A review of health utilities using the EQ-5D in studies of cardiovascular disease

Perfect health not so perfect after all - a methodological study on patient-reported outcome measures in 2574 patients following percutaneous coronary intervention

BACKGROUND

Patient-reported outcome measures (PROMs) are crucial to capture patients' health and illness status. Selecting the most suitable PROM to measure self-reported health in a specific study population is essential. Shortcomings of much used generic instruments have been identified in certain populations, and more investigation is needed to clarify the extent to which the generic instruments capture the aspects of health that really matter to patients. Therefore, the aim of this study was to determine floor and ceiling effects of a generic health utility instrument (EQ-5D-5L) in an international multi-centre cohort of patients after percutaneous coronary intervention (PCI) and further explore those with perfect health scores by using a disease-specific instrument.

METHODS

The CONCARDPCI study was conducted at seven large referral PCI centres in Norway and Denmark between June 2017 and May 2020. In all, 2574 unique patients were available for this analysis. The generic EQ-5D-5L descriptive system and visual analogue scale, and the disease-specific Myocardial Infarction Dimensional Assessment Scale (MIDAS) comprising 35 items measuring seven areas of health status and daily life challenges were used to scrutinize the aims. Latent class analyses were conducted to identify classes with similar patterns of daily life challenges based on MIDAS item scores within the group of patients with best possible EQ-5D-5L score ('perfect scorers').

RESULTS

There was a large ceiling effect on the EQ-5D-5L score in patients with coronary artery disease (CAD) with 32% scoring the best possible EQ-5D-5L score, suggesting perfect health. Latent class analysis on the MIDAS revealed, however, four classes where 17-46% of the perfect scorers did perceive challenges in health, particularly related to symptoms of fatigue, and worries about risk factors and side effects of medication.

CONCLUSION

To obtain an accurate picture of patients' health status, these results emphasize that both generic and disease-specific patient-reported outcomes measures are needed to capture the distinct problems that patients with CAD experience after PCI. Caution should be made when using the EQ-5D-5L as the sole measure, particularly in priority settings, due to its potential ceiling effect and the fact that important aspects of patient health may be neglected.

TRIAL REGISTRATION

NCT03810612.

Dignity, Resilience, and Quality of Life in Patients With Cardiac Disease: A Partial Least Squares Structural Equation Modeling Approach

BACKGROUND

Health-related quality of life (HRQoL) is an important indicator of patient's satisfaction about their disease course. Many factors are influential to life quality, such as dignity and resilience. Dignity is mostly explored in populations with cancer, but the understanding of dignity and its relationship with resilience and HRQoL is limited.

OBJECTIVE

The aim of this study was to explore the relationships between dignity, resilience, and HRQoL among patients with cardiac disease.

METHODS

A purposive sample of patients with cardiac disease with a cross-sectional design was used for this study. Four structured questionnaires were used for data collection. Dignity was measured by the Patient Dignity Inventory-Mandarin version; resilience was measured by the Chinese version of the Resilience Scale; HRQoL was measured by EuroQol 5 Dimensions. Partial least squares structural equation modeling was applied to test the hypothesized structural model. Reporting was consistent with the Strengthening the Reporting of Observational Studies in Epidemiology checklist.

RESULTS

The mean age of all 101 participants was 72.2 years, 88.1% had coronary artery disease, and the prevalence of heart failure was 43.0%. In patients with cardiac disease, their sense of dignity was significantly associated with HRQoL, and resilience was associated with both dignity and quality of life. Notably, resilience had a mediating effect between dignity and HRQoL; dignity and resilience explained 73.0% of the variance of HRQoL.

CONCLUSIONS

Dignity is a new concern in cardiac disease research, which is influential to patients' perception of disease and their HRQoL. Patients with cardiac disease with higher resilience tend to have a better HRQoL.

Health-related quality of life in hypertensive patients with chronic kidney disease in low and middle-income countries

Hypertension and chronic kidney disease (CKD) are interconnected conditions that can significantly affect a person's health-related quality of life (HRQoL). In low- and middle-income countries (LMICs), this disease burden is heightened due to limited health resources and socio-economic challenges. Based on the available literature, this narrative review aims to discuss the HRQoL of hypertensive patients with CKD in LMICs by identifying the current challenges and providing insights into the strategic potential to improve patient's quality of life. This review reveals that the hypertensive population with CKD has a much lower HRQoL than the general population. Various factors, including physical limitations, comorbidities, psychological barriers, logistical challenges, and social support, can influence HRQoL. Limited access to health care, inadequate resources, and a lack of skilled personnel in LMICs further exacerbate these individual challenges. The economic impact of decreased work productivity and increased health costs adds to the disease burden. Improved health access, effective self-management strategies, and social support are needed to improve HRQoL in hypertensive patients with CKD.

Effects of beta-blockers on quality of life and well-being in patients with myocardial infarction and preserved left ventricular function-a prespecified substudy from REDUCE-AMI

AIMS

In the Randomized Evaluation of Decreased Usage of Beta-Blockers after Acute Myocardial Infarction (REDUCE-AMI) study, long-term beta-blocker use in patients after acute myocardial infarction (AMI) with preserved left ventricular ejection fraction demonstrated no effect on death or cardiovascular outcomes. The aim of this prespecified substudy was to investigate effects of beta-blockers on self-reported quality of life and well-being.

METHODS AND RESULTS

From this parallel-group, open-label, registry-based randomized clinical trial, EQ-5D, and World Health Organization well-being index-5 (WHO-5) questionnaires were obtained at 6-10 weeks and 11-13 months after AMI in 4080 and 806 patients, respectively. We report results from intention-to-treat and on-treatment analyses for the overall population and relevant subgroups using Wilcoxon rank sum test and adjusted ordinal regression analyses. Of the 4080 individuals reporting EQ-5D (median age 64 years, 22% female), 2023 were randomized to beta-blockers. The main outcome, median EQ-5D index score, was 0.94 [interquartile range (IQR) 0.88, 0.97] in the beta-blocker group, and 0.94 (IQR 0.88, 0.97) in the no-beta-blocker group 6-10 weeks after AMI, OR 1.00 [95% CI 0.89-1.13; P > 0.9]. After 11-13 months, results remained unchanged. Findings were robust in on-treatment analyses and across relevant subgroups. Secondary outcomes, EQ-VAS and WHO-5 index score, confirmed these results.

CONCLUSION

Among patients after AMI with preserved left ventricular ejection fraction, self-reported quality of life and well-being was not significantly different in individuals randomized to routine long-term beta-blocker therapy as compared to individuals with no beta-blocker use. These results appear consistent regardless of adherence to randomized treatment and across subgroups which emphasizes the need for a careful individual risk-benefit evaluation prior to initiation of beta-blocker treatment.

Evaluation of health-related quality of life changes in an Australian rapid access chest pain clinic

OBJECTIVE

To evaluate the impact of absolute cardiovascular risk counselling on quality-of-life indices within a chest pain clinic.

DATA SOURCES AND STUDY SETTING

Primary data was collected at the Royal Hobart Hospital, Australia, between 2014 and 2020.

STUDY DESIGN

Patients attending an Australian chest pain clinic were randomised into a prospective, open-label, blinded-endpoint study over a minimum 12-months follow-up.

DATA COLLECTION / EXTRACTION METHODS

The SF-36 questionnaire was completed at baseline/follow-up and SF-6D multi-attribute utility instrument's health state utilities (HSU) were generated using SF-36 responses and the SF-6D's Australian tariff. SF-6D minimal important difference was 0.04 points. Absolute cardiovascular risk was also stratified into high/intermediate/low-risk categories for exploratory analysis of summary HSUs and dimensional scores. ANZCTR registration number 12617000615381 (registered 28/4/17).

PRINCIPAL FINDINGS

Of n = 189 patients enrolled, HSUs were generated for 96% at baseline (intervention n = 93, usual care n = 88) and 61% at follow-up. There were no statistical differences in age, sex, absolute cardiovascular risk or mean HSU between groups at baseline. Summary HSUs improved more for the intervention group and the median between-group difference exceeded the minimal important difference threshold (intervention 0.16 utility points, control 0.10 utility points). For Intervention patients with high absolute risk (≥ 15%), HSU did not significantly change.

CONCLUSIONS

Absolute cardiovascular risk counselling in a chest pain clinic yielded clinically meaningful improvement in health-related quality of life.

Updates in innovation of the treatment of pyoderma gangrenosum

INTRODUCTION

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by rapidly enlarging, painful ulcers with undermined borders. The management of PG is challenging due to the lack of standardized evidence-based treatments.

AREAS COVERED

This review examines recent efforts to establish standardized outcomes for clinical trials to facilitate the drug development process for PG. It explores new therapeutics in development and evaluates advanced options for wound and pain management. Literature available on the pathogenesis, treatment, and pain management of PG from database inception to April 2024 was searched in PubMed, Embase, and Cochrane. ClinicalTrials.gov and the EU Clinical Trials Register were searched for clinical trials on PG.

EXPERT OPINION

New therapeutics such as interleukin 36 inhibitor and complement component C5a inhibitor more specifically target key pathways in the pathogenesis of PG have shown promise and can greatly benefit patients with PG, which still lacks an FDA-approved treatment. In addition to systemic therapy, local wound care and pain management should be carried out simultaneously to achieve successful wound healing.

Data Mining to Identify the Right Interventions for the Right Patient for Heart Failure: A Real-World Study

OBJECTIVES

To identify the right interventions for the right heart failure (HF) patients in the real-world setting using machine learning (ML) trained on individual-level clinical data linked with social determinants of health (SDOH) data.

METHODS

In this retrospective cohort study, point-of-care claims data from Komodo Health and SDOH data from the National Health and Wellness Survey (NHWS), from January 2014-December 2020, were linked. Data mining was conducted using K-means clustering, an ML tool. Komodo Health data were used to access longitudinal data for the selected patient cohorts and crosssectional data from NHWS for additional patient information. The primary outcome was HF-related hospitalizations; secondary outcomes, all-cause hospitalization and all-cause mortality. Use of digital healthcare (DHC)/non-DHC interventions and related outcomes were also assessed.

RESULTS

The study population included 353 HF patients (mean age, 63.5 years; 57.2% women). The use of non-DHC (75.9%-81.9%) and DHC (4.0%-9.1%) interventions increased from baseline to followup. Overall, 17.0% of patients had HF-related hospitalizations (DHC, 6.9%; non-DHC, 16.5%) and 45.0% had all-cause hospitalization (DHC, 75.0%; non-DHC, 50.9%). Two archetypes with distinct patient profiles were identified. Archetype 1 (vs. 2) characterised by older age, greater disease severity, more comorbidities, more medication use, took steps to prevent heart attack/problems, had better lifestyle, higher HF-related hospitalizations (18.3% vs. 16.3%) and lower all-cause hospitalizations (42.9% vs. 46.3%). The trends remained the same regardless of the intervention type.

CONCLUSIONS

Identification of patient archetypes with distinct profiles can be useful to understand underlying disease subtypes, identify specific interventions, predict clinical outcomes, and define the right intervention for the right patient.

Effects of Intensive Impairment-Oriented Arm Rehabilitation for Chronic Stroke Survivors: An Observational Cohort Study

Objective: To assess the effects of a two-week course of intensive impairment-oriented arm rehabilitation for chronic stroke survivors on motor function. Methods: An observational cohort study that enrolled chronic stroke survivors (≥6 months after stroke) with mild to severe arm paresis, who received a two-week course of impairment-oriented and technology-supported arm rehabilitation (1:1 participant-therapist setting), which was carried out daily (five days a week) for four hours. The outcome measures were as follows: the primary outcome was the arm motor function of the affected arm (mild paresis: BBT, NHPT; severe paresis: Fugl-Meyer arm motor score). The secondary outcomes were measures of finger strength, active ROM, spasticity, joint mobility/pain, somatosensation, emotional distress, quality of life, acceptability, and adverse events. Results: One hundred chronic stroke survivors (≥6 months after stroke) with mild to severe arm paresis were recruited. The training was acceptable (drop-out rate 3%; 3/100). The clinical assessment indicated improved motor function (SMD 0.42, 95% CI 0.36-0.49; n = 97), reduced spasticity/resistance to passive movement, and slightly improved joint mobility/pain and somatosensation. The technology-based objective measures corroborated the improved active range of motion for arm and finger joints, reduced finger spasticity/resistance to passive movement, and the increased amount of use in daily life, but there was no effect on finger strength. The patient's emotional well-being and quality of life were positively influenced. Adverse events were reported by the majority of participants (51%, 49/97) and were mild. Conclusions: Structured intensive impairment-oriented and technology-supported arm rehabilitation can promote motor function among chronic stroke survivors with mild to severe arm paresis and is an acceptable and tolerable form of treatment when supervised and adjusted by therapists.

Emotional Distress in Younger (<55 Years) and Older (≥55) Patients After a First-Time Myocardial Infarction and Its Prospective Associations With Working Status and Secondary Preventive Goals Among the Younger Cohort: Insights From the Swedish SWEDEHEART Registry Study

BACKGROUND

Research has shown that younger patients who have had a myocardial infarction (MI) experience more emotional distress than their older counterparts.

OBJECTIVE

In this study, we aimed to compare emotional distress 2 months post-MI (follow-up 1) between younger (<55) vs older (≥55) patients in Sweden, and investigate its impact on working status and 4 secondary preventive goals 1 year after MI (follow-up 2).

METHODS

Data (N = 50 213) from the SWEDEHEART National Quality Registers for Cardiac Care, which covers approximately 90% of all MIs in Sweden, were used.

RESULTS

After adjusting for confounders, logistic regression analyses showed that younger patients who had experienced an MI had higher odds of experiencing emotional distress than older patients at follow-up 1 (adjusted odds ratio [AOR], 1.59; 95% confidence interval [CI], 1.52-1.67) and follow-up 2 (AOR, 1.47; 95% CI, 1.40-1.55). Emotional distress at follow-up 1 was associated with lower odds of working (AOR, 0.60; 95% CI, 0.53-0.67) and achieving smoking and physical activity goals (AOR, 0.76; 95% CI, 0.67-0.86; AOR, 0.83; 95% CI, 0.76-0.91) at follow-up 2. However, emotional distress was not associated with achieving goals for low-density lipoproteins or systolic blood pressure at follow-up 2.

CONCLUSIONS

Younger patients experienced emotional distress more often after a first-time MI than their older counterparts, and their distress predicted long-term lower levels of returning to work and achievement of smoking and physical activity goals. The results highlight the importance of identifying younger patients who have had an MI and are experiencing emotional distress, and offering them interventions targeting distress.

Knowledge of Illness Trajectory and Symptoms of Heart Failure in Patients with Acute Coronary Syndrome

BACKGROUND

Preventive management of heart failure (HF) should involve strategies to increase awareness of HF in patients with pre-HF and those at risk of HF. However, the perception of HF in patients with acute coronary syndrome (ACS) remains unclear. This study aimed to assess patient understanding of the definition of HF for the public-that is, its illness trajectory (intermittent decline), impact on life expectancy (HF would limit life expectancy), and symptoms (shortness of breath, swelling)-that was introduced by the Japanese Circulation Society.

METHODS

This cross-sectional, questionnaire-based study enrolled 209 emergently admitted patients with ACS who underwent a cardiac rehabilitation program at a single university-based hospital. We identified the clinical characteristics of patients who understood HF definition.

RESULTS

Among the enrolled patients (median age, 69 years; males, 81.3%; 59.8% with ST-elevation myocardial infarction), 64.0% and 53.1% chose the correct answers regarding HF illness trajectory and impact on life expectancy, respectively. While 92.3% of the patients correctly chose shortness of breath as an HF symptom, 56.7% correctly chose swelling. Patient understanding of the definition of HF was associated with younger age, but not with HF risk (i.e., hypertension, diabetes, higher natriuretic peptide levels, lower left ventricular ejection fraction) and history of symptomatic HF.

CONCLUSIONS

Among patients with ACS who participated in the cardiac rehabilitation program in this cohort, patient understanding of HF definition was suboptimal. Effective measures to improve their understanding should be considered to enhance the prevention of HF.

Evaluating the web-based 'Partner in Balance' program for informal caregivers of people with Huntington's disease: A pilot study

Background

Huntington's disease (HD) poses significant challenges for both affected individuals and their informal caregivers. With the progression of HD, caregivers frequently prioritize caring for the person with HD over their own well-being. 'Partner in Balance' (PiB) is an 8-week online self-management program guided by a personal coach, developed to help caregivers of people with HD cope with challenging situations and develop skills to increase resilience and prevent overburdening.

Aims

This pilot study evaluates the feasibility and preliminary effects of the PiB-HD program.

Methods

The study employed a pre-post design. Perceived feasibility by HD caregivers was evaluated using both quantitative and qualitative measures. Preliminary effects were based on self-report measures of self-efficacy, mastery, mood, quality of life, and capability to function. Coaches' evaluations were conducted using a questionnaire.

Results

In total, 18 caregivers completed the intervention. Findings demonstrate positive responses regarding the program's usability, relevance, and acceptability. Participants found the program helpful in addressing challenges, gaining insight into their actions, and feeling better equipped with skills to face future challenges. Descriptive statistics suggest that the PiB-HD program shows potential for reducing stress and anxiety. Additionally, coaches (n = 9) viewed the program positively for its usability, integration potential into their work, flexibility, and time efficiency.

Conclusions

The PiB-HD program proved to be feasible, usable and acceptable for caregivers of people with HD. These results provide directions for further research into the effectiveness of PiB-HD, and can already be utilized to advise on the deployment of eHealth in the provision of HD care.

Long-Term Patient-Reported Outcomes After Radiofrequency Ablation and Cryoballoon Ablation for Paroxysmal Atrial Fibrillation: The Effect of Additional Ablations

BACKGROUND

pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) improves health-related quality of life (QoL). This study compares QoL improvement after radiofrequency ablation (RF) and cryoballoon ablation (cryo) and assesses additional ablations' role in QoL improvement.

METHODS

we evaluated the QoL of consecutive patients with first-time RF and cryo for PAF between January 2017 and June 2019. A combined EQ-VAS, AFEQT, and EQ-5D-3L paper questionnaire was sent to patients at baseline, 12, and 30 months after the procedure. Procedure and patient details were collected from medical notes.

RESULTS

the analysis included 207 patients, of which 127 (61%) had RF and 144 (70%) were males. RF patients had more additional ablations (52 [41%] versus 22 [28%], p = 0.01). There was a significant improvement from baseline to 12 months post-RF in AFEQT (43 ± 9 to 83 ± 7.8, p < 0.001), EQ-5D-3L (-0.01 ± 0.01 to 1.1 ± 0.02, p < 0.001), and EQ-VAS (51 ± 8 to 77 ± 13, p = 0.01). Similarly, an improvement at 12 months was observed after cryo in AFEQT (55 ± 11 to 77 ± 9, p < 0.001), EQ-5D-3L (-0.04 ± 0.03 to 1.3 ± 0.03, p < 0.001), and EQ-VAS (56 ± 7 to 85 ± 9, p = 0.01). QoL improvement was similar between RF and cryo. Additional ablations provided no additional QoL improvement compared to patients with PVI alone.

CONCLUSIONS

Patients undergoing first-time PVI for PAF, RF, and cryo showed similar QoL improvement at 12 months, which was sustained at 30 months. Additional ablations did not provide further QoL benefits.

Quality of life and utility of patients with peripheral artery disease (PAD): a systematic review and meta-analysis

Peripheral artery disease (PAD) patients experience low utility, especially those having undergone amputation. Utility is one of the quality weights of health status, converted from quality of life (QOL). This study aimed to systematically review published literature and analyze a pooled estimate of utility in PAD patients. The following databases were queried for articles published from inception up to August 30, 2022: PubMed, ScienceDirect, Scopus, ThaiJo, and the Thai thesis database. Four quality assessment tools were used, tailored to each study's design. A pooled utility was estimated by the random effect and reported using Rutherford and Fontaine classification systems due to their common use in practice. The protocol was registered with the International Prospective Registration of Systematic Reviews (CRD42023392775). Fourteen high-quality studies were included, pooling utility from 3,664 PAD patients. The pooled utility by the Rutherford categories was 0.67, with scores for categories 0, 1-3, 4, and 5 being 0.88, 0.65, 0.68, and 0.58, respectively. The pooled utility by the Fontaine stage was 0.68, with stages 1, 2, 3, and 4 scoring 0.88, 0.65, 0.67, and 0.58, respectively. PAD utility is comparable to that of other chronic diseases. The pooled utility could be a valuable parameter for cost-utility analysis in PAD management.

Post-Discharge Self-Care Confidence and Performance Levels in Patients Hospitalized due to Heart Failure

BACKGROUND

Multidisciplinary self-care education plays a critical role in ensuring the high-quality transitional care of patients hospitalized due to heart failure (HF). However, whether confidence concerning self-care during their index hospitalizations would influence their post-discharge self-care performances and long-term outcomes remains uncertain.

METHODS

We conducted an assessment of 100 consecutive patients with HF who completed self-care questionnaires both during their hospitalizations and 1 year after discharge. Among these patients hospitalized due to HF, self-care confidence was assessed immediately after they completed their pre-discharge education program. One year after the index hospitalization, we evaluated self-care performance by using the European Heart Failure Self-care Behavior Scale. Logistic regression analysis was employed to identify determinants of poor self-care behavior 1 year after the hospitalization. Additionally, the Cox proportional hazards model with adjustment for the Seattle Heart Failure Model was applied to assess their association with 2-year mortality and readmission risk.

RESULTS

The enrolled patients predominantly had HF with reduced ejection fraction (43.0%), and approximately half of the patients had experienced a previous hospitalization due to HF (47.0%). The 3 worst-performing aspects of post-discharge self-care behavior (among the 12 items) were appropriate consultation for fatigue (40.0%), weight gain (52.0%) and application of regular exercise (57.0%). After adjustment, low self-care confidence during the index hospitalization was associated with poor post-discharge self-care performance (OR: 1.11, CI: 1.00-1.21). Poor post-discharge self-care behavior was not associated with worse prognoses over a 2-year follow-up (hazard ratio [HR]: 1.82, CI: 0.85-3.86); however, the association was significant in patients with reduced ejection fraction (HR: 4.04, CI: 1.17-13.89) and previous HF hospitalization (HR: 3.66, CI: 1.46-9.13).

CONCLUSIONS

Post-discharge self-care performance was associated with self-care confidence during the index HF hospitalization. Effective measures that improve pre-discharge confidence levels in self-care should be considered to enhance the quality of transitional care.

The validity and reliability of the Arabic version of the EQ-5D in atrial fibrillation patients in a conflict country: a study from Syria

BACKGROUND

The EQ-5D is one of the most commonly used tools to establish health-related quality of life (QoL). EQ-5D data in atrial fibrillation (AF) patients in the Middle East are lacking.

OBJECTIVES

This study aims to evaluate the reliability and validity of the Arabic version of the EQ-5D in AF inpatients in Syria.

METHODS

The study involved patients admitted to the emergency department of Tishreen's University Hospital in Latakia with AF as the primary diagnosis between the 1st of June 2021 and the 1st of June 2023. Arabic versions of the EQ-5D, EQ-VAS and SF36 questionnaires were administered to patients. Validation was done using convergent, discriminant, and known-groups validity, while reliability was conducted using EQ-5D retesting within 2-4 weeks.

RESULTS

432 participants were included in the study with a mean ± standard deviation of 63 ± 15. Males represented 242 (56%) of the participants. All hypotheses relating EQ-5D responses to external variables were satisfied. All three validation hypotheses demonstrated that the EQ-5D had the convergent, discriminant and known group validity to assess QoL in this cohort. The intraclass correlation coefficient (ICC) for test-retest reliability ranged between 0.74 and 0.88, while Cohen's κ ranged between 0.72 and 0.86. Cronbach's α value for internal consistency was 0.73.

CONCLUSION

The Arabic version of EQ-5D was valid and reliable in measuring QoL in AF inpatients in Syria. This validation opens the door for more widespread use of the EQ-5D in Arabic-speaking regions, facilitating better-informed healthcare decisions and improving patient care strategies in Syria and other Middle Eastern countries.

Evaluating artificial intelligence-driven stress echocardiography analysis system (EASE study): A mixed method study

INTRODUCTION

The use and value of artificial intelligence (AI)-driven tools and techniques are under investigation in detecting coronary artery disease (CAD). EchoGo Pro is a patented AI-driven stress echocardiography analysis system produced by Ultromics Ltd. (henceforth Ultromics) to support clinicians in detecting cardiac ischaemia and potential CAD. This manuscript presents the research protocol for a field study to independently evaluate the accuracy, acceptability, implementation barriers, users' experience and willingness to pay, cost-effectiveness and value of EchoGo Pro.

METHODS AND ANALYSIS

The 'Evaluating AI-driven stress echocardiography analysis system' (EASE) study is a mixed-method evaluation, which will be conducted in five work packages (WPs). In WP1, we will examine the diagnostic accuracy by comparing test reports generated by EchoGo Pro and three manual raters. In WP2, we will focus on interviewing clinicians, innovation/transformation staff, and patients within the National Health Service (NHS), and staff within Ultromics, to assess the acceptability of this technology. In this WP, we will determine convergence and divergence between EchoGo Pro recommendations and cardiologists' interpretations and will assess what profile of cases is linked with convergence and divergence between EchoGo Pro recommendations and cardiologists' interpretations and how these link to outcomes. In WP4, we will conduct a quantitative cross-sectional survey of trust in AI tools applied to cardiac care settings among clinicians, healthcare commissioners and the general public. Lastly, in WP5, we will estimate the cost of deploying the EchoGo Pro technology, cost-effectiveness and willingness to pay cardiologists, healthcare commissioners and the general public. The results of this evaluation will support evidence-informed decision-making around the widespread adoption of EchoGo Pro and similar technologies in the NHS and other health systems.

ETHICS APPROVAL AND DISSEMINATION

This research has been approved by the NHS Health Research Authority (IRAS No: 315284) and the London South Bank University Ethics Panel (ETH2223-0164). Alongside journal publications, we will disseminate study methods and findings in conferences, seminars and social media. We will produce additional outputs in appropriate forms, for example, research summaries and policy briefs, for diverse audiences in NHS.

Health-related quality of life assessment in health economic analyses involving type 2 diabetes

AIM

Incorporating health-related quality of life (HRQoL) measures into health economic analyses can help to provide evidence to inform decisions about how to improve patient outcomes in the most cost-effective manner. The aim of this narrative review was to assess which HRQoL instruments have been used in economic evaluations of type 2 diabetes management including in Indigenous communities.

METHOD

MEDLINE (Ovid), Embase (Ovid) and Cochrane were searched from inception to June 2022. Studies included patients with type 2 diabetes; economic evaluations, derived scores from direct questioning of individuals; and were in English. Records were assessed for bias using the JBI critical appraisal tools.

RESULTS

A total of 3737 records were identified, with 22 publications meeting the criteria for inclusion. Across those 22 articles, nine HRQoL instruments had been utilised. Generic tools were most frequently used to measure HRQoL, including EQ-5D (-3 L and -5 L) (n = 10, 38%); SF-12 (n = 5, 19%); and SF-36 (n = 4, 15%). Two tools addressing the specific stressors faced by people with type 2 diabetes were utilised: Problem Areas In Diabetes tool (n = 1, 4%) and Diabetes Distress Scale (n = 1, 4%). Two publications reported whether the study population included Indigenous peoples.

CONCLUSION

A wide range of HRQoL instruments are used in economic evaluations of type 2 diabetes management, with the most frequent being varying forms of the EQ-5D. Few economic evaluations noted whether Indigenous peoples were featured in the study population. More research into HRQoL in people living with type 2 diabetes is urgently needed to improve evidence on effectiveness and cost-effectiveness of interventions.

Characteristics of longitudinal changes in quality of life and associated factors in patients post cardiac and thoracic aortic surgery: insights from a prospective cohort study

BACKGROUND

Although quality of life (QOL) is an outcome of postoperative cardiac rehabilitation (CR), its course and related factors from postoperative hospitalization to the post-discharge period have not been adequately investigated. Additionally, the EuroQol-5Dimension-5Level (EQ-5D-5L) index score has not been characterized over the same period. We aimed to characterize QOL changes assessed by the EQ-5D-5L, over the period from hospitalization to 1 year post-discharge, in patients post-cardiac and thoracic aortic surgery, and investigate the factors associated with these temporal changes.

METHODOLOGY

This prospective, single-center study included 117 patients who underwent open cardiovascular surgery (median age, 72 years; men, 69%). Patients were assessed for QOL status when transferred to the general ward; at discharge; and at 6 and 12 months after discharge, using the EQ-5D-5L index score and a generalized linear mixed model with random intercepts. Patients were classified into two groups based on score changes post-discharge. Logistic regression analysis evaluated factors associated with QOL decrease post-discharge.

RESULTS

The EQ-5D-5L index score significantly increased over time, except between 6 and 12 months post-discharge; "Common activities" was the most common dimension showing score improvement. In 25 patients (21%), the EQ-5D-5L index scores were lower after discharge compared to their scores at discharge. In the logistic regression analysis, Barthel Index pre-admission, preoperative hemoglobin level, and Mini-Mental State Examination-Japanese scores pre-discharge were significantly associated with QOL decline after adjusting for the European System for Cardiac Operative Risk Evaluation II score.

CONCLUSIONS

Most patients post-cardiac or thoracic aortic surgery experienced improved QOL from postoperative hospital stay to 1 year post-discharge. However, in patients with pre-operative basic activities of daily living, hemoglobin and post-operative cognitive decline may require ongoing comprehensive CR because of reduced QOL. Given the potential selection bias introduced by the relatively small sample size in this study, future research involving larger populations is necessary.

Health-related quality of life with rivaroxaban plus aspirin vs. aspirin alone in chronic stable cardiovascular disease: Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial

Aims

This study aimed to compare the effects of the combination of rivaroxaban and aspirin with aspirin alone on health-related quality of life in the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial.

Methods and results

Health-related quality of life assessed using the EQ-5D-3L. The treatment effects on health utility and EQ visual analogue scale (EQ VAS) scores were compared between rivaroxaban plus aspirin and aspirin alone in terms of adjusted mean difference in change from baseline and odds ratio of having deterioration events. Nine thousand forty-nine (98.9%) and 6916 (75.5%) completed the EQ-5D-3L at baseline and at final visit, respectively. Nine thousand twenty-eight (98.9%) and 6887 (76.3%) completed the EQ-5D-3L at baseline and final visit, respectively. Mean (standard deviation) health utility and EQ VAS scores at baseline were 0.871 (0.141) and 76.0 (15.3), respectively, for the rivaroxaban plus aspirin group, compared with 0.873 (0.139) and 75.8 (15.1) for the aspirin group. Adjusted mean difference in change from baseline utility was -0.002 [95% confidence interval (CI), -0.006, 0.002, P = 0.30] between the combination therapy group and the aspirin group. The odds ratio (95% CI) of experiencing deterioration in health utility was 1.01 (95% CI, 0.93, 1.10, P = 0.81) between the two groups. Adjusted mean difference in change from baseline EQ VAS was 0.02 (95% CI, -0.43, 0.47, P = 0.93) between the two groups.

Conclusion

This analysis of the COMPASS trial demonstrated that the quality of life of patients was similar between the rivaroxaban plus aspirin group and the aspirin alone group.

Registration

Trial registration number: ClinicalTrials.gov number (NCT01776424). Trial protocol and statistical analysis plan: https://www.nejm.org/doi/full/10.1056/NEJMoa1709118#APPNEJMoa1709118PRO.

Association of baseline and changes in health-related quality of life with mortality following myocardial infarction: multicentre longitudinal linked cohort study

BACKGROUND

Health-related quality of life (HRQoL) for patients following myocardial infarction (MI) is frequently impaired. We investigated the association of baseline and changes in HRQoL with mortality following MI.

METHODS AND RESULTS

Nationwide longitudinal study of 9474 patients admitted to 77 hospitals in England as part of the Evaluation of the Methods and Management of Acute Coronary Events study. Self-reported HRQoL was collected using EuroQol EQ-5D-3L during hospitalization and at 1, 6, and 12 months following discharge. The data was analysed using flexible parametric and multilevel survival models. Of 9474 individuals with MI, 2360 (25%) were women and 2135 (22.5%) died during the 9-year follow-up period. HRQoL improved over 12 months (baseline mean, mean increase: EQ-5D 0.76, 0.003 per month; EQ-VAS 69.0, 0.5 per month). At baseline, better HRQoL was inversely associated with mortality [Hazard ratio (HR) 0.55, 95% CI 0.47-0.63], and problems with self-care (HR 1.73, 1.56-1.92), mobility (1.65, 1.50-1.81), usual activities (1.34, 1.23-1.47), and pain/discomfort (1.34, 1.22-1.46) were associated with increased mortality. Deterioration in mobility, pain/discomfort, usual activities, and self-care over 12 months were associated with increased mortality (HR 1.43, 95% CI 1.31-1.58; 1.21, 1.11-1.32; 1.20, 1.10-1.32; 1.44, 1.30-1.59, respectively).

CONCLUSION

After MI, poor HRQoL at baseline, its dimensions, and deterioration over time are associated with an increased risk of mortality. Measuring HRQoL in routine clinical practice after MI could identify at-risk groups for interventions to improve prognosis.

The association between living arrangements and health-related quality of life in Korean older people: a nationwide repeated cross-sectional study

BACKGROUND

This study investigated the association between living arrangements and healthrelated quality of life (HRQoL) in older people.

METHODS

A secondary analysis was conducted of 6,153 participants (aged ≥60 years) from the seventh Korean National Health and Nutrition Examination Survey (2016 to 2018). HRQoL was measured using the 3-level version of the EuroQol 5-dimensional questionnaire. The chi-square test, t-test, and multiple regression were used, applying sampling weights for the analysis.

RESULTS

The proportion of respondents living alone was 18.0%, with a higher prevalence among women and older age groups (p<0.001). The overall HRQoL was lower in groups living alone than in groups living with others (p<0.001). Older people living alone showed higher impairments in all dimensions of the 3-level version of the European Quality of Life 5-Dimensional Questionnaire (EQ-5D-3L) than those living with others, including mobility (p<0.001), self-care (p<0.001), usual activities (p<0.001), pain/discomfort (p<0.001), and depression/anxiety (p<0.001). Problems with mobility were most prevalent (42.8%), followed by pain/ discomfort (41.9%) in respondents living alone. Living alone was significantly associated with a lower HRQoL index score (b=-0.048, p<0.001) after adjusting for age, gender, education, exercise, perceived stress, and perceived health status.

CONCLUSION

Living alone was negatively associated with HRQoL. Based on this study, future care planning for older people should consider their living arrangements. The need to strengthen and expand care programs targeting those living alone should also be addressed.

Patients' perspective of quality-of-care and its correlation to quality-of-life following spontaneous coronary artery dissection

AIMS

Spontaneous coronary artery dissection (SCAD) is an under-recognized cause of myocardial infarction. We aimed to investigate SCAD survivors' perceptions of their quality-of-care and its relationship to quality-of-life.

METHODS AND RESULTS

An anonymous survey was distributed online to SCAD survivors involved in Australian SCAD support groups, with 172 (95.3% female, mean age 52.6 ± 9.2 years) participants in the study. The survey involved assessment of quality-of-life using a standardized questionnaire (EQ-5DTM-3L). Respondents rated the quality-of-care received during their hospital admission for SCAD with a median of 8/10 [interquartile range (IQR) 7-10]. Respondents ≤ 50 years vs. >50 years were more likely to perceive that their symptoms were not treated seriously as a myocardial infarction (χ2 = 4.127, df = 1, P < 0.05). Participants rated clinician's knowledge of SCAD with a median of 4/10 (IQR 2-8) and 7/10 (IQR 3-9) for Emergency and Cardiology clinicians, respectively (P < 0.05). The internet was the most selected source (45.4%) of useful SCAD information. The mean EQ-5DTM summary index was 0.79 (population norm 0.87). A total of 47.2% of respondents reported a mental health condition diagnosis, with 36% of these diagnosed after their admission with SCAD. Quality-of-life was significantly associated with perceived quality-of-care: EQ-5DTM index/(1-EQ-5DTM index) increased by 13% for each unit increase in quality-of-care after adjusting for age and comorbidities (P < 0.001).

CONCLUSION

While SCAD survivors rated their overall hospital care highly, healthcare providers' knowledge of SCAD was perceived to be poor, and the most common source of SCAD information was the internet. Mental health conditions were common, and a significant association was observed between perceived quality-of-care and SCAD survivors' quality-of-life.

Determinants of Health-Related Quality of Life in Outpatients with Myocardial Infarction

Background

The health-related quality of life (HRQOL) of patients with myocardial infarction (MI) is suboptimal because of the disease's life-threatening nature, the requirement for long-term lifestyle modifications, and the treatment regimens following MI. This study aimed to evaluate HRQOL and its associated factors in MI patients.

Material and Methods

This study was conducted on patients with MI who attended the outpatient cardiology clinic at a major teaching hospital in Jordan. The EQ-5D-3L questionnaire was used to assess HRQOL of the study participants. Quantile regression analysis was conducted to identify the variables associated with HRQOL.

Results

The study included 333 patients with a history of MI, with a median age of 58 (57-60). The median of the total EQ-5D score was 0.65 (0.216-0.805). Regression results revealed that male patients (Coefficient= 0.110, 95%Cl (0.022-0.197), P=0.014) and not being diagnosed with diabetes (Coefficient= 0.154, 95%Cl (0.042-0.266), P=0.007) were associated with increased HRQOL. On the other hand, low income (Coefficient= -0.115, 95%Cl (-0.203 - -0.026), P=0.011), not receiving DPP-4 (Dipeptidyl Peptidase -4) inhibitors (Coefficient= -0.321 95%Cl (-0.462 - -0.180), P<0.001), and having low (Coefficient= -0.271, 95%Cl (-0.395 - -0.147), P<0.001) or moderate (Coefficient= -0.123, 95%Cl (-0.202 - -0.044), P=0.002) medication adherence was associated with decreased HRQOL.

Conclusion

The current study demonstrated diminished HRQOL among patients with MI, highlighting the necessity of tailoring interventions to tackle medication adherence barriers in this population. Personalized interventions such as educational programs, counseling, and reminders that consider each patient's needs and circumstances can greatly enhance medication adherence and, thus, the HRQOL of MI patients. Individuals with lower income levels, female patients, and those with diabetes should be the specific targets of these interventions.

Health-related quality of life and its predictors among hypertensive patients on follow up at public hospitals in Addis Ababa, Ethiopia: application of Tobit regression model

BACKGROUND

Health-related quality of life and its associated factors among hypertensive patients living in Ethiopia are not well studied. Therefore, this study aims to assess the level of health-related quality of life and its associated factors in hypertensive patients on follow-up in Public Hospitals in Addis Ababa, Ethiopia.

METHODS

A facility-based cross-sectional study was conducted among 339 hypertensive patients on follow-up at Yekatit 12 &Zewditu Hospitals. Data were collected through face-to-face interviews using Euro Quality of Life Groups 5 Dimensions 5 Levels (EQ-5D-5L) in combination with Euro Quality of Life Groups Visual Analog Scale (EQ-VAS). A multivariable Tobit regression model was employed to assess the association between EQ-5D-5L index, EQ-VAS, and potential predicting factors.

RESULTS

The median index value and EQ-VAS Scales score was 0.86 (IQR = 0.74, 0.94) and 69 (IQR = 55, 80) respectively. The proportion of participants reporting anxiety/depression and pain/discomfort problems was highest, while the fewest patients reported problems in the self-care dimension. Older, rural residents, low income, higher stages of hypertension, increased use of antihypertensive medications, and patients with an increased hospitalization rate scored lower on health-related quality of life than others.

CONCLUSION

Health-related quality of life among hypertensive patients attending public health hospitals in Addis Ababa is unacceptably poor. Emphasis should be given to patients with higher stages of hypertension, increased use of antihypertensive medications, and an increased hospitalization rate giving due focus to older, rural residents, and low-income patients to promote their health-related quality of life.

Predictors of quality of life, functional status, depression and fatigue in early arthritis: comparison between clinically suspect arthralgia, unclassified arthritis and rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) is often preceded by symptomatic phases during which classification criteria are not fulfilled. The health burden of these "at-risk" stages is not well described. This study assessed health-related quality of life (HRQoL), function, fatigue and depression in newly presenting patients with clinically suspect arthralgia (CSA), unclassified arthritis (UA) or RA.

METHODS

Cross-sectional analysis of baseline Patient-Reported Outcome Measures (PROMs) was conducted in patients from the Birmingham Early Arthritis Cohort. HRQoL, function, depression and fatigue at presentation were assessed using EQ-5D, HAQ-DI, PHQ-9 and FACIT-F. PROMs were compared across CSA, UA and RA and with population averages from the HSE with descriptive statistics. Multivariate linear regression assessed associations between PROMs and clinical and sociodemographic variables.

RESULTS

Of 838 patients included in the analysis, 484 had RA, 200 had CSA and 154 had UA. Patients with RA reported worse outcomes for all PROMs than those with CSA or UA. However, "mean EQ-5D utilities were 0.65 (95%CI: 0.61 to 0.69) in CSA, 0.61 (0.56 to 0.66) in UA and 0.47 (0.44 to 0.50) in RA, which was lower than in general and older (≥ 65 years) background populations." In patients with CSA or UA, HRQoL was comparable to chronic conditions such as heart failure, severe COPD or mild angina. Higher BMI and older age (≥ 60 years) predicted worse depression (PHQ-9: -2.47 (-3.85 to -1.09), P < 0.001) and fatigue (FACIT-F: 5.05 (2.37 to 7.73), P < 0.001). Women were more likely to report worse function (HAQ-DI: 0.13 (0.03 to 0.21), P = 0.01) and fatigue (FACIT-F: -3.64 (-5.59 to -1.70), P < 0.001), and residents of more deprived areas experienced decreased function (HAQ-DI: 0.23 (0.10 to 0.36), P = 0.001), greater depression (PHQ-9: 1.89 (0.59 to 3.18), P = 0.004) and fatigue (FACIT-F: -2.60 (-5.11 to 0.09), P = 0.04). After adjustments for confounding factors, diagnostic category was not associated with PROMs, but disease activity and polypharmacy were associated with poorer performance across all PROMs.

CONCLUSIONS

Patient-reported outcomes were associated with disease activity and sociodemographic characteristics. Patients presenting with RA reported a higher health burden than those with CSA or UA, however HRQoL in the pre-RA groups was significantly lower than population averages.

Exploring quality of life in postural orthostatic tachycardia syndrome: A conceptual analysis

Postural Orthostatic Tachycardia Syndrome (POTS) is a complex autonomic disorder characterized by an abnormal increase in heart rate upon orthostatic change. While primarily described in its effect on the autonomic and cardiovascular system, it can cause significant functional impairment, leading to a diminished quality of life (QoL). This review paper aims to delve into the multifaceted dimensions of QoL in individuals with POTS by providing a conceptual model to discuss factors influencing QoL. Current QoL assessments used in the POTS population and their findings are described for each domain in this conceptual model. Limitations to this body of research include the literature having no consensus in the most appropriate measure of QoL to use for individuals with POTS, the absence of a POTS-specific measure of QoL, and current measures not assessing concerns germane to this population. The authors emphasize the necessity of a POTS-specific measure to be developed to improve our assessment and understanding of how living with POTS impacts QoL.

Impact of Rapid Up-Titration of Guideline-Directed Medical Therapies on Quality of Life: Insights From the STRONG-HF Trial

BACKGROUND

This analysis provides details on baseline and changes in quality of life (QoL) and its components as measured by EQ-5D-5L questionnaire, as well as association with objective outcomes, applying high-intensity heart failure (HF) care in patients with acute HF.

METHODS

In STRONG-HF trial (Safety, Tolerability, and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Therapies) patients with acute HF were randomized just before discharge to either usual care or a high-intensity care strategy of guideline-directed medical therapy up-titration. Patients ranked their state of health on the EQ-5D visual analog scale score ranging from 0 (the worst imaginable health) to 100 (the best imaginable health) at baseline and at 90 days follow-up.

RESULTS

In 1072 patients with acute HF with available assessment of QoL (539/533 patients assigned high-intensity care/usual care) the mean baseline EQ-visual analog scale score was 59.2 (SD, 15.1) with no difference between the treatment groups. Patients with lower baseline EQ-visual analog scale (meaning worse QoL) were more likely to be women, self-reported Black and non-European (P<0.001). The strongest independent predictors of a greater improvement in QoL were younger age (P<0.001), no HF hospitalization in the previous year (P<0.001), lower NYHA class before hospital admission (P<0.001) and high-intensity care treatment (mean difference, 4.2 [95% CI, 2.5-5.8]; P<0.001). No statistically significant heterogeneity in the benefits of high-intensity care was seen across patient subgroups of different ages, with left ventricular ejection fraction above or below 40%, NT-proBNP (N-terminal pro-B-type natriuretic peptide) and systolic blood pressure above or below the median value. The treatment effect on the primary end point did not vary significantly across baseline EQ-visual analog scale (Pinteraction=0.87).

CONCLUSIONS

Early up-titration of guideline-directed medical therapy significantly improves all dimensions of QoL in patients with HF and improves prognosis regardless of baseline self-assessed health status. The likelihood of achieving optimal doses of HF medications does not depend on baseline QoL.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03412201.

Mobile health technologies to improve walking distance in people with intermittent claudication

BACKGROUND

Peripheral arterial disease (PAD) is the obstruction or narrowing of the large arteries of the lower limbs, which can result in impaired oxygen supply to the muscle and other tissues during exercise, or even at rest in more severe cases. PAD is classified into five categories (Fontaine classification). It may be asymptomatic or various levels of claudication pain may be present; at a later stage, there may be ulceration or gangrene of the limb, with amputation occasionally being required. About 20% of people with PAD suffer from intermittent claudication (IC), which is muscular discomfort in the lower extremities induced by exertion and relieved by rest within 10 minutes; IC causes restriction of movement in daily life. Treatment for people with IC involves addressing lifestyle risk factors. Exercise is an important part of treatment, but supervised exercise programmes for individuals with IC have low engagement levels and high attrition rates. The use of mobile technologies has been suggested as a new way to engage people with IC in walking exercise interventions. The novelty of the intervention, low cost for the user, automation, and ease of access are some of the advantages mobile health (mhealth) technologies provide that give them the potential to be effective in boosting physical activity in adults.

OBJECTIVES

To assess the benefits and harms of mobile health (mhealth) technologies to improve walking distance in people with intermittent claudication.

SEARCH METHODS

The Cochrane Vascular Information Specialist conducted systematic searches of the Cochrane Vascular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL, and also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov. The most recent searches were carried out on 19 December 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in people aged 18 years or over with symptomatic PAD and a clinical diagnosis of IC. We included RCTs comparing mhealth interventions to improve walking distance versus usual care (no intervention or non-exercise advice), exercise advice, or supervised exercise programmes. We excluded people with chronic limb-threatening ischaemia (Fontaine III and IV).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were change in absolute walking distance from baseline, change in claudication distance from baseline, amputation-free survival, revascularisation-free survival. Our secondary outcomes were major adverse cardiovascular events, major adverse limb events, above-ankle amputation, quality of life, and adverse events. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included four RCTs involving a total of 614 participants with a clinical diagnosis of IC. The duration of intervention of the four included RCTs ranged from 3 to 12 months. Participants were randomised to either mhealth or control (usual care or supervised exercise programme). All four studies had an unclear or high risk of bias in one or several domains. The most prevalent risk of bias was in the area of performance bias, which was rated high risk as it is not possible to blind participants and personnel in this type of trial. Based on GRADE criteria, we downgraded the certainty of the evidence to low, due to concerns about risk of bias, imprecision, and clinical inconsistency. Comparing mhealth with usual care, there was no clear evidence of an effect on absolute walking distance (mean difference 9.99 metres, 95% confidence interval (CI) -27.96 to 47.93; 2 studies, 503 participants; low-certainty evidence). None of the included studies reported on change in claudication walking distance, amputation-free survival, or revascularisation-free survival. Only one study reported on major adverse cardiovascular events (MACE) and found no clear difference between groups (risk ratio 1.37, 95% CI 0.07 to 28.17; 1 study, 305 participants; low-certainty evidence). None of the included studies reported on major adverse limb events (MALE) or above-ankle amputations.

AUTHORS' CONCLUSIONS

Mobile health technologies can be used to provide lifestyle interventions for people with chronic conditions, such as IC. We identified a limited number of studies that met our inclusion criteria. We found no clear difference between mhealth and usual care in improving absolute walking distance in people with IC; however, we judged the evidence to be low certainty. Larger, well-designed RCTs are needed to provide adequate statistical power to reliably evaluate the effects of mhealth technologies on walking distance in people with IC.

Smartphone application-based rehabilitation in patients with chronic respiratory and cardiovascular diseases

Rehabilitation improves symptoms, quality of life, and survival in patients with chronic respiratory or cardiovascular disease. We evaluated smartphone application-based rehabilitation programs for patients with chronic respiratory or cardiovascular diseases. This was a single-center prospective single arm study. Participants underwent smartphone application-based pulmonary or cardiac rehabilitation for 12 weeks. A total of 93 participants were recruited, and 75 visited after rehabilitation. Their median age was 67.0 (interquartile range, 60.0-70.8) years, and 60 (80.0%) were men. For patients with chronic respiratory disease (n = 41), VO2peak (median 13.7 to 15.4 ml/kg/min, P = 0.049), chronic obstructive pulmonary disease assessment test (median 14 to 6, P < 0.001), Euro-QoL 5-Dimension 5-Level (EQ-5D-5L) index (median 0.795 to 0.862, P = 0.001), and Health-related Quality of Life Instrument with 8 Items (HINT-8) index (median 0.784 to 0.855, P < 0.001) were significantly improved. For patients with chronic cardiovascular disease (n = 34), VO2peak (median 21.8 to 23.3, P = 0.007), EQ-5D-5L index (median 0.871 to 1.000, P = 0.037), and HINT-8 index (median 0.890 to 0.903, P < 0.001) were significantly improved. The smartphone application-based rehabilitation program improved exercise capacity and quality of life in patients with chronic respiratory or cardiovascular disease.Trial registration: https://clinicaltrials.gov/ct2/show/NCT05383950 (20/05/2022).

The subjective and objective quality of life score (SOQOLTM) for the quantification of general health status: a preliminary study with initial normative population values

BACKGROUND

Established health-related quality of life scores do not consider both subjective and objective indices of health. We propose the subjective and objective quality of life score (SOQOL) for the comprehensive assessment of health-related quality of life and aim to provide normative population data. The SOQOL is compatible with smartphone applications, allowing widespread use on a global scale.

METHODS

Normative SOQOL population data was sourced from pre-existing datasets on the EQ-5D-5L, daily step count, and walking speed. Normative values were calculated using weighted grand means. We trialled the SOQOL in a group of five patients presenting to a spinal neurosurgery clinic.

RESULTS

SOQOL scores decreased with age, and women had lower scores in every age group. In our case series, the spine patients with the biggest SOQOL deficit compared to age- and sex-matched population averages were found to be surgical while the rest were non-surgical.

CONCLUSIONS

The SOQOL shows promise as a simple and effective scoring tool that is compatible with smartphones, potentially useful for screening in primary and specialized care settings, and for assessment following healthcare interventions. This study, however, is preliminary, and the findings are primarily suggestive. They underline the necessity for future, more comprehensive studies to validate and expand upon these initial observations. The conclusion of both this abstract and the full paper will clearly state these limitations and the preliminary nature of the study.

Cost‑effectiveness of add‑on dapagliflozin for heart failure with reduced ejection fraction patients without diabetes

AIM

To evaluate the cost-effectiveness of dapagliflozin added to standard of care (SoC) versus SoC in heart failure with reduced ejection fraction (HFrEF) and without type 2 diabetes mellitus (T2DM) patients from the Qatari healthcare perspective.

MATERIALS AND METHODS

A lifetime Markov model was developed to evaluate the cost-effectiveness of adding dapagliflozin to SoC based on the findings of Petrie et al. 2020, which were based on the DAPA-HF trial. The model was constructed based on four health states: "alive with no event", "urgent visit for heart failure", "hospitalization for heart failure", and "dead". The model considered 1,000 hypothetical HFrEF and without T2DM patients using 3-month cycles over a lifetime horizon. The outcome of interest was the incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year gained (QALY) and years of life lived (YLL). Utility and cost data were obtained from published sources. A scenario analysis was performed to replace the transition probabilities of events in people without T2DM with the transition probabilities of events irrespective of T2DM status, based on findings of the DAPA-HF trial. Sensitivity analyses were conducted to confirm the robustness of the conclusion.

RESULTS

Adding dapagliflozin to SoC was estimated to dominate SoC alone, resulting in 0.6 QALY and 0.8 YLL, at a cost saving of QAR771 (USD211) per person compared with SoC alone, with total healthcare costs of QAR42,413 (USD 11,620) versus 43,184 (USD11,831) per person, respectively. When replacing the transition probabilities of events in people without T2DM with the transition probabilities of events in people irrespective of T2DM status, dapagliflozin was cost-effective at ICER of QAR5,212 (USD1,428) per QALY gained and QAR3,880 (USD1,063) per YLL. In the probabilistic sensitivity analysis, dapagliflozin combined with SoC was cost saving in over 49% of the cases and cost-effective in over 43% of the simulated cases against QALYs gained and YLL.

LIMITATIONS

Data from clinical trials were used instead of local data, which may limit the local relevance. However, evidence from the local Qatari population is lacking. Also, indirect costs were not included due to a paucity of available data.

CONCLUSIONS

Adding dapagliflozin to SoC is likely to be a cost-saving therapy for patients with HFrEF and without T2DM in Qatar.

Factors associated with health-related quality of life in patients undergoing percutaneous coronary intervention: Thai PCI registry

Background

Percutaneous coronary intervention (PCI) has been shown to improve health-related quality of life (HRQoL) in patients with coronary artery disease (CAD). The objectives of this study were to assess the changes in HRQoL and factors influencing these changes in CAD patients after undergoing PCI.

Methods

Data from a nationwide PCI registry across 39 hospitals in Thailand were collected in 2018-2019, including baseline characteristics, comorbid diseases, angiographic CAD severity, procedural details, and type of health insurance. HRQoL, as measured by utility scores, was determined in all patients using the Thai version of EQ-5D-5l at admission, discharge, and 6 and 12 months after discharge. The effects of time after PCI procedure and various factors on mean utility scores were assessed using a mixed-effect linear regression model.

Results

A total of 19,701 patients were included in the analysis; they had a mean age of 64.2 ± 11.7 years and were predominantly (69.1%) male. Following PCI, the mean utility scores increased from 66.6 ± 19.6 at admission to 81.9 ± 13.8 at discharge, and remained stable at 6 and 12 months (86.1 ± 12.3 and 88.0 ± 11.7, respectively). After adjusting for potential confounding variables, several factors were found to be independently associated with improved HRQoL, including angiographic success, male gender, overweight status, dyslipidemia, and radial access. Six other factors were associated with less improved HRQoLs, including cardiogenic shock/IABP support, old age, CKD, clinical presentation (STEMI and NSTEMI), prior cerebrovascular disease, and heart failure. There were no associations of CAD severity and procedural details with HRQoL. No differences were found related to type of health insurance, except that patients who were uninsured or self-pay tended to have less improvement in HRQoL.

Conclusion

HRQoL improved significantly after PCI in these subjects, as observed through 1 year of follow-up. Identifying the factors influencing these improvements may assist clinicians in tailoring patient interventions to optimise quality of life after PCI.

Health-related quality of life among people who inject drugs in Australia

PURPOSE

There is limited research on health-related quality of life (HRQoL) among people who inject drugs (PWID). We aimed to evaluate factors associated with HRQoL among a cohort of PWID in Australia.

METHODS

Participants were enrolled in an observational cohort study (the LiveRLife Study) between 2014 and 2018 at 15 sites in Australia. They provided fingerstick whole-blood samples for point-of-care HCV RNA testing and underwent transient elastography to assess liver disease. Participants completed the EQ-5D-3L survey at enrolment. Regression models were used to assess the impact of clinical and socioeconomic characteristics on the EQ-5D-3L scores.

RESULTS

Among 751 participants (median age, 43 years; 67% male), 63% reported injection drug use in the past month, 43% had current HCV infection, and 68% had no/mild liver fibrosis (F0/F1). The mean EQ-5D-3L and EQ-VAS scores were 0.67 and 62, respectively, for the overall study population. There was no significant difference in the EQ-5D-3L scores among people with and without recent injecting drug use (mean: 0.66 vs. 0.68, median: 0.73 vs. 0.78, P = 0.405), and among people receiving and not receiving opioid agonist therapy (mean: 0.66 vs. 0.68, median: 0.73 vs. 0.76, P = 0.215). Participants who were employed were found to have the highest mean EQ-5D-3L (0.83) and EQ-VAS scores (77). The presence of current HCV infection, liver fibrosis stage, and high-risk alcohol consumption had little impact on HRQoL.

CONCLUSIONS

The study findings provide important HRQoL data for economic evaluations, useful for guiding the allocation of resources for HCV elimination strategies and interventions among PWID.

Cost-effectiveness of a telemonitoring programme in patients with cardiovascular diseases compared with standard of care

OBJECTIVES

The main aim of this work was to analyse the cost-effectiveness of an integrated care concept (NICC) that combines telemonitoring with the support of a care centre in addition to guideline therapy for patients. Secondary aims were to compare health utility and health-related quality of life (QoL) between NICC and standard of care (SoC).

METHODS

The randomised controlled CardioCare MV Trial compared NICC and SoC in patients from Mecklenburg-West Pomerania (Germany) with atrial fibrillation, heart failure or treatment-resistant hypertension. QoL was measured using the EQ-5D-5L at baseline, 6 months and 1 year follow-up. Quality-adjusted life years (QALYs), EQ5D utility scores, Visual Analogue Scale (VAS) Scores and VAS adjusted life years (VAS-AL) were calculated. Cost data were obtained from health insurance companies, and the payer perspective was taken in health economic analyses. Quantile regression was used with adjustments for stratification variables.

RESULTS

The net benefit of NICC (QALY) was 0.031 (95% CI 0.012 to 0.050; p=0.001) in this trial involving 957 patients. EQ5D Index values, VAS-ALs and VAS were larger for NICC compared with SoC at 1 year follow-up (all p≤0.004). Direct cost per patient and year were €323 (CI €157 to €489) lower in the NICC group. When 2000 patients are served by the care centre, NICC is cost-effective if one is willing to pay €10 652 per QALY per year.

CONCLUSION

NICC was associated with higher QoL and health utility. The programme is cost-effective if one is willing to pay approximately €11 000 per QALY per year.

Is Transcatheter Aortic Valve Replacement Futile in Patients Over Ninety Years of Age?

Background

Clinical outcomes and quality of life (QoL) indices are not well described after transcatheter aortic valve replacement (TAVR) in patients aged ≥ 90 years.

Methods

We conducted a retrospective cohort study of TAVR among nonagenarian patients between 2008 and 2020. The survival of TAVR patients among nonagenarians was compared to the provincial estimated survival for an age- and sex-matched general population. QoL was assessed up to 1 year postintervention, using standardized questionnaires.

Results

During the study period, n = 268 patients aged ≥ 90 years were evaluated for severe aortic stenosis. TAVR was performed in n = 171 (48% female; median [IQR] Rockwood Clinical Frailty Scale score: 4 [3-4]); n = 84 underwent medical therapy; and n = 13 underwent surgical aortic valve replacement. Survival was significantly better following TAVR, compared to that after MT (adjusted hazard ratio [95% CI]: 1.99 [1.37-2.88], P < 0.001). TAVR patients demonstrated a survival advantage compared with the general population, with an estimated relative mortality of 0.86 (0.75-0.87). TAVR patients showed sustained improvements in functional status and QoL up to 1 year compared to baseline (all P < 0.05): the 6-minute walk test results improved from 192 to 252 m; the Kansas City Cardiomyopathy Questionnaire score improved from 64 to 81; the Duke Activity Status Index score improved from 13 to 16; and the health state scale result of the Euro Quality of life - 5 Dimensions improved from 63% to 74%.

Conclusions

Nonagenarians undergoing TAVR experience a slightly better survival rate, compared to that of an age- and sex-matched general population, and they have significant improvements in functional status and several QoL indices following the procedure.

Smartphone application-based rehabilitation in patients with chronic respiratory and cardiovascular diseases: a randomised controlled trial study protocol

INTRODUCTION

Rehabilitation is well known to improve clinical symptoms and decrease the risk of mortality in patients with chronic respiratory or cardiovascular diseases. We will evaluate the efficacy of smartphone application-based rehabilitation programmes in patients with chronic respiratory or cardiovascular diseases.

METHODS AND ANALYSIS

This single-centre single-blind randomised controlled trial will recruit a total of 162 participants from Asan Medical Center (81 patients each for pulmonary and cardiac rehabilitation, respectively). Participants will be assigned to the pulmonary or cardiac rehabilitation groups based on their underlying disease. Participants will be allocated randomly into the intervention or control groups at the ratio of 2:1 (54 and 27 patients). The intervention group will be provided with a smartphone application and undergo smartphone application-based rehabilitation for 12 weeks. The control group will receive the usual outpatient medical treatment without rehabilitation. Participants will be evaluated at baseline and at the end of the rehabilitation. The primary outcomes will be exercise capacity, such as maximal oxygen consumption on cardiopulmonary exercise test for both groups, chronic obstructive pulmonary disease assessment test for the pulmonary rehabilitation group, and Health-related Quality of Life Instrument with 8 Items questionnaires for the cardiac rehabilitation group. The secondary outcomes will include quality of life questionnaires, symptom scores, pulmonary function test and limb muscle test.

ETHICS AND DISSEMINATION

The study protocol was approved by the Institutional Review Board of Asan Medical Center. Written informed consent will be obtained from all participants prior to inclusion. The findings from this study will be disseminated through peer-reviewed scientific journals and conferences.

TRIAL REGISTRATION NUMBER

NCT05610358.

The cost-effectiveness of a uniform versus age-based threshold for one-off screening for prevention of cardiovascular disease

The objective of this article was to assess the cost-effectiveness of screening strategies for cardiovascular diseases (CVD). A decision analytic model was constructed to estimate the costs and benefits of one-off screening strategies differentiated by screening age, sex and the threshold for initiating statin therapy ("uniform" or "age-adjusted") from the Spanish NHS perspective. The age-adjusted thresholds were configured so that the same number of people at high risk would be treated as under the uniform threshold. Health benefit was measured in quality-adjusted life years (QALY). Transition rates were estimated from the European Prospective Investigation into Cancer and Nutrition (EPIC-CVD), a large multicentre nested case-cohort study with 12 years of follow-up. Unit costs of primary care, hospitalizations and CVD care were taken from the Spanish health system. Univariate and probabilistic sensitivity analyses were employed. The comparator was no systematic screening program. The base case model showed that the most efficient one-off strategy is to screen both men and women at 40 years old using a uniform risk threshold for initiating statin treatment (Incremental Cost-Effectiveness Ratio of €3,274/QALY and €6,085/QALY for men and women, respectively). Re-allocating statin treatment towards younger individuals at high risk for their age and sex would not offset the benefit obtained using those same resources to treat older individuals. Results are sensitive to assumptions about CVD incidence rates. To conclude, one-off screening for CVD using a uniform risk threshold appears cost-effective compared with no systematic screening. These results should be evaluated in clinical studies.

The Societal Impact of Inclisiran in England: Evidence From a Population Health Approach

OBJECTIVES

As first-in-class cholesterol-lowering small interfering ribonucleic acid, inclisiran provides effective reductions in low-density lipoprotein-cholesterol to achieve better cardiovascular (CV) health. We estimate the health and socioeconomic effects of introducing inclisiran according to a population health agreement in England.

METHODS

Building on the inclisiran cost-effectiveness model, a Markov model simulates health gains in terms of avoided CV events and CV deaths because of add-on inclisiran treatment for patients aged 50 years and older with pre-existing atherosclerotic CV disease. These are translated into socioeconomic effects, defined as societal impact. To that end, we quantify avoided productivity losses in terms of paid and unpaid work productivity and monetize them according to gross value added. Furthermore, we calculate value chain effects for paid work activities, drawing on value-added multipliers based on input-output tables. The derived value-invest ratio compares avoided productivity losses against the increased healthcare costs.

RESULTS

Our results show that 138 647 CV events could be avoided over a period of 10 years. The resulting societal impact amounts to £8.17 billion, whereas additional healthcare costs are estimated at £7.94 billion. This translates into a value-invest ratio of 1.03.

CONCLUSIONS

Our estimates demonstrate the potential health and socioeconomic value of inclisiran. Thereby, we highlight the importance to treat CVD and illustrate the impact that a large-scale intervention can have on population health and the economy.

Quality of Life Measures in Aortic Stenosis Research: A Narrative Review

BACKGROUND

Elderly patients with aortic stenosis (AS) not only have a reduced life expectancy but also a reduced quality of life (QoL). The benefits of an AS intervention may be considered a balance between a good QoL and a reasonably extended life. However, the different questionnaires being used to determine the QoL were generally not developed for the specific situation of patients with AS and come with strengths and considerable weaknesses. The objective of this article was to provide an overview of the available QoL instruments in AS research, describe their strengths and weaknesses, and provide our assessment of the utility of the available scoring instruments for QoL measurements in AS.

SUMMARY

We identified and reviewed the following instruments that are used in AS research: Short Form Health Survey (SF-36/SF-12), EuroQol-5D (EQ-5D), the Illness Intrusiveness Rating Scale (IIRS), the HeartQoL, the Kansas City Cardiomyopathy Questionnaire (KCCQ), the Minnesota Living with Heart Failure Questionnaire (MLHF), the MacNew Questionnaire, and the Toronto Aortic Stenosis Quality of Life Questionnaire (TASQ).

KEY MESSAGES

There is no standardized assessment of QoL in patients with AS. Many different questionnaires are being used, but they are rarely specific for AS. There is a need for AS-specific research into the QoL of patients as life prolongation may compete for an improved QoL in this elderly patient group.

Mapping the Seattle Angina Questionnaire to EQ-5D-5L in patients with coronary heart disease

BACKGROUND

Health economic evaluation is critical in supporting novel cardiovascular disease therapies. However, most clinical studies do not include preference-based questionnaires to calculate utilities for health economic evaluations. Thus, this study aimed to develop mapping algorithms that convert the Seattle Angina Questionnaire (SAQ) to EQ-5D-5L health utility scores for patients with coronary health disease (CHD) in China.

METHODS

Data were obtained from a longitudinal study of patients with CHD conducted at the Tianjin Medical University General Hospital in China. Convenience sampling was used to recruit patients with CHD. The inclusion criteria were having been diagnosed with CHD through a medical examination and being aged 18 years or older. The exclusion criteria were a lack of comprehension ability, serious comorbidities, mental illness, and hearing or vision impairment. All eligible patients were invited to participate, and 305 and 75 patients participated at baseline and in the follow-up, respectively. Seven regression models were developed using a direct approach. Furthermore, we predicted the five EQ-5D items using ordered logit model and derived the utility score from predicted responses using an indirect approach. Model performances were evaluated using mean absolute error (MAE), root mean squared error (RMSE), correlation coefficient (ρ), and Lin's concordance correlation coefficient (CCC). A five-fold cross-validation method was used to evaluate internal validation.

RESULTS

The average age was 63.04 years, and 53.72% of the included patients were male. Most (70.05%) patients had unstable angina pectoris, and the mean illness duration was 2.50 years. The EQ-5D scores were highly correlated with five subscales of the SAQ, with Spearman's rank correlation coefficients ranging from 0.6184 to 0.7093. The mixture beta model outperformed the other regression models in the direct approach, with the lowest MAE and RMSE and highest ρ and CCC. The ordered logit model in the indirect approach performed the same as the mixture beta regression with equal MAE, lower RMSE, and higher ρ and CCC.

CONCLUSION

Mapping algorithms developed using mixture beta and ordered logit models accurately converted SAQ scores to EQ-5D-5L health utility values, which could support health economic evaluations related to coronary heart disease.

The clinical characteristics and quality of life of 248 pediatric and adult patients with Congenital Adrenal Hyperplasia

Background

Congenital Adrenal Hyperplasia (CAH) is a chronic disease that requires lifelong treatment. Patients may face stigmatization, which may affect their quality of life (QoL). Therefore, we assessed the clinical characteristics and QoL of patients with CAH in the Middle East.

Methods

This case-control study included patients with CAH aged >5 years from two tertiary centers (2020-2021). The patients were matched to a healthy control group and were then divided into pediatric and adult groups. Data were collected from their electronic medical records. Additionally, the EQ-5D-5L QoL questionnaire was completed by both the patients and control group to assess five domains (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression).

Results

The study included 248 patients with CAH (females: 58.8%), with a family history of the condition (57.3%) and/or parental consanguinity (68.1%). The most frequently reported gene defect was CYP21A2, while the most commonly reported symptoms/signs were ambiguous genitalia and obesity. Almost all female patients had received corrective surgery. The questionnaire response rate was 86.3% (n=214/248). The CAH patient group's mean total QoL score was 85.2 compared with 99.8 in the control. Further, CAH patients had lower QoL scores in all domains compared to those in the control group (p ≤ 0.0001-0.0023). The pain/discomfort and anxiety/depression domains were affected significantly more than the other domains were, with 47.7% and 44.4% participants, respectively, p<0.0001. Additionally, obesity was found to be a predictor of reduced mobility following a logistic regression analysis (p ≤ 0.04, OR (0.18-0.98)).

Conclusion

Patients with CAH reported lower QoL overall, particularly in the pain/discomfort and anxiety/depression domains. Based on this, we recommend the early involvement of psychologists in a multidisciplinary team approach, pre-marital screening, and the implementation of awareness programs for people diagnosed with CAH in communities with high consanguineous mating.

Effects of the ABC pathway on clinical outcomes in a secondary prevention population of Chinese patients with atrial fibrillation: A report from the Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry

Background

The atrial fibrillation better care (ABC) pathway is a simple, comprehensive framework that facilitates provision of integrated care for atrial fibrillation (AF) patients.

Objective

We evaluated management of AF patients in a secondary prevention cohort using the ABC pathway and examined the impact of ABC adherence on clinical outcomes.

Methods

The Chinese Patients with Atrial Fibrillation registry is a prospective registry conducted in 44 sites across China between October 2014 and December 2018. The primary outcome was the composite of all-cause mortality/any thromboembolism (TE), all-cause death, any TE and major bleeding at 1 year.

Results

Of the 6420 patients, 1588 (24.7%) had a prior stroke or transient ischemic attack and were identified as the secondary prevention cohort. After excluding 793 patients due to insufficient data, 358 (22.5%) were ABC compliant and 437 (27.5%) ABC noncompliant. ABC adherence was associated with a significantly lower risk of the composite outcome of all-cause death/TE, odds ratio (OR) 0.28 (95% confidence interval [CI]: 0.11-0.71) and all-cause death, OR 0.29 (95% CI: 0.09-0.90). Significant differences were not observed for TE, OR 0.27 (95% CI: 0.06-1.27) and major bleeding, OR 2.09 (95% CI: 0.55-7.97). Age and prior major bleeding were significant predictors of ABC noncompliance. Health-related quality of life (QOL) was higher in the ABC compliant group versus the noncompliant group (EQ score 0.83 ± 0.17 vs. 0.78 ± 0.20; p = .004).

Conclusion

ABC pathway adherence in secondary prevention AF patients was associated with a significantly lower risk of the composite outcome of all-cause death/TE and all-cause death, as well as better health-related QOL.

Cost-effectiveness of home-based cardiac rehabilitation: a systematic review

OBJECTIVE

Centre-based cardiac rehabilitation (CR) is recognised as cost-effective for individuals following a cardiac event. However, home-based alternatives are becoming increasingly popular, especially since COVID-19, which necessitated alternative modes of care delivery. This review aimed to assess whether home-based CR interventions are cost-effective (vs centre-based CR).

METHODS

Using the MEDLINE, Embase and PsycINFO databases, literature searches were conducted in October 2021 to identify full economic evaluations (synthesising costs and effects). Studies were included if they focused on home-based elements of a CR programme or full home-based programmes. Data extraction and critical appraisal were completed using the NHS EED handbook, Consolidated Health Economic Evaluation Reporting Standards and Drummond checklists and were summarised narratively. The protocol was registered on the PROSPERO database (CRD42021286252).

RESULTS

Nine studies were included in the review. Interventions were heterogeneous in terms of delivery, components of care and duration. Most studies were economic evaluations within clinical trials (8/9). All studies reported quality-adjusted life years, with the EQ-5D as the most common measure of health status (6/9 studies). Most studies (7/9 studies) concluded that home-based CR (added to or replacing centre-based CR) was cost-effective compared with centre-based options.

CONCLUSIONS

Evidence suggests that home-based CR options are cost-effective. The limited size of the evidence base and heterogeneity in methods limits external validity. There were further limitations to the evidence base (eg, limited sample sizes) that increase uncertainty. Future research is needed to cover a greater range of home-based designs, including home-based options for psychological care, with greater sample sizes and the potential to acknowledge patient heterogeneity.

Economic Outcomes of Transcatheter Versus Surgical Aortic Valve Replacement in Patients with Severe Aortic Stenosis and Low Surgical Risk: Results from the PARTNER 3 Trial

BACKGROUND

In patients with severe symptomatic aortic stenosis at low surgical risk, transfemoral transcatheter aortic valve replacement (TAVR) with the SAPIEN 3 valve has been shown to reduce the composite of death, stroke, or rehospitalization at 2-year follow-up compared with surgical aortic valve replacement (SAVR). Whether TAVR is cost-effective compared with SAVR for low-risk patients remains uncertain.

METHODS

Between 2016 and 2017, 1000 low-risk patients with aortic stenosis were randomly assigned to TAVR with the SAPIEN 3 valve or SAVR in the PARTNER 3 trial (Placement of Aortic Transcatheter Valves). Of these patients, 929 underwent valve replacement, were enrolled in the United States, and were included in the economic substudy. Procedural costs were estimated using measured resource use. Other costs were determined by linkage with Medicare claims or by regression models when linkage was not feasible. Health utilities were estimated using the EuroQOL 5-item questionnaire. With the use of a Markov model informed by in-trial data, lifetime cost-effectiveness from the perspective of the US health care system was estimated in terms of cost per quality-adjusted life-year gained.

RESULTS

Although procedural costs were nearly $19 000 higher with TAVR, total index hospitalization costs were only $591 more with TAVR compared with SAVR. Follow-up costs were lower with TAVR such that TAVR led to 2-year cost savings of $2030/patient compared with SAVR (95% CI, -$6222 to $1816) and a gain of 0.05 quality-adjusted life-years (95% CI, -0.003 to 0.102). In our base-case analysis, TAVR was projected to be an economically dominant strategy with a 95% probability that the incremental cost-effectiveness ratio for TAVR would be <$50 000/quality-adjusted life-year gained (consistent with high economic value from a US health care perspective). These findings were sensitive to differences in long-term survival, however, such that a modest long-term survival advantage with SAVR would render SAVR cost-effective (although not cost saving) compared with TAVR.

CONCLUSIONS

For patients with severe aortic stenosis and low surgical risk similar to those enrolled in the PARTNER 3 trial, transfemoral TAVR with the SAPIEN 3 valve is cost saving compared with SAVR at 2 years and is projected to be economically attractive in the long run as long as there are no substantial differences in late death between the 2 strategies. Long-term follow-up will be critical to ultimately determine the preferred treatment strategy for low-risk patients from both a clinical and economic perspective.

Randomized evaluation of routine beta-blocker therapy after myocardial infarction quality of life (RQoL): design and rationale of a multicentre, prospective, randomized, open, blinded endpoint study

Aims

Most cases of acute myocardial infarction (MI) in Sweden are treated with long-term β-blocker therapy as secondary prevention. Case studies and patient reports have indicated negative effects of β-blockers including symptoms of depression, fatigue, sexual dysfunction, and general low mood, all related to reduced quality of life (QoL). To date, no recent large-scale, randomized trial has explored the effects of β-blockers on these factors.

Methods and results

The ongoing Randomized Evaluation of Decreased Usage of beta-bloCkErs after myocardial infarction (REDUCE): quality of life (RQoL) study is a multicentre, prospective, randomized pre-specified substudy aiming to evaluate the effects of β-blockers on self-reported measures of QoL. Following randomized allocation to long-term β-blocker or no β-blocker treatment, patients complete a total of six baseline measures pertaining to QoL, sexual functioning, and perceived side effects. Data collection is optionally carried out online through a unique and secure portal and repeated again at two follow-up time points. Recruitment began in July 2018. Data from the first 100 patients showed that at the first follow-up, 93% had completed the questionnaires, which decreased to 81% at the second follow-up. The method of digital data collection was utilized by over half of the patients recruited so far.

Conclusion

Data from the first 100 patients indicate success in terms of study design and recruitment. The RQoL substudy investigates the effects of β-blockers on self-reported measures of QoL in MI patients and will potentially contribute to the limited knowledge of QoL-related side effects reported in conjunction with β-blocker use.

Clinical trial registration

Eudra CT number, 2017-002336-17; Clinical trial.gov identifier, NCT03278509.

Prospective single-center study of health-related quality of life after COVID-19 in ICU and non-ICU patients

Long-term sequelae in hospitalized Coronavirus Disease 2019 (COVID-19) patients may result in limited quality of life. The current study aimed to determine health-related quality of life (HRQoL) after COVID-19 hospitalization in non-intensive care unit (ICU) and ICU patients. This is a single-center study at the University Hospital of Wuerzburg, Germany. Patients eligible were hospitalized with COVID-19 between March 2020 and December 2020. Patients were interviewed 3 and 12 months after hospital discharge. Questionnaires included the European Quality of Life 5 Dimensions 5 Level (EQ-5D-5L), patient health questionnaire-9 (PHQ-9), the generalized anxiety disorder 7 scale (GAD-7), FACIT fatigue scale, perceived stress scale (PSS-10) and posttraumatic symptom scale 10 (PTSS-10). 85 patients were included in the study. The EQ5D-5L-Index significantly differed between non-ICU (0.78 ± 0.33 and 0.84 ± 0.23) and ICU (0.71 ± 0.27; 0.74 ± 0.2) patients after 3- and 12-months. Of non-ICU 87% and 80% of ICU survivors lived at home without support after 12 months. One-third of ICU and half of the non-ICU patients returned to work. A higher percentage of ICU patients was limited in their activities of daily living compared to non-ICU patients. Depression and fatigue were present in one fifth of the ICU patients. Stress levels remained high with only 24% of non-ICU and 3% of ICU patients (p = 0.0186) having low perceived stress. Posttraumatic symptoms were present in 5% of non-ICU and 10% of ICU patients. HRQoL is limited in COVID-19 ICU patients 3- and 12-months post COVID-19 hospitalization, with significantly less improvement at 12-months compared to non-ICU patients. Mental disorders were common highlighting the complexity of post-COVID-19 symptoms as well as the necessity to educate patients and primary care providers about monitoring mental well-being post COVID-19.

Estimation of Health State Utility Values in Fabry Disease Using Vignette Development and Valuation

Background: Health state utilities are measures of health-related quality of life that reflect the value placed on improvements in patients' health status and are necessary for estimation of quality-adjusted life-years. Health state utility data on Fabry disease (FD) are limited. In this study we used vignette (scenario) construction and valuation to develop health state utilities. Objectives: The aim of this study was to use vignette construction and valuation to estimate health state utility values suitable for inclusion in economic models of FD treatments. Methods: Health state vignettes were developed from semistructured qualitative telephone interviews with patients with FD and informed by published literature and input from an expert. Each vignette was valued in an online survey by members of the United Kingdom (UK) general population using the composite time trade-off (TTO) method, which aims to determine the time the respondent would trade to live in full health compared with each impaired health state. Results: Eight adults (50% women) with FD from the UK were interviewed. They were recruited via various approaches, including patient organizations and social media. The interviewees' responses, evidence from published literature, and input from a clinical expert informed the development of 6 health state vignettes (pain, moderate clinically evident FD [CEFD], severe CEFD, end-stage renal disease [ESRD], stroke, and cardiovascular disease [CVD]) and 3 combined health states (severe CEFD + ESRD, severe CEFD + CVD, and severe CEFD + stroke). A vignette valuation survey was administered to 1222 participants from the UK general population who were members of an external surveying organization and agreed to participate in this study; 1175 surveys were successfully completed and included in the analysis. Responses to TTO questions were converted into utility values for each health state. Pain was the highest valued health state (0.465), and severe CEFD + ESRD was the lowest (0.033). Discussion: Overall, mean utility values declined as the severity of the vignettes increased, indicating that respondents were more willing to trade life-years to avoid a severe health state. Conclusions: Health state vignettes reflect the effects of FD on all major health-related quality-of-life domains and may help to support economic modeling for treatment of FD.

Persistence with long-term PCSK9 inhibitor treatment and its effectiveness in familial hypercholesterolaemia: data from the SAFEHEART study

AIMS

Most heterozygous familial hypercholesterolaemia (FH) patients require intensive lipid-lowering therapy (LLT) including PCSK9 inhibitors (PCSK9is) to reach current low-density lipoprotein cholesterol (LDL-C) goals. Persistence with chronic treatment is important to reduce the burden of atherosclerotic cardiovascular disease. We analysed persistence, efficacy, and impact on quality of life (QoL) of PCSK9i in FH patients in clinical practice setting.

METHODS AND RESULTS

Spanish Familial Hypercholesterolaemia Cohort Study (SAFEHEART) is an open, prospective study in genetically defined FH patients in Spain. Patients ≥18 years of age (n = 696, 46% females) on stable LLT treated with PCSK9i were analysed. Median LDL-C at starting PCSK9i was 145 mg/dL [interquartile range (IQR), 123-177], 3.8 mmol/L (IQR 3.2-4.6). After a median follow up of 3.7 years (IQR 2.3-4.8), 27 patients (4%) discontinued PCSK9i treatment: 5 temporarily (0.7%) and 22 permanently (3.2%). Persistence with PCSK9i was 96.1% in the whole period. Median LDL-C levels and % LDL-C reduction attained after 1 year of treatment and in the last follow-up visit were 63 mg/dL (IQR 43-88), 1.6 mmol/L (IQR 1.1-2.23); 61 mg/dL (IQR 44-82), 1.6 mmol/L (IQR 1.1-2.1); 57.6% (IQR 39.5-69); and 58% (IQR 44-68), respectively. 2016 and 2019 ESC/EAS LDL-C goals were attained by 77 and 48% of patients, respectively, at the last follow-up visit (P < 0.001). Mean QoL score increased slightly in the first year and remained stable.

CONCLUSION

Long-term persistence with PCSK9i in FH patients is very high, with a good QoL. Effectiveness in LDL-C reduction and LDL-C goal achievement dramatically improved with PCSK9i in this high-risk population in clinical practice setting.

TRIAL REGISTRATION

ClinicalTrials.gov number NCT02693548.

Cost-Effectiveness of Vonoprazan Compared With Proton Pump Inhibitors in Patients Taking Low-Dose Aspirin for Secondary Prevention of Cardiovascular Events in Japan

BACKGROUND

Low-dose aspirin (LDA) is used to prevent recurrent cardiovascular (CV) events, but is associated with upper gastrointestinal (GI) bleeding; concomitant use of a proton pump inhibitor (PPI) reduces this risk. This study aimed to assess the cost-effectiveness of vonoprazan compared with PPIs (lansoprazole and esomeprazole) in patients taking LDA for secondary prevention of CV events.

METHODS AND RESULTS

A Markov simulation model was developed to predict the number of GI bleeding and acute CV events using 3 strategies (vonoprazan+LDA, esomeprazole+LDA, and lansoprazole+LDA), which were translated into quality-adjusted life-years (QALYs) and costs. Transition probabilities and utilities were derived from the results of published literature, and medical costs were based on the Japanese National Health Insurance fee table and claims databases in 2020. Outcomes were projected over 30 years starting at age 65 years and discounted at 2% annually. Expected costs with esomeprazole 20 mg, lansoprazole 15 mg and vonoprazan 10 mg were JPY 1,225,657, JPY 943,930, and JPY 1,059,510, respectively. The QALY gain for vonoprazan vs. esomeprazole was 0.35, thus vonoprazan was dominant against esomeprazole. The QALY gain for vonoprazan vs. lansoprazole was 0.29 and the incremental cost-effectiveness ratio (ICER) was JPY 398,551, thus, vonoprazan was more cost-effective than lansoprazole.

CONCLUSIONS

Vonoprazan is dominant or cost-effective compared with esomeprazole and lansoprazole in patients taking LDA for secondary prevention of CV events.

Confidence in self-care after heart failure hospitalization

BACKGROUND

Understanding patient perspectives of self-care is critical for improving multidisciplinary education programs and adherence to such programs. However, perspectives of self-care for patients with heart failure (HF) as well as the association between patient perspectives and patient-physician communication remain unclear.

METHODS

Confidence levels regarding self-care behaviors (eight lifestyle behaviors and four consulting behaviors) and self-monitoring were assessed using a self-administered questionnaire survey, which was directly distributed by dedicated physicians and nurses to consecutive patients hospitalized with HF in a tertiary-level hospital. Patient-physician communication was evaluated according to the quality of physician-provided information regarding "treatment and treatment choices" and "prognosis" using the Prognosis and Treatment Perception Questionnaire. Out of 202 patients, 187 (92.6 %) agreed to participate, and 176 completed the survey [valid response rate, 87.1 %; male, 67.0 %; median age, 73 (63-81) years]. Multivariate logistic regression analyses were conducted to predict low confidence in self-care (score in the lowest quartile).

RESULTS

High confidence (confident or completely confident >75 % of patients) was observed for all self-care behavior categories except low-salt diet (63.1 %), regular exercise (63.1 %), and flu vaccination (65.9 %). Lower confidence in self-care behavior was associated with low quality of patient-physician communication. With regard to self-monitoring, 62.5 % of patients were not confident in distinguishing worsening symptoms of HF from other diseases; non-confidence was also associated with low quality of patient-physician communication.

CONCLUSIONS

Hospitalized patients with HF had low confidence regarding regular exercise, salt restriction, and flu vaccination. The results also suggest patient-physician communication affects patient confidence.