The influence of parents' and partner's education on own health behaviours

The link between educational attainment and multiple health behaviours has been explained in various ways. This paper provides new insights into the social patterning in health behaviours by investigating the influence of parents' and partners' educational attainments on a composite indicator that integrates the four commonly studied lifestyle behaviours (smoking, alcohol, physical activity and BMI). Two key outcome indicators of interests were created to reflect both ends of the "healthy - unhealthy spectrum". Data was drawn from The Tromsø Study, conducted in 2015/16 (N = 21,083, aged 40-93 years). We controlled for two indicators of early life human capital and one personality trait variable. Partners' education attainments are relatively more important for avoiding unhealthy behaviour than choosing healthy behaviour; on the contrary, parents' education is more important for healthy behaviour. Heterogeneity by sex and age was also evident. The influences of partner's education on widening the socioeconomic contrasts in health behaviours were much stronger in the younger (40-59 years) age group. In conclusion, our results support the hypothesis that own health behaviour is affected by the educational attainments of our 'nearest and dearest' (i.e. spouse, mother, and father), net of own education. This study facilitates a better understanding of education-health behaviours nexus from a life course perspective and supports the importance of family-based interventions to improve healthy behaviours.

The relative importance of education and health behaviour for health and wellbeing

BACKGROUND

Indicators of socioeconomic position (SEP) and health behaviours (HB) are widely used predictors of health variations. Their relative importance is hard to establish, because HB takes a mediating role in the link between SEP and health. We aim to provide new knowledge on how SEP and HB are related to health and wellbeing.

METHODS

The analysis considered 14,713 Norwegians aged 40-63. Separate regressions were performed using two outcomes for health-related quality of life (EQ-5D-5 L; EQ-VAS), and one for subjective wellbeing (Satisfaction with Life Scale). As predictors, we used educational attainment and a composite measure of HB - both categorized into four levels. We adjusted for differences in childhood financial circumstances, sex and age. We estimated the percentage share of each predictor in total explained variation, and the relative contributions of HB in the education-health association.

RESULTS

The reference case model, excluding HB, suggests consistent stepwise education gradients in health-related quality of life. The gap between the lowest and highest education was 0.042 on the EQ-5D-5 L, and 0.062 on the EQ-VAS. When including HB, the education effects were much attenuated, making HB take the lion share of the explained health variance. HB contributes 29% of the education-health gradient when health is measured by EQ-5D-5 L, and 40% when measured by EQ-VAS. For subjective wellbeing, we observed a strong HB-gradient, but no education gradient.

CONCLUSION

In the institutional context of a rich egalitarian country, variations in health and wellbeing are to a larger extent explained by health behaviours than educational attainment.

Related variations: A novel approach for detecting patterns of regional variations in healthcare utilisation rates

Regional variations in healthcare utilisation rates are ubiquitous and persistent. In settings where an aggregate national health service budget is allocated primarily on a per capita basis, little regional variation in total healthcare utilisation rates will be observed. However, for specific treatments, large variations in utilisation rates are observed, iymplying a substitution effect at some point in service delivery. The current paper investigates the extent to which this substitution effect occurs within or between specialties, particularly distinguishing between emergency versus elective care. We used data from Statistics Norway and the Norwegian Patient Registry on eight somatic surgeries for all patients treated from 2010 to 2015. We calculated Diagnosis-Related Group (DRG) -weight per capita in 19 hospital regions. We applied principal component analysis (PCA) to demonstrate patterns in DRG-weight, annual relative changes in DRG-weight, and DRG-weight production for elective care. We show that treatments with similar characteristics cluster within regions. Treatment frequency explains 29% of the total variation in treatment rates. In a dynamic model, treatments with a high degree of emergency care are negatively correlated with treatments with a high degree of elective care. Furthermore, when considering only elective care treatments, the substitution effect occurs between specialties and explains 49% of the variation. When designing policies aimed at reducing regional variations in healthcare utilisation, a distinction between elective and emergency care as well as substitution effects need to be considered.

Inequality in quality-adjusted life expectancy by educational attainment in Norway: an observational study

BACKGROUND

Health inequalities are often assessed in terms of life expectancy or health-related quality of life (HRQoL). Few studies combine both aspects into quality-adjusted life expectancy (QALE) to derive comprehensive estimates of lifetime health inequality. Furthermore, little is known about the sensitivity of estimated inequalities in QALE to different sources of HRQoL information. This study assesses inequalities in QALE by educational attainment in Norway using two different measures of HRQoL.

METHODS

We combine full population life tables from Statistics Norway with survey data from the Tromsø study, a representative sample of the Norwegian population aged ≥ 40. HRQoL is measured using the EQ-5D-5L and EQ-VAS instruments. Life expectancy and QALE at 40 years of age are calculated using the Sullivan-Chiang method and are stratified by educational attainment. Inequality is measured as the absolute and relative gap between individuals with lowest (i.e. primary school) and highest (university degree 4 + years) educational attainment.

RESULTS

People with the highest educational attainment can expect to live longer lives (men: + 17.9% (95%CI: 16.4 to 19.5%), women: + 13.0% (95%CI: 10.6 to 15.5%)) and have higher QALE (men: + 22.4% (95%CI: 20.4 to 24.4%), women: + 18.3% (95%CI: 15.2 to 21.6%); measured using EQ-5D-5L) than individuals with primary school education. Relative inequality is larger when HRQoL is measured using EQ-VAS.

CONCLUSION

Health inequalities by educational attainment become wider when measured in QALE rather than LE, and the degree of this widening is larger when measuring HRQoL by EQ-VAS than by EQ-5D-5L. We find a sizable educational gradient in lifetime health in Norway, one of the most developed and egalitarian societies in the world. Our estimates provide a benchmark against which other countries can be compared.

Amplified disparities: The association between spousal education and own health

Positive associations between own educational attainment and own health have been extensively documented. Studies have also shown spousal educational attainment to be associated with own health. This paper investigates the extent to which spousal education contributes to the social gradient in health, net of own education; and whether parts of a seeming spousal education effect are attributable to differences in early-life human capital, as measured by respondents' height and childhood living standard. Furthermore, we investigate the relative contribution of predictors in the regression analysis by use of Shapley value decomposition. We use data from a comprehensive health survey from Northern Norway (conducted in 2015/16, N = 21,083, aged 40 and above). We apply three alternative health outcome measures: the EQ-5D-5L index, a visual analogue scale (EQ-VAS) and self-rated health. In all models considered, spousal education is generally positively significant for both men and women. The results also suggest that spousal education is generally more important for men than women. In the sub-sample of individuals having a spouse, decomposition analyses showed that the relative contribution of spousal education to the goodness-of-fit in men's (women's) health was 13% (14%) with the EQ-5D-5L; 25% (20%) with the EQ-VAS and; 30% (21%) with self-rated health. Heterogeneity analyses showed stronger spousal education effects in younger age groups. In conclusion, we have provided empirical evidence that spousal education may contribute to explaining the amplified health gradient in an egalitarian country like Norway.

Extending the EQ-5D: the case for a complementary set of 4 psycho-social dimensions

OBJECTIVES

The EQ-5D is the most widely applied preference-based health-related quality of life measure. However, concerns have been raised that the existing dimensional structure lacks sufficient components of mental and social aspects of health. This study empirically explored the performance of a coherent set of four psycho-social bolt-ons: Vitality; Sleep; Personal relationships; and Social isolation.

METHODS

Cross-sectional surveys were conducted with online panel members from five countries (Australia, Canada, Norway, UK, US) (total N = 4786). Four bolt-ons were described using terms aligned with EQ nomenclature. Latent structures among all nine dimensions are studied using an exploratory factor analysis (EFA). The Shorrocks-Shapely decomposition analyses are conducted to illustrate the relative importance of the nine dimensions in explaining two outcome measures for health (EQ-VAS, satisfaction with health) and two for subjective well-being (the hedonic approach of global life satisfaction and an eudemonic item on meaningfulness). Sub-group analyses are performed on older adults (65 +) and socially disadvantaged groups.

RESULTS

Strength of correlations among four bolt-ons ranges from 0.34 to 0.49. As for their correlations with the EQ-5D dimensions, they are generally much less correlated with four physical health dimensions than with mental health dimensions (ranged from 0.21 to 0.50). The EFA identifies two latent factors. When explaining health, Vitality is the most important. When explaining subjective well-being, Social isolation is second most important, after Anxiety/depression.

CONCLUSION

We provide evidence that further complementing the current EQ-5D-5L health state classification system with a coherent set of four bolt-on dimensions that will fill its psycho-social gap.

Inequality of opportunity in a land of equal opportunities: The impact of parents' health and wealth on their offspring's quality of life in Norway

BACKGROUND

The literature on Inequality of opportunity (IOp) in health distinguishes between circumstances that lie outside of own control vs. efforts that - to varying extents - are within one's control. From the perspective of IOp, this paper aims to explain variations in individuals' health-related quality of life (HRQoL) by focusing on two separate sets of variables that clearly lie outside of own control: Parents' health is measured by their experience of somatic diseases, psychological problems and any substance abuse, while parents' wealth is indicated by childhood financial conditions (CFC). We further include own educational attainment which may represent a circumstance, or an effort, and examine associations of IOp for different health outcomes. HRQoL are measured by EQ-5D-5L utility scores, as well as the probability of reporting limitations on specific HRQoL-dimensions (mobility, self-care, usual-activities, pain & discomfort, and anxiety and depression).

METHOD

We use unique survey data (N = 20,150) from the egalitarian country of Norway to investigate if differences in circumstances produce unfair inequalities in health. We estimate cross-sectional regression models which include age and sex as covariates. We estimate two model specifications. The first represents a narrow IOp by estimating the contributions of parents' health and wealth on HRQoL, while the second includes own education and thus represents a broader IOp, alternatively it provides a comparison of the relative contributions of an effort variable and the two sets of circumstance variables.

RESULTS

We find strong associations between the circumstance variables and HRQoL. A more detailed examination showed particularly strong associations between parental psychological problems and respondents' anxiety and depression. Our Shapley decomposition analysis suggests that parents' health and wealth are each as important as own educational attainment for explaining inequalities in adult HRQoL.

CONCLUSION

We provide evidence for the presence of the lasting effect of early life circumstances on adult health that persists even in one of the most egalitarian countries in the world. This suggests that there may be an upper limit to how much a generous welfare state can contribute to equal opportunities.

Combining education and income into a socioeconomic position score for use in studies of health inequalities

Background

In studies of social inequalities in health, there is no consensus on the best measure of socioeconomic position (SEP). Moreover, subjective indicators are increasingly used to measure SEP. The aim of this paper was to develop a composite score for SEP based on weighted combinations of education and income in estimating subjective SEP, and examine how this score performs in predicting inequalities in health-related quality of life (HRQoL).

Methods

We used data from a comprehensive health survey from Northern Norway, conducted in 2015/16 (N = 21,083). A composite SEP score was developed using adjacent-category logistic regression of subjective SEP as a function of four education and four household income levels. Weights were derived based on these indicators’ coefficients in explaining variations in respondents’ subjective SEP. The composite SEP score was further applied to predict inequalities in HRQoL, measured by the EQ-5D and a visual analogue scale.

Results

Education seemed to influence SEP the most, while income added weight primarily for the highest income category. The weights demonstrated clear non-linearities, with large jumps from the middle to the higher SEP score levels. Analyses of the composite SEP score indicated a clear social gradient in both HRQoL measures.

Conclusions

We provide new insights into the relative contribution of education and income as sources of SEP, both separately and in combination. Combining education and income into a composite SEP score produces more comprehensive estimates of the social gradient in health. A similar approach can be applied in any cohort study that includes education and income data.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13366-8.

Who keeps on working? The importance of resilience for labour market participation

Background

It is widely recognized that individuals’ health and educational attainments, commonly referred to as their human capital, are important determinants for their labour market participation (LMP). What is less recognised is the influence of individuals’ latent resilience traits on their ability to sustain LMP after experiencing an adversity such as a health shock.

Aim

We investigate the extent to which resilience is independently associated with LMP and moderates the effect of health shocks on LMP.

Method

We analysed data from two consecutive waves of a Norwegian prospective cohort study. We followed 3,840 adults who, at baseline, were healthy and worked full time. Binary logistic regression models were applied to explain their employment status eight years later, controlling for age, sex, educational attainment, health status at baseline, as well as the occurrences of three types of health shocks (cardiovascular diseases, cancer, psychological problems). Individuals’ resilience, measured by the Resilience Scale for Adults (RSA), entered as an independent variable and as an interaction with the indicators of health shocks. In separate models, we explore the role of two further indicators of resilience; locus of control, and health optimism.

Results

As expected, health shocks reduce the probability to keep on working full-time. While both the RSA and the two related indicators all suggest that resilience increases the probability to keep on working, we did not find evidence that resilience moderates the association between health shocks and LMP.

Conclusion

Higher levels of resilience is associated with full-time work as individuals age.

Explaining subjective social status in two countries: The relative importance of education, occupation, income and childhood circumstances

In the literature on social inequalities in health, subjective socioeconomic position (SEP) is increasingly applied as a determinant of health, motivated by the hypothesis that having a high subjective SEP is health-enhancing. However, the relative importance of determinants of subjective SEP is not well understood. Objective SEP indicators, such as education, occupation and income, are assumed to determine individuals' position in the status hierarchy. Furthermore, an extensive literature has shown that past childhood SEP affects adult health. Does it also affect subjective SEP? In this paper, we estimate the relative importance of i) the common objective SEP indicators (education, occupation and income) in explaining subjective SEP, and ii) childhood SEP (childhood financial circumstances and parents' education) in determining subjective SEP, after controlling for objective SEP. Given that the relative importance of these factors is expected to differ across institutional settings, we compare data from two countries: Australia and Norway. We use data from an online survey based on adult samples, with N ≈ 1400 from each country. Ordinary least squares regression is conducted to assess how objective and childhood SEP indicators predict subjective SEP. We use Shapley value decomposition to estimate the relative importance of these factors in explaining subjective SEP. Income was the strongest predictor of subjective SEP in Australia; in Norway, it was occupation. Of the childhood SEP variables, childhood financial circumstances were significantly associated with subjective SEP, even after controlling for objective SEP. This association was the strongest in the Norwegian sample. Only the mother's education had a significant impact on subjective SEP. Our findings highlight the need to understand the specific mechanisms between objective and subjective SEP as determinants of inequalities in health, and to assess the role of institutional factors in influencing these complex relationships.

Shock decision algorithm for use during load distributing band cardiopulmonary resuscitation

AIM

Chest compressions delivered by a load distributing band (LDB) induce artefacts in the electrocardiogram. These artefacts alter shock decisions in defibrillators. The aim of this study was to demonstrate the first reliable shock decision algorithm during LDB compressions.

METHODS

The study dataset comprised 5813 electrocardiogram segments from 896 cardiac arrest patients during LDB compressions. Electrocardiogram segments were annotated by consensus as shockable (1154, 303 patients) or nonshockable (4659, 841 patients). Segments during asystole were used to characterize the LDB artefact and to compare its characteristics to those of manual artefacts from other datasets. LDB artefacts were removed using adaptive filters. A machine learning algorithm was designed for the shock decision after filtering, and its performance was compared to that of a commercial defibrillator's algorithm.

RESULTS

Median (90% confidence interval) compression frequencies were lower and more stable for the LDB than for the manual artefact, 80 min^-1 (79.9-82.9) vs. 104.4 min^-1 (48.5-114.0). The amplitude and waveform regularity (Pearson's correlation coefficient) were larger for the LDB artefact, with 5.5 mV (0.8-23.4) vs. 0.5 mV (0.1-2.2) (p < 0.001) and 0.99 (0.78-1.0) vs. 0.88 (0.55-0.98) (p < 0.001). The shock decision accuracy was significantly higher for the machine learning algorithm than for the defibrillator algorithm, with sensitivity/specificity pairs of 92.1/96.8% (machine learning) vs. 91.4/87.1% (defibrillator) (p < 0.001).

CONCLUSION

Compared to other cardiopulmonary resuscitation artefacts, removing the LDB artefact was challenging due to larger amplitudes and lower compression frequencies. The machine learning algorithm achieved clinically reliable shock decisions during LDB compressions.

Filling the psycho-social gap in the EQ-5D: the empirical support for four bolt-on dimensions

PURPOSE

The EQ-5D is the most widely applied generic preference-based measure (GPBM) of health-related quality of life (HRQoL). Much concern has been raised that its descriptive system is lacking psycho-social dimensions. A recent paper in this journal provided theoretical support for four dimensions to fill this gap. The current paper aims to provide empirical support for these suggested bolt-on dimensions to the EQ-5D.

METHODS

We use data from the comprehensive Multi-Instrument-Comparison (MIC) study. The four proposed bolt-on dimensions (Vitality, Sleep, Social Relationships, and Community Connectedness) were selected from the Assessment of Quality of Life (AQoL)-8D. We investigate the relative importance of these four dimensions as compared to the five EQ-5D-5L dimensions on explaining HRQoL (measured by a visual analogue scale; N = 7846) or global life satisfaction (measured by the Satisfaction With Life Scale; N = 8005), using the Shorrocks-Shapely decomposition analysis. Robustness analyses on Vitality was conducted using data from the United States National Health Measurement Study (NHMS) (N = 3812).

RESULTS

All five EQ-5D-5L dimensions and four bolt-on dimensions significantly explained the variance of HRQoL. Among them, Vitality was found to be the most important dimension with regard to the HRQoL (relative contribution based on the Shorrocks-Shapely decomposition of R2: 23.0%), followed by Usual Activities (15.1%). Self-Care was the least important dimension (relative contribution: 5.4%). As a comparison, when explaining global life satisfaction, Social Relationships was the most important dimension (relative contribution: 24.0%), followed by Anxiety/Depression (23.2%), while Self-Care remained the least important (relative contribution: 1.6%). The importance of the Vitality dimension in explaining HRQoL was supported in the robustness analysis using the NHMS data (relative contribution: 23.7%).

CONCLUSIONS

We provide empirical support for complementing the current EQ-5D-5L descriptive system with a coherent set of four bolt-on dimensions that will fill its psycho-social gap. Such an extended health state classification system would in particular be relevant for programme evaluations within the expanding fields of mental health and community care.

Health and wellbeing in Norway: Population norms and the social gradient

Measures of health-related quality of life are important in health technology assessments, and useful when analysing health inequalities across population sub-groups. This paper provides population norms on health and wellbeing in Norway based on two waves of a comprehensive health survey: Wave 6 of The Tromsø Study conducted in 2007/08 (N = 12,981) and Wave 7 conducted in 2015/16 (N = 21,083). By use of these data, the paper aims to provide new insight on how different measures of health and wellbeing, and different indicators for socio-economic position, will affect the magnitude of a reported social gradient in health. We apply validated multi-item instruments for measuring health and subjective well-being; the health state utility instrument EQ-5D, and the satisfaction with life scale, as well as a direct valuation of health on a visual analogue scale. We apply three indicators for socio-economic position; education, occupation and household income, each measured along four levels. After descriptive statistics, regression analyses are performed separately for men and women, adjusted for age, to explain the magnitude of the social gradient along each socio-economic indicator. The social gradient in health showed a consistent positive trend, along all three socio-economic indicators; it was strongest with income, and weakest with education. When health had been valued directly on a visual analogue scale, the gradient was steeper than when valued indirectly via the EQ-5D descriptive system. The social gradient in subjective well-being also showed consistent positive trends, except with education as the socio-economic indicator. We have shown that the magnitude of the social gradient critically depends on which socio-economic indicator is used, and whether health is being measured indirectly via the EQ-5D descriptive system or directly on a visual analogue scale. The strongest gradient in subjective well-being was observed with income as the socio-economic indicator.

Associations between utilization rates and patients' health: a study of spine surgery and patient-reported outcomes (EQ-5D and ODI)

Background

A vast body of literature has documented regional variations in healthcare utilization rates. The extent to which such variations are “unwarranted” critically depends on whether there are corresponding variations in patients’ needs. Using a unique medical registry, the current paper investigated any associations between utilization rates and patients’ needs, as measured by two patient-reported outcome measures (PROMs).

Methods

This observational panel study merged patient-level data from the Norwegian Patient Registry (NPR), Statistics Norway, and the Norwegian Registry for Spine Surgery (NORspine) for individuals who received surgery for degenerative lumbar spine disorders in 2010–2015. NPR consists of hospital administration data. NORspine includes two PROMs: the generic health-related quality of life instrument EQ-5D and the disease-specific, health-related quality of life instrument Oswestry Disability Index (ODI). Measurements were assessed at baseline and at 3 and 12 months post-surgery and included a wide range of patient characteristics. Our case sample included 15,810 individuals. We analyzed all data using generalized estimating equations.

Results

Our results show that as treatment rates increase, patients have better health at baseline. Furthermore, increased treatment rates are associated with smaller health gain.

Conclusion

The correlation between treatment rates and patients health indicate the presence of unwarranted variation in treatment rates for lumbar spine disorders.

A conceptual map of health-related quality of life dimensions: key lessons for a new instrument

Purpose

Quality-adjusted life years (QALYs) represent a critical metric in economic evaluations impacting key healthcare decisions in many countries. However, there is widespread disagreement as to which is the best of the health state utility (HSU) instruments that are designed to measure the Q in the QALY. Instruments differ in their descriptive systems as well as their valuation methodologies; that is, they simply measure different things. We propose a visual framework that can be utilized to make meaningful comparisons across HSU instruments.

Methods

The framework expands on existing HRQoL models, by incorporating four distinctive continua, and by putting HRQoL within the broader notion of subjective well-being (SWB). Using this conceptual map, we locate the five most widely used HSU-instruments (EQ-5D, SF-6D, HUI, 15D, AQoL).

Results

By individually mapping dimensions onto this visual framework, we provide a clear picture of the significant conceptual and operational differences between instruments. Moreover, the conceptual map demonstrates the varying extent to which each instrument moves outside the traditional biomedical focus of physical health, to also incorporate indicators of mental health and social well-being.

Conclusion

Our visual comparison provides useful insights to assess the suitability of different instruments for particular purposes. Following on from this comparative analyses, we extract some important lessons for a new instrument that cover the domains of physical, mental and social aspects of health, i.e. it is in alignment with the seminal 1948 WHO definition of health.

Cost-Effectiveness of Telemedicine in Remote Orthopedic Consultations: Randomized Controlled Trial

BACKGROUND

Telemedicine consultations using real-time videoconferencing has the potential to improve access and quality of care, avoid patient travels, and reduce health care costs.

OBJECTIVE

The aim of this study was to examine the cost-effectiveness of an orthopedic videoconferencing service between the University Hospital of North Norway and a regional medical center in a remote community located 148 km away.

METHODS

An economic evaluation based on a randomized controlled trial of 389 patients (559 consultations) referred to the hospital for an orthopedic outpatient consultation was conducted. The intervention group (199 patients) was randomized to receive video-assisted remote orthopedic consultations (302 consultations), while the control group (190 patients) received standard care in outpatient consultation at the hospital (257 consultations). A societal perspective was adopted for calculating costs. Health outcomes were measured as quality-adjusted life years (QALYs) gained. Resource use and health outcomes were collected alongside the trial at baseline and at 12 months follow-up using questionnaires, patient charts, and consultation records. These were valued using externally collected data on unit costs and QALY weights. An extended sensitivity analysis was conducted to address the robustness of the results.

RESULTS

This study showed that using videoconferencing for orthopedic consultations in the remote clinic costs less than standard outpatient consultations at the specialist hospital, as long as the total number of patient consultations exceeds 151 per year. For a total workload of 300 consultations per year, the annual cost savings amounted to €18,616. If costs were calculated from a health sector perspective, rather than a societal perspective, the number of consultations needed to break even was 183.

CONCLUSIONS

This study showed that providing video-assisted orthopedic consultations to a remote clinic in Northern Norway, rather than having patients travel to the specialist hospital for consultations, is cost-effective from both a societal and health sector perspective. This conclusion holds as long as the activity exceeds 151 and 183 patient consultations per year, respectively.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00616837; https://clinicaltrials.gov/ct2/show/NCT00616837 (Archived by WebCite at http://www.webcitation.org/762dZPoKX).

Correction: Violence Affects Physical and Mental Health Differently: The General Population Based Tromsø Study

[This corrects the article DOI: 10.1371/journal.pone.0136588.].

Exploring the causal and effect nature of EQ-5D dimensions: an application of confirmatory tetrad analysis and confirmatory factor analysis

BACKGROUND

The relationship between the various items in an HRQoL instrument is a key aspect of interpreting and understanding preference weights. The aims of this paper were i) to use theoretical models of HRQoL to develop a conceptual framework for causal and effect relationships among the five dimensions of the EQ-5D instrument, and ii) to empirically test this framework.

METHODS

A conceptual framework depicts the symptom dimensions [Pain/discomfort (PD) and Anxiety/depression (AD)] as causal indicators that drive a change in the effect indicators of activity/participation [Mobility (MO), Self-care (SC) and Usual activities (UA)], where MO has an intermediate position between PD and the other two effect dimensions (SC and UA). Confirmatory tetrad analysis (CTA) and confirmatory factor analysis (CFA) were used to test this framework using EQ-5D-5L data from 7933 respondents in six countries, classified as healthy (n = 1760) or in one of seven disease groups (n = 6173).

RESULTS

CTA revealed the best fit for a model specifying SC and UA as effect indicators and PD, AD and MO as causal indicators. This was supported by CFA, revealing a satisfactory fit to the data: CFI = 0.992, TLI = 0.972, RMSEA = 0.075 (90% CI 0.062-0.088), and SRMR = 0.012.

CONCLUSIONS

The EQ-5D appears to include both causal indicators (PD and AD) and effect indicators (SC and UA). Mobility played an intermediate role in our conceptual framework, being a cause of problems with Self-care and Usual activities, but also an effect of Pain/discomfort. However, the empirical analyses of our data suggest that Mobility is mostly a causal indicator.

Assessment of outcome measures for cost-utility analysis in depression: mapping depression scales onto the EQ-5D-5L

BACKGROUND

Many clinical studies including mental health interventions do not use a health state utility instrument, which is essential for producing quality-adjusted life years. In the absence of such utility instrument, mapping algorithms can be applied to estimate utilities from a disease-specific instrument.AimsWe aim to develop mapping algorithms from two widely used depression scales; the Depression Anxiety Stress Scales (DASS-21) and the Kessler Psychological Distress Scale (K-10), onto the most widely used health state utility instrument, the EQ-5D-5L, using eight country-specific value sets.

METHOD

A total of 917 respondents with self-reported depression were recruited to describe their health on the DASS-21 and the K-10 as well as the new five-level version of the EQ-5D, referred to as the EQ-5D-5L. Six regression models were used: ordinary least squares regression, generalised linear models, beta binomial regression, fractional logistic regression model, MM-estimation and censored least absolute deviation. Root mean square error, mean absolute error and r2 were used as model performance criteria to select the optimal mapping function for each country-specific value set.

RESULTS

Fractional logistic regression model was generally preferred in predicting EQ-5D-5L utilities from both DASS-21 and K-10. The only exception was the Japanese value set, where the beta binomial regression performed best.

CONCLUSIONS

Mapping algorithms can adequately predict EQ-5D-5L utilities from scores on DASS-21 and K-10. This enables disease-specific data from clinical trials to be applied for estimating outcomes in terms of quality-adjusted life years for use in economic evaluations.Declaration of interestNone.

Do country-specific preference weights matter in the choice of mapping algorithms? The case of mapping the Diabetes-39 onto eight country-specific EQ-5D-5L value sets

PURPOSE

To develop mapping algorithms that transform Diabetes-39 (D-39) scores onto EQ-5D-5L utility values for each of eight recently published country-specific EQ-5D-5L value sets, and to compare mapping functions across the EQ-5D-5L value sets.

METHODS

Data include 924 individuals with self-reported diabetes from six countries. The D-39 dimensions, age and gender were used as potential predictors for EQ-5D-5L utilities, which were scored using value sets from eight countries (England, Netherland, Spain, Canada, Uruguay, China, Japan and Korea). Ordinary least squares, generalised linear model, beta binomial regression, fractional regression, MM estimation and censored least absolute deviation were used to estimate the mapping algorithms. The optimal algorithm for each country-specific value set was primarily selected based on normalised root mean square error (NRMSE), normalised mean absolute error (NMAE) and adjusted-r². Cross-validation with fivefold approach was conducted to test the generalizability of each model.

RESULTS

The fractional regression model with loglog as a link function consistently performed best in all country-specific value sets. For instance, the NRMSE (0.1282) and NMAE (0.0914) were the lowest, while adjusted-r² was the highest (52.5%) when the English value set was considered. Among D-39 dimensions, the energy and mobility was the only one that was consistently significant for all models.

CONCLUSIONS

The D-39 can be mapped onto the EQ-5D-5L utilities with good predictive accuracy. The fractional regression model, which is appropriate for handling bounded outcomes, outperformed other candidate methods in all country-specific value sets. However, the regression coefficients differed reflecting preference heterogeneity across countries.

Yes, health is important, but as much for its importance via social life: The direct and indirect effects of health on subjective well-being in chronically ill individuals

There is an increasing evidence that health-related quality of life, income, and social relationships are important to our subjective well-being (SWB). Little is known, however, about the specific indirect pathways that link health to SWB via social relationships and income. On the basis of a unique data set of 7 disease groups from 6 OECD-countries (N = 6,173), we investigate the direct and indirect effects of health on SWB by using structural equation modeling. Three alternative measures of health are used: For generic instruments (EQ-5D-5L; SF-6D), the total indirect effect was stronger (0.226; 0.249) than its direct effect (0.157; 0.205). For the visual analogue scale, the direct effect was stronger (0.322) than its total indirect effect (0.179). Most of the indirect effect of improved health on SWB transmitted through social relationships. The effect via income was small. Nevertheless, the presence of unmeasured confounders may bias the estimates. An important lesson for researchers is to include meaningful items on social relationships when measuring the benefits from improved health. An important lesson for policy makers is that social isolation appears to be more detrimental to overall well-being than ill health. Hence, the Health and Care Services should facilitate social arenas for people with chronic conditions.

In search of a common currency: A comparison of seven EQ-5D-5L value sets

The recently published EQ-5D-5L value sets from Canada, England, Japan, Korea, the Netherlands, Spain, and Uruguay are compared with an aim to identify any similarities in preference pattern. We identify some striking similarities for Canada, England, the Netherlands, and Spain in terms of (a) the relative importance of the 5 dimensions; (b) the relative utility decrements across the 5 levels; and (c) the scale length. On the basis of the observed similarities across these 4 Western countries, we develop an amalgam model, WePP (western preference pattern), and compare it with these 4 value sets. The values generated by this model show a high degree of concordance with those of England, Canada, and Spain. Patient level data were obtained from the Multi-Instrument Comparison project, which includes participants from 6 countries in 7 disease groups (N = 7,933): The WePP values lie within the confidence intervals for the value sets in Canada, England, and Spain across the whole severity distribution. We suggest that the WePP model represents a useful "common currency" for (Western) countries that have not yet developed their own value sets. Further research is needed to disentangle the differences between value sets due to preference heterogeneity from those stemming from methodological differences.

Preference Weighting of Health State Values: What Difference Does It Make, and Why?

BACKGROUND

Most patient-reported outcome measures apply a simple summary score to assess health-related quality of life, whereby equal weight is normally assigned to each item. In the generic preference-based instruments, utility weighting is essential whereby health state values are estimated through preference elicitation and complex algorithms.

OBJECTIVES

To examine the extent to which preference-weighted value sets differ from unweighted values in the five-level EuroQol five-dimensional questionnaire and the 15D instrument, on the basis of a comprehensive data set from six member countries of the Organisation for Economic Co-operation and Development, each with a representative healthy sample and seven disease groups (N = 7933).

METHODS

Construct validities were examined. The level of agreement between preference-weighted and unweighted values was also assessed using intraclass correlation coefficient (ICC), Bland-Altman plots, and reduced major axis regression.

RESULTS

The performances of preference-weighted and unweighted measures were comparable with regard to convergent and known-group validities for each instrument. Although unweighted values in the five-level EuroQol five-dimensional questionnaire differ considerably from the preference-weighted values at the individual level, the discrepancy is minimal at the group level with a mean difference of 0.023. The ICC (0.96) and the Bland-Altman plot also suggest strong overall agreement. For the 15D, both the ICC (0.99) and the Bland-Altman plot revealed almost perfect agreement, with a negligible mean difference of -0.001. Results from the reduced major axis regression also showed small bias.

CONCLUSIONS

Overall, preference weighting has minimal effect if the unweighted values are anchored on the same scale as the preference-weighted value sets.

Differential Recall Bias, Intermediate Confounding, and Mediation Analysis in Life Course Epidemiology: An Analytic Framework with Empirical Example

The mechanisms by which childhood socioeconomic status (CSES) affects adult mental health, general health, and well-being are not clear. Moreover, the analytical assumptions employed when assessing mediation in social and psychiatric epidemiology are rarely explained. The aim of this paper was to explain the intermediate confounding assumption, and to quantify differential recall bias in the association between CSES, childhood abuse, and mental health (SCL-10), general health (EQ-5D), and subjective well-being (SWLS). Furthermore, we assessed the mediating role of psychological and physical abuse in the association between CSES and mental health, general health, and well-being; and the influence of differential recall bias in the estimation of total effects, direct effects, and proportion of mediated effects. The assumptions employed when assessing mediation are explained with reference to a causal diagram. Poisson regression models (relative risk, RR and 99% CIs) were used to assess the association between CSES and psychological and physical abuse in childhood. Mediation analysis (difference method) was used to assess the indirect effect of CSES (through psychological and physical abuse in childhood) on mental health, general health, and well-being. Exposure (CSES) was measured at two time points. Mediation was assessed with both cross-sectional and longitudinal data. Psychological abuse and physical abuse mediated the association between CSES and adult mental health, general health, and well-being (6–16% among men and 7–14% among women, p < 0.001). The results suggest that up to 27% of the association between CSES and childhood abuse, 23% of the association between childhood abuse, and adult mental health, general health, and well-being, and 44% of the association between CSES and adult mental health, general health, and well-being is driven by differential recall bias. Assessing mediation with cross-sectional data (exposure, mediator, and outcome measured at the same time) showed that the total effects and direct effects were vastly overestimated (biased upwards). Consequently, the proportion of mediated effects were underestimated (biased downwards). If there is a true (unobserved) direct or indirect effect, and the direction of the differential recall bias is predictable, then the results of cross-sectional analyses should be discussed in light of that.

Modelling Nonlinearities and Reference Dependence in General Practitioners' Income Preferences

This paper tests for the existence of nonlinearity and reference dependence in income preferences for general practitioners. Confirming the theory of reference dependent utility within the context of a discrete choice experiment, we find that losses loom larger than gains in income for Norwegian general practitioners, i.e. they value losses from their current income level around three times higher than the equivalent gains. Our results are validated by comparison with equivalent contingent valuation values for marginal willingness to pay and marginal willingness to accept compensation for changes in job characteristics. Physicians' income preferences determine the effectiveness of 'pay for performance' and other incentive schemes. Our results may explain the relative ineffectiveness of financial incentive schemes that rely on increasing physicians' incomes. Copyright © 2015 John Wiley & Sons, Ltd.

The relative importance of health, income and social relations for subjective well-being: An integrative analysis

There is much evidence that health, income and social relationships are important for our well-being, but little evidence on their relative importance. This study makes an integrative analysis of the relative influence of health related quality of life (HRQoL), household income and social relationships for subjective well-being (SWB), where SWB is measured by the first three of the five items on the satisfaction with life scale (SWLS). In a comprehensive 2012 survey from six countries, seven disease groups and representative healthy samples (N = 7933) reported their health along several measures of HRQoL. A Shapley value decomposition method measures the relative importance of health, income and social relationships, while a quantile regression model tests how the effects of each of the three predictors vary across different points of SWB distributions. Results are compared with the standard regression. The respective marginal contribution of social relationships, health and income to SWB (as a share of goodness-of-fit) is 50.2, 19.3 and 7.3% when EQ-5D-5L is used as a measure of health. These findings are consistent across models based on five alternative measures of HRQoL. The influence of the key determinants varied significantly between low and high levels of the SWB distribution, with health and income having stronger influence among those with relatively lower SWB. Consistent with several studies, income has a significantly positive association with SWB, but with diminishing importance.

Violence Affects Physical and Mental Health Differently: The General Population Based Tromsø Study

This general population-based study examined associations between violence and mental health, musculoskeletal pain, and early disability pension. The prevalence and consequences of good vs. poor adjustment (resilience vs. vulnerability) following encounters with violence were also examined. Data were based on the sixth wave of the "Tromsø Study" (N = 12,981; 65.7% response rate, 53.4% women, M-age = 57.5 years, SD-age = 12.7 years). Self-reported data on psychological (threats) and physical violence (beaten/kicked), mental health (anxiety/depression), musculoskeletal pain (MSP), and granting of disability pension (DP) were collected. Men suffered more violent events during childhood than women did, and vice versa during adulthood. Psychological violence implied poorer mental health and slightly more MSP than physical violence. The risk of MSP was highest for violence occurring during childhood in women and during the last year for men. A dose-response relationship between an increasing number of violent encounters and poorer health was observed. About 58% of individuals reported no negative impact of violence (hence, resilience group), whereas 42% considered themselves as more vulnerable following encounters with violence. Regression analyses indicated comparable mental health but slightly more MSP in the resilience group compared to the unexposed group, whereas the vulnerable group had significantly worse health overall and a higher risk of early granting of DP. Resilience is not an all-or-nothing matter, as physical ailments may characterize individuals adapting well following encounters with violence.

Young doctors' preferences for payment systems: the influence of gender and personality traits

OBJECTIVE

Activity-based payment contracts are common among doctors, but to what extent are they preferred? The aim of this paper is to elicit young doctors' preferences for alternative payment systems before they have adapted to an existing system. We examine the existence of gender differences and the extent to which personality traits determine preferences.

METHODS

A cross-sectional survey of all final-year medical students and all interns in Norway examined the extent to which preferences for different payment systems depend on gender and personality traits. Data analysis relied on one-way ANOVA and multinomial logistic regression.

RESULTS

The current activity-based payment systems were the least preferred, both in hospitals (16.6%) and in general practice (19.7%). The contrasting alternative "fixed salary" achieved similar relative support. Approximately half preferred the hybrid alternative. When certainty associated with a payment system increased, its appeal rose for women and individuals who are less prestige-oriented, risk-tolerant or effort-tolerant. Activity-based systems were preferred among status- and income-oriented respondents.

CONCLUSION

The vast majority of young doctors prefer payment systems that are less activity-based than the current contracts offered in the Norwegian health service. Recruitment and retention in less prestigious medical specialities might improve if young doctors could choose payment systems corresponding with their diverse preferences.

Health Economics and Radium-223 (Xofigo®) in the Treatment of Metastatic Castration-Resistant Prostate Cancer (mCRPC): A Case History and a Systematic Review of the Literature

Objectives:

Prostate cancer (PC) is the most common cancer in Western countries. Recent advances in the treatment of metastatic castration resistant prostate cancer (mCRPC) have caused significant pressure on health care budgets. We aimed to exemplify this dilemma presenting an example, radium-223 (Xofigo®), and review the literature.

Methods:

A 74-year-old man diagnosed with mCRPC was referred to our department in October 2014 for radium-223 therapy. We faced the following dilemma: is radium-223 standard therapy? Is it cost-effective? Medline was searched employing the following search criteria: “radium-223”, “alpharadin”, “Xofigo” and “prostate”. Exclusion and inclusion criteria were applied. Guidelines and cost-effectiveness analyses were focused. We also searched the websites of ASCO, ESMO and ISPOR. The web was searched, using Yahoo and Google search engines, for Health Technology Assessments (HTAs).

Results:

181 publications were identified in the Medline database. Only four studies included the word “cost”, three “economics” and none “budget” in heading or abstract. None of the publications were thorough of cost analysis (cost-effectiveness, cost-utility, cost-minimizing or cost-of-illness analysis). Six HTAs and eight national guidelines were identified. The cost per quality adjusted life years was indicated €80.000-94,000. HTAs concluded reimbursement being not recommendable or no ultimate statement could be made. One pointed towards a limited use with caution.

Conclusion:

Guidelines were based on data from randomized clinical trials (RCTs). Health economics was not considered when guidelines were made. Most HTAs concluded this therapy not cost-effective or there was insufficient data for final conclusions. Licensing and reimbursement processes should be run simultaneously.

General practitioners' altered preferences for private practice vs. salaried positions: a consequence of proposed policy regulations?

Background

General practitioners (GPs) in most high-income countries have a history of being independent private providers with much autonomy. While GPs remain private providers, their autonomous position appears to be challenged by increased policy regulations. This paper examines the extent to which GPs’ preferences for private practice vs. salaried contracts changed in a period where a new health care reform, involving proposed increased regulations of the GPs, was introduced.

Methods

We use data collected from Norwegian GPs through structured online questionnaires in December 2009 and May 2012.

Results

We find that the proportion of GPs who prefer private practice (i.e. the default contract for GPs in Norway) decreases from 52% to 36% in the period from 2009 to 2012. While 67% of the GPs who worked in private practice preferred this type of contract in 2009, the proportion had dropped by 20 percentage points in 2012. Salaried contracts are preferred by GPs who are young, work in a small municipality, have more patients listed than they prefer, work more hours per week than they prefer, have relatively low income or few patients listed.

Conclusion

We find that GPs’ preferences for private practice vs. salaried positions have changed substantially in the last few years, with a significant shift towards salaried contracts. With the proportions of GPs remaining fairly similar across private practice and salaried positions, there is an increasing discrepancy between GPs’ current contract and their preferred one.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0777-4) contains supplementary material, which is available to authorized users.

Role of respondents' education as a mediator and moderator in the association between childhood socio-economic status and later health and wellbeing

Background

Most research assessing the effect of childhood socioeconomic status (CSES) on health in adulthood has focused on cause-specific mortality. Low CSES is associated with mortality from coronary heart disease, lung cancer, and respiratory diseases in adulthood. But little evidence is available on the unique effect of different indicators of CSES on subjective measures of health and wellbeing in adulthood.

Methods

Cross-sectional data from the last wave of The Tromsø Study (n = 12,984) was used to assess the unique effect of three indicators of CSES (childhood financial conditions, mothers’ education and fathers’ education) on a range of subjective health measures: EQ-5D health dimensions, self-rated health, age-comparative self-rated health, as well as subjective wellbeing. Data was analyzed with the Paramed command in Stata. Log-linear regression was used for the subjective measures of health and wellbeing to estimate the natural direct effects (NDE’s), natural indirect effects (NIE’s), controlled direct effects (CDE’s) and marginal total effects (MTE’s) as risk ratios (RRs).

Results

Low childhood financial conditions were associated with lower health and wellbeing in adulthood, independently of respondents’ education. Among men, Low childhood financial conditions increased the risk (NDE) of being unhealthy on the composite EQ-5D by 22% (RR 1.22, 95% 1.14-1.31) and on subjective wellbeing by 24% (RR 1.24, 95% 1.18-1.30), while for women the risk increased by 16% (RR 1.16, 95% 1.10-1.23) and 26% (RR 1.26, 95% 1.19-1.33), respectively. Among men, the NDE of low mothers’ education on age-comparative self-rated health increased by 9% (RR 1.09, 95% 1.01-1.16), while the NIE increased the risk by 3% (RR 1.03, 95% 1.01-1.04). The NDE of low mothers’ education increased the risk on anxiety/depression among women by 38% (RR 1.38, 95% 1.13-1.69), whereas the NIE increased the risk by 5% (RR 1.05, 95% 1.02-1.08).

Conclusions

Childhood financial conditions have a unique direct effect on a wide range of health and wellbeing measures. These findings apply to both men and women. Generally, parental education has an indirect effect on later health, but mothers’ education may also have a long-term direct effect on later health.

Estimating QALY gains in applied studies: a review of cost-utility analyses published in 2010

Reimbursement agencies in several countries now require health outcomes to be measured in terms of quality-adjusted life-years (QALYs), leading to an immense increase in publications reporting QALY gains. However, there is a growing concern that the various 'multi-attribute utility' (MAU) instruments designed to measure the Q in the QALY yield disparate values, implying that results from different instruments are incommensurable. By reviewing cost-utility analyses published in 2010, we aim to contribute to improved knowledge on how QALYs are currently calculated in applied analyses; how transparently QALY measurement is presented; and how large the expected incremental QALY gains are. We searched Embase, MEDLINE and NHS EED for all cost-utility analyses published in 2010. All analyses that had estimated QALYs gained from health interventions were included. Of the 370 studies included in this review, 48% were pharmacoeconomic evaluations. Active comparators were used in 71% of studies. The median incremental QALY gain was 0.06, which translates to 3 weeks in best imaginable health. The EQ-5D-3L is the dominant instrument used. However, reporting of how QALY gains are estimated is generally inadequate. In 55% of the studies there was no reference to which MAU instrument or direct valuation method QALY data came from. The methods used for estimating expected QALY gains are not transparently reported in published papers. Given the wide variation in utility scores that different methodologies may assign to an identical health state, it is important for journal editors to require a more transparent way of reporting the estimation of incremental QALY gains.

Eliciting preferences for prioritizing treatment of rare diseases: the role of opportunity costs and framing effects

BACKGROUND

Understanding societal preferences regarding resource allocation in the health sector has gained importance as countries increasingly base reimbursement decisions on economic evaluations. Preference elicitation using surveys, a common practice in the health sector, is subject to a range of framing effects.

OBJECTIVE

This research investigates the importance of (theoretically relevant) opportunity costs and (theoretically irrelevant) framing effects on stated preferences for prioritizing treatment of rare (orphan) diseases.

METHODS

We elicited preferences from Norwegians, aged 40-67, using simple trade-off exercises. Respondents were randomised to different opportunity costs of the rare disease or to different framings of the trade-off exercises.

RESULTS

Respondents were quite sensitive to the visual presentation of the choice problem, and, to a lesser extent, to focusing and labelling effects. Elicited preferences varied little in response to large changes in opportunity costs, suggesting scope-insensitivity among respondents.

CONCLUSIONS

Preferences for prioritizing treatment of rare diseases elicited using trade-off exercises are insensitive to (theoretically relevant) opportunity costs, but sensitive to (theoretically irrelevant) framing effects.

Priority preferences: "end of life" does not matter, but total life does

There is increasing evidence that the social value of an incremental health gain depends on patient characteristics, such as their age and their prognosis. This article presents an analytical framework to illustrate how a disease splits our life expectancy into 1) past health (age), 2) prognosis untreated, 3) gain from treatment, and 4) incurable loss. A Norwegian population sample was asked to make pairwise choices and prioritize hypothetical patients who differed in terms of age (30, 50, and 70 years old), remaining lifetime without treatment (1, 3, and 10 years), and increase in remaining lifetime with treatment (1 month, 3 months, 1 year, and 3 years). Their preferences reveal strong support for the "fair innings" argument that total lifetime inequalities should be reduced. Differences in patients' remaining lifetime without treatment did not matter, implying little support for the "end-of-life" argument that a short life expectancy makes patients entitled to preferential treatment.

Preferences for the normative basis of health care priority setting: some evidence from two countries

The present paper concerns the criteria people would prefer for prioritising health programmes. It differs from most empirical studies as subjects were not asked about their personal preferences for programmes per se. Rather, they were asked about the principles that should guide the choice of programmes. Four different principles were framed as arguments for alternative programmes. The results from population surveys in Australia and Norway suggest that people are least supportive of the principle that decision makers should follow the stated preferences of the public. Rather, respondents expressed more support for decisions based upon health maximisation, equality and urgency.

What explains willingness to pay for smoking-cessation treatments - addiction level, quit-rate effectiveness or the opening bid?

BACKGROUND

Several countries have now passed laws that place limitations on where smokers may smoke. A range of smoking-cessation treatments have become available, many of which have documented increased quit rates. Population surveys show that most smokers wish to quit, and most non-smokers would prefer to reduce the prevalence of smoking in society. The strengths of these preferences, however, as measured by their willingness to pay (WTP), have not yet been investigated.

OBJECTIVE

This study aims to identify variables that explain variations in people's answers to WTP questions on smoking-cessation treatments.

METHODS

A representative sample of the Norwegian population was asked their WTP in terms of an earmarked contribution to a public smoking-cessation programme. A sub-group of daily smokers was, in addition, asked about their WTP for a hypothetical treatment that would remove their urge to smoke. The impact of variation in the question format (different opening bids) on stated WTP was compared with that of factors suggested by economic theory, such as quit-rate effectiveness, degree of addiction as measured by the 12-item Cigarette Dependence Scale (CDS-12), and degree of peer group influence as measured by the proportion of one's friends who smoke.

RESULTS

In both programmes, the most important determinant for explaining variations in WTP was the size of the opening bid. Differences in quit-rate effectiveness did not matter for people's WTP for the smoking-cessation programme. Addiction, and having a small proportion of friends who smoke, were positively associated with smokers' WTP to quit smoking.

CONCLUSION

Variations in WTP were influenced more by how the question was framed in terms of differences in opening bids, than by variables reflecting the quality (effectiveness) and need (addiction level) for the good in question. While the WTP method is theoretically attractive, the findings that outcomes in terms of different quit rates did not affect WTP, and that WTP answers can be manipulated by the chosen opening bid, should raise further doubts on the ability of this method to provide valid and reliable answers that reflect true preferences for health and healthcare.

Improving response rate and quality of survey data with a scratch lottery ticket incentive

Background

The quality of data collected in survey research is usually indicated by the response rate; the representativeness of the sample, and; the rate of completed questions (item-response). In attempting to improve a generally declining response rate in surveys considerable efforts are being made through follow-up mailings and various types of incentives. This study examines effects of including a scratch lottery ticket in the invitation letter to a survey.

Method

Questionnaires concerning oral health were mailed to a random sample of 2,400 adults. A systematically selected half of the sample (1,200 adults) received a questionnaire including a scratch lottery ticket. One reminder without the incentive was sent.

Results

The incentive increased the response rate and improved representativeness by reaching more respondents with lower education. Furthermore, it reduced item nonresponse. The initial incentive had no effect on the propensity to respond after the reminder.

Conclusion

When attempting to improve survey data, three issues become important: response rate, representativeness, and item-response. This study shows that including a scratch lottery ticket in the invitation letter performs well on all the three.

Does an activity based remuneration system attract young doctors to general practice?

BACKGROUND

The use of increasingly complex payment schemes in primary care may represent a barrier to recruiting general practitioners (GP). The existing Norwegian remuneration system is fully activity based - 2/3 fee-for-service and 1/3 capitation. Given that the system has been designed and revised in close collaborations with the medical association, it is likely to correspond - at least to some degree - with the preferences of current GPs (men in majority). The objective of this paper was to study which preferences that young doctors (women in majority), who are the potential entrants to general practice have for activity based vs. salary based payment systems.

METHODS

In November-December 2010 all last year medical students and all interns in Norway (n = 1.562) were invited to participate in an online survey. The respondents were asked their opinion on systems of remuneration for GPs; inclination to work as a GP; risk attitude; income preferences; work pace tolerance. The data was analysed using one-way ANOVA and multinomial logistic regression analysis.

RESULTS

A total of 831 (53%) responded. Nearly half the sample (47%) did not consider the remuneration system to be important for their inclination to work as GP; 36% considered the current system to make general practice more attractive, while 17% considered it to make general practice less attractive. Those who are attracted by the existing system were men and those who think high income is important, while those who are deterred by the system are risk averse and less happy with a high work pace. On the question of preferred remuneration system, half the sample preferred a mix of salary and activity based remuneration (the median respondent would prefer a 50/50 mix). Only 20% preferred a fully activity based system like the existing one. A salary system was preferred by women, and those less concerned with high income, while a fully activity based system was preferred by men, and those happy with a high work pace.

CONCLUSIONS

Given a concern about low recruitment to general practice in Norway, and the fact that an increasing share of medical students is women, we were interested in the extent to which the current Norwegian remuneration system correspond with the preferences of potential GPs. This study suggests that an existing remuneration mechanism has a selection effect on who would like to become a GP. Those most attracted are income motivated men. Those deterred are risk averse, and less happy with a high work pace. More research is needed on the extent to which experienced GPs differ along the questions we asked potential GPs, as well as studying the relative importance of other attributes than payment schemes.

Societal views on orphan drugs: cross sectional survey of Norwegians aged 40 to 67

OBJECTIVE

To determine whether a general societal preference for prioritising treatment of rare diseases over common ones exists and could provide a justification for accepting higher cost effectiveness thresholds for orphan drugs.

DESIGN

Cross sectional survey using a web based questionnaire.

SETTING

Norway.

PARTICIPANTS

Random sample of 1547 Norwegians aged 40-67.

MAIN OUTCOME MEASURE

Choice between funding treatment for a rare disease versus a common disease and how funds should be allocated if it were not possible to treat all patients, for each of two scenarios: identical treatment costs per patient and higher costs for the rare disease. Respondents rated five statements concerning attitudes to equity on a five point Likert scale (5=completely agree).

RESULTS

For the equal cost scenario, 11.2% (9.6% to 12.8%) of respondents favoured treating the rare disease, 24.9% (21.7% to 26.0%) the common disease, and 64.9% (62.6% to 67.3%) were indifferent. When the rare disease was four times more costly to treat, the results were, respectively, 7.4% (6.1% to 8.7%), 45.3% (42.8% to 47.8%), and 47.3% (44.8% to 49.8%). Rankings for attitude on a Likert scale indicated strong support for the statements "rare disease patients should have the right to treatment even if more expensive" (mean score 4.5, SD 0.86) and "resources should be used to provide the greatest possible health benefits" (3.9, 1.23).

CONCLUSIONS

Despite strong general support for statements expressing a desire for equal treatment rights for patients with rare diseases, there was little evidence that a societal preference for rarity exists if treatment of patients with rare diseases is at the expense of treatment of those with common diseases.

Increasing marginal utility of small increases in life-expectancy? Results from a population survey

The standard practice in cost-effectiveness analyses of health care is to assign a linear value to increasing lifetime gains. The aim of the current study was to examine the possible existence of non-linear utility for short life extensions. A representative sample of the Norwegian population, aged 40-59 years (n=2402), was asked to imagine that they had a limited remaining lifetime (1 year or 10 years) and were offered a treatment that would increase lifetime by a specified amount of time from 1 week to 1 year. In all scenarios, the price per week of life extension was held constant. The proportion of respondents that accepted the treatment increased with increasing extensions, indicating a convex utility function. The result suggests increasing marginal utility for life extensions up to 1 year.

The health related quality of life of people living with HIV/AIDS in sub-Saharan Africa - a literature review and focus group study

Background

While health outcomes of HIV/AIDS treatments in terms of increased longevity has been the subject of much research, there appears to be very limited research on the improved health related quality of life (HRQL) that can be applied in cost-utility analyses in Africa south of the Sahara (SSA). Most of the literature that does exist present HRQL measured by disease specific instruments, but such data is of little use as input to economic evaluations.

Methods

A systematic review of the literature on HRQL weights for people living with HIV/AIDS in Africa was performed, and the findings are presented and interpreted. We also use focus group discussions in panels of clinical AIDS experts to test the preference based on a generic descriptive system EQ-5D. We contrast quality of life with and without antiretroviral treatment (ART), and with and without treatment failure.

Results

In only four papers were the HRQL weights for HIV/AIDS in sub-Saharan Africa estimated with generic preference based methodologies that can be directly applied in economic evaluation. A total of eight studies were based on generic health profiles. While such 'health profiles' are not preference based, the scores could potentially be transformed into health state utilities. Most of the available literature (20 papers) utilized disease specific instrument, which are not applicable for economic evaluation.

The focus group discussions revealed that HRQL weights are strongly correlated to disease stage. Furthermore, clinical experts consistently report that ART has a strong positive impact on the HRQL of patients, although this effect appears to rebound in cases of drug resistance.

Conclusions

EQ-5D appears to be an appropriate tool for measuring and valuing HRQL of HIV/AIDS in Africa. More empirical research is needed on various methodological aspects in order to obtain valid and reliable HRQL weights in economic evaluations of HIV/AIDS prevention and treatment interventions.

Trastuzumab in adjuvant breast cancer therapy. A model based cost-effectiveness analysis

Trastuzumab has shown activity in early breast cancer patients that overexpress HER2. Significant resources have to be allocated to finance this therapy, underlining the need for cost-effectiveness analysis. A model was set up, societal costs were calculated and the discount rate was 3%. Life expectancy data were based on the literature and prolonged according to qualified guess (10% and 20% absolute improvement in overall survival (OS)). The comparator was the FEC(100) regimen. The median additional health care cost per patient treated was 33,597 euros. The yielding cost per life year gained (LYG) was 15,341 euros with a 20% improved OS and 35,947 euros with 10% improved OS. The corresponding net health care cost per quality adjusted life year (QALY) was 19,176 euros and 44,934 euros. Including all resource use the figures were 8148 euros and 30,290 euros per LYG. Sensitivity analyses documented survival gain, price of trastuzumab, production gain and discount rate to be the major factors influencing cost-effectiveness ratio. Trastuzumab is indicated cost effective in Norway.

Properties of the Cigarette Dependence Scale and the Fagerström Test of Nicotine Dependence in a representative sample of smokers in Norway

AIMS

To compare the properties of four measures of dependence to nicotine/tobacco, the 12-item Cigarette Dependence Scale (CDS-12), the six-item Fagerström Test of Nicotine Dependence (FTND) and two shorter versions of the same measures.

METHODS

In a cross-sectional telephone survey of smokers in a representative general population sample in Norway, we compared the measures. We assessed (i) internal consistency reliability with Cronbach's alpha; (ii) compared item scores; and (iii) tested the validity of the questionnaires. Test-retest reliability was assessed in a smaller convenience sample.

RESULTS

Among 1265 respondents (64%), 290 (23%) were daily smokers and included in further analysis. Their mean age was 42 years [standard deviation (SD) 15] and 46% were female. They smoked on average 13 cigarettes per day (SD 6). Internal consistency reliability was 0.61 for the FTND (n = 267) and 0.81 for the CDS-12 (n = 266). Score distributions suggested a floor effect for the FTND. Test-retest reliability was 0.90 for the FTND and 0.97 for the CDS-12 (n = 31). The correlation between the scale scores and a question about the maximum willingness to pay for a cigarette after not smoking all day was 0.36 (P < 0.001) for the FTND (n = 262) and 0.45 (P < 0.001) for the CDS-12 (n = 263). There was little difference in the associations of the two scales or their abbreviated versions with external variables.

CONCLUSIONS

Telephone administration was acceptable for both questionnaires, and we have established population reference values for the four scales. The questionnaires were associated with each other and showed similar properties. The findings support the construct validity of the scales.