarding the domains that are selected to represent health status, this study has shown the importance of considering the inclusion of a cognitive domain.

Translation, validation, and norming of the Dutch language version of the SF-36 Health Survey in community and chronic disease populations

The primary objectives of this research were to translate, validate, and generate normative data on the SF-36 Health Survey for use among Dutch-speaking residents of the Netherlands. Translation of the SF-36 into Dutch followed the stepwise, iterative procedures developed by the IQOLA Project. Following extensive pilot testing, the SF-36 was administered to: (1) a random sample of adult residents of Amsterdam (n = 4172); (2) a random, nationwide sample of adults (n = 1742); (3) a sample of migraine sufferers (n = 423); and (4) a sample of cancer patients undergoing active anti-neoplastic treatment (n = 485). Data quality across the four studies was consistently high. The rates of missing data ranged from 1% to 5% at the item level, and from 1.2% to 2.6% at the scale level. Multitrait scaling analysis confirmed the hypothesized scale structure of the SF-36 and associated scale scoring in all four samples. Cronbach's alpha coefficients surpassed the 0.70 criterion for group comparisons in all but one case (the Social Functioning scale in the cancer sample), with a mean alpha coefficient across all scales and samples of 0.84. Known-group comparisons yielded consistent support for the validity of the SF-36. In the two community samples, statistically significant differences in SF-36 mean scale scores were observed as a function of age, gender, and the prevalence of chronic health conditions. In the migraine and cancer samples, mean SF-36 scale scores varied significantly as a function of various indicators of disease severity. The SF-36 profiles for the two community samples were highly similar. The cancer sample yielded the lowest SF-36 scores, with the migraine sample holding an intermediate position. On-going studies will generate data on the responsiveness of the SF-36 to within-group changes in health over time. Efforts are underway to translate and validate the questionnaire for use among ethnic minority groups in the Netherlands.

Short-term effects of population-based screening for prostate cancer on health-related quality of life

BACKGROUND

Population-based screening for prostate cancer is currently being evaluated in randomized clinical trials in the United States and in Europe. Side effects arising from the process of screening and from the earlier treatment of screen-detected prostate cancer may be important factors in the evaluation. To examine health-related quality of life (or health status) among men screened for prostate cancer, we conducted a longitudinal study of 626 attenders to the Rotterdam (The Netherlands) prostate cancer screening program and of 500 nonparticipants.

METHODS

Attenders of the screening program and nonparticipants completed self-assessment questionnaires (SF-36 [i.e., Medical Outcomes Study 36-Item Short-Form Health Survey] and EQ-5D [i.e., EuroQol measure for health-related quality of life] health surveys) to measure generic health status, as well as an additional questionnaire for anxiety and items relating to prostate cancer screening.

RESULTS

Physical discomfort during digital rectal examination and during transrectal ultrasound was reported by 181 (37%) of 491 men and by 139 (29%) of 487 men, respectively; discomfort during prostate biopsy was reported by 64 (55%) of 116 men. Mean scores for health status and anxiety indicated that the participants did not experience relevant changes in physical, psychological, and social functioning during the screening procedure. However, high levels of anxiety were observed throughout the screening process among men with a high predisposition to anxiety. Similar scores for anxiety predisposition were observed among attenders and nonparticipants.

CONCLUSIONS

At the group level, we did not find evidence that prostate cancer screening induced important short-term health-status effects, despite the short-lasting side effects related to the biopsy procedure. However, subgroups may experience high levels of anxiety. The implication is that unfavorable health-status effects of prostate cancer screening occur mainly in the treatment phase.

The effect of lung transplantation on health-related quality of life: a longitudinal study

STUDY OBJECTIVES

To assess the change in health-related quality of life (HRQL) among Dutch lung transplant patients before and after transplantation.

DESIGN

Prospective longitudinal study on HRQL among 24 Dutch lung transplant patients who participated first as transplant candidates, and later as recipients in the study. This study design provides an accurate estimate of the change in HRQL as a result of lung transplantation because there is no confounding between change due to differences in composition between groups of patients at the different points of follow-up and the true change as a result of the transplantation. Patients completed self-administered questionnaires before transplantation, and at 1, 4, 7, 13, and 19 months after transplantation. The main HRQL measures were: the Nottingham health profile (NHP), the State-trait Anxiety Inventory, the Self-rating Depression Scale-Zung, the Karnofsky Performance Index, the index of well-being, and activities of daily living (ADL).

SETTING

University Hospital Groningen, the Netherlands.

RESULTS

Before transplantation, patients report major restrictions on the dimensions mobility and energy of the NHP, a low level of experienced well-being, and depressive symptoms. In addition, patients experience difficulties in performing ADL and report a low ability to take care of themselves. About 4 months after transplantation, mobility, energy, sleep, ADL dependency level, and dyspnea were particularly positively affected by the lung transplantation. These improvements were maintained in the following 15 months.

CONCLUSIONS

Lung transplantation contributes positively to the HRQL of surviving patients over time.

The comparability and reliability of five health-state valuation methods

The objective of the study was to consider five methods for valuing health states with respect to their comparability (convergent validity, value functions) and reliability. Valuation tasks were performed by 104 student volunteers using five frequently used valuation methods: standard gamble (SG), time trade-off (TTO), rating scale (RS), willingness-to-pay (WTP) and the paired comparisons method (PC). Throughout the study, the EuroQol classification system was used to construct 13 health-state descriptions. Validity was investigated using the multitrait-multimethod (MTMM) methodology. The extent to which results of one method could be predicted by another was examined by transformations. Reliability of the methods was studied parametrically with Generalisability Theory (an ANOVA extension), as well as non-parametrically. Mean values for SG were slightly higher than TTO values. The RS could be distinguished from the other methods. After a simple power transformation, the RS values were found to be close to SG and TTO. Mean values of WTP were linearly related to SG and TTO, except at the extremes of the scale. However, the reliability of WTP was low and the number of inconsistencies substantial. Valuations made by the RS proved to be the most reliable. Paired comparisons did not provide stable results. In conclusion, the results of the parametric transformation function between RS and SG/TTO provide evidence to justify the current use of RS (with transformations) not only for reasons of feasibility and reliability but also for reasons of comparability. A definite judgement on PC requires data of a complete design. Due to the specific structure of the correlation matrix which is inherent in valuing health states, we believe that full MTMM is not applicable for the standard analysis of health-state valuations.

Health-related quality of life: an indicator of quality of care?

There is an increasing interest in the use of outcome indicators to monitor the quality of care. Traditionally, outcome indicators have been based mainly on biological indicators reflecting death or disease. Now that various instruments for health status measurement have become available, questions have been raised as to the potential application of health status scores in monitoring the quality of care. This paper identifies conditions which should be fulfilled before such applications can be recommended. Firstly, the relationship between care delivery processes and health status outcomes must be established. In order to achieve this, health status measures which are clearly able to detect health status variations between groups of patients (i.e. discriminative ability) and variations over time (i.e. sensitivity to change) are needed. Secondly, health status data should be available, preferably from established data collection registries (e.g. computerized hospital records or national registries) where data relating to the description of variations in health status (between physicians, hospitals, regions, etc.) are routinely collected. Thirdly, methods should be found to collect additional data, including 'case-mix' information and health status reference data, in order to enable the interpretation of variations in health status. Because most of these conditions are currently not being fulfilled, we conclude that the state-of-the-art of health status measurement has not yet matured sufficiently to allow for the use of health status as an indicator of quality of care. The present paper provides a framework for both future research and data collection that is needed to improve the applicability of health status measures as quality-of-care indicators.

An empirical comparison of four generic health status measures. The Nottingham Health Profile, the Medical Outcomes Study 36-item Short-Form Health Survey, the COOP/WONCA charts, and the EuroQol instrument

OBJECTIVES

An empirical, head-to-head comparison of the performance characteristics of four generic health status measures.

METHODS

The Nottingham Health Profile, the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36), the COOP/WONCA charts, and the EuroQol instrument were simultaneously employed in a controlled survey measuring the impact of migraine on health status. The feasibility (number of missing cases per item), internal consistency (Cronbach's alpha), construct validity (correlation patterns and common factor analysis), and discriminative ability (Receiver Operating Characteristics analyses) of the four measures were investigated.

RESULTS

The Nottingham Health Profile produced the lowest missing value rate. The internal consistency of the Nottingham Health Profile scales was lower than the scales of the SF-36. Combined factor analyses with data of the four instruments together resulted in two-factor solutions with a physical and a mental factor, explaining approximately 50% of variance. The SF-36 exhibited the best ability to discriminate between groups. Test-retest reliability and sensitivity to change over time could not be tested because of the cross-sectional character of the study.

CONCLUSIONS

None of the instruments performed uniformly as "best" or "worst." Purely on the basis of the results of the psychometric analyses, the SF-36 appeared to be the most suitable measure of health status in this relatively healthy population. In general, the choice of the most suitable instrument for generic health status assessment in a particular study should be guided by the special features of each candidate instrument under consideration.

Sacral rhizotomies and electrical bladder stimulation in spinal cord injury. 2. Cost-effectiveness and quality of life analysis. Dutch Study Group on Sacral Anterior Root Stimulation

OBJECTIVES

To present a cost-effectiveness analysis of sacral rhizotomies and electrical bladder stimulation compared with conventional care of neurogenic bladder dysfunction in patients with spinal cord injury.

METHODS

During a 3-year inclusion period, data on costs and quality of life before the intervention were collected to describe conventional care. Data on the pre-implantation period, the implantation and a follow-up period of 2 years were collected following a strict protocol simultaneous with medical and urodynamic data and were used to calculate the costs and effects on quality of life of the implantation of the stimulator.

RESULTS

Between June 1991 and June 1994, 52 patients with complete cervical or thoracic spinal cord lesions underwent sacral posterior rhizotomies and implantation of a Finetech-Brindley sacral anterior root stimulator. Although the initial costs of sacral anterior root stimulation are high, they are earned back in this series in about 8 years after the implantation. General indicators of the quality of life show no significant changes after the implantation. Factors related to psychological well-being and the patients' satisfaction with the emptying of the bladder increased significantly whereas the experienced problems of micturition and incontinence all decreased significantly.

CONCLUSION

Sacral rhizotomies and electrical bladder stimulation make a cost-effective method of treatment of lower urinary tract dysfunction in patients with spinal cord injury. Considerable savings on health care costs are possible in the long run with simultaneous positive effects on aspects of health status.

Labor and health status in economic evaluation of health care. The Health and Labor Questionnaire

A health care program may influence both costs and health effects. We developed the Health and Labor Questionnaire (HLQ), which consists of four modules, to collect data on absence from work, reduced productivity, unpaid labor production, and labor-related problems. We applied the HLQ in several studies, and the results are encouraging.

On the equivalence of collectively and individually collected responses: standard-gamble and time-tradeoff judgments of health states

The standard-gamble and time-tradeoff methods for valuing health states were compared in a multifactorial design with 104 student volunteers. The main aim of the experiment was to compare average individual responses with group responses for the same tradeoff tasks. Group responses were collected using an interactive voting system. The standard EuroQol system was used to describe the health states to be valued. Generalizability theory was used to analyze the results. The averages and median values of the individual responses differed from the interactively collected group values only for the more severe health states. The results showed almost identical results for the two methods, but the time tradeoff was found to be more consistent than the standard gamble. The authors conclude that 1) there is significant similarity between the results of individual and collective response modes, and 2) the standard-gamble and time-tradeoff methods produce almost equivalent values, despite their different conceptual backgrounds. In this study the aggregated individual responses and the collective response proved to be sufficiently similar to support the validity of using aggregated individual valuations as a measure of the valuation of the group.

NHP or SIP--a comparative study in renal insufficiency associated anemia

In this study we compared the feasibility, internal structure and psychometric characteristics (internal consistency, test-retest reliability, construct validity) of two widely used generic health status measures, i.e. the Nottingham Health Profile (NHP) and the Sickness Impact Profile (SIP) when employed among a sample of patients on renal dialysis (n = 63). The NHP was found to be more feasible, i.e. shorter and less difficult, than the SIP. The NHP scales showed somewhat higher levels of internal consistency (mean alpha = 0.67, range = 0.39-0.80) than the SIP scales (mean alpha = 0.65, range = 0.14-0.82). Test-retest reliability with a 24-hour interval was acceptable for most NHP scales (not available for the SIP in this study). Intercorrelations between the NHP scales were somewhat weaker than those for the SIP, and the expected patterns of scale intercorrelations were largely confirmed. The overall pattern of correlations between NHP scales and SIP scales was consistent with expectations, although the correlations were generally rather weak. Correlations between NHP scales and SIP scales and instruments measuring mainly physical functioning (ADL, Karnofsky) were largely as expected. Similarly, correlations between NHP scales and SIP scales and instruments measuring mainly psychological functioning [STAI (anxiety), SDS-Zung (depression)] were also as expected, although here the correlations were weaker for the SIP when compared with the NHP. The Index of Well-being exhibited intra-class correlations > 0.3 with one SIP scale and with five out of six NHP scales. Common factor analysis, yielding a two-factor solution with a physical and a mental factor of equal importance, showed the SIP scales to load more on the physical factor, while the NHP scales loaded more on the mental factor. The NHP generally performed better than the SIP in terms of feasibility and internal consistency. Physical functioning is emphasized in the SIP, whereas the emphasis of the NHP lies on mental functioning. The analysis confirmed to some extent the intentions of the constructors of NHP and SIP respectively, i.e. the NHP to be a measure of perceived health and the SIP to be a more functional measure.

The impact of migraine on health status

PROBLEMS

What is the effect of migraine on health status, defined as the patient's physical, psychological, and social functioning? And, suppose that the health status of migraine sufferers appears to be impaired, to what extent is this a consequence of migraine-associated comorbidity rather than of migraine itself?

METHODS

A group of 846 migraineurs, selected from the general population following IHS criteria, and a control group were surveyed with the Medical Outcomes Study 36-item Short-Form Health Survey, Nottingham Health Profile, EuroQol instrument, and the COOP/WONCA charts. Questions on demographic characteristics and comorbidity were included.

RESULTS

The health status of migraineurs appeared to be significantly impaired in comparison to the control group. Because statistical significance is distinct from relevance, effect size estimators were employed. Although the direction of the differences indicated consistently a worse health status of the migraineurs, regardless of the instrument used, the sizes of the differences were small to medium. Self-reported comorbidity, especially depression, was more prevalent in the migraine group. However, this offered only a partial explanation for the impaired health status of the migraine group.

CONCLUSIONS

Migraine has an independent moderately deteriorating effect on the daily functioning of individuals.

Societal perspective on the burden of migraine in The Netherlands

This study presents a comprehensive overview of the societal burden of migraine in The Netherlands. We assessed the direct and indirect costs of this disease, and the health status of patients with migraine. We developed the 'illness and labour' (I&L) questionnaire to collect data on the effect of illness on labour performance. 846 migraine patients and 834 controls were selected from the general population. Participants completed an I&L questionnaire as well as generic health status questionnaires. The direct costs of migraine amounted to 134 million Netherlands guilders (NLG) [$US1 = NLG1.68, October 1994]. Conservative calculations of the costs of absence from work and reduced productivity at work were NLG264 and NLG277 million per year, respectively. Our study did not indicate that migraine caused household productivity losses. The baseline estimate of the total societal costs of migraine in The Netherlands was NLG675 million per year. The assessment of health status showed considerable impairment of psychological and social functioning in migraine patients.

Test-retest reliability of health state valuations collected with the EuroQol questionnaire

This study is a contribution by the Dutch participants to the research programme of the EuroQol Group. This collaborative group of researchers engaged in outcome measurement is working towards the development of a standardized, non-disease-specific instrument for describing and particularly valuing health-related quality of life. The present article analyses the test-retest reliability of the valuations collected with the EuroQol questionnaire in a population survey (n = 208). The choice of the appropriate method for test-retest analysis is discussed and the results of several approaches with the EuroQol data are shown. Generalizability Theory is proposed as the most suitable method. This method is the most comprehensive, giving distinct information about the relative contributions of different sources of variance. The EuroQol valuations appear to have good test-retest reliability.

Test-retest reliability of health state valuations collected with the EuroQol questionnaire

This study is a contribution by the Dutch participants to the research programme of the EuroQol Group. This collaborative group of researchers engaged in outcome measurement is working towards the development of a standardized, non-disease-specific instrument for describing and particularly valuing health-related quality of life. The present article analyses the test-retest reliability of the valuations collected with the EuroQol questionnaire in a population survey (n = 208). The choice of the appropriate method for test-retest analysis is discussed and the results of several approaches with the EuroQol data are shown. Generalizability Theory is proposed as the most suitable method. This method is the most comprehensive, giving distinct information about the relative contributions of different sources of variance. The EuroQol valuations appear to have good test-retest reliability.

Generalizability of valuations on health states collected with the EuroQolc-questionnaire

PROBLEM

Non-response and non-usable response were found in population surveys on valuation of health states. If non-response is selective regarding valuations, then generalization of the resulting values to the whole survey population is not permitted. This could limit the use of empirical utility values in resource allocation in health care.

METHODS

Response behaviour of a sample of 1400 from the Dutch general population to the mailed EuroQolc-questionnaire was analyzed by four methods. I. Phoning resolute non-respondents; II. comparison of zip code characteristics of respondents and non-respondents (because individual data on background characteristics were not available for the non-respondents); III. analysis of response over time (wave-analysis); IV: comparison of background variables of successful (less than two valuations missing) and unsuccessful respondents, combined with analysis of the effect of these background variables on valuations.

RESULTS

No indications for selective non-response were found, although the phenomenon appeared hard to investigate. The successful response came from a slightly younger and better educated subsample. However, a general influence of age and educational level on valuations could not be shown. This finding is consistent with the literature.

CONCLUSION

Although the existence of selective non-response cannot be excluded, its relevance can be considered to be small. This finding is encouraging for the use of empirical utility values in allocative decisions.

Assessment of the quality of life before and following liver transplantation. First results

Analysis of quality-of-life effects is part of the current technology assessment of the Dutch orthotopic liver transplant-program. Data are collected by means of computer-assisted interviewing, including one interview before transplantation and annual follow-up interviews. Data on psychiatric morbidity are obtained from medical records. This article shows preliminary results of a cross-sectional analysis of data collected from 1987 to 1989. Eighty-eight measurements were obtained from 46 adult patients (response rate 82%). Pretransplant scores suggest major restrictions on all domains of life, especially a low amount of energy. After transplantation all indicators show improvement, although the level of the general population is not always attained. Improvement of subjective quality of life is more marked, possibly due to euphoria at surviving the hazardous procedure. Psychiatric events occurred only infrequently. We conclude that orthotopic liver transplantation contributes positively to the quality of life of surviving patients. In addition, computer-assisted interviewing proved to be a feasible survey technique, even when very ill patients were involved.

Orthotopic liver transplantation in The Netherlands. The results and impact of a medical technology assessment

In 1985 Dutch health care authorities and health insurance companies initiated a large-scale technology assessment (TA) of liver transplantation (LTx) in The Netherlands. The 10-year experience of the existing programme in the University Hospital Groningen was investigated. Topics included were patient flow, selection policies, survival, quality-of-life, costs, need, supply of donor organs and organisational aspects. Estimation of the consequences of a non-transplantation scenario allowed for the execution of a cost-effectiveness analysis. Results showed clear improvement by LTx of survival and quality-of-life, though to a lesser degree than expected. Costs of the first transplantation year amounted to Dfl 180,000 (approx US $90,000). The cost-effectiveness ratio ranged from Dfl 47,000 to Dfl 133,000 per life year gained. No overt imbalance between need and donor supply existed or was expected in the near future. The impact of this study is related to the informational value and to the contribution to the decision-process. Even at its appearance in 1988, the final report provided health policy makers with new information. Health policy concerning LTx was considerably influenced, as a rule in agreement with the study conclusions. We conclude the Dutch case study to be an example of a useful and efficient TA.

Valuation of health states by the general public: feasibility of a standardized measurement procedure

In the context of an international collaborative study we tested the feasibility of a utility measurement procedure in the Dutch general population. A postal questionnaire was sent to a random sample of 200 households in a town in the Netherlands (+/- 50,000 inh.). Respondents were requested to value 14 six-dimensional health states by means of visual analogue scaling (VAS). The response was satisfactory (57%), though about a fifth of those willing to complete the questionnaire did not manage to use a VAS to express their opinion. Inconsistent answers occurred relatively seldom. Generally consensus existed with regard to relative (ranking) and absolute values of different health states. These first results encourage us to go on with the development of this international instrument for the valuation of health states. We conclude the present instrument to be a feasible tool for valuation research, although questions relating to its measuring properties, as well as its reliability and validity remain to be answered.