Pattern of use of DXA scans in men: a cross-sectional, population-based study.

UNLABELLED: Osteoporosis in men is underdiagnosed. The use of dual-emission X-ray absorptiometry (DXA) was evaluated in almost 5,000 men aged 60-74 years. DXA was infrequent, despite the presence of multiple risk factors for osteoporosis and a high FRAX score. There is a need for improved targeting of DXA scans for men at high risk. INTRODUCTION: Clinical and socioeconomic factors associated with bone mass assessment (DXA) in men have seldom been evaluated. This study aimed to evaluate factors associated with the use of DXA in men. METHODS: Self-report information on prior DXA and osteoporosis risk factors were obtained from the baseline data of a study investigating the health perspectives of men aged 60-75 years. Socioeconomic and comorbidity data were retrieved from national registers. The FRAX algorithm was used to calculate the absolute fracture risk. Regression analysis was used to identify factors significantly associated with previous DXA scan. RESULTS: Of the 4,696 men returning questionnaires (50% response rate), 2.7% had prior DXA but 48% had at least one osteoporosis risk factor. Previous DXA was associated with oral glucocorticoid treatment, secondary osteoporosis, rheumatoid arthritis, fracture after age 50, falls within the previous year, smoking, and higher age. Twenty-one percent of men with prior DXA and 10% of men without prior DXA had greater than 20% risk of a major osteoporotic fracture within the next 10 years. One third of those with previous DXA had none of the FRAX osteoporosis risk factors. When family history of osteoporosis and falls were included as risk factors, 18% with previous DXA had no clinical risk factors for osteoporosis. CONCLUSIONS: DXA was infrequent in this group of elderly men, despite the presence of risk factors for osteoporosis. DXA was also used despite a low fracture risk. There is a need for improved targeting of DXA scans for men at high risk.

Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L).

PURPOSE: This article introduces the new 5-level EQ-5D (EQ-5D-5L) health status measure. METHODS: EQ-5D currently measures health using three levels of severity in five dimensions. A EuroQol Group task force was established to find ways of improving the instrument's sensitivity and reducing ceiling effects by increasing the number of severity levels. The study was performed in the United Kingdom and Spain. Severity labels for 5 levels in each dimension were identified using response scaling. Focus groups were used to investigate the face and content validity of the new versions, including hypothetical health states generated from those versions. RESULTS: Selecting labels at approximately the 25th, 50th, and 75th centiles produced two alternative 5-level versions. Focus group work showed a slight preference for the wording 'slight-moderate-severe' problems, with anchors of 'no problems' and 'unable to do' in the EQ-5D functional dimensions. Similar wording was used in the Pain/Discomfort and Anxiety/Depression dimensions. Hypothetical health states were well understood though participants stressed the need for the internal coherence of health states. CONCLUSIONS: A 5-level version of the EQ-5D has been developed by the EuroQol Group. Further testing is required to determine whether the new version improves sensitivity and reduces ceiling effects.

Why women want prenatal ultrasound in normal pregnancy.

OBJECTIVES: To investigate women's reasons for requesting prenatal ultrasound in the absence of clinical indications. METHODS: A postal questionnaire was completed by 370 pregnant women with no apparent obstetric risk factors, who had expressed a desire to have ultrasound scanning in their current pregnancy. The women were asked to indicate, from a list of 12 items, their three most important reasons for wanting scanning. Ninety per cent of the women were in the first trimester of pregnancy, and 10% in the second trimester. RESULTS: The items most frequently identified as important reasons for ultrasound were to check for fetal abnormalities (60% of women), to see that all was normal (55%) and for own reassurance (44%). Lower income was related to wanting to see the baby (P = 0.028) and wanting an ultrasound picture (P = 0.017); higher income was related to checking that all was normal (P = 0.003) and for own reassurance (P = 0.015). Women in their first pregnancy were more likely to want themselves and the father to see the baby (P = 0.001); women who had given birth previously were more likely to want reassurance (P = 0.002), as were women with a previous miscarriage or induced abortion. Women who believed that the presence of fetal trisomy justifies abortion or who would vote for free abortion were more likely to want to know about abnormalities (P < 0.001 and P < 0.004, respectively). Women in the second trimester were more likely to want to check for abnormalities (P = 0.041) and appropriate fetal growth (P = 0.047) than those in the first trimester. CONCLUSIONS: It would appear that women in normal pregnancy have specific reasons for wanting prenatal ultrasound that are influenced by sociodemographic, obstetric and attitudinal factors.

Effect of dystonia and botulinum toxin treatment on health-related quality of life.

In view of the steadily rising demand for treatment of dystonia with botulinum toxin (BT), a relatively expensive neurologic paralytic agent, an exploratory study was undertaken to assess the extent to which dystonia and BT treatment affect the quality of people's lives. One hundred thirty adults with a current diagnosis of dystonia completed two generic measures of health-related quality of life (HRQoL) at regular intervals over a minimum of 6 months. One hundred two participants were receiving regular injections of BT; 28 were not taking BT. The HRQoL instruments used were the EuroQol and the Short Form 36 health survey questionnaire (SF-36). Compared with general population samples, study participants reported greater impairment on all EuroQol and SF-36 dimensions and gave a lower rating to their own health status. Participants with nonfocal dystonia had significantly more problems with usual activities than participants with focal dystonia, and a higher number had problems with mobility and self-care. The groups reported similar levels of pain and emotional well-being. Small improvements in HRQoL were seen after the administration of BT, although few of these were statistically significant. The study results offer further psychometric evidence for the discriminant and construct validity of both the EuroQol and the SF-36.

Variations in population health status: results from a United Kingdom national questionnaire survey.

OBJECTIVE: To measure the health of a representative sample of the population of the United Kingdom by using the EuroQoL EQ-5D questionnaire. DESIGN: Stratified random sample representative of the general population aged 18 and over and living in the community. SETTING: United Kingdom. SUBJECTS: 3395 people resident in the United Kingdom. MAIN OUTCOME MEASURES: Average values for mobility, self care, usual activities, pain or discomfort, and anxiety or depression. RESULTS: One in three respondents reported problems with pain or discomfort. There were differences in the perception of health according to the respondent's age, social class, education, housing tenure, economic position, and smoking behaviour. CONCLUSIONS: The EQ-5D questionnaire is a practical way of measuring the health of a population and of detecting differences in subgroups of the population.

Measuring patient benefit from botulinum toxin in the treatment of dystonia. Feasibility of cost-utility analysis.

The dystonias are a group of movement disorders arising from CNS dysfunction and characterised by involuntary and prolonged spasms of muscle contraction. Recently there has been increasing demand for treatment with botulinum toxin (BT), a relatively expensive neurological paralytic agent. As there has been no systematic assessment of patient benefit from BT, this study was undertaken to develop and test a methodology for assessing the cost utility of BT therapy for patients with dystonias. A generic health status instrument, the EuroQOL, was completed at regular intervals over at least 6 months by 130 patients with a current diagnosis of dystonia. A general population tariff was used to calculate quality-adjusted life-year (QALY) gains from BT treatment, and relevant cost data were obtained from patients and medical records. The cost-per-QALY estimates ranged considerably, depending on the type of dystonia, the duration of BT treatment, type of health-related quality-of-life (HR-QOL) tariff used and baseline characteristics of participants. The study findings reflect the general clinical impression of BT: that it can benefit patients with dystonia, but the benefit may be small compared with many treatments for other diseases. The nature of the disease and its cyclical treatment caused practical difficulties in recruiting participants, administering questionnaires and in estimating QALY gains.

The use of generic measures of health-related quality of life in the assessment of outcome from transurethral resection of the prostate.

OBJECTIVES: To investigate the performance of the EuroQol (EQ) quality-of-life measure and the Nottingham Health Profile (NHP) in assessing the outcome of transurethral resection of the prostate (TURP) for lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction (BPO), and to determine which men experience the greatest increase in health-related quality of life (HRQL) after TURP. PATIENTS AND METHODS: A prospective cohort study was undertaken over 12 months from Arpil 1992 of 314 men who completed the EQ, the NHP and a symptom inventory before undergoing elective TURP for probable BPO (Group 1). Identical postal questionnaires were used to follow up this group at 6 weeks, 6 months and 12 months post-operatively, with response rates of 79%, 74% and 69%, respectively. Overall, 92% of patients responded at either 6 or 12 months after surgery. A group of 51 men who had not undergone operation, also with LUTS and probable BPO, were similarly followed over 6 months, before eventually undergoing TURP (Group 2). These patients differed from Group 1 in being younger, less symptomatic and having a higher baseline quality-of-life score, but the inclusion of this group from a broadly similar diagnostic category allowed outcome to be assessed over time in the absence of surgery. RESULTS: There was a significant improvement in all LUTS 6 weeks after TURP; post-micturition dribbling and storage symptoms continued to improve for up to one year. The NHP revealed pre-operative morbidity in all dimensions of the profile. At 12 months after surgery there were significant improvements in the domains of social interaction, energy, pain, emotional reactions and sleep. The EQ profile also showed morbidity in all dimensions before surgery, with significant improvement at 12 months in usual activities, mood and pain/discomfort. The EQ self-rated health and composite quality-of-life score also showed improvement with TURP which continued for 12 months after surgery. The patients in Group 2 tended to deteriorate over the 6 months of follow-up using all measures, but the changes were not significant. The EQ composite quality-of-life score also discriminated between patients on the basis of age, number of symptoms and ASA grade, suggesting that these subgroups experienced differing amounts of benefit from surgery. CONCLUSION: TURP led to significant improvement in the indices of generic HRQL as measured using the NHP and EQ; this improvement continued for 12 months after surgery and mirrored the symptomatic improvement. The EQ confirmed clinical experience, in that men who were younger, fitter and most symptomatic experienced the greatest benefit from surgery. This has not been shown previously using a quality-of-life measure. Generic HRQL measures can be incorporated easily into clinical trials and both the measures used in this study have sufficient sensitivity to be used in this population. The EQ has the advantage of generating a composite quality-of-life score which is easy to interpret and can be used in cost-utility analysis. The addition of HRQL measures leads to a more robust appraisal of the results of surgical intervention. Ultimately, patient-based outcome from TURP will be assessed using a combination of psychometrically tested disease-specific and generic measures, together with symptom scoring.

Health state valuations from the general public using the visual analogue scale.

In the clinical and economic evaluation of health care, the value of benefit gained should be determined from a public perspective. The objective of this study was to establish relative valuations attached to different health states to form the basis for a 'social tariff' for use in quantifying patient benefit from health care. Three thousand three hundred and ninety-five interviews were conducted with a representative sample of the adult British population. Using the EuroQol health state classification and a visual analogue scale (VAS), each respondent valued 15 health states producing, in total, direct valuations for 45 states. Two hundred and twenty-one re-interviews were conducted approximately 10 weeks later. A near complete, and logically consistent, VAS data set was generated with good test-retest reliability (mean ICC = 0.78). Both social class and education had a significant effect, where higher median valuations were given by respondents in social classes III-V and by those with intermediate or no educational qualifications. These effects were particularly noticeable for more severe states. The use of such valuations in a social tariff raises important issues regarding the use of the VAS method itself to elicit valuations for hypothetical health states, the production of separate tariffs according to social class and/or education and the appropriate measure of central tendency.

Valuing health states: a comparison of methods.

In eliciting health state valuations, two widely used methods are the standard gamble (SG) and the time trade off (TTO). Both methods make assumptions about individual preferences that are too restrictive to allow them to act as perfect proxies for utility. Therefore, a choice between them might instead be made on empirical grounds. This paper reports on a study which compared a "props" (using specifically-designed boards) and a "no props" (using self-completion booklets) variant of each method. The results suggested that both non props variants might be susceptable to framing effects and that TTP props outperformed SG props.

The time trade-off method: results from a general population study.

An important consideration when establishing priorities in health care is the likely effects that alternative allocations of resources will have on health-related quality-of-life (HRQoL). This paper reports on a large-scale national study that elicited the relative valuations attached by the general public to different states of health (defined in HRQoL terms). Health state valuations were derived using the time trade-off (TTO) method. The data from 3395 respondents were highly consistent, suggesting that it is feasible to use the TTO method to elicit valuations from the general public. The paper shows that valuations for severe health states appear to be affected by the age and the sex of the respondent; those aged 18-59 have higher valuations than those aged 60 or over and men have higher valuations than women. These results contradict those reported elsewhere and suggest that the small samples used in other studies may be concealing real differences that exist between population sub-groups. This has important implications for public policy decisions.

The WHO (Ten) Well-Being Index: validation in diabetes.

BACKGROUND: In a European trial in 8 countries, the subjective well-being of patients on alternative forms of treatment for insulin-dependent diabetes was compared using the 28-item WHO Well-Being Questionnaire, covering four dimensions of depression, anxiety, energy and positive well-being. The objective of the analysis reported here has been to identify the items of the WHO questionnaire which belong to an overall index of negative and positive well-being. METHODS: Adult patients at 10 study centres in 8 countries who had been on insulin for at least 2 years were invited to participate in a randomised, cross-over trial to compare insulin pump treatment with injection therapy. At each phase, patients completed questions on well-being and general health. Internal validity of the well-being index was evaluated by Cronbach's alpha and Loevinger's and Mokken's homogeneity coefficients, as well as factor analysis. External validity was evaluated by comparisons with results of the general assessment questions and by the ability to discriminate between the alternative forms of treatment. RESULTS: 358 patients had sufficient data for analysis. Ten items were found to constitute a valid index of well-being with respect to internal and external validity. Coefficients of homogeneity were acceptable and there was evidence for both concurrent and discriminant validity. CONCLUSIONS: The WHO (Ten) well-being index includes negative and positive aspects of well-being in a single uni-dimensional scale. Its advantage lies in its ability to show overall change along the continuum of well-being, thus facilitating comparisons between patient groups and treatments. It is not specific to diabetes, and therefore may be useful as a disease-independent index of well-being in a broad range of health care studies.

Measuring patient benefit in mental illness.

This paper provides a brief overview of issues to consider in evaluating patient benefit from health care. Different types of measures are described and it is noted that the choice of measure is dependent upon the purpose of the study. The cost-utility approach to evaluation is discussed in more detail. This approach is often criticised but it raises important issues in medical decision-making and has considerable potential in the evaluation of patient benefit from health care.

Health-related quality of life in endstage renal failure.

The objective of this study was to describe the health-related quality of life (HRQOL) of patients on different forms of treatment for endstage renal failure in such a way that the data could be used in a cost-utility analysis of renal failure treatment in Britain. Twenty-four British renal units participated in this study. 997 adult dialysis and transplant patients were randomly selected from these units using the European Dialysis and Transplant (EDTA) Registry Database. The Health Measurement Questionnaire was completed by 705 of the 900 patients who were alive at the time of the survey (response rate of 78%). The HRQOL data were linked with comorbidity data and with clinical data from the EDTA Registry. Compared to the general population, patients with endstage renal failure experienced a lower quality of life. Many factors contributed to this, but uncertainty about the future and lack of energy emerged as key components. Transplant recipients reported better HRQOL than dialysis patients, they reported fewer problems with physical mobility, self-care, social and personal relationships and usual activities. They also experienced significantly less distress, while dialysis patients reported problems with depression, anxiety, pain and uncertainty about the future. These differences remained after controlling for age and comorbidity.

Time preference, duration and health state valuations.

There is increasing interest in health status measurement and the relative weights that people attach to different states of health and illness. One important issue which has been raised is the effect that the time spent in a health state may have on the way that state is perceived. Previous studies have suggested that the worse a state is, the more intolerable it becomes as it lasts longer. However, for most of these studies, it is impossible to determine how much of what was observed is attributable to the time spent in the state and how much is attributable to when it was occurring. This paper reports on a pilot study designed to test the feasibility of using the Time Trade-Off (TTO) method to isolate the effect of pure time preference from the effect of duration per se. Interviews were conducted with 39 members of the general population who were asked to rate 5 health states for durations of one month, one year and ten years. In aggregate, rates of time preference were very close to zero which suggests that the implicit assumption of the TTO method that there is no discounting may be a valid one. However, that more respondents had negative (rather than positive) rates, casts some doubt on the axions of discounted utility theory. In addition, implied valuations for states lasting for short periods were often counter-intuitive which questions the feasibility of using the TTO method to measure preferences for temporary health states.

Quality of life in liaison psychiatry. A comparison of patient and clinician assessment.

BACKGROUND: This exploratory study investigates the performance of the Health Measurement Questionnaire (HMQ), as compared with the Psychiatric Assessment Schedule (PAS) and the Nottingham Health Profile (NHP), and compares self- and observer-completed measures. METHOD: A total of 138 medical patients scoring over the screening threshold for probable psychiatric illness completed the HMQ, NHP and PAS, and were rated by a psychiatrist on Rosser disability and distress. RESULTS: HMQ disability correlated well with NHP and PAS physical health items, while HMQ distress correlated well with the NHP emotional reactions and PAS Index of Definition. There was significant correlation between self-report and psychiatrist ratings, the latter being more sensitive to distress. CONCLUSION: The HMQ is a useful measure of generic health status in liaison psychiatry settings.

Lay people's evaluations of health: are there variations between different subgroups?

STUDY OBJECTIVE: To elicit lay concepts of health and to see whether these are related to various sociodemographic factors, as has been suggested by previous smaller studies. DESIGN AND SETTING: A total of 196 people aged 18 and over were selected, as a representative sample of the general population, from the electoral registers of Walsall and Dudley in the West Midlands. Respondents were interviewed in their own homes in the autumn of 1989. MEASUREMENTS: Open ended and structured questions were used to elicit concepts of health. The three main stages consisted of an unprompted section in which respondents were asked to describe the features of good or poor health in themselves or others; a prompted section in which they were asked to rate 37 health statements using a series of categories from "very important" to "not at all important"; and a section in which they were asked to indicate which of six groups of statements, each representing a particular concept of health, best represented their own notions of health. RESULTS: Health was seen as multidimensional. Irrespective of whether respondents addressed health in self or health in others, or good or poor health, the biomedical dimension remained an important one. The manner by which concepts of health are elicited may provide some explanation as to why so many and varied concepts are alleged to be held by different subgroups of the population (notably different social classes). CONCLUSIONS: The differences found in this study between models of health employed by different subgroups of the general population have not been as great as has previously been suggested in the published reports. This is encouraging for those using existing health status measurements.

Measuring health status in the community: a comparison of methods.

STUDY OBJECTIVE--The measurement of health outcomes is central to the evaluation of medical treatment and intervention. It is generally acknowledged that such measurement ought to include an assessment of the impact of health care on the quality of life, as well as its quantity. The Health Measurement Questionnaire (HMQ) was developed as a means of identifying respondents in terms of Rosser's classification of illness states. This study examines the extent of convergent validity of the HMQ when used as a self report measure of health status, alongside the General Health Questionnaire (GHQ) and the Nottingham Health Profile (NHP). DESIGN--A randomised survey of residents of Wolverhampton was drawn from the electoral register. Interviews were conducted in the respondents' own homes. The three measurement instruments formed part of an extensive battery of questionnaires aimed at assessing a broad range of health issues. PARTICIPANTS--A total of 430 respondents were interviewed, of whom 407 completed the HMQ. Altogether 210 also completed the GHQ, and a further 207 completed the NHP. Failure in the interview protocol meant that 12 respondents did not complete either the GHQ or the NHP; these respondents did complete their HMQ. MEASUREMENTS AND MAIN RESULTS--At the descriptive level, Rosser distress categories derived from the HMQ seem to correlate well with the GHQ. There is a strong association between weighted Rosser disability/distress states and scores produced using the NHP. All three measures discriminated between "healthy" and "not healthy" subgroups of respondents. CONCLUSIONS--The results indicate strong evidence for convergent validity. There are significant levels of physical and psychological morbidity within the community. The results of this study reinforce the case for the continued measurement of health status within the general population. Low cost techniques such as the HMQ offer the prospect of such measurement.

Adverse effects of benzodiazepines.

The growing realisation that the benzodiazepines have potential for causing serious harm has caused concern due to their wide and common use. This paper is a review of the adverse effects of benzodiazepines, and concentrates on four areas of particular concern: drug dependence with the consequent withdrawal symptoms; psychological effects while on the drugs; use by the elderly; and tolerance to the drug effects. Although the phenomenon of a benzodiazepine withdrawal syndrome is generally accepted, there is still controversy over the frequency amongst users. A number of major studies are reviewed here, and the main methodological issues are discussed. These include definition of the withdrawal symptoms, selection of subjects, and use of double-blind, placebo-controlled conditions. The studies investigating psychological impairment with benzodiazepine use deal mainly with motor performance and co-ordination, although there is a large group of studies looking at the effect of the drugs on memory. Although the studies reviewed make a considerable contribution to the understanding of the effects of benzodiazepines, they focus on physiological and specific psychological variables, rather than more global measures of functioning and behaviour. It is suggested here that this emphasis needs to change in order to obtain a clearer picture of how benzodiazepines affect quality of life. Future studies should also be prospective in design, and include clear criteria for the selection of subjects and for the definition of withdrawal symptoms.

Prioritising waiting lists.

The 'top 22' patient conditions on the general surgical waiting list at Guy's Hospital were rated independently by five general surgeons. Each surgeon estimated the peri-operative mortality rates associated with each treatment; the proportion of patients who failed to benefit; the effect of successful treatment on life expectancy and on the patients' quality of life. the mean values were used to estimate the expected net benefits (in terms of quality-adjusted life-years) from treatment one year earlier than might otherwise have been the case. These benefits were then related to the operating times and length of stay associated with each treatment; this identified which treatments offered the greatest benefit per unit of each constrained resource. Of all conditions examined anal fissures where shown to be the least resource intensive in relation to the benefits generated, whilst varicose veins and epigastric hernias proved otherwise. For the full potential of this approach to be realised it needs to be repeated in other places and in other specialties. It nevertheless offers a more rational basis for interpreting waiting list data than presently exists and by using the short-cut methods is a relatively cheap way of generating much useful data.