To undertake an economic evaluation alongside the largest randomised controlled trial comparing Levonorgestrel-releasing intrauterine device ('LNG-IUS') and usual medical treatment for women with ...menorrhagia in primary care; and compare the cost-effectiveness findings using two alternative measures of quality of life.
571 women with menorrhagia from 63 UK centres were randomised between February 2005 and July 2009. Women were randomised to having a LNG-IUS fitted, or usual medical treatment, after discussing with their general practitioner their contraceptive needs or desire to avoid hormonal treatment. The treatment was specified prior to randomisation. For the economic evaluation we developed a state transition (Markov) model with a 24 month follow-up. The model structure was informed by the trial women's pathway and clinical experts. The economic evaluation adopted a UK National Health Service perspective and was based on an outcome of incremental cost per Quality Adjusted Life Year (QALY) estimated using both EQ-5D and SF-6D.
Using EQ-5D, LNG-IUS was the most cost-effective treatment for menorrhagia. LNG-IUS costs £100 more than usual medical treatment but generated 0.07 more QALYs. The incremental cost-effectiveness ratio for LNG-IUS compared to usual medical treatment was £1600 per additional QALY. Using SF-6D, usual medical treatment was the most cost-effective treatment. Usual medical treatment was both less costly (£100) and generated 0.002 more QALYs.
Impact on quality of life is the primary indicator of treatment success in menorrhagia. However, the most cost-effective treatment differs depending on the quality of life measure used to estimate the QALY. Under UK guidelines LNG-IUS would be the recommended treatment for menorrhagia. This study demonstrates that the appropriate valuation of outcomes in menorrhagia is crucial.
ObjectiveConduct an economic evaluation based on best currently available evidence comparing alternative treatments levonorgestrel-releasing intrauterine system, depot-medroxyprogesterone acetate, ...combined oral contraceptive pill (COCP) and ‘no treatment’ to prevent recurrence of endometriosis after conservative surgery in primary care, and to inform the design of a planned trial-based economic evaluation.MethodsWe developed a state transition (Markov) model with a 36-month follow-up. The model structure was informed by a pragmatic review and clinical experts. The economic evaluation adopted a UK National Health Service perspective and was based on an outcome of incremental cost per quality-adjusted life year (QALY). As available data were limited, intentionally wide distributions were assigned around model inputs, and the average costs and outcome of the probabilistic sensitivity analyses were reported.ResultsOn average, all strategies were more expensive and generated fewer QALYs compared to no treatment. However, uncertainty attributing to the transition probabilities affected the results. Inputs relating to effectiveness, changes in treatment and the time at which the change is made were the main causes of uncertainty, illustrating areas where robust and specific data collection is required.ConclusionsThere is currently no evidence to support any treatment being recommended to prevent the recurrence of endometriosis following conservative surgery. The study highlights the importance of developing decision models at the outset of a trial to identify data requirements to conduct a robust post-trial analysis.
‘Menorrhagia’, or heavy menstrual bleeding, is a common problem affecting women. The principal driver for treatment is women's experience of its interference in their lives, so a measure of quality ...of life (QoL) is increasingly used as the primary outcome to assess treatment success. QoL measures need to accurately reflect women's concerns as these measures are often used to inform resource allocation decisions within the healthcare service. Healthcare decision-makers often advocate the use of generic measures so as to achieve consistency when making decisions. Generic measures, by definition, have a broad focus on QoL in contrast to disease-specific measures that focus on dimensions of health relevant to the condition. We report a systematic review of studies that have either used or assessed economic outcome measures in menorrhagia, and present criteria for assessing which measure is the most appropriate. Studies including women presenting with menorrhagia, and using or assessing economic measures were sought by searching nine electronic databases.
Fifty-six eligible studies were identified. A narrative synthesis was most suitable to the review question. Eleven studies assessed the psychometric properties of the outcome measures, twelve studies applied the measures in an economic evaluation, and thirty-three used them in effectiveness studies. Mixed results on the psychometric properties of the instruments were observed. Studies were often found to include both a disease-specific and a generic measure. We found no consensus on the most appropriate economic outcome measure to use when assessing the cost-effectiveness of treatment for menorrhagia. This is an important finding as QoL is the primary focus for treatment decisions. The cyclical nature of the condition has a large impact on the reliability and validity of outcome measurement. Alternative measures, such as willingness-to-pay, which embrace more than health and avoid standard recall periods should be explored.
•There is no consensus on which economic QoL measure to use in menorrhagia.•Typical measures (EQ-5D, SF-36) are unsuitable as non-health benefits are excluded.•The timing of assessment can impact the QoL results obtained from EQ-5D or SF-36.•Willingness-to-pay avoids the problems of current measures but is currently under-researched and should be explored.
Objectives
Willingness‐to‐pay (WTP) provides a broad assessment of well‐being, capturing benefits beyond health. However, the validity of the approach has been questioned and the evidence relating to ...the sensitivity of WTP to changes in health status is mixed. Using menorrhagia (heavy menstrual bleeding) as a case study, this exploratory study assesses the sensitivity to scale of WTP to change in health status as measured by a condition‐specific measure, MMAS, which includes both health and non‐health benefits. The relationship between EQ‐5D and change in health status is also assessed.
Methods
Baseline EQ‐5D and MMAS values were collected from women taking part in a randomized controlled trial for pharmaceutical treatment of menorrhagia. Following treatment, these measures were administered along with a WTP exercise. The relationship between the measures was assessed using Spearman's correlation analysis, and the sensitivity to scale of WTP was measured by identifying differences in WTP alongside differences in MMAS and EQ5D values.
Results
Our exploratory findings indicated that WTP, and not EQ‐5D, was significantly positively correlated with change in MMAS, providing some evidence for convergent validity. These findings suggest that WTP is capturing the non‐health benefits within the MMAS measure. Mean WTP also increased with percentage improvements in MMAS, suggesting sensitivity to scale.
Conclusion
When compared to quality of life measured using the condition‐specific MMAS measure, the convergent validity and sensitivity to scale of WTP is indicated. The findings suggest that WTP is more sensitive to change in MMAS, than with EQ‐5D.
Background
The extra-welfarist theoretical framework tends to focus on health-related quality of life, whilst the welfarist framework captures a wider notion of well-being. EQ-5D and SF-6D are ...commonly used to value outcomes in chronic conditions with episodic symptoms, such as heavy menstrual bleeding (clinically termed menorrhagia). Because of their narrow-health focus and the condition’s periodic nature these measures may be unsuitable. A viable alternative measure is willingness to pay (WTP) from the welfarist framework.
Objective
We explore the use of WTP in a preliminary cost-benefit analysis comparing pharmaceutical treatments for menorrhagia.
Methods
A cost-benefit analysis was carried out based on an outcome of WTP. The analysis is based in the UK primary care setting over a 24-month time period, with a partial societal perspective. Ninety-nine women completed a WTP exercise from the ex-ante (pre-treatment/condition) perspective. Maximum average WTP values were elicited for two pharmaceutical treatments, levonorgestrel-releasing intrauterine system (LNG-IUS) and oral treatment. Cost data were offset against WTP and the net present value derived for treatment. Qualitative information explaining the WTP values was also collected.
Results
Oral treatment was indicated to be the most cost-beneficial intervention costing £107 less than LNG-IUS and generating £7 more benefits. The mean incremental net present value for oral treatment compared with LNG-IUS was £113. The use of the WTP approach was acceptable as very few protests and non-responses were observed.
Conclusion
The preliminary cost-benefit analysis results recommend oral treatment as the first-line treatment for menorrhagia. The WTP approach is a feasible alternative to the conventional EQ-5D/SF-6D approaches and offers advantages by capturing benefits beyond health, which is particularly relevant in menorrhagia.
This thesis applies alternative modelling approaches to the economic evaluation of a Chlamydia trachomatis screening programme. The first modelling approach used is a â staticâ approach represented ...by a decision tree. It is referred to as â staticâ because it assumes a constant force of infection. The results and policy recommendations based on the static approach are compared with those produced when the evaluation is based on a transmission dynamic model using discrete event simulation. This latter approach can accommodate a changing force of infection and can incorporate the effects on screening outcomes of the ongoing transmission of infection in the population. The literature review demonstrated that the vast majority of economic evaluations on Chlamydia screening used static models. The thesis shows that the results of the static models were associated with systematically more favourable results than the dynamic counterpart, but the direction of the bias is not necessarily predictable. The thesis argues that the most appropriate model to use in an economic evaluation of a screening programme for an infectious disease such as Chlamydia trachomatis, is a transmission dynamic model.
Does the way women exit welfare affect their probability of returning to welfare? Using data drawn from the 1979–2000 National Longitudinal Surveys of Youth, I examine the effect of marital and ...employment transitions on recidivism rates. I find that women who combine employment and marriage after exiting welfare, in that order, have significantly lower risks of recidivism than other women. Women who marry but do not enter employment have higher recidivism rates than women who combine employment and marriage, but they are less likely to return to welfare than women who are only employed. The data suggest that simply encouraging marriage or women's employment may not reduce welfare recidivism. The best policy strategy to reduce welfare dependence and encourage healthy marriages may be to strengthen work support programs and improve the circumstances of employment (and opportunities for strong marriages) for low-income men and women.
Thesis (M.A.) -- University of Maryland, College Park, 2005.
Thesis research directed by: Dept. of Sociology. Title from t.p. of PDF. Includes bibliographical references. Published by UMI ...Dissertation Services, Ann Arbor, Mich. Also available in paper.
Idiopathic sudden sensorineural hearing loss (ISSNHL) is the rapid onset of reduced hearing due to loss of function of the inner ear or hearing nerve of unknown aetiology. Evidence supports improved ...hearing recovery with early steroid treatment, via oral, intravenous, intratympanic or a combination of routes. The STARFISH trial aims to identify the most clinically and cost-effective route of administration of steroids as first-line treatment for ISSNHL. STARFISH is a pragmatic, multicentre, assessor-blinded, three-arm intervention, superiority randomised controlled trial (1:1:1) with an internal pilot (ISRCTN10535105, IRAS 1004878). 525 participants with ISSNHL will be recruited from approximately 75 UK Ear, Nose and Throat units. STARFISH will recruit adults with sensorineural hearing loss averaging 30dBHL or greater across three contiguous frequencies (confirmed via pure tone audiogram), with onset over a ≤3-day period, within four weeks of randomisation. Participants will be randomised to 1) oral prednisolone 1mg/Kg/day up to 60mg/day for 7 days; 2) intratympanic dexamethasone: three intratympanic injections 3.3mg/ml or 3.8mg/ml spaced 7±2 days apart; or 3) combined oral and intratympanic steroids. The primary outcome will be absolute improvement in pure tone audiogram average at 12-weeks following randomisation (0.5, 1.0, 2.0 and 4.0kHz). Secondary outcomes at 6 and 12 weeks will include: Speech, Spatial and Qualities of hearing scale, high frequency pure tone average thresholds (4.0, 6.0 and 8.0kHz), Arthur Boothroyd speech test, Vestibular Rehabilitation Benefit Questionnaire, Tinnitus Functional Index, adverse events and optional weekly online speech and pure tone hearing tests. A health economic assessment will be performed, and presented in terms of incremental cost effectiveness ratios, and cost per quality-adjusted life-year. Primary analyses will be by intention-to-treat. Oral prednisolone will be the reference. For the primary outcome, the difference between group means and 97.5% confidence intervals at each time-point will be estimated via a repeated measures mixed-effects linear regression model.
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