Estimating utility values for vesicoureteral reflux in the general public using an online tool

Accuracy, readability, and understandability of large language models for prostate cancer information to the public

BACKGROUND

Generative Pretrained Model (GPT) chatbots have gained popularity since the public release of ChatGPT. Studies have evaluated the ability of different GPT models to provide information about medical conditions. To date, no study has assessed the quality of ChatGPT outputs to prostate cancer related questions from both the physician and public perspective while optimizing outputs for patient consumption.

METHODS

Nine prostate cancer-related questions, identified through Google Trends (Global), were categorized into diagnosis, treatment, and postoperative follow-up. These questions were processed using ChatGPT 3.5, and the responses were recorded. Subsequently, these responses were re-inputted into ChatGPT to create simplified summaries understandable at a sixth-grade level. Readability of both the original ChatGPT responses and the layperson summaries was evaluated using validated readability tools. A survey was conducted among urology providers (urologists and urologists in training) to rate the original ChatGPT responses for accuracy, completeness, and clarity using a 5-point Likert scale. Furthermore, two independent reviewers evaluated the layperson summaries on correctness trifecta: accuracy, completeness, and decision-making sufficiency. Public assessment of the simplified summaries' clarity and understandability was carried out through Amazon Mechanical Turk (MTurk). Participants rated the clarity and demonstrated their understanding through a multiple-choice question.

RESULTS

GPT-generated output was deemed correct by 71.7% to 94.3% of raters (36 urologists, 17 urology residents) across 9 scenarios. GPT-generated simplified layperson summaries of this output was rated as accurate in 8 of 9 (88.9%) scenarios and sufficient for a patient to make a decision in 8 of 9 (88.9%) scenarios. Mean readability of layperson summaries was higher than original GPT outputs ([original ChatGPT v. simplified ChatGPT, mean (SD), p-value] Flesch Reading Ease: 36.5(9.1) v. 70.2(11.2), <0.0001; Gunning Fog: 15.8(1.7) v. 9.5(2.0), p < 0.0001; Flesch Grade Level: 12.8(1.2) v. 7.4(1.7), p < 0.0001; Coleman Liau: 13.7(2.1) v. 8.6(2.4), 0.0002; Smog index: 11.8(1.2) v. 6.7(1.8), <0.0001; Automated Readability Index: 13.1(1.4) v. 7.5(2.1), p < 0.0001). MTurk workers (n = 514) rated the layperson summaries as correct (89.5-95.7%) and correctly understood the content (63.0-87.4%).

CONCLUSION

GPT shows promise for correct patient education for prostate cancer-related contents, but the technology is not designed for delivering patients information. Prompting the model to respond with accuracy, completeness, clarity and readability may enhance its utility when used for GPT-powered medical chatbots.

Framing the picture: Impact of radiographic imaging on parental vesicoureteral reflux management preferences

INTRODUCTION/OBJECTIVE

Given the variety of treatment options for vesicoureteral reflux (VUR), shared decision making between clinicians and parents is essential. Despite its importance, shared decision making is limited by the framing effect - people process the same information differently depending on how it is presented. Studies have also demonstrated that showing patients their radiology images can impact behaviors. In this pilot study, we sought to determine if showing parents radiographic images could serve as a framing tool that impacts the decision of whether to pursue surgery, endoscopic intervention, or conservative management for VUR.

METHODS

We designed a survey instrument which provided background on VUR and a hypothetical scenario of a 2-year-old child with VUR who had a breakthrough febrile urinary tract infection (UTI). Guideline-concordant management options were presented: (1) change antibiotics, (2) endoscopic management, or (3) open or laparoscopic surgery. All options were similarly presented regarding risks, benefits, and length of stay. Respondents were randomized into a group with no image accompanying the clinical scenario or a group which had a labeled image of a voiding cystourethrogram (VCUG) demonstrating unilateral VUR. Respondents also answered demographic and health experience questions. The instrument was published on Amazon's Mechanical Turk online work interface which provides reliable and validated results in VUR experiments. Parents aged 18-60 years old were eligible. Responses with failed attention questions, duplicate internet addresses, or submission times <1 or >30 min were disqualified. Data were analyzed using t-test, chi-square, and multinomial logistic regression. Sensitivity analyses were performed after excluding all responses submitted under 2, 3, and 5 min.

RESULTS

There were a total of 914 responses, 426 met inclusion criteria. The presence or absence of a VCUG image did not result in a statically significant difference in the management decision (p = 0.081). Multinomial logistic regression demonstrated that prior UTI experience influenced the management decision (p = 0.027). Sensitivity analyses revealed a significant difference in the management decision when excluding responses <5 min (p = 0.039).

CONCLUSION

In this analysis, there was no statistically significant framing effect by radiographic images on parental management decision for VUR. Multinomial analyses suggested that prior experience with UTI has an impact on VUR management decisions. These results need to be considered within the limitations of this pilot study - the respondents were given a hypothetical clinical scenario and the survey instrument cannot replace an in-office discussion. Further analyses on framing and its role in pre-operative counseling is warranted.

Parental preferences for vesicoureteral reflux treatment: Profile case best-worst scaling

INTRODUCTION

Vesicoureteral reflux is a common pediatric urologic condition that often has several reasonable treatment options depending on condition severity. In order to choose the best treatment for their child, parents are expected to make judgements that weigh attributes such as treatment cost, effectiveness, and complication rate. Prior research has shown that factors such as treating hospital and surgeon also influence patient treatment choice.

OBJECTIVES

This study evaluates parental preferences for reflux treatment using profile case best-worst scaling, an emerging technique in both urologic and health care preference estimation. The study also uses latent class analysis (LCA) to identify parental sub-classes with different preferences.

STUDY DESIGN

Data were collected from a community sample of parents via a multimedia best-worst scaling survey instrument published to Amazon's Mechanical Turk online community. After extensive review of the literature, reflux attributes and attribute levels were selected to correspond with available treatments. The profile case best-worst scaling exercise elicited preferences for granular attributes of reflux treatments. Data were analyzed using multinomial logistic regression and class analysis to distinguish preference heterogeneity. Probability scaled values (PSVs) reflected the order of desirability of the attributes. Attribute preference importance was rescaled into dollar units for comparison as well.

RESULTS

We analyzed data for 248 respondents. The highest treatment effectiveness was more desirable than all other leveled treatment attributes (PSV 17.8, all p < 0.01) (Table). Low complication rate and doctor recommendation were amongst the other most desirable treatment attributes (PSV 11.3 and 9.0, respectively). Latent class analysis identified a class with more extreme preferences, for whom doctor recommendation and avoiding hospitalization were particularly desirable.

DISCUSSION

In this community-based sample, high treatment effectiveness and low complication rate were the most desirable treatment attributes to parents, though parents likely have heterogenous treatment preference structures. Shared parent-physician decision-making that incorporates parental preferences will likely allow more effective, targeted decision-making in the future.

Community perspectives on difference of sex development (DSD) diagnoses: A crowdsourced survey

INTRODUCTION AND OBJECTIVES

Differences of sex development (DSD) engender ethical, social and psychosexual complexities that can complicate medical decision-making. We performed a web-based pilot study to estimate the utility value of a DSD diagnosis and to identify community concerns regarding DSD management.

METHODS

A cross-sectional survey was posted on Amazon's Mechanical Turk, an online crowdsourcing platform. Respondents were ≥18y and were randomized to receive information on one of three common DSD conditions: Congenital Adrenal Hyperplasia (CAH), Mixed Gonadal Dysgenesis (MGD), and Partial Androgen Insensitivity Syndrome (PAIS). Time trade-off methodology was used to estimate utility values. Likert scale and statement-ranking questions were used to assess respondent perceptions.

RESULTS

Of 1,628 respondents, median age was 34y; most respondents were parents (59.1%), white (77.1%), and previously unfamiliar with DSD (60.4%). The median overall utility value was 0.70 (IQR 0.50-0.90), similar to moderately severe chronic health conditions. Utility estimates varied based on the DSD scenario presented (0.80 CAH vs. 0.70 MGD vs. 0.80 PAIS, p = 0.0006), respondent gender (p < 0.0001), race (p = 0.002), religion (p = 0.005), and prior knowledge of DSD (p < 0.0001). Reported concerns included gender identity (23.4%), urinary function (20.5%) and surgical complications (17.4%). Most (67.5%) supported early surgical intervention at 6-18 mo; 10.4% thought surgery should occur ≥18 y.

COMMENT

Limitations of this study include that survey participants were aware of the nature of the study, thus some respondents may have participated to skew the results. Given the nature of this pilot study, the representation of families with children with DSD within the study is severely limited given the rarity of DSDs. This means that their opinions may be diluted by the large sample size. However, because utility values are classically estimated according to community opinions, the utility data presented should be taken to reflect that of the specific sample studied and is not reflective of that of families with a vested interest in such cases.

CONCLUSIONS

Community-based respondents perceived that DSD conditions were associated with a reduction in utility values (0.70-0.80), on par with moderately severe chronic health conditions. Estimates varied based on respondents' gender, race, religion and prior knowledge of DSD. Gender identity was the most concerning aspect for respondents.

Cost-Effectiveness of Screening Ultrasound after a First, Febrile Urinary Tract Infection in Children Age 2-24 Months

OBJECTIVE

To estimate the cost-effectiveness of routine, screening renal bladder ultrasound (RBUS) for children age 2-24 months after a first febrile urinary tract infection (UTI), as recommended by the American Academy of Pediatrics.

STUDY DESIGN

We developed a decision analytic model that simulates a population of children after a first febrile UTI. The model incorporates the diagnostic utility of RBUS to detect vesicoureteral reflux and genitourinary anomalies. We adopted a health-system perspective, 5-year horizon, and included 1-way and 2-way sensitivity analyses. Costs were inflated to 2018 US dollars, and our model incorporated a 3% discounting rate. We compared routine RBUS after first, febrile UTI compared with routine RBUS after second UTI (ie, control arm). Our main outcomes were recurrent UTI rate and incremental cost per quality-adjusted life-year (QALY).

RESULTS

Among children 2-24 months after a first febrile UTI, RBUS had an overall accuracy (true positives + true negatives) of 64.4%. The recurrent UTI rate in the intervention arm was 19.9% compared with 21.0% in the control arm. Thus, 91 patients would need to be screened with RBUS to prevent 1 recurrent UTI. RBUS increases QALYs by +0.0002 per patient screened, corresponding to an incremental cost-effectiveness ratio of $803 000/QALY gained. In the RBUS arm, 20.6% of children would receive unnecessary voiding cystourethrograms compared with 12.2% of children in the control group.

CONCLUSIONS

Screening RBUS after a first, febrile UTI in children age 2-24 months does not meet cost-effectiveness guidelines. Our findings support deferred screening until a second UTI.

Parental Preferences for Vesicoureteral Reflux Treatment: A Crowd-sourced, Best-worst Scaling Study

OBJECTIVE

To quantitatively evaluate parental preferences for the various treatments for vesicoureteral reflux using crowd-sourced best-worst scaling, a novel technique in urologic preference estimation.

METHODS

Preference data were collected from a community sample of parents via 2 best-worst scaling survey instruments published to Amazon's Mechanical Turk online community. Attributes and attribute levels were selected following extensive review of the reflux literature. Respondents completed an object case best-worst scaling exercise to prioritize general aspects of reflux treatments and multiprofile case best-worst scaling to elicit their preferences for the specific differences in reflux treatments. Data were analyzed using multinomial logistic regression. Results from the object-case provided probability scaled values (PSV) that reflected the order of importance of attributes.

RESULTS

We analyzed data for 248 and 228 respondents for object and multiprofile case BWS, respectively. When prioritizing general aspects of reflux treatment, effectiveness (PSV = 20.37), risk of future urinary tract infection (PSV = 14.85), and complication rate (PSV = 14.55) were most important to parents. Societal cost (PSV = 1.41), length of hospitalization (PSV = 1.09), and cosmesis (PSV = 0.91) were least important. Parents perceived no difference in preference for the cosmetic outcome of open vs minimally invasive surgery (P = .791). Bundling attribute preference weights, parents in our study would choose open surgery 74.9% of the time.

CONCLUSION

High treatment effectiveness was the most important and preferred attribute to parents. Alternatively, cost and cosmesis were among the least important. Our findings serve to inform shared parent-physician decision-making for vesicoureteral reflux.

The Psychometric Properties of a Self-Administered, Open-Source Module for Valuing Metastatic Epidural Spinal Cord Compression Utilities

INTRODUCTION

Web surveys are often used for utility valuation. Typically, custom utility valuation tools that have not undergone psychometric evaluation are used.

OBJECTIVES

This study aimed to determine the psychometric properties of a metastatic epidural spinal cord compression (MESCC) module run on a customizable open-source, internet-based, self-directed utility valuation platform (Self-directed Online Assessment of Preferences [SOAP]).

METHODS

Individuals accompanying patients to the emergency department waiting room in Ottawa, Canada, were recruited. Participants made SOAP MESCC health state valuations in the waiting room and 48 h later at home. Validity, agreement reliability, and responsiveness were measured by logical consistency of responses, smallest detectable change, the interclass correlation coefficient, and Guyatt's responsiveness index, respectively.

RESULTS

Of 285 participants who completed utility valuations, only 113 (39.6%) completed the re-test. Of these 113 participants, 92 (81.4%) provided valid responses on the first test and 75 (66.4%) provided valid responses on the test and re-test. Agreement for all groups of health states was adequate, since their smallest detectable change was less than the minimal clinically important difference. The mean interclass correlation coefficients for all health states were > 0.8, indicating at least substantial reliability. Guyatt's responsiveness indices all exceeded 0.80, indicating a high level of responsiveness.

CONCLUSIONS

To our knowledge, this is the first validated open-source, web-based, self-directed utility valuation module. We have demonstrated the SOAP MESCC module is valid, reproducible, and responsive for obtaining ex ante utilities. Considering the successful psychometric validation of the SOAP MESCC module, other investigators can consider developing modules for other diseases where direct utility valuation is needed.

Relative importance of attribute preferences for radial vs. femoral arterial access: A crowdsourcing study of healthy online-recruited volunteers

INTRODUCTION

Percutaneous coronary intervention (PCI) is typically performed with vascular access provided by the radial or femoral artery. However, little is known about how patients value aspects of these different vascular access approaches.

METHODS

Conjoint analysis is a survey-based statistical technique used in market research that helps determine how individuals value different attributes that make up a particular product or services. We utilized conjoint analysis to assess the relative importance of four attributes associated with PCI: access site, risk of bleeding, hospital stay, and radiation exposure. Participants were healthy individuals recruited by Amazon Mechanical Turk (MTURK). After completing a conjoint analysis survey, the software Conjoint.ly was used to calculate the relative importance for these four different attributes of PCI.

RESULTS

The relative importance of hospital stay, radiation exposure, bleeding risk, and procedure site was 32.7% (95% CI 29.5-35.8), 27.3% (95% CI 24.8-29.8), 24.4% (95% CI 22.3-26.5), and 15.7% (95% CI 13.6-17.8), respectively. The difference between these groups was statistically significant (P-value < 0.00001). The difference between duration of hospital stay and radiation exposure was statistically significant (P-value < 0.00433).

CONCLUSION

Patients undergoing PCI place largest relative value on duration of hospital stay. Access site appears the least valued attribute. These findings carry implications to guide further research on access site choices and the consent process in the context of shared decision-making.

Mapping of Crowdsourcing in Health: Systematic Review

Background

Crowdsourcing involves obtaining ideas, needed services, or content by soliciting Web-based contributions from a crowd. The 4 types of crowdsourced tasks (problem solving, data processing, surveillance or monitoring, and surveying) can be applied in the 3 categories of health (promotion, research, and care).

Objective

This study aimed to map the different applications of crowdsourcing in health to assess the fields of health that are using crowdsourcing and the crowdsourced tasks used. We also describe the logistics of crowdsourcing and the characteristics of crowd workers.

Methods

MEDLINE, EMBASE, and ClinicalTrials.gov were searched for available reports from inception to March 30, 2016, with no restriction on language or publication status.

Results

We identified 202 relevant studies that used crowdsourcing, including 9 randomized controlled trials, of which only one had posted results at ClinicalTrials.gov. Crowdsourcing was used in health promotion (91/202, 45.0%), research (73/202, 36.1%), and care (38/202, 18.8%). The 4 most frequent areas of application were public health (67/202, 33.2%), psychiatry (32/202, 15.8%), surgery (22/202, 10.9%), and oncology (14/202, 6.9%). Half of the reports (99/202, 49.0%) referred to data processing, 34.6% (70/202) referred to surveying, 10.4% (21/202) referred to surveillance or monitoring, and 5.9% (12/202) referred to problem-solving. Labor market platforms (eg, Amazon Mechanical Turk) were used in most studies (190/202, 94%). The crowd workers’ characteristics were poorly reported, and crowdsourcing logistics were missing from two-thirds of the reports. When reported, the median size of the crowd was 424 (first and third quartiles: 167-802); crowd workers’ median age was 34 years (32-36). Crowd workers were mainly recruited nationally, particularly in the United States. For many studies (58.9%, 119/202), previous experience in crowdsourcing was required, and passing a qualification test or training was seldom needed (11.9% of studies; 24/202). For half of the studies, monetary incentives were mentioned, with mainly less than US $1 to perform the task. The time needed to perform the task was mostly less than 10 min (58.9% of studies; 119/202). Data quality validation was used in 54/202 studies (26.7%), mainly by attention check questions or by replicating the task with several crowd workers.

Conclusions

The use of crowdsourcing, which allows access to a large pool of participants as well as saving time in data collection, lowering costs, and speeding up innovations, is increasing in health promotion, research, and care. However, the description of crowdsourcing logistics and crowd workers’ characteristics is frequently missing in study reports and needs to be precisely reported to better interpret the study findings and replicate them.

Comparing Amazon's Mechanical Turk Platform to Conventional Data Collection Methods in the Health and Medical Research Literature

BACKGROUND

The goal of this article is to conduct an assessment of the peer-reviewed primary literature with study objectives to analyze Amazon.com 's Mechanical Turk (MTurk) as a research tool in a health services research and medical context.

METHODS

Searches of Google Scholar and PubMed databases were conducted in February 2017. We screened article titles and abstracts to identify relevant articles that compare data from MTurk samples in a health and medical context to another sample, expert opinion, or other gold standard. Full-text manuscript reviews were conducted for the 35 articles that met the study criteria.

RESULTS

The vast majority of the studies supported the use of MTurk for a variety of academic purposes.

DISCUSSION

The literature overwhelmingly concludes that MTurk is an efficient, reliable, cost-effective tool for generating sample responses that are largely comparable to those collected via more conventional means. Caveats include survey responses may not be generalizable to the US population.

A Computer-Assisted Personal Interview App in Research Electronic Data Capture for Administering Time Trade-off Surveys (REDCap): Development and Pretest

Background

The time trade-off (TTO) task is a method of eliciting health utility scores, which range from 0 (equivalent to death) to 1 (equivalent to perfect health). These scores numerically represent a person’s health-related quality of life. Software apps exist to administer the TTO task; however, most of these apps are poorly documented and unavailable to researchers.

Objective

To fill the void, we developed an online app to administer the TTO task for a research study that is examining general public proxy health-related quality of life estimates for persons with Alzheimer’s disease. This manuscript describes the development and pretest of the app.

Methods

We used Research Electronic Data Capture (REDCap) to build the TTO app. The app’s modular structure and REDCap’s object-oriented environment facilitated development. After the TTO app was built, we recruited a purposive sample of 11 members of the general public to pretest its functionality and ease of use.

Results

Feedback from the pretest group was positive. Minor modifications included clarity enhancements, such as rearranging some paragraph text into bullet points, labeling the app to delineate different question sections, and revising or deleting text. We also added a research question to enable the identification of respondents who know someone with Alzheimer’s disease.

Conclusions

We developed an online app to administer the TTO task. Other researchers may access and customize the app for their own research purposes.

Crowdsourcing utility estimation for spina bifida in the general population

INTRODUCTION

Cost-utility analyses (CUA) are useful when the treatment conditions depend on patient preferences that are in turn dependent on health state utility value. Spina bifida (SB) is an example of such a preference-sensitive condition. Historically, the SB utility value for CUA has been gathered via a traditional face-to-face interview. However, due to funding and time constrains, utility estimation via online crowdsourcing has recently gained popularity. Our aim was to estimate the utility value for a generic SB health state using a validated online tool.

METHODS

A cross-sectional survey of American adults was conducted using the time-trade-off (TTO) method. Participants were recruited from an online crowdsourcing interface, Amazon's Mechanical Turk (mTurk). Demographic information and prior knowledge of SB were assessed. Respondents were provided a written passage and an online video explaining SB and its potential associated comorbidities. Participants were queried on hypothetical ascending time-trades from a child-parent dyad perspective to determine the utility of a SB health state in an affected 6-year-old child. Respondents were also asked to indicate the percentage of time traded from their life in relation to their child's. Utility estimates were then calculated and compared using bivariate and multivariate analyses.

RESULTS

We obtained 503 responses (85% response rate). Mean respondent age was 34 (± 11); 247 (49%) were female; 386 (77%) were white; 189 (38%) were married, and 234 (46%) had children. Mean proportion of longevity traded by participants in the dyadic interaction was 66% (± 27) from the parent's life. Only 51 respondents (9%) reported having "ample" prior knowledge of SB; 8 respondents (0.02%) had SB themselves. Few others had previous experience with SB or myelomeningocele either in a child (4, 1%), or friend/relative (28, 5%). Compared with a perfect health state of 1.0, we found mean utilities of 0.85 (± 0.20) for SB.

CONCLUSIONS

Utility estimation for SB is feasible through crowdsourcing, and the resultant values are similar to previous estimates using traditional techniques. Subjects view the SB health state to be inferior to perfect health.

Utility Estimation for Pediatric Vesicoureteral Reflux: Methodological Considerations Using an Online Survey Platform

PURPOSE

The advent of online task distribution has opened a new avenue for efficiently gathering community perspectives needed for utility estimation. Methodological consensus for estimating pediatric utilities is lacking, with disagreement over whom to sample, what perspective to use (patient vs parent) and whether instrument induced anchoring bias is significant. We evaluated what methodological factors potentially impact utility estimates for vesicoureteral reflux.

MATERIALS AND METHODS

Cross-sectional surveys using a time trade-off instrument were conducted via the Amazon Mechanical Turk® (https://www.mturk.com) online interface. Respondents were randomized to answer questions from child, parent or dyad perspectives on the utility of a vesicoureteral reflux health state and 1 of 3 "warm-up" scenarios (paralysis, common cold, none) before a vesicoureteral reflux scenario. Utility estimates and potential predictors were fitted to a generalized linear model to determine what factors most impacted utilities.

RESULTS

A total of 1,627 responses were obtained. Mean respondent age was 34.9 years. Of the respondents 48% were female, 38% were married and 44% had children. Utility values were uninfluenced by child/personal vesicoureteral reflux/urinary tract infection history, income or race. Utilities were affected by perspective and were higher in the child group (34% lower in parent vs child, p <0.001, and 13% lower in dyad vs child, p <0.001). Vesicoureteral reflux utility was not significantly affected by the presence or type of time trade-off warm-up scenario (p = 0.17).

CONCLUSIONS

Time trade-off perspective affects utilities when estimated via an online interface. However, utilities are unaffected by the presence, type or absence of warm-up scenarios. These findings could have significant methodological implications for future utility elicitations regarding other pediatric conditions.

Patient Preferences in Treatment Choices for Early-Stage Lung Cancer

BACKGROUND

Decision-making for lung cancer treatment can be complex because it involves both provider recommendations based on the patient's clinical condition and patient preferences. This study describes the relative importance of several considerations in lung cancer treatment from the patient's perspective.

METHODS

A conjoint preference experiment began by asking respondents to imagine that they had just been diagnosed with lung cancer. Respondents then chose among procedures that differed regarding treatment modalities, the potential for treatment-related complications, the likelihood of recurrence, provider case volume, and distance needed to travel for treatment. Conjoint analysis derived relative weights for these attributes.

RESULTS

A total of 225 responses were analyzed. Respondents were most willing to accept minimally invasive operations for treatment of their hypothetical lung cancer, followed by stereotactic body radiation therapy (SBRT); they were least willing to accept thoracotomy. Treatment type and risk of recurrence were the most important attributes from the conjoint experiment (each with a relative weight of 0.23), followed by provider volume (relative weight of 0.21), risk of major complications (relative weight of 0.18), and distance needed to travel for treatment (relative weight of 0.15). Procedural and treatment preferences did not vary with demographics, self-reported health status, or familiarity with the procedures.

CONCLUSIONS

Survey respondents preferred minimally invasive operations over SBRT or thoracotomy for treatment of early-stage non-small cell lung cancer. Treatment modality and risk of cancer recurrence were the most important factors associated with treatment preferences. Provider experience outweighed the potential need to travel for lung cancer treatment.

Economic analysis of continuous antibiotic prophylaxis for prevention of urinary tract infections in infants with high-grade hydronephrosis

BACKGROUND

For infants with hydronephrosis, continuous antibiotic prophylaxis (CAP) may reduce urinary tract infections (UTIs); however, its value remains controversial. Recent studies have suggested that neonates with severe obstructive hydronephrosis are at an increased risk of UTIs, and support the use of CAP. Other studies have demonstrated the negligible risk for UTIs in the setting of suspected ureteropelvic junction obstruction and have highlighted the limited role of CAP in hydronephrosis. Furthermore, economic studies in this patient population have been sparse.

OBJECTIVE

This study aimed to evaluate whether the use of CAP is an efficient expenditure for preventing UTIs in children with high-grade hydronephrosis within the first 2 years of life.

STUDY DESIGN

A decision model was used to estimate expected costs, clinical outcomes and quality-adjusted life years (QALYs) of CAP versus no CAP (Fig. 1). Cost data were collected from provincial databases and converted to 2013 Canadian dollars (CAD). Estimates of risks and health utility values were extracted from published literature. The analysis was performed over a time horizon of 2 years. One-way and probabilistic sensitivity analyses were carried out to assess uncertainty and robustness.

RESULTS

Overall, CAP use was less costly and provided a minimal increase in health utility when compared to no CAP (Table). The mean cost over two years for CAP and no CAP was CAD$1571.19 and CAD$1956.44, respectively. The use of CAP reduced outpatient-managed UTIs by 0.21 infections and UTIs requiring hospitalization by 0.04 infections over 2 years. Cost-utility analysis revealed an increase of 0.0001 QALYs/year when using CAP. The CAP arm exhibited strong dominance over no CAP in all sensitivity analyses and across all willingness-to-pay thresholds.

DISCUSSION

The use of CAP exhibited strong dominance in the economic evaluation, despite a small gain of 0.0001 QALYs/year. Whether this slight gain is clinically significant remains to be determined. However, small QALY gains have been reported in other pediatric economic evaluations. Strengths of this study included the use of data from a recent systematic review and meta-analysis, in addition to a comprehensive probabilistic sensitivity analysis. Limitations of this study included the use of estimates for UTI probabilities in the second year of life and health utility values, given that they were lacking in the literature. Spontaneous resolution of hydronephrosis and surgical management were also not implemented in this model.

CONCLUSION

To prevent UTIs within the first 2 years of life in infants with high-grade hydronephrosis, this probabilistic model has shown that CAP use is a prudent expenditure of healthcare resources when compared to no CAP.

Utility scores for vesicoureteral reflux and anti-reflux surgery

BACKGROUND

Management of vesicoureteral reflux (VUR) continues to be controversial. In conditions of uncertainty, decision analytic techniques such as cost-utility analysis (CUA) can help to structure the decision-making process. However, CUA analyses require a "utility," a value between 0 (death) and 1 (perfect health) corresponding to the quality of life associated with a health state. Ideally, utility values are elicited directly from representative community samples, but utilities have not been rigorously measured for pediatric urology conditions.

OBJECTIVES

To elicit utility scores for VUR and open anti-reflux surgery (ARS) from a representative, well-characterized community sample of adults who have been parents.

METHODS

Cross-sectional survey of nationally representative adults who had ever been parents. Each respondent saw one of four descriptions of VUR, with or without continuous antibiotic prophylaxis (CAP) and occurrence of febrile urinary tract infection (UTI). A 6-week postoperative health state following ARS was also assessed. We used the time trade-off (TTO) method to elicit utility scores. Factors associated with utility score were assessed with a multivariate linear regression model.

RESULTS

The survey was completed by 1200 individuals. Data were weighted to adjust for demographic differences between responders and non-responders. Mean age was 52 ± 15 years, 44% were male, and 68% were White. In terms of education, 29% had a college degree or higher. The mean utility score for VUR overall was 0.82 ± 0.28. VUR utility scores did not differ significantly based on inclusion of CAP or UTI in the health state description (p = 0.21). The 6-week postoperative period garnered a utility of 0.71 ± 0.43.

DISCUSSION

Our results showed that VUR has a mean utility score of 0.82, which indicates that the community perceives this condition to be a substantial burden. For comparison, conditions with similar utility scores include compensated hepatitis B-related cirrhosis (0.80) and glaucoma (0.82); conditions with higher utilities include neonatal jaundice (0.99) and transient neonatal neurological symptoms (0.95); and conditions with lower utility scores include severe depression (0.43) and major stroke (0.30). Our results suggest that parents consider the burden associated with VUR to be significant, and that the impact of the condition on families and children is substantial.

CONCLUSIONS

VUR is perceived as having a substantial impact on health-related quality of life, with a utility value of 0.82. However, use of CAP and occurrence of UTI do not seem to affect significantly the community perspective on HRQOL associated with living with VUR.