The Danish EQ-5D-5L Value Set: A Hybrid Model Using cTTO and DCE Data

EQ-5D-5L is a relevant tool for detecting patients with myasthenia gravis needing medical treatment

The generic and easy-to-use questionnaire EQ-5D-5L measures health status in five dimensions and is translated into one utility score, EQ-Utility. The study examined if the EQ-5D-5L could be a useful tool for identifying difficult-to-treat patients with myasthenia gravis who needed new therapies. The patients were informed about the study by phone and invited for a test visit. Close to the test visit, the patients completed online questionnaires. Four hundred twenty-five patients are registered with an MG diagnosis in our clinic. Of these, 80 could not be contacted, 39 were excluded, and 85 did not want to participate. Two hundred twenty-one patients participated in the tests, and of these, 178 completed the EQ-5D-5L and were included. The mean EQ-Utility (SD) was 0.85 ± 0.19. Women reported lower EQ-Utility than men (0.79 versus 0.92, p < .0001). The health-related quality of life decreased with increasing disease severity (p < .0001). The symptoms that impacted the EQ-Utility were swallowing (β = 0.065, p = .007), brushing hair/teeth (β = 0.089, p < .0001), rising from a chair (β = 0.069, p < .001), and ptosis (β = 0.045, p = .038). Factors influencing the EQ-Utility were MG-ADL score and depression. The EQ-5D-5L could detect patients with unmet needs and can be used routinely in the clinic.

Trajectory of quality of life among patients with cancer at the end of life: a longitudinal survey study

PURPOSE

Measuring and understanding the determinants of HRQoL is essential to the delivery of effective and high-quality end-of-life (EoL) care to patients with cancer. Despite this, the evidence base remains sparse and with much of the existing literature relying on data from cross-sectional studies and clinical trials.

AIM

The objective of this study was to describe HRQoL in a population of patients with cancer leading up till death using both the generic preference-based scale European Quality of Life 5 Dimensions 5 Level Version and the disease-specific scale European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire.

METHODS

Using a longitudinal prospective study design, HRQoL data was collected in four waves over the course of one year. The population consisted of all patients who received cancer-targeted drug treatment at the Department of Oncology at Odense University Hospital, Denmark. Only patients who died during the data collection period were included.

RESULTS

HRQoL in patients with cancer was stable for most months and close to the level of the general Danish population at the same age but deteriorated considerably in the last three months of life. The same pattern was observed for both HRQoL scales.

CONCLUSION

Despite current efforts to deliver high-quality EoL care to patients with cancer, we see a general decrease in HRQoL in the months leading up to death. The generic and disease-specific HRQoL scales do capture different dimensions of HRQoL which also, by construct, are weighted differently in the two approaches.

Valuing health-related quality of life: an EQ-5D-5L value set for Morocco

PURPOSE

There is a growing interest in Health Technology Assessment (HTA) in Morocco. A national EQ-5D-5L value set would allow for the computation of Quality Adjusted Life Years (QALYs) in economic evaluations of healthcare interventions to support decision-making. This study aimed to develop a Moroccan EQ-5D-5L value set based on data from a representative sample of the Moroccan adult general population.

METHODS

A Moroccan representative sample of adults was recruited using stratified quota sampling based on gender, age category, and place of residence. Data were collected between November 2022 and December 2023 using the international EuroQol valuation protocol, EQ-VT version 2.6.1. This protocol includes two elicitation techniques: the composite time trade-off (cTTO) and the discrete choice experiment (DCE). cTTO and DCE data were modeled using a heteroskedastic Tobit model and a conditional logit model, respectively. In addition, these models were combined using a hybrid model.

RESULTS

A total of 976 respondents were included in the final analysis. The hybrid heteroskedastic model was considered the preferred model. The predicted utility values ranged from -1.492 for the worst health state (55555) to 1 for full health (11111), where the two mildest impaired states (11211 and 21111) had a utility value of 0.979. Pain/discomfort had the largest effect on health utility values, followed by anxiety/depression, mobility, self-care and usual activities.

CONCLUSION

Morocco is the third country in the Middle East and North Africa (MENA) region with an EQ-5D-5L value set. This study supports the use of EQ-5D-5L data for healthcare decision-making in the Moroccan context.

The Evolving Landscape of Discrete Choice Experiments in Health Economics: A Systematic Review

INTRODUCTION

Stakeholder preference evaluations are increasingly emphasized in healthcare policy and health technology assessment. Discrete choice experiments (DCEs) are the most common method for quantifying preferences among patients, the public, and healthcare professionals. While prior reviews (1990-2017) have examined DCE trends, no comprehensive synthesis exists for studies published since 2018. This updated review (2018-2023) provides critical insights into evolving methodologies and global trends in health-related DCEs.

METHODS

A systematic search (2018-2023) of Medline, Embase, and Web of Science identified relevant studies. Studies were screened for inclusion and data were extracted, including details on DCE design and analysis. To enable trend comparisons, the search strategy and extraction items aligned with previous reviews.

RESULTS

Of 2663 identified papers, 1279 met the inclusion criteria, reflecting a significant rise in published DCEs over time. DCEs were conducted globally, with a remarkable increase in publications from Asia and Africa compared with previous reviews. Experimental designs and econometric models have advanced, continuing prior trends. Notably, most recent DCEs were administered online.

DISCUSSION

The rapid growth of DCE applications underscores their importance in health research. While the methodology is advancing rapidly, it is crucial that researchers provide full transparency in reporting their methods, particularly in detailing experimental designs and validity tests, which are too often overlooked. Key recommendations include improving reporting of experimental designs, applying validity tests, following good practices for presenting benefit-risk attributes, and adopting open science practices. Ensuring methodological rigor will maximize the impact and reproducibility of DCE research in health economics.

Incidence, Disease Burden, and Clinical Presentation of Patients Newly Diagnosed With Inflammatory Bowel Disease in a Population-Based Inception Cohort

BACKGROUND AND AIMS

Emerging data indicate a stabilizing incidence of inflammatory bowel diseases (IBD), including ulcerative colitis (UC), Crohn's disease (CD), and IBD unclassified (IBDU) in Western countries. We aimed to investigate the incidence of IBD, its initial clinical presentation, and patient-reported burden.

METHODS

Copenhagen IBD Inception Cohort is a prospective, population-based cohort of patients with newly diagnosed IBD according to the ECCO guidelines in the period between May 2021 and May 2023, within a catchment area covering 20% of the Danish population.

RESULTS

Based on 554 patients (UC: 308, CD: 201, and IBDU: 18), the incidence rates per 100 000 person-years were as follows: IBD: 23.4 (95% confidence interval, 21.5-25.4), UC: 14.0 (12.6-15.6), CD: 8.6 (7.4-9.8), and IBDU: 0.8 (0.5-1.3). The median diagnostic delay was significantly shorter for UC (2.5 months [interquartile range {IQR} 1-6]) than for CD (5 months [IQR 1.5-11], p < 0.01). Moderate-to-severe disability was reported by 34% of CD patients and 22% of UC patients (p = 0.01), severe fatigue by 30% and 26% (p = 0.43), and severely impaired health-related quality of life (HRQoL) by 43% and 30% of patients, respectively (p = 0.01). Hospitalization rates (UC: 20%, CD: 34%, p < 0.01), and need for immunomodulators, biologics, or surgery within 3 months of diagnosis, were high in both UC (3%, 7%, and 37%, respectively) and CD (31%, 18%, and 10%, respectively).

CONCLUSIONS

We found a high incidence of IBD in Copenhagen with a substantial disease burden characterized by early and high requirements for advanced therapies and high rates of fatigue, disability, and impaired HRQoL at diagnosis.

Self-reported outcomes following lower extremity, carotid and aortic artery disease: protocol for the Danish Vascular (DanVasc) survey

INTRODUCTION

Among lower extremity artery disease (LEAD), symptomatic carotid stenosis (SCS) and abdominal aortic aneurysm (AAA), the disease burden is insufficiently illuminated from a patient and societal perspective. Such knowledge is central to identifying patients at risk of poorer outcomes. Therefore, the Danish Vascular (DanVasc) survey aims to describe self-reported health status, health literacy, medication adherence and loneliness, including changes over time, and investigate characteristics associated with worse self-reported health at baseline and their associations with poorer outcomes within 1 year (healthcare utilisation and mortality) in patients with LEAD, SCS and AAA.

METHODS AND ANALYSIS

The DanVasc survey, a national prospective cohort study combining survey data measured at several time points with register-based data, includes validated patient-reported outcome measures (PROMs) and ancillary questions developed with patient representatives. Our baseline survey (T0) follows the index contact in vascular outpatient clinics with follow-up surveys determined by the patient's trajectory: (1) newly referred patients in conservative treatment trajectories; the date for the outpatient visit activates 1-month (T1), 3-month (T2) and 12-month (T3) follow-ups. (2) Patients referred for vascular surgery; the surgery date activates 1-month (T1), 3-month (T2) and 12-month (T3) follow-ups. The included PROMs assess health-related quality of life (HRQoL), anxiety and depression, sleep, frailty status, health literacy, medication adherence and loneliness. For LEAD, a disease-specific PROM evaluates HRQoL. For AAA, disease-specific ancillary questions are added. Additionally, the DanVasc survey includes questions on health behaviour, preventive measures and sexual life. The DanVasc survey will be linked to national registries to obtain socio-demographic information and data on redeemed prescriptions, clinical information, healthcare utilisation, comorbidities and mortality. From December 2023 to December 2024, we aim to recruit approximately 5500 patients from all seven DanVasc surgery departments. Patient characteristics will be reported using descriptive statistics. Changes over time and factors associated with poorer health outcomes will be analysed using linear, logistic and Cox proportional hazard models, presented as univariate and multivariate regressions.

ETHICS AND DISSEMINATION

Approval for the collection of medical record data was granted by the Central Denmark Region, acting on behalf of all Danish regions (record 1-45-70-94-22). Consent to participate is obtained prior to answering the survey. Results will be disseminated through peer-reviewed scientific publications and conference presentations, and findings will be shared with patients and relevant stakeholders via public and social media.

Predicting Danish EQ-5D-5L Utilities Based on United Kingdom EQ-5D-3L Utilities for Use in Health Economic Models

OBJECTIVES

Since 2021, the Danish Medicines Council recommends the use of the Danish EQ-5D-5L value set when estimating utilities. The aim of this research was to develop and validate an algorithm that can accurately predict mean Danish EQ-5D-5L utilities based on published mean UK EQ-5D-3L utilities.

METHODS

The study design incorporated a secondary analysis of patient-level UK EQ-5D-3L utility index scores from 11 oncology clinical trials. The EQ-5D-3L responses were mapped to EQ-5D-5L responses with the van Hout and Shaw preferred mapping algorithm. Model fitting and internal cross-validation were completed on a pooled dataset formed from eight trials including a total of 30,755 EQ-5D-3L responses. Three other trials were used for external validation (21,587 EQ-5D-3L observations).

RESULTS

From the model fitting phase, a simple linear model for mean utility scores exhibited good fit and was selected as the optimal prediction algorithm. External validation using the algorithm to predict mean Danish EQ-5D-5L utilities was excellent, with the largest absolute prediction error being 0.020 (observed UK EQ-5D-3L means: 0.628-0.835).

CONCLUSIONS

The prediction algorithm developed in this research can increase analysts' ability to apply utilities aligned with the Danish EQ-5D-5L value set and guideline recommendations, reducing decision uncertainty. Many health technology assessment (HTA) institutions are transitioning from the EQ-5D-3L to the EQ-5D-5L in the coming years; therefore, prediction algorithms are likely of interest to additional HTA institutions in the near future. This study can provide a blueprint for future studies.

Cost-Effectiveness of Hospital-at-Home and Fecal Microbiota Transplantation in Treating Older Patients With Clostridioides difficile

BACKGROUND

Clostridioides difficile infection (CDI) primarily affects older patients with comorbid conditions and has a high mortality rate. Fecal microbiota transplantation (FMT) is effective and cost-effective for CDI. In a recent study, we demonstrated the clinical benefits of combining hospital-at-home care with FMT for older patients with CDI, but its cost-effectiveness remains unknown. The current study aimed to evaluate the cost-effectiveness of the intervention in patients aged ≥70 years with CDI, compared with standard treatment.

METHODS

The cost-utility analysis was conducted using data from a randomized clinical trial enrolling 217 patients, assessing the cost-effectiveness of the intervention over 90 days. Resource use was assessed from a healthcare sector perspective. Missing data were handled with proxy replacement and multiple imputation. Sensitivity analyses included probabilistic analysis, complete case analysis, adjustment of key unit prices, and a hospital perspective. A willingness-to-pay threshold was set to €22 994 or $24 863 per quality-adjusted life year (QALY).

RESULTS

In the base case analysis, the intervention was dominant, with mean cost savings of €2556 ($2764) and a mean gain of 0.004 QALY. Although resource use was higher, the intervention resulted in an average reduction of 6 hospital admission days per patient and increased odds of clinical resolution. The results remained robust across different perspectives, the exclusion of patients with missing data, and variations in hospital admission costs.

CONCLUSIONS

In patients aged ≥70 years with CDI, an intervention combining hospital-at-home care and FMT is cost-effective compared with standard treatment. The cost-effectiveness is mainly driven by fewer hospital admission days.

Musculoskeletal Symptoms and Clinical Findings in Bio-naïve Patients with Inflammatory Bowel Disease Prior to Biological Treatment Initiation: A Prospective Cohort Study

BACKGROUND

Musculoskeletal involvement in inflammatory bowel disease (IBD) patients contributes to poorer outcomes and reduced quality of life (QoL). We aimed to describe the prevalence and distribution of peripheral and axial musculoskeletal symptoms and clinical findings in patients with IBD prior to biological treatment.

METHODS

Bio-naïve patients with IBD were consecutively recruited. Musculoskeletal symptoms were assessed using questionnaires and a structured interview. A rheumatologist conducted a clinical evaluation of peripheral joints and entheses, spine mobility, and considered various differential diagnoses.

RESULTS

Of 82 patients (ulcerative colitis (UC): 33, Crohn's disease (CD): 49, mean age 46 years, 55% male), 51 (62.2%) had musculoskeletal symptoms and 51 (62.2%) had clinical findings. Peripheral joint pain was reported by 39 (47.6%) patients, entheseal pain by 15 (18.3%), and back pain by 33 (40.2%) patients. Clinical evaluation revealed arthritis in 24 (29%) patients and enthesitis in 50 (61%); enthesitis was asymptomatic in 72% of the cases. The Assessment of Spondyloarthritis international Society (ASAS) classification criteria for peripheral spondyloarthritis were met in 36 (44%) patients, and for fibromyalgia in 7 (8.5%) patients. Being female was associated with more frequent musculoskeletal symptoms and clinical findings. Significantly more patients with CD reported joint pain, but no differences in clinical findings were observed between UC and CD, nor between those with active and inactive IBD.

CONCLUSION

Two-thirds of patients with IBD scheduled for their first biological treatment exhibited musculoskeletal involvement, sometimes asymptomatically. Axial and peripheral symptoms were equally common. A multidisciplinary approach is crucial for early detection and integrated treatment aiming for remission in all disease domains to improve patients' QoL.

In varietate concordia - cluster analysis of EQ-5D-5L value sets in European Union countries

BACKGROUND

The transferability of health policies in the European Union (EU) faces challenges due to economic, political, and healthcare system factors, including cross-country differences in health preferences. In order to aid policymaking, previous research has grouped EU countries based on geographical proximity or literature-based criteria, but not on health preference data. The EQ-5D-5L instrument, which measures health-related quality of life and reflects unique national health preferences shaped by cultural and social factors, is used to evaluate policies, technologies and interventions, but has not been used to group countries. Thus, this study aims to identify clusters of EU-27 countries with similar preference patterns using published EQ-5D-5L value sets.

METHODS

Hierarchical agglomerative clustering was employed on 13 EU-27 countries' EQ-5D-5L value sets, first analyzing regression coefficients for each dimension-level and then creating a simulated coefficient distribution considering uncertainty.

FINDINGS

Five clusters of EU-27 countries emerged: (1) Belgium, Netherlands, Sweden, Germany); (2) Hungary, Italy, Portugal; (3) Poland, Romania; (4) France, Spain; (5) Denmark, Ireland. All clusters except cluster 5 gave higher importance to "Pain and Discomfort"; all clusters except cluster 1 gave less importance to "Usual Activities". "Anxiety and Depression" and "Pain and Discomfort" had the largest heterogeneity in valuation across severity level.

INTERPRETATION

Identified clusters of countries with distinct health preferences provide insights for health policy transferability in the EU. Recognizing countries with similar health preferences can aid EU policymaking and transferability efforts, particularly in early-stage policymaking, while also fostering closer collaboration on health policy decisions and best practice sharing. Further development of national value sets within the EU is necessary for a more accurate representation.

Effects of population-based screening for atrial fibrillation on quality of life

BACKGROUND

Screening for atrial fibrillation is rising and may worsen or improve quality of life.

METHODS

We assessed quality of life (EQ-5D-5L) data in 6,004 participants with stroke risk factors randomised to usual care (n=4,503) or implantable loop recorder with anticoagulation upon detection of atrial fibrillation (n=1,501). Five domains (mobility, selfcare, usual activities, pain/discomfort, anxiety/depression) each scored from one to five were calculated into individual index scores (worst=-0.76, best=1.00). Changes in the index score and the visual analogue scale score (EQ VAS (0=worst, 100=best)) from baseline to year three were the primary outcomes, which were analysed using linear mixed models. Major problem was defined as a domain score ≥3 and analysed with logistic regression in year three.

RESULTS

Of 6,004 participants, 5,733 (95 %) were alive after three years, and 5,162 (86 %) had complete EQ-5D-5L data. The baseline index score of 5,733 participants was 0.88 ±0.16, which decreased by -0.05 (-0.05; -0.04) in the control vs -0.04 (-0.05; -0.03) in the screening group after three years, and a baseline EQ VAS score of 78.4±16.2, which decreased by -6.06 (-6.54; -5.57) in control vs -5.18 (-5.95; -4.40) in the screening group after three years, with no significant difference between the groups (p=0.063 and p=0.056, respectively). The most frequent problem was major pain/discomfort (1,202 of 5,162 (23.3 %)), and any major problem occurred equally in the groups after three years (OR 0.91 (0.79;1.05)).

CONCLUSION

A population-based, long-term, and continuous screening for atrial fibrillation in high-risk individuals did not translate into increased quality of life.

Preoperative Psychopharmacological Treatment Is Not a Risk Factor for Poorer Patient-Reported Improvements 12 months After Hip or Knee Arthroplasty: A Multicenter Registry-Based Cohort Study of 7,247 Procedures

BACKGROUND

Preoperative psychopharmacological treatment (PPT) has been associated with increased hospital length of stay and readmission rate after hip and knee arthroplasty. However, little is known regarding the association between PPT and improvements in patient-reported outcomes postoperatively in a multicenter fast-track setting. Thus, the primary objective was to investigate whether PPT is a risk factor for poorer patient-reported improvements 12 months after surgery. Secondary objectives included assessment of additional time points and subgroups of PPT.

METHODS

This multicenter registry-based cohort study included 4,021 primary hip and 3,226 primary knee arthroplasties performed from 2016 to 2020 at three fast-track departments in Denmark due to primary osteoarthritis. The Oxford Hip Score/Oxford Knee Score (OHS/OKS), EuroQol-5 Dimensions-3 Levels/EuroQol-5 Dimensions-5 Levels, and EuroQol visual analog scale were collected at baseline and 3, 6, 12, and 24 months after surgery. Exposure status was assigned using the Danish National Prescription Registry. Marginal mean differences (MD) with 95% confidence intervals (CIs) were estimated using multilevel Tobit regression and adjusted for age, sex, and the Charlson Comorbidity Index obtained from the Danish National Patient Register.

RESULTS

No associations were found between PPT and improvements in OHS (MD -0.5, CI -1.4 to 0.4) or OKS (MD -0.3, CI -1.2 to 0.5) after 12 months. However, PPT was associated with lower baseline OHS (MD -1.4, CI -2.2 to -0.6) and OKS (MD -2.1, CI -2.9 to -1.3), and 12 months follow-up OHS (MD -1.9, CI -2.8 to -1.1) and OKS (MD -2.4, CI -3.2 to -1.6). Similar findings were observed at other time points, using EuroQol-5 Dimensions-3 Levels/EuroQol-5 Dimensions-5 Levels or EuroQol visual analog scale, and when evaluating PPT subgroups.

CONCLUSIONS

In hip and knee arthroplasty, PPT was not a risk factor for poorer patient-reported improvements 12 months after surgery. However, PPT was associated with marginally poorer baseline and follow-up scores. Thus, arthroplasties remain effective treatments despite PPT from a patient-centered perspective.

Minimal important change in the Hip Disability and Osteoarthritis Outcome Score and the European Quality of Life 5 Dimensions in adults with hip osteoarthritis after 12 weeks of exercise

BACKGROUND

Minimal important change (MIC) is the smallest change that can be considered important. In hip osteoarthritis (OA) several measurement instruments are recommended but lack MIC estimates.

OBJECTIVES

The objective was to estimate the MIC after supervised group-based exercise for the following measurement instruments; Hip Disability and Osteoarthritis Outcome Score (HOOS), European Quality of Life 5 Dimensions (EQ-5D-5L), 30-s Chair Stand Test, 40-m Fast-paced Walk Test, 9-step Stair Climb Test, Nottingham Leg Extension Power Rig, and unilateral One-Repetition-Maximum Leg Press.

DESIGN

Secondary analysis from a randomized trial of 160 participants with hip OA randomized to two different exercise interventions.

METHODS

Participants were assessed using the instruments at baseline and after 12 weeks of exercise. At follow-up the participants also rated their perceived change using a Global Rating of Change Score (GRCS). A correlation of >0.3 between the measurement instruments and the GRCS was a prerequisite for estimating the MIC using the predictive modeling approach.

RESULTS

Only two measurement instruments had acceptable correlations and were included in the MIC analysis. The MIC for the five HOOS subscales ranged from 6 to 10 points (scale range: 0-100). The MIC for the EQ-5D-5L index (scale range: -0.757 to 1) and EQ-VAS (scale range: 0-100) were 0.054 (0.03; 0.08) and 4.83 (1.37; 8.48), respectively.

CONCLUSIONS

The reported MIC values indicate the minimal improvement that the average patient with hip OA would consider important after 12 weeks of exercise and will help clinicians and researchers interpret the clinical importance of the results of exercise interventions.

Impact of a transition of care bundle on health-related quality of life after major emergency abdominal surgery: before-and-after study

INTRODUCTION

The transition from hospital to home can be challenging. This study investigated whether a standardized transition of care bundle could enhance health-related quality of life (HRQoL), reduce readmission rates, and increase days alive and out of hospital after major emergency abdominal surgery.

METHODS

A single-centre before-and-after study including consecutive patients undergoing major emergency abdominal surgery was conducted at Copenhagen University Hospital Herlev from 1 January 2022 to 31 December 2023. A transition of care bundle including standardized discharge coordination, written material, and multidisciplinary information meetings for patients and relatives was implemented on 1 January 2023. Patients were followed up by phone interviews and hospital records. HRQoL was assessed by the EQ-5D-5L questionnaire.

RESULTS

A total of 667 patients were included (before group 333 patients (median age 70.9), after group 335 patients (median age 72.2)). The predominant surgical procedure was emergency laparotomy for bowel obstruction (before group: n = 187, 56.2%, after group: n = 171, 51.5%). HRQoL was significantly higher in the after group compared with the before group at postoperative day (POD) 30 (0.846 versus 0.750, P < 0.001), postoperative day 90 (0.925 versus 0.847, P < 0.001), and at postoperative day 180 (0.907 versus 0.875, P = 0.039). No difference in days alive and out of hospital or readmission was found between the groups. A significant reduction in patients transitioning to a rehabilitation facility at discharge was found in the after group versus before group (12.5% versus 23.3%).

CONCLUSIONS

A transition of care bundle with coordination, written material, and multidisciplinary efforts increased HRQoL up to 180 days after major emergency abdominal surgery.

Patient-reported outcome 1 to 4 years after periprosthetic knee fracture: a nationwide cross-sectional matched study

BACKGROUND AND PURPOSE

 Periprosthetic knee fractures (PPKFs) can be a serious complication after total knee arthroplasty (TKA). We aimed to compare patient-reported outcome (PRO) scores reported between 1 and 4 years after PPKF with a matched uncomplicated TKA control group.

METHODS

 This nationwide cross-sectional matched cohort study included 372 TKA patients with a PPKF occurring from 2019 to 2022 and a control group of 878 uncomplicated TKA patients matched by age, time since TKA, and sex. The study population was derived from the Danish National Patient Register. The patients received questionnaires regarding knee function, quality of life, pain and satisfaction in 2023. The questionnaires included Oxford Knee Score (OKS), the Forgotten Joint Score (FJS), and the EQ-5D-5L Index.

RESULTS

 The response rate was 48%. Mean OKS was 7 (confidence interval [CI] 5-9) points lower after a PPKF with a score of 30 (standard deviation [SD] 11) in the PPKF group vs 37 (SD 11) in the control group. The FJS was 13 (CI 7-19) points lower after a PPKF with a score of 50 (SD 30) in the PPKF group vs 63 (SD 30) in the control group. Mean EQ-5D-5L Index scores were 0.17 (CI 0.12-0.22) lower after a PPKF with a score of 0.68 (SD 0.25) in the PPKF group vs 0.85 (SD 0.25) in the control group. Additional analysis of patients who completed PROMs 1-2 years compared with 3-4 years after PPKF showed better PRO scores after 3-4 years with an OKS of 32 (SD 12) vs 27 (SD 12), FJS 55 (SD 32) vs 43 (SD 32), and EQ-5D-5L Index of 0.74 (SD 0.34) vs 0.60 (SD 0.34).

CONCLUSION

 Following PPKF, patients reported worse knee function, more pain, lower satisfaction, and poorer quality of life than those with uncomplicated TKAs.

Perioperative Intensive Smoking Cessation Intervention Among Smokers Who Underwent Transurethral Resection of Bladder Tumor (TURBT) in Two Different Settings: A Randomized Controlled Trial

Background/Objective: Smoking is an individual risk factor for bladder cancer. Many patients are still smoking at the time of their diagnosis, yet few trials have examined smoking cessation interventions (SCIs) in relation to transurethral resection of the bladder tumor (TURBT). This study therefore aimed to compare the efficacy of a hospital-based 6-week intensive SCI with standard treatment among this patient group. Methods: A parallel-arm randomized controlled trial was conducted from December 2021 to March 2024 at two university hospital urology departments in Denmark. A total of 38 daily smokers undergoing TURBT were allocated to the hospital-based intensive SCI, including weekly meetings, patient education, motivational support, and complimentary nicotine replacement therapy or the standard treatment with very brief advice and referral to the same intensive SCI at a municipality clinic. The primary outcome was smoking cessation at the end of the intervention, assessed through participant interviews. The secondary outcomes included continuous abstinence at three and six months, quality of life, and frailty. Analyses were performed as intention-to-treat. Results: After six weeks, 37% in the hospital-based group and 6% in the standard group achieved smoking cessation (p = 0.042). At three and six months the quit rates were, 37% and 26% in the hospital-based group, compared to 0% and 0% in the standard group, respectively. No significant differences in quality of life or frailty were found. Conclusions: This trial found that hospital-based intensive SCI increased cessation rates compared to standard treatment. It would be valuable to evaluate the impact on postoperative complications, cancer prognosis, and long-term cessation in a sizeable new study.

Is there a link between health care utilisation and subjective well-being? An exploratory study among older Danes

While extensive research has explored the influence of traditional factors such as socioeconomic position on health care utilisation, the independent role of an individual's well-being in their health care seeking behaviour remains largely uncharted territory. In this study, we delve into the role of subjective well-being (SWB) in health care utilisation. We use a unique link between survey data from a representative group of Danish citizens aged 50-80 and administrative register data containing information on health care utilisation and sociodemographics. We explore whether SWB is a predictor of health care utilisation (general practice services) over and above health (as measured by health-related quality of life (HRQoL)). We find that the association between SWB and number of services provided in general practice differs across levels of HRQoL. Among those with lower HRQoL, we find a positive association between health care utilisation and SWB. Results hold true even when controlling for previous health care utilisation, suggesting that the mechanism is not driven by reverse causality. Our findings suggest that, in particular for vulnerable individuals in poor health and with poor SWB, the propensity to seek care is inappropriately low, and there is a need for more proactive supply-driven health care.

EQ-5D-5L value set for Norway: a hybrid model using cTTO and DCE data

PURPOSE

To develop the Norwegian value set for the EQ-5D-5L based on interviews with a representative sample of the Norwegian adult population.

METHODS

Random and quota sampling were used to recruit the sample of adults (age> 18 years) representative of the Norwegian general population. Data collection followed EQ-VT 2.1 undertaken before and after the COVID-19 pandemic from November 2019 to December 2022, using PC-assisted and video conferencing interviews, respectively. Each respondent valued 10 health states using composite time trade-off (cTTO) and 7 health states using a discrete choice experiment (DCE). Different statistical models were assessed for logical consistency and predictive accuracy using cTTO and DCE data alone or in combination as hybrid models.

RESULTS

Of the 1,321 respondents, 1,237 met inclusion criteria. All statistical models demonstrated logical consistency. The weighted hybrid model combining both cTTOand DCE data was preferred and had the highest predictive accuracy. Predicted values ranged from -0.453 to 1, and the dimension of anxiety/depression was the most highly valued by respondents, followed by pain/discomfort, self-care, mobility, and usual activities. These findings are not dissimilar to those for most Western European countries, and regression coefficients are closest to those for other Scandinavian countries.

CONCLUSION

This study provides the Norwegian value set for the EQ-5D-5L based on health state values obtained from members of the adult general population in Norway. This is an important contribution to economic evaluation and the broader application ofthe EQ-5D-5L in Norway including clinical and health services research, and quality measurement.

A new SF-6Dv2 value set based on a hybrid model using SG, cTTO, and DCE data

OBJECTIVE

To develop a value set for the Short-Form 6-Dimension version 2 (SF-6Dv2) by incorporating societal preferences obtained from three distinct approaches: Standard Gamble (SG), composite Time Trade-Off (cTTO), and Discrete Choice Experiment (DCE).

METHODS

Data were gathered from the general population of Quebec, Canada, using the standardized valuation protocol developed by EuroQol for the cTTO and DCE tasks, as well as the valuation protocol developed by Sheffield University for the SG. The SG and cTTO data were analyzed using OLS, GLS, GLS Tobit, and heteroskedastic Tobit models. Conditional logit model was used for the DCE, while hybrid, hybrid Tobit, and heteroskedastic hybrid were applied to analyze the combined data from SG, cTTO, and DCE. The performance of models was assessed using mean absolute error (MAE), the logical consistency of the parameters, and significance levels.

RESULTS

Over 56,000 observations collected from the SG, cTTO, and DCE were analyzed. The utility values generated by DCE were generally lower than those provided by cTTO and SG. Among the models tested, the heteroskedastic hybrid model demonstrated the best fit in terms of logical consistency and statistically significant coefficients. This model generated a value set ranging from -0.216 for the worst health state (555655) to 1 for full health (111111), with 0.52% of the values being negative and a MAE of 0.281. Among dimensions, the largest decrements were consistently found in the pain dimension, highlighting its significant impact on overall health state valuations.

CONCLUSION

A heteroskedastic hybrid model using data from SG, cTTO, and DCE was identified as the most effective approach for generating the SF-6Dv2 value set and is expected to provide key input for healthcare decision-making.

Long-term impact of emergency laparotomy on health-related quality of life

PURPOSE

Emergency laparotomy can result in a range of physical and neuropsychiatric postoperative complaints, potentially impacting quality of life. This study aimed to assess the effect of emergency laparotomy on health-related quality of life (HRQoL) and how HRQoL influences the risk of readmission.

METHOD

HRQoL was assessed in patients undergoing emergency laparotomy during a 1-year period. Patients who completed the baseline HRQoL evaluation underwent a reassessment on postoperative day (POD) 30, 90, and 180. HRQoL was measured with the EQ5D index, and patients were categorized in 'high' and 'low' HRQoL. A decrease from high baseline HRQoL to low HRQoL by POD 30 was classified as 'acquired low HRQoL'.

RESULTS

All 215 patients who completed the baseline HRQoL evaluation were followed. On average, patients reported a lower mean (M) HRQoL from baseline (M = 0.876, standard deviation (SD) = 0.171) to POD 30 (M = 0.735, SD = 0.260). On POD 90, HRQoL had somewhat improved (M = 0.763, SD = 0.298), and by POD 180 HRQoL had returned to normal (M = 0.853, SD = 0.235). From the full-record population (n = 73), 20.5% acquired low HRQoL of whom 33% had not recovered by POD180. For patients with acquired low HRQoL, the risk of 180-day readmission was increased, and days alive and out of hospital within 180 days was reduced.

CONCLUSION

For most patients, HRQoL has returned to normal within 180 days after emergency laparotomy. However, patients who acquired low HRQoL after the procedure had an increased risk of long-term readmission.

Intraosseous or Intravenous Vascular Access for Out-of-Hospital Cardiac Arrest

BACKGROUND

Out-of-hospital cardiac arrest is a leading cause of death worldwide. Establishing vascular access is critical for administering guideline-recommended drugs during cardiopulmonary resuscitation. Both the intraosseous route and the intravenous route are used routinely, but their comparative effectiveness remains unclear.

METHODS

We conducted a randomized clinical trial to compare the effectiveness of initial attempts at intraosseous or intravenous vascular access in adults who had nontraumatic out-of-hospital cardiac arrest. The primary outcome was a sustained return of spontaneous circulation. Key secondary outcomes were survival at 30 days and survival at 30 days with a favorable neurologic outcome, defined by a score of 0 to 3 on the modified Rankin scale (scores range from 0 to 6, with higher scores indicating greater disability).

RESULTS

Among 1506 patients who underwent randomization, 1479 were included in the primary analysis (731 in the intraosseous-access group and 748 in the intravenous-access group). The successful establishment of vascular access within two attempts occurred in 669 patients (92%) assigned to the intraosseous-access group and in 595 patients (80%) assigned to the intravenous-access group. Sustained return of spontaneous circulation occurred in 221 patients (30%) in the intraosseous-access group and in 214 patients (29%) in the intravenous-access group (risk ratio, 1.06; 95% confidence interval [CI], 0.90 to 1.24; P = 0.49). At 30 days, 85 patients (12%) in the intraosseous-access group and 75 patients (10%) in the intravenous-access group were alive (risk ratio, 1.16; 95% CI, 0.87 to 1.56); a favorable neurologic outcome at 30 days occurred in 67 patients (9%) and 59 patients (8%), respectively (risk ratio, 1.16; 95% CI, 0.83 to 1.62). Prespecified adverse events were uncommon.

CONCLUSIONS

There was no significant difference in sustained return of spontaneous circulation between initial intraosseous and intravenous vascular access in adults who had out-of-hospital cardiac arrest. (Funded by the Novo Nordisk Foundation and others; IVIO EU Clinical Trials Register number, 2022-500744-38-00; ClinicalTrials.gov number, NCT05205031.).

Cluster randomised controlled trial on the effects of long-term home-based exercise for patients with chronic obstructive pulmonary disease with recent exacerbation: research protocol of the COPDtoParis Project

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a highly prevalent respiratory disease associated with significant health decline and economic burdens. Pulmonary rehabilitation is an effective intervention, but securing adherence to exercise is difficult, particularly for frail and disabled patients, challenged by leaving their home. Home-based exercise is an emerging alternative for persons with COPD, but long-term adherence is unclear. This study aims to investigate the effects, experiences and acceptability of long-term home-based cycling for patients with COPD post exacerbation.

METHODS AND ANALYSES

This cluster randomised controlled trial will recruit hospitalised patients with COPD following hospitalisation following exacerbation of COPD. Participants will be referred to acute rehabilitation for 8 weeks at discharge. After rehabilitation, participants are randomised in clusters of five into 1 year of home-based cycling with the goal of cycling from Aalborg to Paris, or into the control group, who will receive standard care. Data will be collected at baseline, postrehabilitation/intervention initiation, at 6 and 12 months. Primary outcome is physical performance, while secondary outcomes include daily activity levels, lung function, mobility, frailty, symptom severity, health-related quality of life, survival rates and readmissions. A qualitative substudy will uncover experiences from participants. Daily activity levels will be measured using leg-mounted triaxial accelerometers. Other parameters will be tested with physical tests, questionnaires and interviews. The study aims to include 50 patients, with 25 participants in each group. A cost-effectiveness analysis will assess the impact on disease prevention and hospitalisation.

ETHICS AND DISSEMINATION

This study, approved by The North Denmark Region Committee on Health Research Ethics (N-20230008) and compliant with the Helsinki Declaration, includes annual safety and progress reporting of potential adverse events. Results will be disseminated through peer-reviewed publications, conference presentations and community outreach to ensure accessibility to participants, healthcare professionals and the public.

TRIAL REGISTRATION NUMBER

NCT06235502 and Northern Jutland trial register (F2023-066).

Cost-Effectiveness of Trastuzumab Deruxtecan in Patients with Unresectable or Metastatic HER2-Low Breast Cancer Who Have Received Prior Chemotherapy

INTRODUCTION

In 2021, breast cancer affected 75,619 women in Denmark. Approximately 50% of breast cancers are considered human epidermal growth factor receptor 2 (HER2)-low. The DESTINY-Breast04 (DB-04) trial led to European Medicines Agency (EMA) approval of trastuzumab deruxtecan (T-DXd) as a treatment for patients with unresectable or metastatic HER2-low breast cancer who have received prior chemotherapy in the metastatic setting or developed disease recurrence during or within 6 months of completing adjuvant chemotherapy. Moreover, the Danish Breast Cancer Group guidelines recently included T-DXd as a treatment for HER2-low metastatic breast cancer. This economic evaluation aims to estimate the cost-effectiveness of T-DXd for the approved EMA indication in Denmark.

METHODS

A three-state-progression-free, post-progression, and death-partitioned survival model was developed to estimate the cost-effectiveness of T-DXd versus treatment of physician's choice over a lifetime horizon following the Danish Medicines Council guidelines. Clinical data were gathered from the DB-04 trial, and cost and resource use data were sourced from the literature. Sensitivity and scenario analysis were conducted to explore uncertainty.

RESULTS

T-DXd led to 0.78 incremental quality-adjusted life years (QALYs) gained and incurred DKK 621,325 in incremental costs compared to the treatment of physician's choice. This resulted in an incremental cost-effectiveness ratio of DKK 795,181 per QALY gained, which falls below the willingness-to-pay threshold. Sensitivity and scenario analyses showed the robustness of the deterministic result, with T-DXd remaining cost-effective.

CONCLUSION

Our study demonstrates that T-DXd is a cost-effective treatment for patients with HER2-low unresectable or metastatic breast cancer who have received prior chemotherapy in Denmark.

Correlation Between Radiological Measurements for Patellar Instability and Patient-Reported Outcome Measurements in Adolescents: A Study From the Faroese Knee Cohort

BACKGROUND

Radiological measurements can predict patellar dislocation and are used to plan patella-stabilizing surgery in patients who have patellofemoral instability. However, it is unclear whether these measurements can predict subjective symptoms in patients without previous stabilizing surgery.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

HYPOTHESIS/PURPOSE

The purpose was to investigate the correlation between radiological measurements and subjective symptoms in individuals with previous patellar dislocation without previous patella-stabilizing surgery. It was hypothesized that this correlation would be negative.

METHODS

A national cohort of patients with previous patellar dislocation was created by inviting all inhabitants of the Faroe Islands aged 15 to 19 years to answer an online survey. All patients with previous patellar dislocation and no previous surgery to the knee were invited to undergo radiography and magnetic resonance imaging of both knees. The radiological measurements were the Dejour classification, lateral trochlear inclination angle, trochlear depth, Caton-Deschamps index, and tibial tubercle-trochlear groove distance. The participants completed patient-reported outcome measures (PROMs), which were the Banff Patellar Instability Score 2.0, Kujala score, Marx score, and EQ-5D-5L score. Continuous data from each radiological measurement were plotted against each PROM to create scatter plots for visual inspection and analysis.

RESULTS

A total of 1714 (46%) invited individuals responded to the survey invitation, of whom 595 were excluded because of not answering at least 1 PROM. After exclusion of participants with previous knee surgery, 102 participants reported a history of patellar dislocation. Of these, 75 participants underwent radiography and magnetic resonance imaging of their knees and were included in the study for further analysis. Scatter plots and R2 values showed no correlation between radiological measurements and PROM scores.

CONCLUSION

This study found no correlation between the most used radiological measurements in patellar instability and PROM scores. The results imply that radiological measurements are not indicative of subjective health and well-being of patients undergoing nonoperative management of patellar dislocations.

An EQ-5D-5L Value Set for Ghana Using an Adapted EuroQol Valuation Technology Protocol

OBJECTIVES

Ghana's economic evaluation reference case recommends quality-adjusted life-years as an outcome measure for the conduct of cost-utility analysis. There is no Ghanaian value set available to be used in estimating quality-adjusted life-years. This study aimed to develop a value set for Ghana using the EQ-5D-5L instrument.

METHODS

Face-to-face preference data were collected from 300 adults across 3 regions of Ghana using the adapted version of the EuroQol valuation technology (EQ-VT) standardized valuation protocol; with composite time-trade-off (cTTO) and discrete-choice experiments (DCEs) elicitation techniques. The cTTO and DCE data were modeled individually or together to provide complementary results on respondents' utility preferences. Models explored were generalized least squares, Tobit, heteroskedastic, logit, and hybrid. The best-fitting model for the value set was selected based on its logical consistency, accounting for left-censored and heteroscedasticity data, and the statistical significance of parameters.

RESULTS

The 300 interviews provided 4500 cTTO responses and 4200 DCE responses. The preferred model chosen for the Ghana value set was the Hybrid Tobit random effect heteroscedastic-constrained model. The predicted value for the worst attainable health state (55555) was -0.493 and the best health state (11112) was 0.969. The largest decrement was registered for level 5 mobility (0.369) followed by pain/discomfort (0.312), self-care (0.273), anxiety/depression (0.271), and usual activities (0.268).

CONCLUSIONS

This is the first Ghanaian EQ-5D-5L value set based on social preference derived from a nationally representative sample. The value set will play a key role in the use of economic evaluation studies to inform priority setting in Ghana where different health technologies can be compared.

Patient reported outcomes after laparoscopic appendectomy for acute appendicitis

PURPOSE

The purpose of this study is to establish more evidence to provide the clinicians with a greater knowledge on the patient reported outcomes and quality of life (QoL) after laparoscopic appendectomy (LA).

METHOD

105 patients who had undergone LA for acute appendicitis regardless of severity, were included prospectively at Odense University Hospital, Svendborg. The patient reported consequence of surgery were assessed through the validated electronic survey from European-QoL questionnaire (5Q-5D-5L) including a self-reported VAS-score (0-100). The first survey was sent out the first day after surgery and the subsequent surveys at 7, 30 and 90 days. The replies was converted into an index-score expressing the QoL from 0 (death) to 1 (full health).

RESULTS

All patients experienced pain/discomfort at day 1. At day 7, 30 and 90 it was 95%, 45% and 25%, respectively. The median index-score at day 1, 7, 30 and 90 was 0.778, 0.840, 0.984 and 1.00, respectively.

Effectiveness and cost-effectiveness of a structured integrated post-pulmonary embolism follow-up care model (Attend-PE): a rationale and protocol for a multicentre clinical pre-post study

INTRODUCTION

Patients with pulmonary embolism (PE) experience impaired functional ability and reduced quality of life long after discharge from the hospital. However, there are no structured follow-up programmes in Denmark for these patients, and there is considerable variation in practice patterns of post-PE management. No studies have investigated the effectiveness of structured follow-up care models in patients with PE. This study aims to investigate the effect and cost-effectiveness of a structured integrated post-pulmonary embolism follow-up care model (Attend-PE) compared with usual care. The Attend-PE model outlines a structured approach for in-hospital follow-up, involving group-based patient education, individual consultations and systematic use of patient-reported outcome measures to assess the patient's physical and psychological well-being.

METHODS AND ANALYSIS

The study is conducted in Denmark, where the healthcare system is tax-funded and services are freely available for all citizens, with an expected inclusion of 2000 patients in total. A pre-post-intervention study design is used to compare outcomes in the post-implementation cohort with the pre-implementation cohort. The co-primary outcomes are (1) health-related quality of life (patient-reported outcome, PRO) and (2) adherence to medical treatment (register-based data). Secondary outcomes include PROs on disability, treatment satisfaction, self-management, anxiety, depression and work productivity, and register-based outcomes, including recurrent PE, bleeding, mortality and healthcare use. Register-based data will be assessed at baseline (date of PE event), 6 and 12 months, while PRO-data will be assessed at 6 and 12 months after the PE event. The health economic evaluation of the Attend-PE model will include a cost-effectiveness analysis and a cost-utility analysis.

ETHICS AND DISSEMINATION

The project will be conducted by the Declaration of Helsinki. In accordance with the Danish Act on Health Research Ethics §14, the study is exempt from approval. The use of survey responses in research (in anonymous form) is, however, contingent on participants' consent, and the invitation letter therefore included information about the purpose of the study and participants' rights to withdraw consent at any time, and that completion of the questionnaire is considered as consent to their survey data to be included in research.Study findings will be disseminated in scientific peer-reviewed journals, at national and international conferences, and for staff and decision-makers at participating hospitals and patients and relatives via the Danish Heart Association.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov NCT06037096.

Rehabilitation and care after hip fracture: a cost-utility analysis of stepped-wedge cluster randomized trial

OBJECTIVE

To estimate the effectiveness and costs of Rehabilitation for Life (RFL) compared with usual rehabilitation and care after hip fracture to determine which course offered the most value for money.

DESIGN

Cost-utility analysis.

PATIENT

Community-dwelling patients aged 65+ after hip fracture.

METHOD

123 intervention and 122 control patients were included. Data was collected at 5 points from discharge to 1-year follow-up. Cost analysis included expenses to hospital, general practice, specialist services, medications, rehabilitation, home and informal care, transport, and waiting times. The primary outcome was the incremental cost per quality-adjusted life year (QALY).

RESULTS

The intervention group experienced a statistically significant mean QALY gain of 0.02 -compared with the control group. The intervention was more costly by €4,224, resulting in an incremental cost of €159,990 per QALY gained. Two municipalities had several patients in respite care, yielding an imbalance. A subanalysis excluding these patients demonstrated QALY gain at 0.03 and the cost difference of €2,586 was not statistically significant.

CONCLUSION

The intervention demonstrated a slight improvement in effectiveness over the control but was costly. For patients not requiring respite care, the intervention effect was slightly higher, and the cost differences statistically insignificant. In total 91% received informal care and the economic contribution of informal care exceeded the municipal home care services.

Adolescents with prior patellar dislocation report affected quality of life and function, as measured using the Banff Patella Instability Instrument, Kujala and EQ-5D-5L index scores

PURPOSE

We aimed to establish patient-reported outcome measure (PROM) reference data for a cohort of patients with prior patellar dislocation without previous knee surgery.

METHODS

All inhabitants of the Faroe Islands aged 15-19 years were sent an online survey via secure email to establish a national cohort. They were asked to answer questions regarding demographics, whether they had prior patellar dislocation and to complete the PROMs: the Banff Patella Instability Instrument (BPII), Kujala, Marx activity and EQ-5D-5L questionnaires. Participants who had undergone knee surgery were excluded. Participants who had prior patellar dislocation underwent radiographic examinations to diagnose trochlear dysplasia. The study included three cohorts: the general population, prior patellar dislocation and prior patellar dislocation and trochlear dysplasia cohorts.

RESULTS

Of the 3749 individuals contacted, 1119 completed the survey and responded to at least one PROM. Of these, 102 reported a history of patellar dislocation and 57 of them had trochlear dysplasia. All PROMs, except the Marx score, reflected a worse quality of life and function after patellar dislocation than in the general population cohort; this was most pronounced in the BPII. The percentage of people experiencing problems in EQ-5D-5L dimensions was higher in the patellar dislocation and trochlear dysplasia cohorts than in the general population cohort in all EQ-5D-5L domains, except anxiety/depression.

CONCLUSION

Adolescents who had patellar dislocation reported reduced quality of life and function according to the BPII, Kujala and EQ-5D-5L index values, as well as all EQ-5D-5L domains, except for anxiety/depression. However, their activity levels remained high.

LEVEL OF EVIDENCE

Level III.

EQ-5D-5L Population Scores in Mainland China: Results From a Nationally Representative Survey 2021

OBJECTIVES

There is a lack of monitoring changes in the population scores of the most recent version, EQ-5D-5L, in mainland China. This study aimed to address this knowledge gap by assessing the EQ-5D-5L scores in mainland China using a nationally representative sample.

METHODS

Data were extracted from the 2021 Survey of Health Index of Chinese Families, which covered 31 provinces/autonomous regions/municipalities in mainland China. The survey used a multistage quota sampling strategy encompassing 120 prefecture-level cities. Quotas were allocated to each prefecture-level city in accordance with the 2020 China Population Census. This approach resulted in a final sample of 11 030 eligible questionnaires. The utility index (UI) and EuroQol Visual Analog Scale (EQ VAS) scores were reported for the entire sample (age-gender-urban/rural weighted) and by the characteristics of the study participants.

RESULTS

The study participants had a weighted mean UI of 0.939 (SD 0.135) and EQ VAS score of 80.19 (SD 18.39). The most commonly reported problem was anxiety/depression (26.37%), whereas self-care was the least reported problem (6.18%). Those who were male, were younger, lived without chronic conditions and disabilities, had higher levels of education, earned higher monthly household income, and were covered by basic medical insurance for urban employees had higher scores in both the UI and EQ VAS.

CONCLUSION

This study revealed slightly lower UI scores despite a much higher drop in EQ VAS scores whereas China maintained minimum cases of COVID-19 in 2021 compared with the population norms recorded in 2019. Further studies are warranted to unveil the full impacts of COVID-19 outbreaks.

Telemedicine as a tool for bridging geographical inequity: insights in geospatial interactions from a study on chronic heart failure patients

INTRODUCTION

Chronic heart failure patients experience large disparities in quality of and access to treatment, with rural populations receiving lower levels of care. Telemonitoring of patients is increasingly being used as an important tool for improving patient management and care and might reduce geographical inequities in healthcare.

METHODS

We investigate the presence and magnitude of a geospatial interaction effect on the health benefit of a supplementary telemedicine intervention, by analyzing the relationship between distance to regular place of treatment and the benefit of telemedicine in a secondary analysis of data from a previously conducted RCT. We use change in EQ5D health status, SF-36 Physical component score and SF-36 Mental component score as the outcomes. In the unadjusted analysis, intervention group and distance group and the interaction term are included as the independent variables, in the adjusted analysis, multiple socioeconomic and health related variables are included to account for potential confounders.

RESULTS

We find evidence of a significant interaction between the effects of telemedicine and long distance to treatment for change in EQ5D health status (unadjusted: p = 0.016, adjusted p = 0.009) and unadjusted but not adjusted mental component score (unadjusted: p = 0.013, adjusted p = 0.0728), for the change in physical component score the interaction term was not significant (unadjusted: p = 0.118, adjusted p = 0.092).

CONCLUSION

In our study we find that supplementary telemedicine is likely to reduce the health access inequities associated with geographical distance for chronic heart failure patients. However, our sample size was modest and further research is needed to confirm these findings.

Impact of motivational feedback on levels of physical activity and quality of life by activity monitoring following knee arthroplasty surgery-protocol for a randomized controlled trial nested in a prospective cohort (Knee-Activity)

BACKGROUND

Evidence on how to improve daily physical activity (PA) levels following total knee arthroplasty (TKA) or medial uni-compartmental knee arthroplasty (mUKA) by motivational feedback is lacking. Moreover, it is unknown whether a focus on increased PA after discharge from the hospital improves rehabilitation, physical function, and quality of life. The aim of this randomized controlled trial (RCT) nested in a prospective cohort is (a) to investigate whether PA, physical function, and quality of life following knee replacement can be increased using an activity monitoring device including motivational feedback via a patient app in comparison with activity monitoring without feedback (care-as-usual), and (b) to investigate the potential predictive value of PA level prior to knee replacement for the length of stay, return to work, and quality of life.

METHODS

The study is designed as a multicenter, parallel-group, superiority RCT with balanced randomization (1:1) and blinded outcome assessments. One hundred and fifty patients scheduled for knee replacement (TKA or mUKA) will be recruited through Odense University Hospital, Denmark, Vejle Hospital, Denmark and Herlev/Gentofte Sygehus, Denmark. Patients will be randomized to either 12 weeks of activity monitoring and motivational feedback via a patient app by gamification or 'care-as-usual,' including activity monitoring without motivational feedback. The primary outcome is the between-group change score from baseline to 12-week follow-up of cumulative daily accelerometer counts, which is a valid proxy for average objectively assessed daily PA.

DISCUSSION

Improving PA through motivational feedback following knee replacement surgery might improve post-surgical function, health-related quality of life, and participation in everyday life.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT06005623. Registered on 2023-08-22.

TRIAL STATUS

Recruiting.

Implementing teleophthalmology services to improve cost-effectiveness of the national eye care system

BACKGROUND AND PURPOSE

Optometrist-assisted and teleophthalmology-enabled referral pathway (OTRP) for community optometry referrals has the potential to improve the capacity and efficiency of eye care delivery systems through risk stratification and limiting the number of improved referrals. This study investigates the expected future costs and benefits of implementing OTRP under various possible organizational set-ups relevant to a Danish context.

METHODS

A decision-analytic model (decision tree) with a one-year time horizon was constructed to portray alternative future patient referral pathways for people examined in optometry stores for suspected ocular posterior segment eye disease. The main outcomes were total healthcare costs per patient, average waiting time from eye examination in store until the start of treatment or end of referral pathway, and quality-adjusted life-years (QALY) gained. The economic evaluation compares the general ophthalmologist referral pathway (GO-RP) with a potential reimbursement model for the optometrist-assisted teleophthalmology referral pathways (R-OTRP) and a procurement model for the optometrist-assisted teleophthalmology referral pathways (P-OTRP).

RESULTS

The cost per individual with suspected ocular posterior segment eye disease was estimated to be £116 for GO-RP and £75 and £94 for P-OTRP and R-OTRP respectively. The average waiting time for diagnosis or end of referral pathway was 25 weeks for GO-RP and 5.8 and 5.7 for P-OTPR and R-OTPR respectively. QALY gain was 0.15 for P-OTRP/R-OTRP compared to 0.06 for GO-RP.

CONCLUSION

OTRP is effective in reducing unnecessary referrals and waiting times, increasing patients' HRQoL, and decreasing the costs of diagnosing individuals with suspected ocular posterior segment eye disease.

A New and Improved Experimental Design for the Discrete Choice Experiment Module of the EuroQol Valuation Technology Protocol

OBJECTIVES

The EuroQol Valuation Technology (EQ-VT) protocol, which is used to value the EQ-5D-5L instrument, comprises a composite time trade-off and a discrete choice experiment (DCE) module. Despite significant limitations, the DCE module has not been updated since its inception in 2012. This study aimed to update the EQ-VT DCE design using state-of-the-art methods.

METHODS

DCE data from 19 EQ-5D-5L valuation studies were summarized using a Bayesian hierarchical meta-analysis model, which created the priors for our Bayesian efficient DCE design. This design comprised 20 subdesigns, each with 12 choice tasks, and included 2 levels that overlapped to reduce the complexity of the choice tasks. The relative efficiency and robustness of the new design were established by comparing the D-errors and minimal sample size requirements for the 19 within-sample and 7 out-of-sample countries with the previous DCE design.

RESULTS

The updated DCE design shows large reductions in the D-error: by 20% and 22% for the 19 within-sample and 7 out-of-sample countries, respectively. Sample size requirements were also reduced, resulting in an average reduction of 45% for both the within and out-of-sample countries.

CONCLUSIONS

The updated DCE design outperforms the current EQ-VT design. Given its enhanced performance and reduced complexity, it is set to replace the existing DCE design in future EQ-5D-5L valuation studies using the EQ-VT protocol.

Metabolic syndrome and patient-reported outcome two years after hip and knee arthroplasty

Aims

The influence of metabolic syndrome (MetS) on the outcome after hip and knee arthroplasty is debated. We aimed to investigate the change in patient-reported outcome measure (PROM) scores after hip and knee arthroplasty, comparing patients with and without MetS.

Methods

From 1 May 2017 to 30 November 2019, a prospective cohort of 2,586 patients undergoing elective unilateral hip and knee arthroplasty was established in Denmark. Data from national registries and a local database were used to determine the presence of MetS. Patients' scores on Oxford Hip Score (OHS) or Oxford Knee Score (OKS), EuroQol five-dimension five-level questionnaire (EQ-5D-5L), University of California, Los Angeles (UCLA) Activity Scale, and Forgotten Joint Score (FJS) at baseline, three, 12, and 24 months after surgery were collected. Primary outcome was the difference between groups from baseline to 12 months in OHS and OKS. Secondary outcomes were scores of OHS and OKS at three and 24 months and EQ-5D-5L, UCLA Activity Scale, and FJS at three, 12, and 24 months after surgery. Generalized linear mixed model was applied, adjusting for age, sex, Charlson Comorbidity Index, and smoking to present marginal mean and associated 95% CIs.

Results

A total of 62.3% (1,611/2,586) of the cohort met the criteria for MetS. Both groups showed similar increase in mean OHS (MetS group 22.5 (95% CI 21.8 to 23.1), non-MetS group 22.1 (21.3 to 22.8); p = 0.477) and mean OKS (MetS group 18.0 (17.4 to 18.6), non-MetS group 17.8 (17.0 to 18.7); p = 0.722) at 12 months' follow-up. Between groups, similar improvements were seen for OHS and OKS at three and 24 months postoperatively and for the mean EQ-5D-5L, EuroQol-visual analogue scale (EQ-VAS), UCLA Activity Scale, and FJS at every timepoint.

Conclusion

Patients meeting the criteria for MetS obtain the same improvement in PROM scores as individuals without MetS up to 24 months after hip and knee arthroplasty. This is important for the clinician to take into account when assessing and advising patients with MetS.

Vein bypass first vs. best endovascular treatment first revascularisation strategy for chronic limb-threatening ischaemia due to infra-popliteal disease: the BASIL-2 RCT

Background

Chronic limb-threatening ischaemia with ischaemic pain and/or tissue loss.

Objective

To examine the clinical and cost-effectiveness of a vein bypass-first compared to a best endovascular treatment-first revascularisation strategy in preventing major amputation or death.

Design

Superiority, open, pragmatic, multicentre, phase III randomised trial.

Setting

Thirty-nine vascular surgery units in the United Kingdom, and one each in Sweden and Denmark.

Participants

Patients with chronic limb-threatening ischaemia due to atherosclerotic peripheral arterial disease who required an infra-popliteal revascularisation, with or without an additional more proximal infra-inguinal revascularisation procedure, to restore limb perfusion.

Interventions

A vein bypass-first or a best endovascular treatment-first infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation strategy.

Main outcome measures

The primary outcome was amputation-free survival. Secondary outcomes included overall survival, major amputation, further revascularisation interventions, major adverse limb event, health-related quality of life and serious adverse events.

Methods

Participants were randomised to a vein bypass-first or a best endovascular treatment-first revascularisation strategy. The original sample size of 600 participants (247 events) was based on a hazard ratio of 0.66 with amputation-free survival rates of 0.72, 0.62, 0.53, 0.47 and 0.35 in years 1-5 in the best endovascular treatment-first group with 90% power and alpha at p = 0.05. The sample size was revised to an event-based approach as a result of increased follow-up time due to slower than anticipated recruitment rates. Participants were followed up for a minimum of 2 years. A cost-effectiveness analysis was employed to estimate differences in total hospital costs and amputation-free survival between the groups. Additionally, a cost-utility analysis was carried out and the total cost and quality-adjusted life-years, 2 and 3 years after randomisation were used.

Results

Between 22 July 2014 and 30 November 2020, 345 participants were randomised, 172 to vein bypass-first and 173 to best endovascular treatment-first. Non-amputation-free survival occurred in 108 (63%) of 172 patients in the vein bypass-first group and 92 (53%) of 173 patients in the best endovascular treatment-first group [adjusted hazard ratio 1.35 (95% confidence interval 1.02 to 1.80); p = 0.037]. Ninety-one (53%) of 172 patients in the vein bypass-first group and 77 (45%) of 173 patients in the best endovascular treatment-first group died [adjusted hazard ratio 1.37 (95% confidence interval 1.00 to 1.87)]. Over follow-up, the economic evaluation discounted results showed that best endovascular treatment-first was associated with £1690 less hospital costs compared to vein bypass-first. The cost utility analysis showed that compared to vein bypass-first, best endovascular treatment-first was associated with £224 and £2233 less discounted hospital costs and 0.016 and 0.085 discounted quality-adjusted life-year gain after 2 and 3 years from randomisation.

Limitations

Recruiting patients to the Bypass versus Angioplasty in Severe Ischaemia of the Leg Trial-2 trial was difficult and the target number of events was not achieved.

Conclusions

A best endovascular treatment-first revascularisation strategy was associated with better amputation-free survival, which was largely driven by fewer deaths. Overall, the economic evaluation results suggest that best endovascular treatment-first dominates vein bypass-first in the cost-effectiveness analysis and cost-utility analysis as it was less costly and more effective than a vein bypass-first strategy.

Future work

The Bypass versus Angioplasty in Severe Ischaemia of the Leg Trial-2 investigators have a data sharing agreement with the BEst Surgical Therapy in patients with Chronic Limb threatening Ischaemia investigators. One output of this collaboration will be an individual patient data meta-analysis.

Study registration

Current Controlled Trials ISRCTN27728689.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/35/45) and is published in full in Health Technology Assessment; Vol. 28, No. 65. See the NIHR Funding and Awards website for further award information.

Mapping the Lequesne Functional Index Into the EQ-5D-5L Utility Index in Patients With Knee Osteoarthritis

OBJECTIVE

This study aimed to map the Lequesne index onto the EuroQol 5 Dimension (EQ-5D-5L) utility index for patients with knee osteoarthritis.

METHODS

Baseline data from a previous randomized controlled trial were used; 461 patients were involved in the mapping development, and 230 in the validation phase. Various modeling techniques, including generalized linear models, tobit, and beta regression, were used. Factors such as age, sex, and body mass index were considered as covariates. Model selection was based on criteria such as Akaike and Bayesian information criteria, adjusted R2, mean absolute error, and root mean squared error. Validation involved assessing the preselected models using mean absolute error, root mean squared error, and intraclass correlation coefficient. This study follows the Mapping Onto Preference-Based Measures Reporting Standards statement.

RESULTS

Five models were developed, with 2 incorporating age, sex, with or without body mass index along with the Lequesne index showing the best fit across regressions. Validation results were similar for the 3 regressions, with beta regression models exhibiting wider ranges closer to the validation data set. Intraclass correlation coefficient values were better for beta regression models. Both models tended to overpredict for lower EQ-5D-5L values and underpredict for better health status.

CONCLUSION

These mapping functions, the first of their kind, effectively translate the Lequesne index to EQ-5D-5L values in patients with knee osteoarthritis. They demonstrate satisfactory fit and precision, providing valuable tools for clinicians and researchers, particularly in situations where generic preference-based health-related quality of life instruments are inaccessible for utility derivation in cost-effectiveness studies.

Long-term mortality and health-related quality of life with lower versus higher oxygenation targets in intensive care unit patients with COVID-19 and severe hypoxaemia

PURPOSE

The aim of this study was to evaluate one-year outcomes of lower versus higher oxygenation targets in intensive care unit (ICU) patients with coronavirus disease 2019 (COVID-19) and severe hypoxaemia.

METHODS

We conducted pre-planned analyses of one-year mortality and health-related quality of life (HRQoL) in the Handling Oxygenation Targets in COVID-19 trial. The trial randomised 726 ICU patients with COVID-19 and hypoxaemia to partial pressure of arterial oxygen targets of 8 kPa (60 mmHg) versus 12 kPa (90 mmHg) during ICU stay up to 90 days, including readmissions. HRQoL was assessed using EuroQol visual analogue scale (EQ-VAS) and 5-level 5-dimension questionnaire (EQ-5D-5L). Outcomes were analysed in the intention-to-treat population. Non-survivors were assigned the worst possible score (zero), and multiple imputation was applied for missing EQ-VAS values.

RESULTS

We obtained one-year vital status for 691/726 (95.2%) of patients and HRQoL data for 642/726 (88.4%). At one year, 117/348 (33.6%) of patients in the lower-oxygenation group had died compared to 134/343 (39.1%) in the higher-oxygenation group (adjusted risk ratio: 0.85; 98.6% confidence interval (CI) 0.66-1.09; p = 0.11). Median EQ-VAS was 50 (interquartile range, 0-80) versus 40 (0-75) (adjusted mean difference: 4.8; 98.6% CI  - 2.2 to 11.9; p = 0.09) and EQ-5D-5L index values were 0.61 (0-0.81) in the lower-oxygenation group versus 0.43 (0-0.79) (p = 0.20) in the higher-oxygenation group, respectively.

CONCLUSION

Among adult ICU patients with COVID-19 and severe hypoxaemia, one-year mortality results were most compatible with benefit of the lower oxygenation target, which did not appear to result in more survivors with poor quality of life.

Multicentre investigation on the effect of decompressive surgery on Balance and physical ActiviTy Levels amongst patients with lumbar Spinal stenosis (B-ATLAS): protocol for a prospective cohort study

INTRODUCTION

Patients with lumbar spinal stenosis may have poor balance, decreased physical function and problems maintaining physical activity levels due to radiculopathy. Decompressive surgery is often indicated if conservative management fails to achieve a satisfactory clinical outcome. While surgical management has proven effective at treating radiculopathy, and patients report increased physical function postoperatively, objective measures of postural control and physical activity remain sparse. This study aims to investigate the effects of decompressive surgery on postural control and activity levels of elderly patients with lumbar spinal stenosis using objective measurements.

METHODS AND ANALYSIS

This is a 24-month, multicentre, prospective cohort study. Patients ≥65 years of age with MRI-verified symptomatic lumbar central canal stenosis will be recruited from two separate inclusion centres, and all participants will undergo decompressive surgery. Preoperative data are collected up to 3 months before surgery, with follow-up data collected at 3, 6, 12 and 24 months postoperatively. Postural control measurements are performed using the Wii Balance Board, mini Balance Evaluation Systems Test and Tandem test, and data concerning physical activity levels are collected using ActiGraph wGT3X-BT accelerometers. Patient-reported outcomes regarding quality-of-life and physical function are collected from the EuroQol-5D, 36-Item Short Form Health Survey and Zurich Claudication Questionnaire. Primary outcomes are the change in the sway area of centre of pressure and total activity counts per day from baseline to follow-up at 24 months. A sample size of 80 participants has been calculated.

ETHICS AND DISSEMINATION

The study has been approved by the Regional Ethics Committee of Region Zealand (ID EMN-2022-08110) and the Danish Data Protection Agency (ID REG-100-2022). Written informed consent will be required from all participants before enrolment. All results from the study, whether positive, negative or inconclusive, will be published in international peer-reviewed journals and presented at national and international scientific meetings. Study findings will be further disseminated through national patient associations.

TRIAL REGISTRATION NUMBERS

NCT06075862 and NCT06057428.

Cost-effectiveness analysis of app-delivered self-management support (selfBACK) in addition to usual care for people with low back pain in Denmark

OBJECTIVES

This study aims to investigate the cost-effectiveness of individually tailored self-management support, delivered via the artificial intelligence-based selfBACK app, as an add-on to usual care for people with low back pain (LBP).

DESIGN

Secondary health-economic analysis of the selfBACK randomised controlled trial (RCT) with a 9-month follow-up conducted from a Danish national healthcare perspective (primary scenario) and a societal perspective limited to long-term productivity in the form of long-term absenteeism (secondary scenario).

SETTING

Primary care and an outpatient spine clinic in Denmark.

PARTICIPANTS

A subset of Danish participants in the selfBACK RCT, including 297 adults with LBP randomised to the intervention (n=148) or the control group (n=149).

INTERVENTIONS

App-delivered evidence-based, individually tailored self-management support as an add-on to usual care compared with usual care alone among people with LBP.

OUTCOME MEASURES

Costs of healthcare usage and productivity loss, quality-adjusted life-years (QALYs) based on the EuroQol-5L Dimension Questionnaire, meaningful changes in LBP-related disability measured by the Roland-Morris Disability Questionnaire (RMDQ) and the Pain Self-Efficacy Questionnaire (PSEQ), costs (healthcare and productivity loss measured in Euro) and incremental cost-effectiveness ratios (ICERs).

RESULTS

The incremental costs were higher for the selfBACK intervention (mean difference €230 (95% CI -136 to 595)), where ICERs showed an increase in costs of €7336 per QALY gained in the intervention group, and €1302 and €1634 for an additional person with minimal important change on the PSEQ and RMDQ score, respectively. At a cost-effectiveness threshold value of €23250, the selfBACK intervention has a 98% probability of being cost-effective. Analysis of productivity loss was very sensitive, which creates uncertainty about the results from a societal perspective limited to long-term productivity.

CONCLUSIONS

From a healthcare perspective, the selfBACK intervention is likely to represent a cost-effective treatment for people with LBP. However, including productivity loss introduces uncertainty to the results.

TRIAL REGISTRATION NUMBER

NCT03798288.

Effectiveness of a novel digital patient education programme to support self-management of early rheumatoid arthritis: a randomized controlled trial

OBJECTIVES

To evaluate the effectiveness of a novel digital patient education (PE) programme in improving self-management in patients newly diagnosed with rheumatoid arthritis (RA).

METHODS

This was a parallel, open-label, two-armed, randomized controlled trial with superiority design. Patients from five rheumatology clinics were randomized into digital PE (intervention) or face-to-face PE (control). The primary outcome was self-efficacy, measured by average difference in the Rheumatoid Arthritis Self-Efficacy (RASE) score from baseline to month 12. Secondary outcomes were RA knowledge, health literacy, adherence and quality of life. Healthcare utilization data and digital PE programme usage were recorded. Self-efficacy, knowledge and health literacy data were analysed using mixed-effects repeated measures modelling; adherence using logistic regression, and quality of life and healthcare utilization using descriptive statistics with the Wilcoxon rank-sum test.

RESULTS

Of the 180 patients randomized (digital PE, n = 89; face-to-face PE, n = 91), 175 had data available for analysis. Median age was 59.0 years and 61% were women. The average difference in self-efficacy between groups from baseline to month 12 was significant by a -4.34 difference in RASE score, favouring the intervention group (95% CI: -8.17 to -0.51; P = 0.026). RA knowledge, health literacy and quality of life showed minor improvements over time but no difference between groups, except out-patient clinic contacts, which were fewer in the intervention group.

CONCLUSION

The findings suggest that digital PE is effective in improving self-efficacy and therefore self-management in patients with early RA. This intervention has potential to lower healthcare costs by decreasing out-patient clinic contacts.

TRIAL REGISTRATION NUMBER

clinicaltrials.gov, NCT04669340.

Opium tincture has anti-propulsive effects in patients with chronic diarrhea: a randomized, placebo-controlled, and cross-over trial

OBJECTIVE

Chronic diarrhea affects approximately 5% of the population. Opioids inhibit gastrointestinal motility, and opium tincture has shown anti-propulsive effects in healthy, but no controlled studies of its clinical efficacy exist. We aimed to investigate the anti-propulsive and central nervous system (CNS) effects of opium tincture in patients with chronic diarrhea.

MATERIALS AND METHODS

The study was a randomized, double-blinded, placebo-controlled, cross-over trial in subjects with chronic diarrhea refractory to standard treatment. Participants received opium tincture or placebo during two intervention periods, each lasting seven days. Bowel movements were recorded daily, and gastrointestinal transit time was investigated with the wireless motility capsule system. Gastrointestinal symptoms, health-related quality of life, and CNS effects (pupil size, reaction time, memory, and general cognition) were also investigated, along with signs of addiction.

RESULTS

Eleven subjects (mean age: 45 ± 17 years, 46% males) with a median of 4.7 daily bowel movements were included. The number of daily bowel movements was reduced during opium tincture treatment to 2.3 (p = 0.045), but not placebo (3.0, p = 0.09). Opium tincture prolonged the colonic transit time compared to placebo (17 h vs. 12 h, p < 0.001). In both treatment arms, there were no changes in self-reported gastrointestinal symptoms, health-related quality of life, or CNS effects, and no indication of addiction was present.

CONCLUSION

Opium tincture induced anti-propulsive effects in patients with chronic diarrhea refractory to standard treatment. This indicates that opium tincture is a relevant treatment strategy for selected patients with chronic diarrhea. Moreover, no evidence of opioid-induced sedation or addiction was found.Trial Registration Number: NCT05690321 (registered 2023-01-10).

Empirical meropenem versus piperacillin/tazobactam for adult patients with sepsis (EMPRESS) trial: Protocol

BACKGROUND

Piperacillin/tazobactam may be associated with less favourable outcomes than carbapenems in patients with severe bacterial infections, but the certainty of evidence is low.

METHODS

The Empirical Meropenem versus Piperacillin/Tazobactam for Adult Patients with Sepsis (EMPRESS) trial is an investigator-initiated, international, parallel-group, randomised, open-label, adaptive clinical trial with an integrated feasibility phase. We will randomise adult, critically ill patients with sepsis to empirical treatment with meropenem or piperacillin/tazobactam for up to 30 days. The primary outcome is 30-day all-cause mortality. The secondary outcomes are serious adverse reactions within 30 days; isolation precautions due to resistant bacteria within 30 days; days alive without life support and days alive and out of hospital within 30 and 90 days; 90- and 180-day all-cause mortality and 180-day health-related quality of life. EMPRESS will use Bayesian statistical models with weak to somewhat sceptical neutral priors. Adaptive analyses will be conducted after follow-up of the primary outcome for the first 400 participants concludes and after every 300 subsequent participants, with adaptive stopping for superiority/inferiority and practical equivalence (absolute risk difference <2.5%-points) and response-adaptive randomisation. The expected sample sizes in scenarios with no, small or large differences are 5189, 5859 and 2570 participants, with maximum 14,000 participants and ≥99% probability of conclusiveness across all scenarios.

CONCLUSIONS

EMPRESS will compare the effects of empirical meropenem against piperacillin/tazobactam in adult, critically ill patients with sepsis. Due to the pragmatic, adaptive design with high probability of conclusiveness, the trial results are expected to directly inform clinical practice.

On the ability of the SF-6D to capture the consequences of chronic illnesses on subjective well-being: Evidence from France

Using cross-sectional data from a representative sample of the French population (the 2008 Disability Health survey), this paper examines whether the SF-6D, a widely used preference-based measure of health-related quality of life in economic evaluations, fully captures the variation in subjective well-being (SWB) due to chronic illnesses. We conduct a mediation analysis to disentangle the direct and indirect, through the SF-6D, effects of various chronic conditions on SWB (happiness). Our results show that the SF-6D reflects changes in happiness due to most illnesses except mental illness. Changes in SWB mediated by the SF-6D account for 74% of the total effect. The variation unexplained by the SF-6D is significant and increases substantially in the presence of multimorbidity when a chronic illness is combined with anxiety or depression. Overall, our results suggest that the SF-6D incompletely captures the subjective experience of chronically ill patients, especially those with comorbid conditions.

Salutogenic health measures: Psychometric properties of the Danish versions of the Flourish Index and the Secure Flourish Index

Measurement of human flourishing represents a salutogenic approach to epidemiological and behavioral research emphasizing factors contributing to "good lives" rather than pathology. The objective of this study was to translate and psychometrically test the 10-item Flourish Index (FI) and 12-item Secure Flourish Index (SFI) in a convenience sample of Danish adults. A total of 325 participants completed a cross-sectional survey, with 148 of those participants completing the survey a second time (retest). Confirmatory factor analysis in a structural equation modelling framework was used to establish structural validity by comparing four different pre-specified models of the indexes. Additionally, internal consistency, convergent and incremental validity, and retest reliability were examined. The FI models exhibited superior structural validity compared with similar models of the SFI, although all models had good fits. Internal consistencies with McDonald's omega were 0.89 and 0.87 for the FI and SFI, respectively. The five (FI) or six (SFI) domains were happiness & life satisfaction, mental & physical health, meaning & purpose, character & virtue, close social relationships, and financial & material stability (λ4 = 0.51-0.91). Convergent and incremental validity tests supported predefined hypotheses. Retest analyses with the FI and SFI showed a high degree of retest reliability. Based on the psychometric evidence reported in this study, the Danish Flourish Index and Secure Flourish Index seem suitable for use with healthy adult Danes. The authors hope that this psychometric evaluation of the FI and SFI will stimulate research on patterns, health and economic outcomes, and predictors of human flourishing in Denmark.

Acupuncture for fatigue in breast cancer survivors: a study protocol for a pragmatic, mixed method, randomised controlled trial

INTRODUCTION

Fatigue is a common symptom observed in post-cancer treatment, yet its underlying mechanisms remain poorly understood. Acupuncture has been employed to alleviate cancer-related fatigue (CRF); however, its effectiveness in addressing associated comorbidities that may influence fatigue is also poorly understood. This study represents the first investigation to use acupuncture as an intervention for fatigue in breast cancer survivors within a Norwegian cohort. The study will employ questionnaires to evaluate various facets of fatigue. As a pragmatic trial, it statistically assesses its clinical relevance, documents adverse events and evaluates the cost-effectiveness of the acupuncture treatment.

METHODS AND ANALYSIS

This assessor-blinded, pragmatic, randomised, mixed method, controlled trial with two parallel arms aims to evaluate the effectiveness, safety and cost-effectiveness of acupuncture. It will recruit 250 participants presented with CRF for 6 months or longer. Patients will be randomly allocated either to acupuncture and usual care (n=125) or to usual care alone (n=125). Acupuncture treatments (12 in total) are to be given within 12 weeks. The statistician who will analyse the data will be blinded to group allocation. The primary outcome will be changes in CRF measured by the Chalder fatigue scale. Measurements will be taken 12 weeks and 6 months after randomisation. The secondary outcomes include patient-reported outcomes of pain, anxiety, depression, hot flashes, insomnia and sleepiness. Health-related quality of life and economic evaluation will also be conducted 12 weeks and 6 months after randomisation. Nested within this randomised controlled trial are two qualitative studies and one sub-study measuring biomarkers (C-reactive protein, interleukin (IL)-1, IL-6, tumour necrosis factor alpha (TNF-α) and aPL in addition to the current genotype genes TNF-308 and IL-6-174) from blood samples (n=80). Such biomarkers can potentially address changes in CRF.

ETHICS AND DISSEMINATION

Ethical approval of this study has been granted by the Regional Committees for Medical and Health Research Ethics (REC southeast ID number: 112285). Written informed consent will be obtained from all participants. The outcomes of the trial will be disseminated through peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT04418115.

Three-Year Outcomes of Oral Antibiotics vs Intravenous and Oral Antibiotics for Uncomplicated Acute Appendicitis: A Secondary Analysis of the APPAC II Randomized Clinical Trial

Importance

Current short-term evidence has shown that uncomplicated acute appendicitis can be treated successfully with oral antibiotics alone, but longer-term results are lacking.

Objective

To assess the treatment effectiveness of oral antibiotic monotherapy compared with combined intravenous (IV) and oral antibiotics in computed tomography-confirmed uncomplicated acute appendicitis at a longer-term follow-up.

Design, Setting, and Participants

This secondary analysis of a predefined year 3 follow-up of the Appendicitis Acuta II (APPAC II) noninferiority, multicenter randomized clinical trial compared oral moxifloxacin with combined IV ertapenem plus oral levofloxacin and metronidazole for the treatment of uncomplicated acute appendicitis. The trial was conducted at 9 university and central hospitals in Finland from April 2017 to November 2018, with the last follow-up in November 2022. Participants included patients aged 18 to 60 years, who were randomized to receive either oral antibiotics monotherapy (n = 301) or combined IV and oral antibiotics (n = 298).

Interventions

Antibiotics monotherapy consisted of oral moxifloxacin, 400 mg/d, for 7 days. Combined IV and oral antibiotics consisted of IV ertapenem sodium, 1 g/d, for 2 days plus oral levofloxacin, 500 mg/d, and metronidazole, 500 mg 3 times/d, for 5 days.

Main Outcomes and Measures

The primary end point was treatment success, defined as the resolution of acute appendicitis and discharge from hospital without the need for surgical intervention and no appendicitis recurrence at the year 3 follow-up evaluated using a noninferiority design. The secondary end points included late (after 1 year) appendicitis recurrence as well as treatment-related adverse events, quality of life, length of hospital stay, and length of sick leave, which were evaluated using a superiority design.

Results

After exclusions, 599 patients (mean [SD] age, 36 [12] years; 336 males [56.1%]) were randomized; after withdrawal and loss to follow-up, 582 patients (99.8%) were available for the year 3 follow-up. The treatment success at year 3 was 63.4% (1-sided 95% CI, 58.8% to ∞) in the oral antibiotic monotherapy group and 65.2% (1-sided 95% CI, 60.5% to ∞) in the combined IV and oral antibiotics group. The difference in treatment success rate between the groups at year 3 was -1.8 percentage points (1-sided 95% CI, -8.3 percentage points to ∞; P = .14 for noninferiority), with the CI limit exceeding the noninferiority margin. There were no significant differences between groups in treatment-related adverse events, quality of life, length of hospital stay, or length of sick leave.

Conclusions and Relevance

This secondary analysis of the APPAC II trial found a slightly higher appendectomy rate in patients who received oral antibiotic monotherapy; however, noninferiority of oral antibiotic monotherapy compared with combined IV and oral antibiotics could not be demonstrated. The results encourage future studies to assess oral antibiotic monotherapy as a viable treatment alternative for uncomplicated acute appendicitis.

Trial Registration

ClinicalTrials.gov Identifier: NCT03236961.

Patient-Reported Outcome Measures in Patients with and without Non-Expandable Lung Secondary to Malignant Pleural Effusion-A Single-Centre Observational Study

BACKGROUND

Malignant pleural effusion (MPE) affects up to 15% of patients with malignancy, and the prevalence is increasing. Non-expandable lung (NEL) complicates MPE in up to 30% of cases. However, it is not known if patients with malignant pleural effusion and NEL are more symptomatic in activities of daily living compared to patients with MPE with expandable lung.

METHODS

This was an observational study on consecutively recruited patients with MPE from our pleural clinic. Before thoracentesis, patients completed patient-reported outcomes on cancer symptoms (ESAS), health-related quality of life (5Q-5D-5L), and dyspnoea scores. Following thoracentesis, patients scored dyspnoea relief and symptoms during thoracentesis. Data on focused lung ultrasound and pleural effusion biochemistry were collected. The non-expandable lung diagnosis was made by pleural experts based on radiological and clinical information.

RESULTS

We recruited 43 patients, including 12 with NEL (28%). The NEL cohort resembled those from previous studies concerning ultrasonography, pleural fluid biochemistry, and fewer cases with high volume thoracentesis. Patients with and without NEL were comparable concerning baseline demography. The 5Q-5D-5L utility scores were 0.836 (0.691-0.906) and 0.806 (0.409-0.866), respectively, for patients with and without NEL. We observed no between-group differences in symptom burden or health-related quality of life.

CONCLUSION

While the presence of NEL affects the clinical management of recurrent MPE, the presence of NEL seems not to affect patients' overall symptom burden in patients with MPE.

Poor Rhinitis and Asthma Control Is Associated With Decreased Health-Related Quality of Life and Utilities: A MASK-air Study

BACKGROUND

Allergic rhinitis (AR) and asthma may affect health-related quality of life. However, national estimates on the quality of life of patients with AR or asthma are lacking.

OBJECTIVE

To provide estimates for utility scores and EuroQoL five-dimension (EQ-5D) visual analog scale (VAS) for patients with AR or asthma.

METHODS

We conducted a cross-sectional study using direct patient data from the MASK-air app on European MASK-air users with self-reported AR or asthma. We used a multi-attribute instrument (EQ-5D) to measure quality of life (as utility scores and EQ-5D VAS values). Mean scores were calculated per country and disease control level using multilevel regression models with poststratification, accounting for age and sex biases.

RESULTS

We assessed data from 7905 MASK-air users reporting a total of up to 82,737 days. For AR, utilities ranged from 0.86 to 0.99 for good control versus 0.72 to 0.85 for poor control; EQ-5D VAS levels ranged from 78.9 to 87.9 for good control versus 55.3 to 64.2 for poor control. For asthma, utilities ranged from 0.84 to 0.97 for good control versus 0.73 to 0.87 for poor control; EQ-5D VAS levels ranged from 68.4 to 81.5 for good control versus 51.4 to 64.2 for poor control. Poor disease control was associated with a mean loss of 0.14 utilities for both AR and asthma. For the same control levels, AR and asthma were associated with similar utilities and EQ-5D VAS levels. However, lower values were observed for asthma plus AR compared with AR alone.

CONCLUSIONS

Poor AR or asthma control are associated with reduced quality of life. The estimates obtained from mobile health data may provide valuable insights for health technology assessment studies.

Hospital at home for elderly acute patients: a study protocol for a randomised controlled trial

INTRODUCTION

The increasing elderly population has led to a growing demand for healthcare services. A hospital at home treatment model offers an alternative to standard hospital admission, with the potential to reduce readmission and healthcare consumption while improving patients' quality of life. However, there is little evidence regarding hospital at home treatment in a Danish setting. This article describes the protocol for a randomised controlled trial (RCT) comparing standard hospital admission to hospital at home treatment. The main aim of the intervention is to reduce 30-day acute readmission after discharge and improve the quality of life of elderly acute patients.

METHODS AND ANALYSIS

A total of 849 elderly acute patients will be randomised in a 1:2 ratio to either the control or intervention group in the trial. The control group will receive standard hospital treatment in a hospital emergency department while the intervention group will receive treatment at home. The primary outcomes of the trial are the rate of 30-day acute readmission and quality of life, assessed using the European Quality of Life-5 Dimensions-5-Level instrument. Primary analyses are based on the intention-to-treat principle. Secondary outcomes are basic functional mobility, resource use in healthcare, primary and secondary healthcare cost, incremental cost-effectiveness ratio, and the mortality rate 3 months after discharge.

ETHICS AND DISSEMINATION

The RCT was approved by the Ethical Committee, Central Denmark Region (no. 1-10-72-67-20). Results will be presented at relevant national and international meetings and conferences and will be published in international peer-reviewed journals. Furthermore, we plan to communicate the results to relevant stakeholders in the Danish healthcare system.

TRIAL REGISTRATION NUMBER

NCT05360914.