From Health to Wellbeing: Toward a Monetary Valuation of a Wellbeing-Adjusted Life-Year.

OBJECTIVES: Economic evaluations using broader measures to capture benefits beyond improved health can inform policy making, but only if the monetary value of gains measured using these instruments is understood. This study explored contingent valuation as a method to estimate the monetary value of a wellbeing-adjusted life-year (WALY) as measured by ICEpop Capability Measure for Adults (ICECAP-A). METHODS: In a large online survey of representative samples from 7 European countries, participants valued a change in the ICECAP-A from their current health state to a randomly assigned hypothetical state. Participants were instructed that an unspecified treatment could avoid a loss or produce a gain in wellbeing and were asked for their willingness to pay (WTP) for this treatment. WTP per WALY was calculated using an aggregated approach that used ICECAP-A tariffs from the United Kingdom. RESULTS: We analyzed a sample of 7428 observations, focusing on avoided losses (n = 6002) because the results for gains were not theoretically valid. Different cutoff points for a marginal change were explored. Depending on the definition of a marginal change, WTP per WALY averaged between €13 323.28 and €61 375.63 for avoided losses between [0, 0.5] and [0, 0.1], respectively, for 1 month. Mean WTP per WALY varied across the countries as follows: Denmark (€17 867.93-€88 634.14), France (€10 278.35-€45 581.28), Germany (€12 119.39-€54 566.56), Italy (€11 753.69-€52 161.25), The Netherlands (€14 612.88-€58 951.74), Spain (€11 904.12-€57 909.17), and United Kingdom (€13 133.75-€68 455.85). CONCLUSION: Despite the inherent limitations of our study, it offers valuable insights into methods for eliciting the WTP for changes in capability wellbeing as measured with ICECAP-A.

Construct Validity, Reliability, and Responsiveness of the 10-Item Well-being Instrument for Use in Economic Evaluation Studies.

OBJECTIVES: Economic evaluations of interventions in health and social care require outcome measures that capture their full benefits, including those beyond health. This study aimed to assess construct validity, test-retest reliability, and responsiveness of the newly developed 10-item Well-being instrument (WiX). METHODS: Data were gathered via an online survey in a representative sample of the adult general population in The Netherlands (N = 1045). Construct validity was assessed by inspecting convergent, structural, and discriminant validity, following the COnsensus-based Standards for the selection of health status Measurement INstruments methodology. Regression analyses of the WiX and its items on other validated measures of well-being were performed to assess the convergent validity of the instrument and the relevance of its items. Dimensionality of the WiX was assessed using exploratory factor analysis. To assess discriminant validity, several hypotheses in terms of well-being differences were assessed. Finally, a second survey was sent out 2 weeks after the initial survey (n = 563; 53.9% response rate) to assess the test-retest reliability and responsiveness of the WiX. RESULTS: The WiX showed to be correlated with alternative well-being measures as expected and able to sufficiently differentiate between relevant subgroups in the population. Moreover, the dimensionality analysis indicated that the WiX captures a broad array of elements relevant to well-being, including physical and mental health. The test-retest reliability was good, with an intraclass correlation coefficient of 0.82. CONCLUSIONS: The results regarding the WiX are favorable and indicate that this new instrument may be a promising alternative for existing measures of well-being for evaluating interventions in health and social care.

Estimating a Preference-Based Value Set for the Mental Health Quality of Life Questionnaire (MHQoL).

BACKGROUND: Health economic evaluations using common health-related quality of life measures may fall short in adequately measuring and valuing the benefits of mental health care interventions. The Mental Health Quality of Life questionnaire (MHQoL) is a standardized, self-administered mental health-related quality of life instrument covering 7 dimensions known to be relevant across and valued highly by people with mental health problems. The aim of this study was to derive a Dutch value set for the MHQoL to facilitate its use in cost-utility analyses. METHODS: The value set was estimated using a discrete choice experiment (DCE) with duration that accommodated nonlinear time preferences. The DCE was embedded in a web-based self-complete survey and administered to a representative sample (N = 1,308) of the Dutch adult population. The matched pairwise choice tasks were created using a Bayesian heterogeneous D-efficient design. The overall DCE design comprised 10 different subdesigns, with each subdesign containing 15 matched pairwise choice tasks. Each participant was asked to complete 1 of the subdesigns to which they were randomly assigned. RESULTS: The obtained coefficients indicated that "physical health,""mood," and "relationships" were the most important dimensions. All coefficients were in the expected direction and reflected the monotonic structure of the MHQoL, except for level 2 of the dimension "future." The predicted values for the MHQoL ranged from -0.741 for the worst state to 1 for the best state. CONCLUSIONS: This study derived a Dutch value set for the recently introduced MHQoL. This value set allows for the generation of an index value for all MHQoL states on a QALY scale and may hence be used in Dutch cost-utility analyses of mental healthcare interventions. HIGHLIGHTS: A discrete choice experiment was used to derive a Dutch value set for the MHQoL.This allows the use of the MHQoL in Dutch cost-utility analyses.The dimensions physical health, mood, and relationships were the most important.The utility values range from -0.741 for the worst state to 1 for the best state.

Adaptation in life satisfaction and self-assessed health to disability - Evidence from the UK.

Experiencing deteriorating health has implications for your quality of life. The theory of adaptation suggests that with time spend living in a health state individuals can adapt, resulting in observed quality of life levels to revert or stagnate despite persistently decreased health. Adaptation has implications for the use of subjective quality of life indicators when quantifying the impact of health changes or the benefits from new medical technologies. As both the impact from ill health and the benefit from new interventions might be disease- or subgroup-specific adaptation further raises ethical concerns but empirical evidence on its existence, magnitude, and heterogeneity remains inconclusive. This paper uses a general population sample of 9,543 individuals that participate in the UK Understanding Society survey and experience the onset of a long-standing illness or disability to provide evidence on these questions. Using ordered-response fixed effects models we explore longitudinal changes in self-assessed health and life satisfaction around the onset of disability. Our results indicate that disability onset is associated with large decreases in subjective health and well-being. Over time this initial decrease in subjective quality of life indicators attenuates, especially in life satisfaction and to a lesser extent for self-assessed health. While the relative difference in adaptation across these two measures remains persistent, we find that across demographic and severity groups the initial impact of disability onset and adaptation differs considerably in its magnitude. These results have important implications for studies aiming to quantify the impact of health conditions on quality of life outcomes, especially when using observational datasets.

Psychometric evaluation of the Mental Health Quality of Life (MHQoL) instrument in seven European countries.

INTRODUCTION: To make efficient use of available resources, decision-makers in healthcare may assess the costs and (health) benefits of health interventions. For interventions aimed at improving mental health capturing the full health benefits is an important challenge. The Mental Health Quality of Life (MHQoL) instrument was recently developed to meet this challenge. Evaluating the pyschometric properties of this instrument in different contexts remains important. METHODS: A psychometric evaluation of the MHQoL was performed using existing international, cross-sectional data with 7155 respondents from seven European countries (Denmark, France, Germany, Italy, Portugal, The Netherlands, Portugal and the United Kingdom). Reliability was examined by calculating Cronbach's alpha, a measure of internal consistency of the seven MHQoL dimensions, and by examining the association of the MHQoL sum scores with the MHQoL-VAS scores. Construct validity was examined by calculating Spearman's rank correlation coefficients between the MHQoL sum scores and EQ-5D index scores, EQ-VAS scores, EQ-5D anxiety/depression dimension scores, ICECAP-A index scores and PHQ-4 sum scores. RESULTS: The MHQoL was found to have good internal consistency for all seven countries. The MHQoL sum score and the MHQoL-VAS had a high correlation. Spearman's rank correlation coefficients were moderate to very high for all outcomes. CONCLUSION: Our results, based on data gathered in seven European countries, suggest that the MHQoL shows favourable psychometrical characteristics. While further validation remains important, the MHQoL may be a useful instrument in measuring mental health-related quality of life in the Western European context.

Reference-dependent age weighting of quality-adjusted life years.

People do not only care about maximizing health gains but also about their distribution. For example, they give more weight to younger patients than older patients. This pilot study aims to investigate if age weighting is reinforced by loss aversion if young people are falling behind one's perceived 'normal' quality of life (QoL), while older people do not. We apply a person trade-off method in a large representative sample (n = 990) to estimate age weighting factors. We also measure QoL levels that individuals regard as 'normal' for different ages, serving as reference points. We observe a considerable amount of age weighting, with 20-year-old patients on average receiving 1.7 times as much weight as 80-year-old patients. Perceived 'normal' QoL rapidly decreases with age of a patient. Older people are more optimistic about what constitutes 'normal QoL' than younger people, but they express a faster decline in normal QoL due to aging. Respondents who view all improvements to be gain enlarging show the least age weighting, but loss aversion cannot explain the results. Still, one's age-related reference level is an important predictor of age weights. Given the explorative nature of this study, further studies are called for to generate more robust evidence.

Do Health Technology Assessment organisations consider manufacturers' costs in relation to drug price? A study of reimbursement reports.

INTRODUCTION: Drug reimbursement decisions are often made based on a price set by the manufacturer. In some cases, this price leads to public and scientific debates about whether its level can be justified in relation to its costs, including those related to research and development (R&D) and manufacturing. Such considerations could enter the decision process in collectively financed health care systems. This paper investigates whether manufacturers' costs in relation to drug prices, or profit margins, are explicitly mentioned and considered by health technology assessment (HTA) organisations. METHOD: An analysis of reimbursement reports for cancer drugs was performed. All relevant Dutch HTA-reports, published between 2017 and 2019, were selected and matched with HTA-reports from three other jurisdictions (England, Canada, Australia). Information was extracted. Additionally, reimbursement reports for three cases of expensive non-oncolytic orphan drugs prominent in pricing debates in the Netherlands were investigated in depth to examine consideration of profit margins. RESULTS: A total of 66 HTA-reports concerning 15 cancer drugs were included. None of these reports contained information on manufacturer's costs or profit margins. Some reports contained general considerations of the HTA organisation which related prices to manufacturers' costs: six contained a statement on the lack of price setting transparency, one mentioned recouping R&D costs as a potential argument to justify a high price. For the case studies, 21 HTA-reports were selected. One contained a cost-based price justification provided by the manufacturer. None of the other reports contained information on manufacturer's costs or profit margins. Six reports contained a discussion about lack of transparency. Reports from two jurisdictions contained invitations to justify high prices by demonstrating high costs. CONCLUSION: Despite the attention given to manufacturers' costs in relation to price in public debates and in the literature, this issue does not seem to get explicit systematic consideration in the reimbursement reports of expensive drugs.

The Role of Perceived Utility of Full Health in Age Weighting.

OBJECTIVES: People often give different weights to quality-adjusted life-years (QALYs) gained by different socioeconomic groups. It is well known that QALY gains of younger patients generally get more weight than the same QALY gains accruing to older patients. This study aims to separate these age-related preferences into "pure age weighting" and age weighting caused by full health not perceived as being the same for the old as for the young. METHODS: We apply a person trade-off method in a large sample representative (N = 500) of the Dutch general adult population to estimate age weighting factors. We describe health as a percentage of what is considered full health for a given age, for which we obtain a proxy in a separate task. RESULTS: A high amount of age weighting is observed, with QALYs to 20-year-old patients receiving approximately 1.5 times as much weight as QALYs to 80-year-old patients. At the same time, we see that individuals do not perceive full health to be the same for young and older people. In fact, the age weighting disappears once we control for these differences in full health perceptions. CONCLUSIONS: Respondents had strong preferences for the young relative to the old, but these preferences were related to full health perceptions, that is, more weight being assigned to younger because full health is at a higher absolute level for them than for the old.

Do Profit Margins of Pharmaceuticals Influence Reimbursement Decisions? A Discrete Choice Experiment Among Dutch Healthcare Decision Makers.

OBJECTIVES: This study aimed to investigate whether the profit margins of pharmaceuticals would influence the outcome of reimbursement decisions within the Dutch policy context. METHODS: We conducted a discrete choice experiment among 58 Dutch decision makers. In 20 choice sets, we asked respondents to indicate which of 2 pharmaceutical treatment options they would select for reimbursement. Options were described using 5 attributes (disease severity, incremental costs per quality-adjusted life-year, health gain, budget impact, and profit margin) with 3 levels each. Additionally, cognitive debriefing questions were presented, and for validation debriefing, interviews were conducted. Choice data were analyzed using mixed logit models, also to calculate marginal effects and choice probabilities. RESULTS: Results indicated that the specified levels of profit margins significantly influenced choices made. Decision makers were less likely to reimburse a product with a higher profit margin. The relative importance of profit margins was lower than that of the included traditional health technology assessment criteria, but not negligible. When asked directly, 61% of respondents indicated that profit margin should play a role in reimbursement decision making, although concerns about feasibility and the connection to price negotiations were voiced. CONCLUSIONS: Our results suggest that if available to decision makers the profit margin of pharmaceutical products would influence reimbursement decisions within the Dutch policy context. Higher profit margins would reduce the likelihood of reimbursement. Whether adding profit margin as an additional, explicit criterion to the health technology assessment decision framework would be feasible and desirable is open to further exploration.

Psychometric evaluation of the Health-Risk Attitude Scale (HRAS-13): assessing the reliability, dimensionality and validity in the general population and a patient population.

OBJECTIVES: The aim of this study was to assess the reliability, dimensionality and validity of the self-report questionnaire Health-Risk Attitude Scale (HRAS-13) in a sample of the general population and a patient population. METHODS: Sample 1 (n = 930) was recruited from the general population aged 18-65 years in the Netherlands. Sample 2 (n = 486) was recruited from the population of knee and hip osteoarthritis patients aged 45 and over, also from the Netherlands. Reliability was assessed using Cronbach's alpha, average inter-item correlation and item-total correlations. Dimensionality was examined using confirmatory factor analysis (CFA), principal component analysis (PCA) and bifactor analysis. Validity was assessed by performing known-group analysis using ANOVA tests. RESULTS: Cronbach's alphas of the HRAS-13 were 0.73 in sample 1 and 0.69 in sample 2. Reliability and dimensionality analyses differed slightly between the samples, and suggest that a short version of the HRAS may capture a general component of health-risk attitude. Validity assessment of known groups showed that the HRAS-13 and a likely HRAS-6 distinguished between subgroups of respondents based on most of the assessed characteristics, but not all. DISCUSSION: These findings are a preliminary indication that the HRAS-13 is a promising multidimensional instrument for measuring health-risk attitude. However, further research in various samples on decisions where health risks play a role is warranted to confirm the dimensionality of the HRAS-13 and the items to be retained in a full or a shorter version.

Caring for Children with an Autism Spectrum Disorder: Factors Associating with Health- and Care-Related Quality of Life of the Caregivers.

This study investigated the association of child, caregiver, and caregiving measurements with the quality of life (QoL) in 81 caregivers (mostly parents) of clinically referred children with autism spectrum disorder (ASD). We used the EuroQol five-dimensional (EQ-5D) questionnaire and the care-related QoL questionnaire (CarerQol) to respectively assess health-related QoL and care-related QoL. Health-related QoL was associated with the caregiver's internalizing problems and adaptive coping, explaining 38% of the variance. Parenting stress and adaptive coping were associated with the care-related QoL and explained 60% of the variance. Child variables were not associated with the caregiver's health- and care-related QoL if caregiver and caregiving variables were taken into account. Findings indicate the importance of the caregiver's mental health, coping, and parenting stress in caring for children with ASD.

Productivity of Working at Home and Time Allocation Between Paid Work, Unpaid Work and Leisure Activities During a Pandemic.

BACKGROUND AND OBJECTIVE: The COVID-19 pandemic and the measures taken by governments to contain it have affected many aspects of the daily lives of citizens. This study aimed to describe changes in the productivity of paid work and time allocation to paid and unpaid work and leisure resulting from working at home during the pandemic. METHODS: A sample of 851 people from the Netherlands who had paid work (≥ 24 h/week) and worked at least 4 hours per week extra at home because of lockdown measures completed a questionnaire during the first COVID-19 lockdown (April 2020). Respondents reported time spent on paid and unpaid work and leisure before and during the lockdown. Productivity was measured in terms of quantity and quality of paid work. RESULTS: On average, respondents spent less time (14%) on paid work and productivity decreased 5.5%. Changes in productivity were associated with the age of children, net income and having a separate home office. Respondents spent more time on unpaid work (27%) and leisure (11%). Women spent more time on unpaid work in absolute but not in relative terms. People with a partner and with children spent more time on unpaid work and less time on leisure. CONCLUSIONS: Productivity of paid work decreased, and people reallocated time between paid and unpaid work and leisure during the first COVID-19 lockdown. Changes in time allocation and productivity differed across subgroups. If working at home becomes more common, future research should focus on the long-term impact on productivity and mental and physical health.

Measurement Instruments of Productivity Loss of Paid and Unpaid Work: A Systematic Review and Assessment of Suitability for Health Economic Evaluations From a Societal Perspective.

OBJECTIVES: This study aimed (1) to perform a systematic literature review of instruments for measuring productivity loss of paid and unpaid work and (2) to assess the suitability (in terms of identification, measurement, and valuation) of these instruments for use in health economic evaluations from a societal perspective. METHODS: Articles published from 2018 were sourced from PubMed/Medline, PsycInfo, Embase, and Econlit. Using 2 separate search strategies, eligible economic evaluations and validation studies were selected and unique measurement instruments identified. A data-extraction form was developed by studying previous literature and consulting an international panel of experts in the field of productivity costs. This data-extraction form was applied to assess the suitability of instruments for use in economic evaluations. RESULTS: A total of 5982 articles were retrieved from the databases, of which 99 economic evaluations and 9 validation studies were included in the review. A total of 42 unique measurement instruments were identified. Nine instruments provided quantified measures of absenteeism, presenteeism, and unpaid work. Five instruments supplied the necessary information to enable the use of at least 1 common valuation method. The Health and Labour Questionnaire-Short Form, Health and Labour Questionnaire, and Institute for Medical Technology Assessment Productivity Cost Questionnaire met both criteria. Nevertheless, the developers replaced the Health and Labour Questionnaire-Short Form and Health and Labour Questionnaire by the more recently developed Institute for Medical Technology Assessment Productivity Cost Questionnaire. CONCLUSIONS: Although many instruments for measuring productivity loss were identified, most were not suitable for capturing productivity changes for economic evaluations from a societal perspective. Future research can benefit from this study by making an informed instrument choice for the measurement of productivity loss of paid and unpaid work.

Life satisfaction: The role of domain-specific reference points.

In the evaluation of well-being, it is not only important what people have in absolute terms, but also how this compares to reference points in relative terms. We explore the relevance of relative comparisons by testing the effect of people's self-rated position on potential reference points for income and health on their subjective well-being. We used Multiple Discrepancies Theory as a framework to identify seven potentially relevant reference points for income and health. A representative sample (N = 550) of the Netherlands assessed their income and health relative to these reference points. In addition, we elicited monthly household income, health status (EQ-5D-5L), and subjective well-being (SWLS). In line with the literature, we found a negative convex relationship between subjective well-being and age and a positive relationship with being employed, income, and health. For income, subjective well-being was also associated with how current income compared to respondents' needs and progression over time, and for health especially with how current health compared to what they felt they deserved. Our findings suggest that income and health are important for subjective well-being both in absolute and relative terms. We found negative effects on life satisfaction if some of the domain specific reference points were not met.

Content validation of the Well-being of Older People measure (WOOP).

BACKGROUND: Valid measures of the well-being of older people are important for the evaluation of health and social care services. The nine-item Well-being of Older People measure (WOOP) was based on a novel framework derived from a recent Q-methodology study, and was developed to capture a comprehensive set of well-being domains relevant to older people, as identified by themselves. This study introduces the WOOP and describes the qualitative assessment of its feasibility and content validity. METHODS: Between December 2017 and January 2018, a sampling agency retrieved data from 269 adults aged 65 years and older in the Netherlands. Using an online survey, participants were asked to complete the WOOP and to indicate the importance of each item to their well-being. Open-ended questions were used to collect information about participants' own definition of well-being, their interpretation of the items of the WOOP, and their assessment of the descriptions and response options provided with each item. Data were analysed using inductive content analysis with the software package ATLAS.ti. RESULTS: The WOOP closely resembled respondents' own description of what well-being means to them. The majority of the respondents reported no important well-being aspects to be missing from the WOOP, and indicated all WOOP items to be at least 'reasonably important' to their well-being. Many linked the WOOP items to well-being aspects as intended, and only a few had suggestions for improving the items' descriptions and response options. CONCLUSIONS: Given these results, all nine items were retained, and no items were added to the measure. Based on respondents' feedback, minor changes were made to the wording of some descriptions and response options of items. Concluding, the feasibility and content validity of the WOOP seem satisfactory. Further validation of this new measure is required, in different health and social care settings and among subgroups of older people with potentially different views on what constitutes well-being.

Development and psychometric evaluation of the Decision Tool Anxiety Disorders, OCD and PTSD (DTAOP): Facilitating the early detection of patients in need of highly specialized care.

BACKGROUND: Early identification of patients with an anxiety disorder, obsessive-compulsive disorder (OCD), or post-traumatic stress disorder (PTSD) in need of highly specialized care could facilitate the selection of the optimal initial treatment in these patients. This paper describes the development and psychometric evaluation of the Decision Tool Anxiety Disorders, OCD and PTSD (DTAOP), which aims to aid clinicians in the early identification of patients with an anxiety disorder, OCD, or PTSD in need of highly specialized mental healthcare. METHODS: A systematic literature review and a concept mapping procedure were carried out to inform the development of the DTAOP. To evaluate the psychometric properties of the DTAOP, a cross-sectional study in 454 patients with a DSM-IV-TR anxiety disorder was carried out. Feasibility was evaluated by the completion time and the content clarity of the DTAOP. Inter-rater reliability was assessed in a subsample of 87 patients. Spearman's rank correlation coefficients between the DTAOP and EuroQol five-dimensional questionnaire (EQ-5D-5L) scores were computed to examine the convergent validity. Criterion validity was assessed against independent clinical judgments made by clinicians. RESULTS: The average time required to complete the eight-item DTAOP was 4.6 min and the total DTAOP was evaluated as clear in the majority (93%) of the evaluations. Krippendorff's alpha estimates ranged from 0.427 to 0.839. Based on the qualitative feedback, item wording and instructions were improved. As hypothesized, the DTAOP correlated negatively with EQ-5D-5L scores. The area under the curve was 0.826 and the cut-off score of ≥4 optimized sensitivity (70%) and specificity (71%). CONCLUSIONS: The DTAOP demonstrated excellent feasibility and good validity, but weak inter-rater reliability. Based on the qualitative feedback and reliability estimates, revisions and refinements of the wording and instructions were made, resulting in the final version of the DTAOP.

Modeling of Individual Fruit-Bearing Capacity of Trees Is Aimed at Optimizing Fruit Quality of Malus x domestica Borkh. 'Gala'.

The capacity of apple trees to produce fruit of a desired diameter, i.e., fruit-bearing capacity (FBC), was investigated by considering the inter-tree variability of leaf area (LA). The LA of 996 trees in a commercial apple orchard was measured by using a terrestrial two-dimensional (2D) light detection and ranging (LiDAR) laser scanner for two consecutive years. The FBC of the trees was simulated in a carbon balance model by utilizing the LiDAR-scanned total LA of the trees, seasonal records of fruit and leaf gas exchanges, fruit growth rates, and weather data. The FBC was compared to the actual fruit size measured in a sorting line on each individual tree. The variance of FBC was similar in both years, whereas each individual tree showed different FBC in both seasons as indicated in the spatially resolved data of FBC. Considering a target mean fruit diameter of 65 mm, FBC ranged from 84 to 168 fruit per tree in 2018 and from 55 to 179 fruit per tree in 2019 depending on the total LA of the trees. The simulated FBC to produce the mean harvest fruit diameter of 65 mm and the actual number of the harvested fruit >65 mm per tree were in good agreement. Fruit quality, indicated by fruit's size and soluble solids content (SSC), showed enhanced percentages of the desired fruit quality according to the seasonally total absorbed photosynthetic energy (TAPE) of the tree per fruit. To achieve a target fruit diameter and reduce the variance in SSC at harvest, the FBC should be considered in crop load management practices. However, achieving this purpose requires annual spatial monitoring of the individual FBC of trees.

The value of health-Empirical issues when estimating the monetary value of a quality-adjusted life year based on well-being data.

Decisions on interventions or policy alternatives affecting health can be informed by economic evaluations, like cost-benefit or cost-utility analyses. In this context, there is a need for valid estimates of the monetary equivalent value of health (gains), which are often expressed in € per quality-adjusted life years (QALYs). Obtaining such estimates remains methodologically challenging, with a recent addition to the health economists' toolbox, which is based on well-being data: The well-being valuation approach. Using general population panel data from Germany, we put this approach to the test by investigating several empirical and conceptual challenges, such as the appropriate functional specification of income utility, the choice of health utility tariffs, or the health state dependence of consumption utility. Depending on specification, the bulk of estimated € per QALY values ranged from €20,000-60,000, with certain specifications leading to more considerable deviations, underlining persistent practical challenges when applying the well-being valuation methodology to health and QALYs. Based on our findings, we formulate recommendations for future research and applications.

[Standards in the use of fiberoptic endoscopic evaluation of swallowing in Germany : A questionnaire survey]. / Standards bei der Anwendung der fiberendoskopischen Schluckuntersuchung in Deutschland : Eine Fragebogenerhebung.

BACKGROUND: The fiberoptic endoscopic evaluation of swallowing (FEES) is considered to be an indispensable instrumental procedure in the management of patients with dysphagia. The aim of the implemented training curriculum is to raise the quality standards and to contribute to an upgrading of the procedure. OBJECTIVE: The study evaluated to what extent a standardized implementation, evaluation and documentation of FEES takes place in Germany after the introduction of the curriculum. MATERIAL AND METHODS: In this study 603 neurological and geriatric hospitals in Germany were interviewed by the use of an online questionnaire regarding structural features and the course of the investigation. RESULTS: A total of 190 institutions completed the survey. Of the institutions 43.31% had only implemented FEES since the publication of the curriculum. The practical application is increasingly carried out by physicians (59%), the clinical reports and cost recommendations are carried out by speech therapists (62% and 83%, respectively). The practical application by speech therapists increases with increasing level of training. Despite orientation towards the standard protocol according to Langmore, there are differences in the implementation of the anatomical physiological examination, the consistencies and foods administered and the scoring of swallowing-relevant parameters. DISCUSSION: The introduction of the curriculum has led to an upgrading of the FEES and to a strengthening of speech therapy as the implementing professional group. At the current state of the art there is a homogeneous course of the examination in essential aspects but it shows a need for further uniformity. The FEES curriculum could be used as a guiding instrument for further standardization.

Effect of Chlorine Dioxide Treatment on Human Pathogens on Iceberg Lettuce.

In the vegetable processing industry, the application of chlorine dioxide (ClO2) as a disinfectant solved in washing water to eliminate undesirable microorganisms harmful to consumers' health and the shelf life of produce has been discussed for years. The disinfection efficacy depends on various factors, e.g., the location of microorganisms and the organic load of the washing water. The present study analyzed the sanitation efficacy of various concentrations of water-solved ClO2 (cClO2: 20 and 30 mg L-1) on Escherichia coli (1.1 × 104 cfu mL-1), Salmonella enterica (2.0 × 104 cfu mL-1) and Listeria monocytogenes (1.7 × 105 cfu mL-1) loads, located on the leaf surface of iceberg lettuce assigned for fresh-cut salads. In addition, it examined the potential of ClO2 to prevent the cross-contamination of these microbes in lettuce washing water containing a chemical oxygen demand (COD) content of 350 mg L-1 after practice-relevant washing times of 1 and 2 min. On iceberg leaves, washing with 30 mg L-1 ClO2 pronouncedly (1 log) reduced loads of E. coli and S. enterica, while it only insignificantly (<0.5 × log) diminished the loads of L. monocytogenes, irrespective of the ClO2 concentration used. Although the sanitation efficacy of ClO2 washing was only limited, the addition of ClO2 to the washing water avoided cross-contamination even at high organic loads. Thus, the application of ClO2 to the lettuce washing water can improve product quality and consumer safety.