Health values of patients infected with human immunodeficiency virus. Relationship to mental health and physical functioning

The association of symptomatic vitreous floaters with depression and anxiety

PURPOSE

To evaluate the levels of anxiety and depression in patients with symptomatic vitreous floaters and to determine the possible correlations of psychological implications with the symptoms duration and possible improvement, the degree of posterior vitreous detachment, and the discomfort severity.

METHODS

Ninety patients complaining for floaters and fifty-seven age- and gender-matched healthy-control subjects were recruited. Every participant underwent a complete ophthalmological examination, including funduscopy and optical coherence tomography scans, while clinical and demographic data were also gathered. The Patient Health Questionnaire-9 (PHQ-9), the Zung Depression Inventory-Self-Rating Depression Scale (Zung SDS), and the Hospital Anxiety and Depression Scale (HADS) were completed by everyone.

RESULTS

Between the studied groups, no significant differences were detected regarding the clinical and demographic data (p > 0.05). The patients with floaters had significantly higher scores of PHQ-9, Zung SDS, HADS Anxiety, and HADS Depression (p < 0.001). After adjustment for several confounders, PHQ-9 (p = 0.041), Zung SDS (p = 0.003), and HADS Anxiety (p = 0.036) values remained significantly impaired. Among the patients, PHQ-9 and Zung SDS scores were significantly elevated in the patients with floaters duration less than 4 weeks (p < 0.05). Finally, anxiety and depression were significantly correlated with the symptoms duration and intensity, with the floater-associated discomfort, and with the stage of posterior vitreous detachment.

CONCLUSION

Vitreous floaters have a negative impact on patients' psychological status, by the terms of enhanced depressive and anxiety levels. To the best of our knowledge, our study is the first in the literature to elaborate the aforementioned association, by assessing three different questionnaires simultaneously.

The devastating effects of humeral nonunion on health-related quality of life

BACKGROUND

Humeral nonunion is estimated to occur at a rate of 1.1%-25% depending on the fracture location and pattern, mechanism of injury, patient compliance with the immobilization protocol and patient's nutritional status and medical comorbidities. Fracture nonunion can cause chronic pain and limited range of motion and may hinder normal function. There is very little data from the patients' perspective regarding their experience with a humeral nonunion. The aim of this study was to establish health-related quality of life (HRQoL) norms for patients diagnosed with a humeral nonunion.

MATERIALS AND METHODS

We reviewed a prospectively collected database of 185 humeral nonunions seen and treated at our quaternary referral center. We recorded patient characteristics including sex, age, history of infection, previous surgery, associated nerve palsy, handedness, and the anatomic location of the nonunion. At initial clinical evaluation, all patients were asked to complete the 12-Item Short Form Health Survey (SF-12), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, Brief Pain Inventory (BPI), and a time trade-off questionnaire. These scores were compared to other well-known chronic medical conditions' HRQoL scores.

RESULTS

The cohort reported an average utility score of 0.55 ± 0.35, average SF-12 Physical Component Summary score of 30.2 ± 7.6, average SF-12 Mental Component Summary score of 42.5 ± 6.1, and average raw DASH score of 69 ± 21, which was worse than the general US population, patients with asthma, hypertension, stroke, type 2 diabetes, and AIDS. Patients with humeral nonunion are willing to trade 45% of their remaining life to obtain perfect health, and when stratified by handedness, we found that patients with a humeral nonunion of their dominant arm were willing to trade 49.7% compared with 39.7% in patients with a humeral nonunion of their nondominant arm (P = .04).

DISCUSSION

The results of our study show that humeral nonunion is a chronic medical condition that has a debilitating effect on patients, both physically and mentally. It is important for orthopedic surgeons to acknowledge these conditions as physically and mentally debilitating to their patients. Our study highlights these physical and mental burdens and helps to quantify humeral nonunion in relation to more well-known chronic conditions, such as asthma, diabetes, AIDS, and stroke.

CONCLUSIONS

Humeral nonunions have a devastating effect on a patient's physical and mental health with HRQoL measures lower than patients with other chronic conditions, such as asthma, diabetes, AIDS, and stroke. We found that our patients, on average, would trade approximately 45% of their remaining life span for perfect health.

Self-esteem in patients with venous thromboembolism predicts time trade-off values for own health

Background

The time trade-off (TTO) is a commonly used preference based method to assess health related values used in health economic analyses. Surprisingly little is known about the factors influencing the TTO. Since self-esteem is a predictor for health status measurements, and health status affects the TTO, we studied the relation between self-esteem and TTO values.

Methods

Data of 128 patients treated with vitamin K antagonists for venous thromboembolism on Short Form-36 (SF-36), Rosenberg self-esteem and patient characteristics were collected. TTO values were obtained for ‘current health’ and three chronic health states related to thrombosis, in face-to-face interviews with patients. Regression analyses were performed with the TTO as dependent variable. Analyses were performed in two groups; the complete sample, and traders only. Selected predictors were entered in four blocks: socio-demographic factors, medical-clinical factors, health status, and self-esteem.

Results

In the complete sample (N = 128), bivariate regression analysis showed that self-esteem explained 14% of the variance in TTO values for current health (p < .000, N = 117). In traders, multivariate regression analysis showed a significant relationship between self-esteem and TTO values for current health. Self-esteem increased the variance explained (R²) by 8.8%, from 28.1 to 36.9%, (p = 0.01; N = 57). For hypothetical health states, the effect of self-esteem was weaker and mostly absent after controlling for selected variables.

Conclusions

In patients willing to trade-off time, higher self-esteem was associated with higher TTO values for own current health. Self-esteem explained an appreciable proportion of the variance in TTO values in traders. For hypothetical health states such associations were weak or absent.

Protective and Compensatory Effects of Group Identification on the Mental Health of People Living with HIV

Despite persistent stigmatization of people living with HIV (PLHIV) across the globe, group identification among these individuals may serve to counteract the detrimental effect of prejudice and discrimination associated with the stigmatized identity. Drawing on resilience theory and social identity theory, this study examined how multiple dimensions of group identification (i.e., in-group ties, in-group affect, and centrality) function to buffer and neutralize the negative impact of HIV stigma. A total of 281 PLHIV were recruited from the only community-based public HIV clinic in Hong Kong to participate in this study. The results revealed a protective effect of in-group affect, which moderated the relationship between HIV stigma and mental health, such that HIV stigma was not associated with mental health among people with higher positive in-group affect. In addition, a positive compensatory effect of in-group ties was found in people with higher HIV identity centrality. Given the protective effect of in-group affect, it is important to re-story the lives among PLHIV by challenging their maladaptive beliefs about being PLHIV and building a positive sense of identity in their personal narratives. Community-based interventions should be provided to individuals with higher HIV identity centrality by offering peer support groups and engaging them in community work.

Safety and Efficacy of YAG Laser Vitreolysis for the Treatment of Vitreous Floaters: An Overview

Emerging evidence has suggested that the entoptic phenomena associated with vitreous opacities (i.e. vitreous floaters) are more bothersome than previously believed. In addition, the prevalence of vitreous floaters is likely increasing due to the evolving global pandemic of myopia. The use of YAG laser vitreolysis for the treatment of annoying vitreous floaters has attracted significant attention in recent years as the technique offers a number of potential advantages. Unfortunately, the currently available evidence that is needed to guide clinical practice is both very limited and contradictory. As a consequence, the technique remains highly controversial. A review of the existing literature sheds light on patient- and treatment-related factors that may significantly affect both the effectiveness and the safety of the procedure. The current article discusses important aspects of key publications on the topic, offers suggestions for clinical practice, and highlights unmet needs that should be addressed by future research.

Utilizing the Time Trade-Off, Standard Gamble, and Willingness to Pay Utility Measures to Evaluate Health-Related Quality of Life Prior to Knee or Hip Arthroplasty

BACKGROUND

Time trade-off, standard gamble, and willingness to pay assess the number of years, risk of death, and income a patient would give up for perfect health. These questions were used to evaluate the impact knee arthritis, hip arthritis, or failed total knee (TKA) or hip arthroplasty (THA) has on patients' health-related quality of life prior to surgery.

METHODS

Three hundred sixty patients including 176 undergoing primary TKA, 127 undergoing primary THA, 31 undergoing revision TKA, and 26 undergoing revision THA were assessed. Time trade-off and standard gamble were converted to utility scores with 1.0 suggesting perfect health and 0 suggesting preference for death rather than living in current state. Willingness to pay is the percentage of yearly income that a patient would pay for perfect health.

RESULTS

The mean time trade-off, standard gamble, and willingness to pay scores were 0.74, 0.83, and 0.32 without significant difference between procedures with the numbers available for study (P = .16, .31, and 0.41, respectively). Increasing body mass index was correlated with decreasing time trade-off scores (P = .014).

CONCLUSION

Patients scheduled for primary or revision THA and TKA would accept an average 17% risk of death, lose 2.6 years of an additional 10-year life expectancy, and pay 32% of their income for perfect health. The time trade-off (0.74) was similar to patients with history of acute myocardial infarction (0.74) or minor stroke (0.72) and worse than those with chronic hepatitis C (0.83) or human immunodeficiency virus/acquired immunodeficiency syndrome infection (0.86). These data highlight the high value that patients place on adult reconstructive procedures.

Health Disparities and the Digital Divide: The Relationship between Communication Inequalities and Quality of Life among Women in a Nationwide Prospective Cohort Study in the United States

Background: Communication inequalities can affect health-seeking behaviors yet the relationship between Internet use and overall health is inconclusive. Communication-related inequalities vary by race/ethnicity and SES but existing research primarily includes middle-class Whites. We therefore examined the relationship between communication-related inequalities-measured by daily Internet use-and health-related quality of life (QOL) using a nationwide prospective cohort study in the United States that consists of primarily low income, minority women. Methods: We examined Internet use and QOL among participants in the Women's Interagency HIV Study. Data collection occurred from October 2014-September 2015 in Chicago, New York, Washington DC, San Francisco, Atlanta, Chapel Hill, Birmingham/Jackson and Miami. We used multi-variable analyses to examine the relationship between daily Internet use and QOL. Results: The sample of 1,915 women was 73% African American and 15% Hispanic; 53% reported an annual income of ≤$12,000. Women with daily Internet use reported a higher QOL at six months, as did women with at least a high school diploma, income >$12,000, and non-White race; older women and those with reported drug use, depressive symptoms and loneliness had lower QOL. Conclusions: Overcoming communication inequalities may be one pathway through which to improve overall QOL and address public health priorities. Reducing communication-related inequalities-e.g, by providing reliable Internet access-and thus improving access to health promoting information, may lead to improved health outcomes.

Quality of Life in Older Adults with HIV Disease

Quality-of-life (QOL) measures have become valuable additions to traditional morbidity and mortality outcomes in evaluating the progression of disease or the efficacy of medical interventions. With significant increases in longevity and an expanding treatment repertoire, QOL issues for people with HIV/AIDS have become increasingly important. Furthermore, as people are living longer with HIV/AIDS and the population in general ages, the number of persons older than age 50 who have HIV/AIDS is increasing. As QOL issues become more important for people with HIV/AIDS and as the population with HIV/AIDS ages, several issues related to QOL among older people arise. These include conceptual issues related to QOL and aging, as well as methodological issues of QOL assessments among older persons. This article begins with a brief discussion of why QOL is important to measure, various measurement strategies, and QOL comparisons between HIV/AIDS populations and other chronic disease groups. This is followed by a discussion of conceptual and methodological issues in measuring QOL among older persons. Finally, the authors conclude with recommendations for future research.

Utilities Derived from Visual Analog Scale Scores in Patients with HIV/AIDS

Background. Visual analog scale (VAS) scores are used as global quality-of-life indicators and, unlike true utilities (which assess the desirability of health states v. an external metric), are often collected in HIV-related clinical trials. The purpose of this study was to derive and evaluate transformations relating aggregate VAS scores to utilities for current health in patients with HIV/AIDS. Methods. HIV-specific transformations were developed using linear and nonlinear regression to attain models that best fit mean VAS and standard gamble (SG) utility values directly derived from 299 patients with HIV/AIDS participating in a multicenter study of health values. The authors evaluated the transformations using VAS and SG utility values derived directly from patients in other HIV/AIDS studies. Derived transformations were also compared with published transformations. Results. A simple linear transformation was derived (u = 0.44v + 0.49), as was the exponent for a curvilinear model (u = 1-[1- v ]1.6 ), where u = the sample mean utility and v the sample mean VAS score. The curvilinear transformation predicted values within 0.10 of the actual SG utility in 5 of 8 estimates and within 0.05 in 3 of 8 estimates (absolute error ranged from -0.01 to +0.21). The linear transformation performed some-what better, predicting within 0.10 of the actual SG value in 6 of 8 cases and within 0.05 in 5 of 8 estimates (absolute error ranged from -0.05 to +0.13). An alternative linear model (u =v + 0.018) derived from the literature performed similarly to our linear model (7 of 8 predictions within 0.10, 1 of 8 estimates within 0.05, and absolute error ranging from -0.15 to +0.10), whereas an alternative published curvilinear model (u = 1 - [1 - v ]2.3 ) performed the least well (2 of 8 estimates within 0.10 of the actual values and no estimates within 0.05). Conclusions. Predicted utilities are a reasonable alter-native for use in HIV/AIDS decision analyses and costeffectiveness analyses. Linear transformations performed better than curvilinear transformations in this context and can be used to convert aggregate VAS scores to aggregate SG values in large HIV/AIDS studies that collect VAS data but not utilities.

Time Trade-Off as a Measure of Health-Related Quality of Life: Long Bone Nonunions Have a Devastating Impact

BACKGROUND

Long bone nonunions have an important impact on a patient's quality of life. The purpose of this study was to compare long bone nonunions with use of the Time Trade-Off direct measure to compute utility scores and to determine which nonunion anatomic location had the lowest health-related quality of life. The Time Trade-Off assesses the percentage of a patient's remaining life that the patient would be willing to trade for perfect health.

METHODS

Eight hundred and thirty-two consecutive long bone nonunions with Time Trade-Off data were identified and were retrospectively studied from a prospectively collected patient database. Nonunions with infections and those involving the articular portion of the bone were recorded. Time Trade-Off utility scores were obtained for all nonunion cases upon their initial clinical evaluation by a single surgeon specializing in reconstructive trauma.

RESULTS

The mean utility score of our nonunion cohort was 0.68 and it differed significantly by long bone (p = 0.037). Nonunions of the forearm had the lowest utility score (0.54), followed by the clavicle (0.59), femur (0.68), tibia or fibula (0.68), and humerus (0.71). Post hoc tests showed that patients with nonunions of the forearm had significantly lower utility scores (p = 0.031) compared with all other bones.

CONCLUSIONS

Patients diagnosed with a long bone nonunion have a very low health-related quality of life. We found that this single cohort's mean utility score was 0.68. This result is well below that of illnesses such as type-I diabetes mellitus (0.88), stroke (0.81), and acquired immunodeficiency syndrome (0.79). We found that patients with forearm nonunions had the lowest utility scores.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Quality of Life of People Living with HIV/AIDS: A Cross-Sectional Study in Zhejiang Province, China

Health-related quality of life (HRQOL) has become a concept commonly used in the related research. Using the World Health Organization Quality of Life Questionnaire for Brief Version (WHOQOL-BREF), this study evaluated the Quality of Life (QOL) of people living with HIV/AIDS (PLWHA) in Zhejiang province, China, and assessed the influences of demographic, laboratory and disease-related variables on QOL. This cross-sectional study was conducted among PLWHA aged ≥ 18 years in Taizhou municipality, Zhejiang province, China, between August 1 and October 31, 2014. A multiple linear regression model was used to analyze the influential factors. Of 403 subjects, 72.48% were male, 72.46% had received a high- school or above education, 94.79% were of Han ethnicity, and 65.51% were non farmers. The total score of QOL was 15.99±1.99. The scores of QOL in physiological, psychological, social relation, and environmental domains were 14.99 ±2.25, 14.25 ±2.12, 13.22 ±2.37, and 13.31 ±1.99 respectively. Except the total score of QOL and the score of environmental domain (p<0.05), the scores in other domains had no significant difference with the results of the national norm level. The multiple linear regression model identified the physical domain related factors to be age (β = -0.045), CD4 count (β = 0.002), and ART adherence(β = 1.231). And it also showed that psychological domain related factors included CD4 count (β = 0.002) and WHO clinical stage (β = -0.437); social domain related factors included WHO clinical stage (β = -0.704) and ART adherence (β = 1.177); while environmental domain related factors included WHO clinical stage (β = -0.538), educational status(β = 0.549) and ART adherence(β = 1.078).Those who are young, with higher level of education, higher CD4 count and good access and adherence of ART, are likely to have better QOL among PLWHA in Zhejiang province. This suggests that in addition to ART, many other factors should be taken into consideration to improve the QOL of PLWHA. The relatively lower scores the subjects received in social relation and environmental domains also suggest that social relation and environmental interventions need to be strengthened.

Utility estimation of hypothetical chronic obstructive pulmonary disease health states by the general population and health professionals

PURPOSE

This study attempted to estimate the utility weights for hypothetical chronic obstructive pulmonary disease (COPD) health states, including the effect of exacerbation, and based on utilities elicited from a representative sample using the time trade-off (TTO).

METHODS

A total of 200 study subjects were recruited using a quota sampling method in Seoul, Korea. Ten COPD health profiles were described reflecting the severity of COPD and the extent of exacerbation. Respondents evaluated each health state using a visual analogue scale and TTO during a personal interview. TTO values were estimated using a linear mixed model, and the model performance was evaluated in terms of its predictive ability and goodness of fit.

RESULTS

The estimated TTO values were 0.824 in moderate, 0.646 in severe, and 0.305 in very severe COPD health states. The estimated utility decrements in TTO varied from 0.082 for a non-serious exacerbation to 0.228 for one non-serious plus one serious exacerbation per year. The mean absolute error of the TTO model was 0.008, and the generalized R(2) was 0.86.

CONCLUSION

The social preference of various COPD health states and the utility decrement due to exacerbation can be useful for the economic evaluation of COPD intervention in Korea.

Prediction of health preference values from CD4 counts in individuals with HIV

BACKGROUND

A common measure of health benefit in technology assessments is the quality-adjusted life year, which incorporates health preference or utility scores.

OBJECTIVE

To build and test a predictive model using CD4 counts to derive health preference scores.

DESIGN

Predictive modeling. Setting. Ontario HIV Treatment Network Cohort Study. Measurement. The relationship between HUI3-derived health preference score and HIV health status measured by CD4 count was examined by a regression model. Additional independent variables considered included age, time since HIV diagnosis, AIDS-defining condition, sex, and education level. A polynomial regression model was fit to predict health preference scores. The final model was established using automated backwards stepwise variable elimination using the Akaike information criterion. Tenfold cross-validation was used to assess the model.

RESULTS

Data from 841 participants were available. Mean age and time since diagnosis were 46.78 and 11.03 years, respectively. CD4 counts ranged from 2 to 995 cells per mm(3) with 267 (31.75%) individuals having less than 350 cells per mm(3). Mean HUI3 utility score was 0.72 and ranged from -0.25 to 1. The final model retained squared terms for CD4 counts, age, and time since HIV diagnosis and eliminated history of AIDS-defining condition and the nonsquared time since HIV diagnosis. Prediction error was assessed in 14 subgroups using the validation set. Two subgroups had mean prediction errors greater than 0.02. Limitations. All statistical models are limited by the data used to develop and test the model. The model estimates health utility scores primarily through CD4 counts. Therefore, the model may be inappropriate if noninfectious diseases are a significant factor.

CONCLUSIONS

Results provide a model for predicting health preference values from CD4 counts.

Utility values associated with vitreous floaters

PURPOSE

To ascertain the health-related quality of life associated with symptomatic degenerative vitreous floaters.

DESIGN

Cross-sectional questionnaire survey.

METHODS

In this institution-based study, 311 outpatients aged 21 years and older who presented with symptoms of floaters were enrolled. Data from 266 patients (85.5%) who completed the questionnaire were analyzed. Utility values were assessed using a standardized utility value questionnaire. The time trade-off (TTO) and standard gamble (SG) for death and blindness techniques were used to calculate the utility values. Descriptive, univariate, and multivariate analyses were performed using Stata Release 6.0.

RESULTS

The mean age of the study population was 52.9 ± 12.02 years (range, 21-97). The mean utility values were 0.89, 0.89, and 0.93 for TTO, SG (death), and SG (blindness), respectively. Patients aged ≤55 years reported significantly lower SG (blindness) utility values when compared with patients above 55 years of age (age ≤55 = 0.92, age >55 = 0.94, P = .007). Utility measurements did not demonstrate significant relationship with any of the other socio-demographic variables examined in this study. The utility values did not demonstrate any significant relationship with other ocular characteristics such as duration of symptoms, presence of a posterior vitreous detachment, and presence or severity of myopia.

CONCLUSIONS

Symptomatic degenerative vitreous floaters have a negative impact on health-related quality of life. Younger symptomatic patients are more likely to take a risk of blindness to get rid of the floaters than older patients.

Factors related to quality of life in treatment-adherent, successfully treated HIV patients in France

The objectives of this study were to document the psychosocial characteristics of treatment-adherent, successfully treated HIV patients and to examine the relationships between psychosocial variables. The sample was composed of 133 persons living with HIV, with optimal adherence to antiretroviral therapy and with no detectable viral load. The psychosocial profile of the cohort showed that participants had moderate levels of stress, used a wide range of strategies to adjust to their situation and perceived their social support to be good. As well, they evaluated their quality of life (Medical Outcome Study-HIV) as moderate. Quality of life in psychological domain is largely explained by perceived stress (53%). Quality of life in physical domain is largely dependent on discomfort reported arising from HIV-associated symptoms and treatment (39%). Findings suggest that treatment-adherent, successfully treated patients with HIV are still a fragile population, and that it is essential to provide interventions that reinforce their ways of coping.

Health-related quality of life in a randomized trial of antiretroviral therapy for advanced HIV disease

OBJECTIVE

To assess and compare alternative approaches of measuring preference-based health-related quality of life (HRQoL) in treatment-experienced HIV patients and evaluate their association with health status and clinical variables.

DESIGN

Cross-sectional study.

SETTING

Twenty-eight Veterans Affairs hospitals in the United States, 13 hospitals in Canada, and 8 hospitals in the United Kingdom.

PATIENTS

Three hundred sixty-eight treatment-experienced HIV-infected patients enrolled in the Options in Management with Antiretrovirals randomized trial.

MEASUREMENTS

Baseline sociodemographic and clinical indicators and baseline HRQoL using the Medical Outcome Study HIV Health Survey (MOS-HIV), the EQ-5D, the EQ-5D visual analog scale (EQ-5D VAS), the Health Utilities Index Mark 3 (HUI3), and standard gamble (SG) and time trade-off (TTO) techniques.

RESULTS

The mean (SD) baseline HRQoL scores were as follows: MOS-HIV physical health summary score 41.70 (11.16), MOS-HIV mental health summary score 44.76 (11.38), EQ-5D 0.77 (0.19), HUI3 0.59 (0.32), EQ-5D VAS 65.94 (21.71), SG 0.75 (0.29), and TTO 0.80 (0.31). Correlations between MOS-HIV summary scores and EQ-5D, EQ-5D VAS, and HUI3 ranged from 0.60 to 0.70; the correlation between EQ-5D and HUI3 was 0.73; and the correlation between SG and TTO was 0.43. Preference-based HRQoL scores were related to physical, mental, social, and overall health as measured by MOS-HIV. Concomitant medication use, CD4 cell count, and HIV viral load were related to some instruments' scores.

CONCLUSIONS

On average, preference-based HRQoL for treatment-experienced HIV patients was decreased relative to national norms but also highly variable. Health status and clinical variables were related to HRQoL.

Converting the SF-12 into the EQ-5D: an empirical comparison of methodologies

BACKGROUND

For cost-utility analysis, analysts need a measure that summarizes health-status utilities in a single index of health-related quality of life (HR-QOL). It is common to find in clinical studies that only an HR-QOL profile measure such as the SF-36 is included, but not the summary HR-QOL index. Therefore, the economist's usual practice is to reprocess the profile data into a single index format. Several 'after-market' tools are available to convert the SF-36 or SF-12 into a single form with or without utility-weighting metric property. However, there has been no consensus with regard to a regression method that should be recommended for such a mapping task.

OBJECTIVE

To report on the performance of different regression methods that have previously been applied to the conversion of SF-12 data in the analysis of a single common dataset. The mapping between the SF-12 and EQ-5D is the focus.

METHODS

The data were adopted from the Medical Expenditure Panel Survey 2003 where 19 678 adults completed both EQ-5D and SF-12 questionnaires. Four econometric techniques, namely ordinary least squares (OLS), censored least absolute deviation, multinomial logit model and two-part model regressions were investigated together with two main types of model specifications: item-based and summary score-based. The performance of each examined model was judged by various criteria, including its estimated mean, the size of mean absolute error and the number of errors.

RESULTS

Among four compared econometric techniques, OLS regression was the most accurate model in estimating the group mean. Models with item-based model specification performed better than those with summary score-based regardless of the chosen econometric technique. Nevertheless, the accuracy of OLS deteriorates in older and less healthy subgroups. The results also suggested that the two-part model, which addresses the heterogeneity issue, performs better in these vulnerable subgroups.

CONCLUSIONS

None of the mapping methods included in the current study are suitable for estimating at the individual level. The methodology exemplified here has wider applicability and might just as readily be applied to other members of the SF family or indeed to other profile measures of HR-QOL. However, it is recommended that a preference-based, single index measure of HR-QOL should be included in the clinical studies for the purpose of economic evaluation.

Cost-effectiveness of voluntary HIV screening in Russia

Russia has one of the world's fastest growing HIV epidemics, and HIV screening has been widespread. Whether such screening is an effective use of resources is unclear. We used epidemiologic and economic data from Russia to develop a Markov model to estimate costs, quality of life and survival associated with a voluntary HIV screening programme compared with no screening in Russia. We measured discounted lifetime health-care costs and quality-adjusted life years (QALYs) gained. We varied our inputs in sensitivity analysis. Early identification of HIV through screening provided a substantial benefit to persons with HIV, increasing life expectancy by 2.1 years and 1.7 QALYs. At a base-case prevalence of 1.2%, once-per-lifetime screening cost $13,396 per QALY gained, exclusive of benefit from reduced transmission. Cost-effectiveness of screening remained favourable until prevalence dropped below 0.04%. When HIV-transmission-related costs and benefits were included, once-per-lifetime screening cost $6910 per QALY gained and screening every two years cost $27,696 per QALY gained. An important determinant of the cost-effectiveness of screening was effectiveness of counselling about risk reduction. Early identification of HIV infection through screening in Russia is effective and cost-effective in all but the lowest prevalence groups.

Health Utility Bias: A Systematic Review and Meta-Analytic Evaluation

Background. A common assertion is that rating scale (RS) values are lower than both standard gamble (SG) and time tradeoff (TTO) values. However, differences among these methods may be due to method specific bias. Although SG and TTOs suffer systematic bias, RS responses are known to depend on the range and frequency of other health states being evaluated. Over many diverse studies this effect is predicted to diminish. Thus, a systematic review and data synthesis of RS-TTO and RS-SG difference scores may better reveal persistent dissimilarities. Purpose. The purpose of this study was to establish through systematic review and meta-analysis the net effect of biases that endure over many studies of utilities. Methods. A total of 2206 RS and TTO and 1318 RS and SG respondents in 27 studies of utilities participated. MEDLINE was searched for data from 1976 to 2004, complemented by a hand search of full-length articles and conference abstracts for 9 journals known to publish utility studies, as well as review of results and additional recommendations by 5 outside experts in the field. Two investigators abstracted the articles. We contacted the investigators of the original if required information was not available. Results. No significant effect for RS and TTO difference scores was observed: effect size (95% confidence interval [CI]) = 0.04 (−0.02, 0.09). In contrast, RS scores were significantly lower than SG scores: effect size (95% CI ) =−0.23 (−0.28, −0.19). Correcting SG scores for 3 known biases (loss aversion, framing, and probability weighting) eliminated differences between RS and SG scores: effect size (95% CI ) = 0.01 (−0.03, 0.05). Systematic bias in the RS method may exist but be heretofore unknown. Bias correction formulas were applied to mean not individual utilities. Conclusions. The results of this study do not support the common view that RS values are lower than TTO values, may suggest that TTO biases largely cancel, and support the validity of formulas for correcting SG bias.

Health state valuation in mild to moderate cognitive impairment: feasibility of computer-based, direct patient utility assessment

BACKGROUND

Most patients with dementia will, at some point, need a proxy health care decision maker. It is unknown whether persons with various degrees of cognitive impairment can reliably report their health-related preferences.

METHODS

The authors performed health state valuations (HSVs) of current and hypothetical future health states on 47 pairs of patients with mild to moderate cognitive impairment and their caregivers using computer-based standard gamble, time tradeoff, and rating scale techniques.

RESULTS

Patients' mean (SD) age was 74.6 (9.3) years. About half of the patients were women (48%), as were most caregivers (73%), who were on average younger (mean age= 66.2 years, SD= 12.2). Most participants were white (83%); 17% were African American. The mean (SD) Mini-Mental State Examination (MMSE) score of patients was 24.2 (4.6) of 30. All caregivers and 77% of patients (36/47) completed all 18 components of the HSV exercise. Patients who completed the HSV exercise were slightly younger (mean age [SD]= 74.1 [8.5] v. 75.9 [11.8]; P = 0.569) and had significantly higher MMSE scores (mean score [SD] = 25.0 [4.3] v. 21.4 [4.4]; P = 0.018). Although MMSE scores below 20 did not preclude the completion of all 18 HSV ratings, being classified as having moderate cognitive impairment was associated with a lower likelihood of completing all scenario ratings (44% v. 82%). Patient and caregiver responses showed good consistency across time and across techniques and were logically consistent.

CONCLUSION

Obtaining HSVs for current and hypothetical health states was feasible for most patients with mild cognitive impairment and many with moderate cognitive impairment. HSV assessments were consistent and reasonable.

The cost-effectiveness of counseling strategies to improve adherence to highly active antiretroviral therapy among men who have sex with men

OBJECTIVE

Inadequate adherence to highly active antiretroviral therapy (HAART) may lead to poor health outcomes and the development of HIV strains that are resistant to HAART. The authors developed a model to evaluate the cost-effectiveness of counseling interventions to improve adherence to HAART among men who have sex with men (MSM).

METHODS

The authors developed a dynamic compartmental model that incorporates HIV treatment, adherence to treatment, and infection transmission and progression. All data estimates were obtained from secondary sources. The authors evaluated a counseling intervention given prior to initiation of HAART and before all changes in drug regimens, combined with phone-in support while on HAART. They considered a moderate-prevalence and a high-prevalence population of MSM.

RESULTS

If the impact of HIV transmission is ignored, the counseling intervention has a cost-effectiveness ratio of $25,500 per quality-adjusted life year (QALY) gained. When HIV transmission is included, the cost-effectiveness ratio is much lower: $7400 and $8700 per QALY gained in the moderate- and high-prevalence populations, respectively. When the intervention is twice as costly per counseling session and half as effective as estimated in the base case (in terms of the number of individuals who become highly adherent, and who remain highly adherent), then the intervention costs $17,100 and $19,600 per QALY gained in the 2 populations, respectively.

CONCLUSIONS

Counseling to improve adherence to HAART increased length of life, modestly reduced HIV transmission, and cost substantially less than $50,000 per QALY gained over a wide range of assumptions but did not reduce the proportion of drug-resistant strains. Such counseling provides only modest benefit as a tool for HIV prevention but can provide significant benefit for individual patients at an affordable cost.

The value of vision

BACKGROUND

The value of vision is assumed to be very high. To verify this assumption and to assign resources in medical care accordingly, it is necessary to quantify the value of vision. Although the value of vision is difficult to measure, visual quality of life can be quantified as a surrogate criterion. The measured value gains even more relevance if a comparison can be made between visual quality of life and systemic diseases. Multidisciplinary comparisons are only possible by using utility analysis. Two established methods to measure utility values are the standard gamble method and the time trade-off method. The purpose of this review is to find ophthalmologic utility values, and utility values affected by systemic diseases that correlate to the ophthalmologic ones.

METHODS

A literature search was conducted through PubMed of the National Library of Medicine ( http://www.ncbi.nlm.nih.gov ; date: 06.02.2006). The search terms were: "time trade-off / standard gamble" [text word] and "eye / vision / visual" [text word]; results 24. A report was classified as relevant if visually impaired persons were tested by the time trade-off method or the standard gamble method, or if information was provided on the reliability and validity of these measurements in a group of visually impaired persons. Additional searches were done to find associated publications. A total of 42 publications were found to be of interest.

RESULTS

Results showed that patients, with 20/30-20/50 visual acuity would be willing to pay 19% of their lifetime to get back normal visual acuity. Patients with 20/200-20/400 visual acuity would give up 48% of their lifetime, and blind people would give 60% of their lifetime to regain normal visual acuity. Comparable utility values are seen in patients with AIDS (21%), patients after a stroke who are unable to walk and wash themselves without assistance (46%), and bedridden and incontinent patients following a stroke (66%).

CONCLUSION

Patients attach great value to vision. The time trade-off method appears to be an appropriate tool to quantify visual quality of life, and one that can be used to compare utility values of different diseases.

Item-based versus subscale-based mappings from the SF-36 to a preference-based quality of life measure

OBJECTIVES

Algorithms for mapping descriptive measures of health status into preference-based measures are now widely available and their application in economic evaluation is increasingly commonplace. Existing algorithms make use of scale, subscale, or item scores on descriptive measures. Item-based algorithms entail fewer restrictions than their scale or subscale-based equivalents but are subject to problems in estimation and application. The objective of the present study is to quantify any loss of predictive validity associated with using subscale or scale scores (rather than item scores) to derive conversion algorithms.

METHODS

Multiple linear regression methods to derive item-based, subscale-based, and scale-based algorithms for mapping SF-36 data into Assessment of Quality of Life (AQoL) utility scores in a stratified sample of persons aged more than 16 years and resident in Victoria, Australia. The theoretical consistency and predictive validity of competing algorithms is evaluated against criteria reflecting the intended use of predicted utility scores.

RESULTS

Three mappings were suitable for between-group comparisons. There was no discernible increase in error associated with a move from the item-based mapping to either the subscale- or scale-based mapping.

CONCLUSIONS

Our results do not support the hypothesis that fewer restrictions on functional form necessarily result in a lower magnitude of error when predicting between-group differences. Rather, it appears that the subscale-based mapping offers a good compromise--requiring fewer restrictions on the form of the relationship between SF-36 responses and the AQoL utility score than the scale-based mapping and permitting a more efficient use of SF-36 data than the item-based mapping.

Comparing the Incomparable? A Systematic Review of Competing Techniques for Converting Descriptive Measures of Health Status into QALY-Weights

Background . Algorithms for converting descriptive measures of health status into quality-adjusted life year (QALY)—weights are now widely available, and their application in economic evaluation is increasingly commonplace. The objective of this study is to describe and compare existing conversion algorithms and to highlight issues bearing on the derivation and interpretation of the QALY-weights so obtained. Methods . Systematic review of algorithms for converting descriptive measures of health status into QALY-weights. Results . The review identified a substantial body of literature comprising 46 derivation studies and 16 studies that provided evidence or commentary on the validity of conversion algorithms. Conversion algorithms were derived using 1 of 4 techniques: 1) transfer to utility regression, 2) response mapping, 3) effect size translation, and 4) “revaluing” outcome measures using preference-based scaling techniques. Although these techniques differ in their methodological/theoretical tradition, data requirements, and ease of derivation and application, the available evidence suggests that the sensitivity and validity of derived QALY-weights may be more dependent on the coverage and sensitivity of measures and the disease area/patient group under evaluation than on the technique used in derivation. Conclusions . Despite the recent proliferation of conversion algorithms, a number of questions bearing on the derivation and interpretation of derived QALY-weights remain unresolved. These unresolved issues suggest directions for future research in this area. In the meantime, analysts seeking guidance in selecting derived QALY-weights should consider the validity and feasibility of each conversion algorithm in the disease area and patient group under evaluation rather than restricting their choice to weights from a particular derivation technique.

Patient preference quality of life measures in dermatology

Patient quality of life (QOL) is an important aspect of health care. It is crucial that we continue to develop instruments to assist in detecting burden of disease, interpreting outcomes of clinical trials, determining cost effectiveness of therapies, and guiding clinical decision making. The measurement of patient preferences, specifically utilities and contingent valuation, for health states provides data that can assist in the aforementioned endeavors. Patient preferences have been measured in many areas of medicine. However, it is relatively new to the field of dermatology. The present authors provide an overview of the basic concepts of patient preference measures and how they compare to the widely used health status instruments. Various techniques that have been used to elicit patient preferences are discussed, including standard gamble, time trade-off, willingness-to-pay, rating scales, health utilities index, and EuroQol (EQ-5D). In addition, the present authors review the current literature reporting utilities relevant to dermatology.

Health-related quality of life in veterans and nonveterans with HIV/AIDS

PURPOSE

To compare health-related quality of life (HRQoL) between patients receiving care in Veterans Administration (VA) settings (veterans) and non-VA settings (nonveterans), and to explore determinants of HRQoL and change in HRQoL over time in subjects living with HIV/AIDS.

SUBJECTS

One hundred veterans and 350 nonveterans with HIV/AIDS from 2 VA and 2 university-based sites in 3 cities interviewed in 2002 to 2003 and again 12 to 18 months later.

METHODS

We assessed health status (functional status and symptom bother), health ratings, and health values (time tradeoff [TTO] and standard gamble [SG] utilities). We also explored bivariate and multivariable associations of HRQoL measures with a number of demographic, clinical, spiritual/religious, and psychosocial characteristics.

RESULTS

Compared with nonveterans, the veteran population was older (47.7 vs 42.0 years) and consisted of a higher proportion of males (97% vs 83%), of participants with a history of injection drug use (23% vs 15%), and of subjects with unstable housing situations (14% vs 6%; P<.05 for all comparisons). On scales ranging from 0 (worst) to 100 (best), veterans reported significantly poorer overall function (mean [SD]; 65.9 [17.2] vs 71.9 [16.8]); lower rating scale scores (67.6 [21.7] vs 73.5 [21.0]), lower TTO values (75.7 [37.4] vs 89.0 [23.2]), and lower SG values (75.0 [35.8] vs 83.2 [28.3]) than nonveterans (P<.05 for all comparisons); however, in multivariable models, veteran status was only a significant determinant of SG and TTO values at baseline. Among other determinants that were associated with multiple HRQoL outcomes in baseline and follow-up multivariable analyses were: symptom bother, overall function, religiosity/spirituality, depressive symptoms, and financial worries.

CONCLUSIONS

Veterans reported significantly poorer HRQoL than nonveterans, but when controlling for other factors, veteran status was only a significant determinant of TTO and SG health values at baseline. Correlates of HRQoL such as symptom bother, spirituality/religiosity, and depressive symptoms could be fruitful potential targets for interventions to improve HRQoL in patients with HIV/AIDS.

Quality of life in HIV subtype C infection among asymptomatic subjects and its association with CD4 counts and viral loads--a study from South India

OBJECTIVE

To study the association between quality of life (QOL) domains and biological markers of disease progression of HIV infection, i.e. viral load (VL) and CD4 counts among asymptomatic subjects with HIV subtype C infection in South India.

DESIGN

Quality of life was measured using the locally validated version of the WHOQOL HIV-BREF. The subjects were neurologically asymptomatic, non psychiatrically ill HIV infected men and women participating in a cohort study.

RESULTS

The results indicated mixed findings, with some QOL dimensions being associated with high VLs and low CD4 counts while several others did not show any associations. Significant associations were seen between low CD4 counts and the psychological and social relationships domain, with lower mean scores in these domains being reported by subjects having CD4 counts <200/mm. However, there were no significant differences between the CD4 subgroups for the domains related to physical health, level of independence, environment, and spirituality domains. Significant lower mean QOL scores were found in the highest VL subgroup compared to other groups for the following WHOQOL HIV-BREF domains: physical, psychological, level of independence, and environmental.

CONCLUSIONS

In this sample of HAART naïve asymptomatic HIV infected subjects, some QOL dimensions were associated with the biological markers of disease progression i.e. VL and CD4 counts, while several were not. The associations were significant only in the high VL and low CD4 groups.

Clinical and Economic Outcomes of Nonadherence to Highly Active Antiretroviral Therapy in Patients With Human Immunodeficiency Virus

BACKGROUND

Nonadherence with highly active antiretroviral therapy (HAART) is common in typical human immunodeficiency virus (HIV) patient care settings, but the consequences have not been well described. This study aimed to quantify the clinical and economic effects of nonadherence and estimate the cost-effectiveness of improving adherence in treatment-naive HIV patients.

METHODS

A Markov model was developed to project quality-adjusted life expectancy and direct medical costs for patients on an initial once-daily regimen of efavirenz, lamivudine, and stavudine XR. The model compared 2 adherence scenarios: "ideal" (based on clinical trials) and "typical" (based on observational studies in actual practice). Disease progression was a function of viral load, CD4 count, and adherence. Data on HIV natural history, treatment benefits, costs, and utilities were derived from the literature.

RESULTS

With typical adherence, patients lose 1.2 quality-adjusted life years (QALYs) that could be gained with ideal adherence. Improving adherence to ideal levels is cost-effective at 29,400 US dollars/QALY gained. As much as 1,600 US dollars/y per patient could be spent on an intervention to improve adherence to ideal levels, and the incremental cost-effectiveness would remain less than 50,000 US dollars/QALY gained. A cost-effectiveness ratio of 50,000 US dollars/QALY is a commonly accepted minimum standard for cost-effective medical interventions in the United States, although many experts believe this standard has drifted upwards over time.

CONCLUSIONS

Typical adherence with HAART reduces quality-adjusted life expectancy by 12% compared with ideal adherence. Interventions to improve adherence appear to be a highly cost-effective use of resources.

Theories of fatigue: application in HIV/AIDS

A number of theoretical fatigue frameworks have been developed by nurse scientists with the intention of guiding research, practice, and education in fatigue. However, there is a significant gap between theory development and research utilization of fatigue frameworks in clinical and intervention trials. The purpose of this report is to assess an example of an inductive fatigue framework and a deductive symptom management model: The Integrated Fatigue Model (IFM) and the revised University of California, San Francisco, Symptom Management Model (UCSF-SMM), to investigate their potential to guide future nursing research projects on fatigue. The IFM is a fatigue-specific comprehensive framework of 14 biological and psychosocial patterns that influence signs and symptoms of fatigue and trigger six fatigue dimensions. The developers emphasized that patterns could be interrelated and influence the dimensionality of fatigue. The UCSF-SMM is a multidimensional symptom management model embedded within the three nursing domains: person, environment, and health and illness. The model places symptom perceptions, symptom management strategies, and outcomes within these nursing domains to be the key components of a highly complex symptom management process. The IFM is an important development in the understanding and conceptualization of fatigue in cancer and in HIV/AIDS. However, it does not reach the level of integration of the UCSF-SMM in taking fatigue research a significant step forward by integrating symptom impact, symptom management, and symptom outcomes. Both models have significant weaknesses because of their complexity.

Variations in Self-Rated Health Among Patients with HIV Infection

PURPOSE

To assess how patients with HIV who are enrolled in a clinical trials cohort rate their health and to compare their ratings with those of patients with HIV from 2 other cohorts: the HIV Cost and Services Utilization Study (HCSUS), and Adult AIDS Clinical Trials Group protocol 320 (ACTG 320).

METHODS

We analyzed baseline information for the 1649 subjects enrolled in the Adult AIDS Clinical Trials Group Longitudinal Linked Randomized Trials (ALLRT) study prior to March 2002 who had self-rated health data available. We compared those results with results from 2 other groups: HCSUS, the only nationally representative sample of people in care for HIV in the U.S., which conducted baseline interviews in 1996 and 1997, and ACTG 320, a randomized, double-blinded, placebo-controlled trial comparing a 3-drug antiretroviral regimen with a 2-drug combination, which enrolled subjects in the same general time frame as HCSUS. We used t tests, Pearson correlations, and linear regression to determine factors associated with self-rated health and z scores to compare results between cohorts.

RESULTS

The mean (SD) rating scale value on a 0-100 scale for ALLRT participants was 79.8 (16.8). Values were significantly lower for subjects who were older, had a history of injection drug use, had lower CD4 cell counts, or were beginning salvage antiretroviral therapy. Subjects in ALLRT reported significantly better self-rated health at baseline than those in HCSUS or ACTG 320 (11-12% higher rating scale values in ALLRT; p<0.05). When cohort differences were accounted for through regression and stratification, the differences in scores between subjects in ALLRT and HCSUS increased and the differences in scores between subjects in ALLRT and ACTG 320 diminished.

CONCLUSIONS

Self-rated health varied significantly by age, CD4 count, injection drug use history, and salvage therapy status. Differences in self-rated health for clinical trials and non-clinical trials samples appear to be substantial and should be considered when applying trial results to clinical populations.

The effect of diagnosis with HIV infection on health-related quality of Life

We sought to understand how diagnosis with HIV affects health-related quality of life. We assessed health-related quality of life using utility-based measures in a Department of Veterans Affairs (VA) clinic and a University-based clinic. Respondents assessed health-related quality of life regarding their current health, and retrospectively assessed their health 1 month prior to and 2 months after diagnosis with HIV infection. Sixty-six patients completed the study. The overall mean utilities for health 1 month before and 2 months after diagnosis were 0.87 (standard error 0.037), and 0.80 (0.043) (p<0.005 by rank sign test), but the effect of diagnosis differed between the two clinics, with a substantial decrease in the university clinic and a small non-significant decrease in the VA clinic. The overall mean utility for current health was 0.85 (0.034), assessed on average 7.5 years after diagnosis. When asked directly whether diagnosis of HIV decreased health-related quality of life, 47% agreed, but 35% stated that HIV diagnosis positively affected health-related quality of life. Diagnosis with HIV decreased health-related quality of life at 2 months on average, but this effect diminished over time, and differed among patient populations. Years after diagnosis, although half of the patients believed that diagnosis reduced health-related quality of life, one-third reported improved health-related quality of life.

Health values of patients coinfected with HIV/hepatitis C: are two viruses worse than one?

OBJECTIVES

We sought to assess health values of patients coinfected with HIV/hepatitis C (HCV) and compare them with those of patients singly infected with HIV or HCV and to characterize and assess the relationship of clinical and nonhealth-related factors with health values.

SUBJECTS

We studied a total of 203 subjects infected with HIV, HCV, or both.

MEASURES

We assessed rating scale (RS), time tradeoff (TTO), and standard gamble (SG) values, and we explored associations of health values with the Mental Component Summary (MCS) and Physical Component Summary (PCS) of the SF-12; number of bothersome symptoms from the HIV Symptoms Index; spirituality, as assessed by the Functional Assessment of Chronic Illness Therapy, Spiritual Well-being scale; as well as with a number of demographic, clinical, and psychosocial characteristics.

RESULTS

Of the 203 subjects, 59 (29%) had HIV monoinfection, 69 (34%) had HCV monoinfection, and 75 (37%) were coinfected. The mean (SD) health values for the cohort were: RS = 0.69 (0.23), TTO= 0.88 (0.24), and SG = 0.78 (0.30). Infection type was related, albeit differently, to TTO values (mean values for patients with coinfection = 0.82; HIV = 0.91; and HCV = 0.91 [P < 0.05]) and SG values (coinfection = 0.77; HIV = 0.70; and HCV = 0.87; P < 0.05). In multivariable models, RS scores were significantly associated with sexual orientation, PCS scores, MCS scores, symptoms, and spirituality (adjusted R = 0.61); TTO with symptoms and spirituality (adjusted R = 0.23); and SG with infection type, PCS scores, and symptoms (adjusted R = 0.24).

CONCLUSIONS

Health values and their correlates varied by method of assessment. Health values appear to be driven more by symptoms, health status, and spirituality than by number of viral infections.

Better quality of life with neuropsychological improvement on HAART

BACKGROUND

Successful highly active antiretroviral therapy (HAART) regimens have resulted in substantial improvements in the systemic health of HIV infected persons and increased survival times. Despite increased systemic health, the prevalence of minor HIV-associated cognitive impairment appears to be rising with increased longevity, and it remains to be seen what functional outcomes will result from these improvements. Cognitive impairment can dramatically impact functional ability and day-to-day productivity. We assessed the relationship of quality of life (QOL) and neuropsychological functioning with successful HAART treatment.

METHODS

In a prospective longitudinal study, subjects were evaluated before instituting HAART (naïve) or before changing HAART regimens because current therapy failed to maintain suppression of plasma viral load (treatment failure). Subjects underwent detailed neuropsychological and neurological examinations, as well as psychological evaluation sensitive to possible confounds. Re-evaluation was performed six months after institution of the new HAART regimen and/or if plasma viral load indicated treatment failure. At each evaluation, subjects underwent ultrasensitive HIV RNA quantitative evaluation in both plasma and cerebrospinal fluid.

RESULTS

HAART successes performed better than failures on measures exploring speed of mental processing (p < .02). HAART failure was significantly associated with increased self-reports of physical health complaints (p < .01) and substance abuse (p < .01). An interesting trend emerged, in which HAART failures endorsed greater levels of psychological and cognitive complaints (p = .06). Analysis between neuropsychological measures and QOL scores revealed significant correlation between QOL Total and processing speed (p < .05), as well as flexibility (p < .05).

CONCLUSION

Our study investigated the relationship between HIV-associated neurocognitive impairment and quality of life. HAART failures experienced slower psychomotor processing, and had increased self-reports of physical health complaints and substance abuse. Contrariwise, HAART successes experienced improved mental processing, demonstrating the impact of successful treatment on functioning. With increasing life expectancy for those who are HIV seropositive, it is important to measure cognitive functioning in relation to the actual QOL these individuals report. The study results have implications for the optimal management of HIV-infected persons. Specific support or intervention may be beneficial for those who have failed HAART in order to decrease substance abuse and increase overall physical health.

Herbal medicine use and quality of life among people living with HIV/AIDS in northeastern Thailand

Many people living with HIV/AIDS (PHA) use herbal medicine as one of alternative therapies, where curative options are limited. This study aimed to examine the association between the herbal medicine use and quality of life (QOL) among PHA in northeastern Thailand. Participants were 132 HIV-positive Thai adults who attended the PHA's self-help group meetings from June to July 2002. Health-related QOL scores were measured by self-administered questionnaire from the Medical Outcomes Study-HIV Health Survey. Dimensions of physical function (PF) and mental health (MH) in QOL were assessed. Additional data were collected on herbal medicine use, socio-demographic, psychosocial and HIV-related characteristics. The herbal medicine users had significantly better MH scores than the non-users, while the herbal medicine use was not statistically associated with PF scores. When stratified, herbal medicine users with the following characteristics had significantly better MH scores than the non-users: female, widowed, having no income, reporting any HIV-related symptom, having no instrumental support or receiving subsidies. In conclusion, herbal medicine use was associated with better MH especially among socially vulnerable PHA. This study suggests that herbal medicine has a potential to improve the MH aspect of QOL among socially vulnerable PHA who cannot easily receive antiretroviral therapy in Thailand.

Gender differences in health-related quality of life in patients with HIV/AIDS

BACKGROUND

In studies evaluating the general US population, patients in primary care, and patients with chronic conditions, women consistently report poorer health-related quality of life (HRQoL) than men; however, studies evaluating HRQoL in patients with HIV/AIDS have not completely corroborated those findings. The objective of this study was to evaluate gender differences in HRQoL for participants in a large randomized trial comparing antiretroviral regimens.

METHODS

AIDS Clinical Trials Group (ACTG) 320 was a randomized, blinded, placebo-controlled trial comparing the 3-drug regimen of indinavir + zidovudine (or stavudine) + lamivudine with the 2-drug combination of zidovudine (or stavudine) + lamivudine in subjects with CD4 cell counts less than 200 cells/microl and no prior treatment with protease inhibitors. Nine quality of life domains scored on 0-100 scales were assessed using the ACTG QOL 601-602 Health Survey at 3 points in the trial: baseline, 24 weeks and 40 weeks. Differences between men and women in HRQoL scores were assessed using the Wilcoxon rank-sum test and generalized estimating equation (GEE) models.

RESULTS

Overall, 202 females and 976 males were randomized to one of two treatment arms. Female participants were more likely to be black or Hispanic and tended to be younger. At baseline, females reported lower HRQoL scores than males in all of the domains except social functioning, and at week 40, women scored lower in all of the domains except overall health. In repeated measures models, women were found to score lower in all HRQoL domains except overall health, with significant differences of 3.5-6.7 points in 3 of the 9 quality of life domains: physical functioning, pain, and energy/fatigue. HRQoL scores improved for participants in the study over time and in response to potent treatment, and the improvements were similar for men and women.

CONCLUSIONS

Women with HIV/AIDS report substantially poorer HRQoL than men with HIV/AIDS in several HRQoL domains. However, changes in domain scores over time and in response to treatment do not differ significantly by gender, implying that changes in domain scores may be better HRQoL outcomes to compare between HIV-infected men and women in clinical trials than mean domain scores.

Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy

BACKGROUND

The costs, benefits, and cost-effectiveness of screening for human immunodeficiency virus (HIV) in health care settings during the era of highly active antiretroviral therapy (HAART) have not been determined.

METHODS

We developed a Markov model of costs, quality of life, and survival associated with an HIV-screening program as compared with current practice. In both strategies, symptomatic patients were identified through symptom-based case finding. Identified patients started treatment when their CD4 count dropped to 350 cells per cubic millimeter. Disease progression was defined on the basis of CD4 levels and viral load. The likelihood of sexual transmission was based on viral load, knowledge of HIV status, and efficacy of counseling.

RESULTS

Given a 1 percent prevalence of unidentified HIV infection, screening increased life expectancy by 5.48 days, or 4.70 quality-adjusted days, at an estimated cost of 194 dollars per screened patient, for a cost-effectiveness ratio of 15,078 dollars per quality-adjusted life-year. Screening cost less than 50,000 dollars per quality-adjusted life-year if the prevalence of unidentified HIV infection exceeded 0.05 percent. Excluding HIV transmission, the cost-effectiveness of screening was 41,736 dollars per quality-adjusted life-year. Screening every five years, as compared with a one-time screening program, cost 57,138 dollars per quality-adjusted life-year, but was more attractive in settings with a high incidence of infection. Our results were sensitive to the efficacy of behavior modification, the benefit of early identification and therapy, and the prevalence and incidence of HIV infection.

CONCLUSIONS

The cost-effectiveness of routine HIV screening in health care settings, even in relatively low-prevalence populations, is similar to that of commonly accepted interventions, and such programs should be expanded.

A catalog of dermatology utilities: a measure of the burden of skin diseases

Utilities are measures of quality of life that reflect the strength of individuals' preferences or values for a particular health outcome. As such, utilities represent a measure of disease burden. The aim of this article is to introduce the concept of utilities to the dermatology community and to present a catalog of dermatology utilities obtained from direct patient interviews. Our data are based on 236 total subjects from Grady Hospital (Atlanta, GA), Stanford Medical Center (Palo Alto, CA), and Parkland Hospital (Dallas, TX). The mean time trade-off utilities ranged from 0.640 for blistering disorders to 1.000 for alopecia, cosmetic, and urticaria. The mean utility across all diagnoses was 0.943. We present utilities for 17 diagnostic categories and discuss the underlying reasons for the significant disease burden that these utilities represent. We also present these dermatology categories relative to noncutaneous diseases to place the cutaneous utilities in perspective and to compare the burden of disease. We have demonstrated that skin diseases have considerable burden of disease and provided a preliminary repository of utility data for future researchers and policy makers.

Impact of indinavir on the quality of life in patients with advanced HIV infection treated with zidovudine and lamivudine

OBJECTIVE

In AIDS Clinical Trial Group (ACTG) study 320, triple-combination antiretroviral therapy including indinavir significantly slowed progression to acquired immunodeficiency syndrome or death, compared with treatment with dual nucleoside reverse-transcriptase inhibitors (NRTIs) alone, in zidovudine-experienced patients with advanced human immunodeficiency virus (HIV) infection. We examined the impact of indinavir on quality of life in participants from this study.

METHODS

A total of 1156 protease inhibitor- and lamivudine-naive patients stratified by CD4 cell count (<or=50 and 51-200 cells/mm(3)) were randomized to receive zidovudine (or stavudine) and lamivudine, with or without indinavir. Health-related quality of life was measured using the ACTG QoL601-602 questionnaire, which assesses general health status measured on a visual analogue scale and 8 specific health-related domains. Quality-adjusted survival time was estimated using the visual analogue scale for general health.

RESULTS

Mean changes in general health scores after 24 weeks were +2.9 in the triple-therapy group versus -0.2 in the dual-therapy group (P=.018). By week 24, scores in all specific domains were higher with triple-drug therapy than dual-drug therapy, with statistically significant differences in role function, energy, and pain scores. Benefits of triple-drug therapy were largely confined to patients with CD4 cell counts of <or=50 cells/mm(3). Quality-adjusted survival time did not differ significantly between the 2 treatment groups.

CONCLUSIONS

Triple-drug therapy with indinavir and 2 NRTIs resulted in a significant improvement in general health status after 24 weeks, especially in patients with low CD4 cell counts. Patients receiving triple-drug therapy also had significantly better role function, energy, and pain scores than did patients treated with dual-drug therapy.

Predicting EuroQoL EQ-5D preference scores from the SF-12 Health Survey in a nationally representative sample

PURPOSE

To predict the EuroQoL EQ-5D utility index from the SF-12 Health Survey for a US national sample of adults.

METHODS

The authors used the 2000 Medical Expenditure Panel Survey to examine the relationship between instruments. Linear regression was used to predict EQ-5D scores from Physical Component Summary (PCS) and Mental Component Summary (MCS) scores of the SF-12. A prediction model was derived in one half of the sample and validated in the other half.

RESULTS

Complete responses to both measures were available for 14,580 adults; 7313 (50.2%) surveys were used for the derivation set. The 2-variable model predicted 61% of the variance in EQ-5D scores and provided reasonable ability to predict mean EQ-5D scores from mean PCS and MCS scores. Confidence intervals are dependent on sample size and variance of PCS and MCS scores.

CONCLUSIONS

EQ-5D scores can be reasonably predicted from the SF-12. This model allows researchers to estimate utility data for use in decision and cost-utility analyses.

Costs and net health effects of contraceptive methods

BACKGROUND

Pregnancy and contraceptive methods both have important health effects that include risks and benefits. The net impact of contraception on women's health has not been reported previously.

STUDY DESIGN

This is a cost-utility analysis using a Markov model evaluated by Monte Carlo simulation using the societal perspective for costs. The analysis compared 13 methods of contraception to nonuse of contraception with respect to healthcare costs and quality-adjusted life years (QALYs). Discounting was applied for future costs and health effects. The base-case analysis applies to women of average health and fertility, ranging from 15 to 50 years of age, who are sexually active in a mutually monogamous relationship; smoking rates observed in women of reproductive age were used. Sensitivity analysis extended the analysis to nonmonogamous status and smoking status.

RESULTS

Compared with use of no contraception, contraceptive methods of all types result in substantial cost savings over 2 years, ranging from US$5907 per woman for tubal sterilization to US$9936 for vasectomy and health gains ranging from 0.088 QALYs for diaphragm to 0.147 QALYs for depot medroxyprogesterone acetate. Compared with nonuse, even with a time horizon as short as 1 year, use of any method other than sterilization results in financial savings and health gains. Most of the financial savings and health gains were due to contraceptive effects. In a population of patients, even modest increases in the use of the most effective methods result in financial savings and health gains.

CONCLUSIONS

Every method of contraception dominates nonuse in most clinical settings. Increasing the use of more effective methods even modestly at the expense of less effective methods will improve health and reduce costs. Methods that require action by the user less frequently than daily are both less costly and more effective than methods requiring action on a daily basis.

Social support and quality of life over time among adults living with HIV in the HAART era

Stability in perceived social support and associations between social support and health-related quality of life for a sample of 41 adult outpatients living with HIV/AIDS (PHA) in Canada were assessed longitudinally. Construct-specific dimensions of the Medical Outcomes Study Social Support Survey (SSS), the Physical and Mental components of the Short-Form-36 (SF-36) quality of life measure, as well as clinical factors (i.e., symptomatology, immunologic/virologic variables), were measured in three waves: initial consecutive registration (T1, 1997), 2-year (T2, 1999) and 4-year (T3, 2001) follow-up, and evaluated for changes using repeated-measures analysis of variance, supplemented by Friedman tests for SSS and SF-36 ratings. Proportions of the PHA sample with clinically significant SSS changes (i.e., greater than 0.5 standardized effect size) were also calculated. Effects of improvement versus deterioration in SSS ratings on SF-36 ratings, and vice versa, were explored. Associations between SSS and SF-36 ratings, as well as between changes in SSS ratings and SF-36 ratings, were assessed using multiple regression analyses controlling for clinical factors. Cross-lagged analyses were conducted to examine predictive potential between SSS and SF-36 ratings. Clinical outcomes suggested immunologic improvement tempered by symptoms and/or treatment side effects. SSS and SF-36 mean ratings were moderately stable over time, but clinically significant 4-year decrements in SSS ratings occurred for approximately 40% of patients. A trend occurred in which poorer SF-36 mental outcomes portended poorer emotional and informational support. Otherwise, relations between SSS and SF-36 ratings appeared to be reciprocal. Cross-sectional associations between SSS and SF-36 ratings were more pronounced at T2 compared to baseline and T3. Changes in SSS and SF-36 ratings were somewhat related over the consecutive 2-year periods but not over the long term. T1-T2 SSS changes were associated with changes in the SF-36 mental component. T2-T3 SSS changes were associated with changes in the SF-36 physical component. Cross-lagged analyses yielded little explanation concerning direction of causation in terms of associations between social support and quality of life for the PHA in this study.

Outcomes after treatment of high-energy tibial plafond fractures

BACKGROUND

Although a number of investigators have documented clinical outcomes and complications associated with tibial plafond, or pilon, fractures, very few have examined functional and general health outcomes associated with these fractures. Our purpose was to assess midterm health, function, and impairment after pilon fractures and to examine patient, injury, and treatment characteristics that influence outcome.

METHODS

A retrospective cohort analysis of pilon fractures treated at two centers between 1994 and 1995 was conducted. Patient, injury, and treatment characteristics were recorded from patient interviews and medical record abstraction. Study participants returned to the initial treatment centers for a comprehensive evaluation of their health status. The primary outcomes that were measured included general health, walking ability, limitation of range of motion, pain, and stair-climbing ability. A secondary outcome measure was employment status.

RESULTS

Eighty (78%) of 103 eligible patients were evaluated at a mean of 3.2 years after injury. General health, as measured with the Short Form-36 (SF-36), was significantly poorer than age and gender-matched norms. Thirty-five percent of the patients reported substantial ankle stiffness; 29%, persistent swelling; and 33%, ongoing pain. Of sixty-five participants who had been employed before the injury, twenty-eight (43%) were not employed at the time of follow-up; nineteen (68%) of the twenty-eight reported that the pilon fracture prevented them from working. Multivariate analyses revealed that presence of two or more comorbidities, being married, having an annual personal income of less than 25,000 US dollars, not having attained a high-school diploma, and having been treated with external fixation with or without limited internal fixation were significantly related to poorer results as reflected by at least two of the five primary outcome measures.

CONCLUSIONS

At more than three years after the injury, pilon fractures can have persistent and devastating consequences on patients' health and well-being. Certain social, demographic, and treatment variables seem to contribute to these poor outcomes.

Neurocognitive performance and quality of life in patients with HIV infection

We examined the relationship of HIV-related cognitive impairment and health-related quality of life (QoL). Subjects were administered measures of cognitive function (a battery of 17 neuropsychological tests) and of QoL (the MOS-HIV questionnaire). Study measures also included comprehensive clinical and neurological evaluation, laboratory testing, and brain imaging studies in patients with impaired neuropsychological evaluation. One-hundred and eleven subjects were examined. Cognitively impaired patients (33.3%) reported poorer QoL scores in all domains (p < 0.05): physical health summary score (PHS) (44.6 vs. 49.9), mental health summary score (MHS) (37.7 vs. 44.4), pain (67.6 vs. 79.4), physical functioning (75.9 vs. 87.7), role functioning (32.4 vs. 41.5), social functioning (70.3 vs. 83.5), mental health (48.2 vs. 61.0), energy (53.1 vs. 63.0), health distress (60.8 vs. 75.5), cognitive functioning (CF) (60.5 vs. 71.8), general health perceptions (29.2 vs. 43.4), and QoL (36.5 vs. 47.0). The number of altered neuropsychological tests correlated significantly with MHS (p < 0.001), PHS (p < 0.03), CF (p < 0.02), and QoL (p < 0.02) scores. A correlation between seven of seven neuropsychological measures exploring speed of mental processing, three of four exploring mental flexibility, four of six exploring memory, and two of two exploring fine motor functioning and MHS, PHS, CF, or QoL scores was also found. Poor performance on the Digit Symbol test was most strongly associated with poor MHS (OR 1.04, 95% CI 1.01-1.08, p < 0.009) and PHS (OR 1.04, 95% CI 1.01-1.08, p < 0.01) scores, controlling for CD4 count, previous AIDS diagnosis, receiving HAART, and drug abuse. Cognitive impairment is associated with poor QoL. People with more severe cognitive impairment have the highest probability of having a poor QoL. Cognitive impairment in any cognitive domain explored in our battery is also associated with poor QoL. Poor performance on the Digit Symbol Test is the strongest predictor of poor QoL.

Commentary on using the SF-36 or MOS-HIV in studies of persons with HIV disease

The purpose was to compare and comment on use of the SF-36 and MOS-HIV instruments in studies of persons with HIV disease. Three medical information databases were searched to identify examples of HIV studies that included the MOS-HIV or SF-36. Thirty-nine and 14 published articles were identified for illustration in comparing the use of the MOS-HIV and SF-36 in HIV disease, respectively. Support for the reliability and construct validity of the MOS-HIV and SF-36 was found. Ceiling and floor effects were reported for both the MOS-HIV and SF-36; however, ceiling effects were more common for the MOS-HIV, in part due to fewer items in the physical, social, and role functioning domains. The MOS-HIV measures three domains hypothesized to be associated with the health deterioration of HIV disease not measured by the SF-36; however, these domains may not assess aspects of HIV disease that typify the majority of the persons with HIV disease today. National norms for the U.S. adult population (and other nations) are available for the SF-36. In addition, the SF-36 has been used in a wide variety of patient populations, enabling comparisons of HIV-infected persons with persons with other health conditions. No national norms for the MOS-HIV are available. We conclude that there is currently insufficient evidence in the literature to recommend the use of the MOS-HIV over the SF-36 in HIV-infected persons. Although the SF-36 is not targeted at HIV, it may be preferable to use the SF-36 over the MOS-HIV due to fewer ceiling effects, availability of national norms, and the vast amount of data for other populations in the U.S. and around the world. Head-to-head comparisons demonstrating the unique value of the MOS-HIV over the SF-36 are clearly needed. More importantly, additional work needs to be directed at comparing the MOS-HIV and other putatively HIV-targeted instruments to one another to help demarcate aspects of HRQOL that are truly generic versus specific to HIV disease. Using both a generic and targeted HRQOL measure is a good general strategy, but this has not been a typical practice in studies of HIV because the MOS-HIV is so similar in content to the SF-36.

Quality of life associated with visual loss: a time tradeoff utility analysis comparison with medical health states

PURPOSE

To assess the visual utility values of patients with ocular disease and to compare these values with those of patients with systemic health states

DESIGN

Cross-sectional utility value assessment.

METHODS

Consecutive patients with ophthalmic diseases were interviewed in a one-on-one fashion using a standardized time tradeoff utility value assessment form. These values were compared with utility values for systemic health states present in the literature.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Time tradeoff utility value on a scale ranging from 1.0 (perfect visual health) to 0.0 (death). The ophthalmic patient groups were stratified into 4 visual groups dependent on the visual acuity in the better-seeing eye. The groups were as follows: group 1, 20/20 to 20/25; group 2, 20/30 to 20/50; group 3, 20/60 to 20/100; group 4, 20/200 to no light perception.

RESULTS

A total of 500 subjects were enrolled in the study. The mean utility values for the visually stratified groups were: group 1, 0.88; group 2, 0.81; group 3, 0.72; group 4, 0.61. Comparable respective systemic health state utility values for each of the ophthalmic groups were: diabetes mellitus, status after kidney transplantation, moderate stroke, and moderately severe stroke.

CONCLUSIONS

Visual loss is associated with a substantial and measurable diminution in quality of life. This diminution in quality of life can be directly compared with that induced by systemic health states.

iMPACT3: Internet-based development and administration of utility elicitation protocols

iMPACT3 (Internet Multimedia Preference Assessment Instrument Construction Tool, version 3) is a software development environment that helps researchers build Internet-capable multimedia utility elicitation software programs. The program is a free, openly accessible Web site (http.// preferences.ucsd.edu/impact3/asp). To develop a utility elicitation software program using iMPACT3, a researcher selects modular protocol components from a library and custom tailors the components to the details of his or her research protocol. iMPACT3 builds a Web site implementing the protocol and downloads it to the researcher's computer. In a study of 75 HIV-infected patients, an iMPACT3-generated protocol showed substantial evidence of construct validity and good internal consistency (logic error rates of 4% to 10% and procedural invariance error rates of 10% to 28%, depending on the elicitation method) but only fair 3- to 6-week test-retest reliability (intraclass correlation coefficient= 0.42 to 0.55). Further work may be needed on specific utility assessment procedures, but this study's results confirm iMPACT3's feasibility in facilitating the collection of health state utility data.

Effects of depressive symptoms and mental health quality of life on use of highly active antiretroviral therapy among HIV-seropositive women

This study examines the effects of depressive symptoms and mental health quality of life on utilization of highly active antiretroviral therapy (HAART) among HIV-seropositive women. Data were collected biannually from 1996 through 1998 in a prospective cohort study. Women reported use of antiretroviral therapy, health and mental health status, demographics, and social and behavioral factors; CD4 count and viral load also were assessed. Random effects regression models estimated the longitudinal effects of depressive symptoms and mental health quality of life on the probability of HAART utilization, controlling for clinical indicators (CD4 count, viral load, symptom presence), demographics (race, age, education), behavioral factors (drug/alcohol use, clinical trials participation), service features (insurance status, mental health service utilization), and study site. High levels of depressive symptoms and poor mental health quality of life were found, and they significantly reduced the probability of HAART utilization. Receiving mental health services significantly increased the probability of utilizing HAART. HIV-seropositive women characterized as being in poor mental health were less likely to use HAART, whereas those receiving treatment of mental health difficulties were more likely to use HAART. These findings suggest that efforts to enhance women's access to psychological treatment may increase their use of the latest HIV therapies.

Psychometric properties of the HIV-Related Fatigue Scale

The HIV-Related Fatigue Scale (HRFS) was developed to address the specific aspects of fatigue experienced by people who are HIV-positive and are not measured in any commonly used fatigue scale. The necessity for a new scale was determined after analysis of a qualitative study to explore HIV-related fatigue in which it was found that HIV-related fatigue has components related to intensity, circumstances, and consequences that must be included in the measurement of fatigue for this population. The HRFS has 56 items, most of which are on a 1-to-10 scale, drawn from five existing fatigue scales and the data from this qualitative study. The items were deemed content valid, easy to understand, and not fatiguing to complete by people with HIV-related fatigue. Cronbach's alpha for the entire tool was .94; internal consistency for each of the three preliminary subscales is reported as well. Test-retest reliability was moderate at r = .43. Further testing needs to be done, but the HRFS has the potential to be a valuable addition to the measurement of fatigue in seropositive persons.

A Monte Carlo simulation for modelling outcomes of AIDS treatment regimens

Healthcare providers are often faced with the need to make treatment decisions about antiretroviral therapy regimens for patients with HIV infection without definitive information as to the optimal sequencing of drug regimens. In this paper we describe our model developed to simulate the impact of differing drug sequencing strategies used in the treatment of patients with HIV/AIDS. In addition, we present the methods used to estimate the efficacy and duration of antiretroviral therapies to populate the model at baseline. We conducted a hypothetical application of the model using three alternative series of therapies: a series containing no drug therapy, a series starting with a protease inhibitor-containing regimen, and a series starting with a non-nucleoside reverse transcriptase inhibitor-containing regimen. The model described in this article can be used to compare and contrast the relative impact of different treatment guidelines in the absence of necessary clinical data and may serve as a means of evaluation until clinical trials or observational databases provide guidance as to the optimal treatment regimen(s). The model is flexible and permits adaptation to the changing treatment environment in HIV infection.