Catalog of EQ-5D-3L Health-Related Quality-of-Life Scores for 199 Chronic Conditions and Health Risks in Denmark.

Background. Assessments of health-related quality of life (HRQoL) are essential in estimating quality-adjusted life-years. It is sometimes not feasible to collect primary HRQoL data, and reliable secondary sources are necessary. Current "off-the-shelf" HRQoL catalogs are based on older diagnosis classifications and include a limited number of diseases. This article aims to provide 1) a Danish EQ-5D-3L-based HRQoL catalog for 199 nationally representative chronic conditions based on ICD-10 codes and 2) a complementary model-based catalog controlling for age, sex, comorbidities, lifestyle, and health risks. Design. A total of 55,616 respondents from 3 national health survey samples were pooled and combined with 7 national registers containing patient-level information on diagnoses, health care activity, and sociodemographics. EQ-5D-3L data were converted to utility scores using the Danish EQ-5D-3L value set to estimate the mean utility for each chronic disease population. Adjusted limited dependent variable mixture models were estimated and used to provide a regression-based catalog of utilities/disutilities. Results. Diseases with the lowest mean EQ-5D score in the Danish population were systemic sclerosis (M34; score = 0.432), fibromyalgia (M797; score = 0.490), rheumatism (M790; score = 0.515), dementia (F00, G30; score = 0.546), posttraumatic stress syndrome (F431; score = 0.557), and systemic atrophies (G10-G14; score = 0.583. Based on the estimated models, the largest estimated disutilities were cystic fibrosis, cerebral palsy, depression, dorsalgia, sclerosis, and fibromyalgia. Lifestyle factors, including perceived stress, loneliness, and body mass index, were also significantly associated with low HRQoL. Conclusions. This study provides a comprehensive nationally representative catalog and a model-based catalog of EQ-5D-3L-based HRQoL scores for Denmark that can be used to describe aspects of disease burden and allocate resources within health care. Additional Stata programs are also provided to facilitate predictions in other populations. Highlights: A Danish national representative catalog of health-related quality-of-life scores for 199 chronic conditions is presented, which provides population estimates for chronic conditions subgroups that can be used for health economic evaluation.Two separate regression models of EQ-5D-3L utility scores with different sets of control variables are estimated to allow researchers to adjust for differences in the composition of the subgroups and provide a tool that can be used in other settings.Results indicate that health-related quality of life varies across disease groups but is lowest for renal disease, mental and behavioral disorders, benign neoplasms and diseases of the blood, digestive systems, and nervous systems.Health risks and lifestyle factors such as perceived stress, loneliness, and a large body mass index are highly correlated with health-related quality of life, and, in many cases, the correlation is higher than with individual diseases.

The construct validity of the Child Health Utility 9D-DK instrument.

BACKGROUND: Relative to their application with adults there is currently little information about the application of preference-based health-related quality of life (HRQL) instruments among populations of young people. The Child Health Utility 9D (CHU9D) is a paediatric-specific generic preference-based HRQL instrument, recently translated and linguistically validated into Danish (CHU9D-DK). The purpose of this study was to investigate the construct validity of the CHU9D-DK in a sample of Danish high school students. METHODS: All students attending a Danish High School were invited to participate in a web-based survey in January 2018 (N = 272). The survey included the CHU9D-DK, the young adult version of the Pediatric Quality of Life Inventory™ 4.0 Generic Core Scales (PedsQL), self-reported health status, presence/absence of disability/chronic diseases, life satisfaction, and socio-economic questions. CHU9D-DK utility scores were generated by employing the two scoring algorithms developed from adults in the UK and adolescents in Australia, respectively. Internal consistency, reliability and construct validity of the CHU9D-DK instrument were investigated. RESULTS: Two hundred and twenty-eight (84%) students consented to participate and completed the survey. The mean ± (standard deviation) values of the CHU9D-DK utilities were 0.84 (0.11) when the UK adult algorithm was applied and 0.70 (0.22), when the Australian adolescent algorithm was applied. The mean PedsQL score was 82.32 (13.14). The CHU9D-DK showed good internal consistency reliability (Cronbach's alpha = 0.803). Higher levels of health status and life satisfaction were significantly associated with higher CHU9D-DK utility scores regardless of which scoring algorithm was applied (p-values < 0.001). Students living with a disability/chronic disease exhibited significantly lower utility scores relative to their healthy peers (p-values < 0.05). Higher socio-economic status (approximated by financial situation and frequency of family vacations) was also associated with higher utility scores (p-values < 0.005). CONCLUSION: The CHU9D-DK demonstrated good psychometric performance overall and shows potential as a valid and reliable instrument for assessing the HRQL of Danish young people. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03391999, Registered 15 October 2017.

Measuring Health-Related Quality of Life in Adolescent Populations: An Empirical Comparison of the CHU9D and the PedsQLTM 4.0 Short Form 15.

OBJECTIVE: The aim was to conduct an empirical assessment of the measurement properties of the preference-based Child Health Utility 9D (CHU9D) versus the non-preference-based Pediatric Quality of Life Inventory (PedsQL)™ 4.0 Short Form 15 Generic Core Scales (referred to as 'PedsQL') in an Australian community-based sample of adolescents. METHODS: An online survey including the CHU9D, the PedsQL, a self-reported general health question, and socio-demographic questions was administered to adolescents (aged 15-17 years). Descriptive summary statistics and psychometric analyses were conducted to assess levels of agreement and convergent validity between the instruments. RESULTS: A total of 775 adolescents (mean ± SD age 15.8 ± 0.8 years) completed the survey. The mean ± SD scores of the CHU9D and the PedsQL were 0.72 ± 0.22 and 72.86 ± 16.56, respectively. For both instruments, there were significant differences in health-related quality of life scores according to self-reported health status and socio-economic status. Overall, both the Spearman's correlation (r = 0.63) and the intraclass correlation coefficient (0.77) suggested a high level of agreement. CONCLUSIONS: The findings indicate good levels of agreement overall between the CHU9D and PedsQL and provide further support for the validity of the application of the CHU9D in the economic evaluation of adolescent health care treatment and service programmes.

Economic evaluation of an implementation strategy for the management of low back pain in general practice.

In connection with the publication of a clinical practice guideline on the management of low back pain (LBP) in general practice in Denmark, a cluster randomised controlled trial was conducted. In this trial, a multifaceted guideline implementation strategy to improve general practitioners' treatment of patients with LBP was compared with a usual implementation strategy. The aim was to determine whether the multifaceted strategy was cost effective, as compared with the usual implementation strategy. The economic evaluation was conducted as a cost-utility analysis where cost collected from a societal perspective and quality-adjusted life years were used as outcome measures. The analysis was conducted as a within-trial analysis with a 12-month time horizon consistent with the follow-up period of the clinical trial. To adjust for a priori selected covariates, generalised linear models with a gamma family were used to estimate incremental costs and quality-adjusted life years. Furthermore, both deterministic and probabilistic sensitivity analyses were conducted. Results showed that costs associated with primary health care were higher, whereas secondary health care costs were lower for the intervention group when compared with the control group. When adjusting for covariates, the intervention was less costly, and there was no significant difference in effect between the 2 groups. Sensitivity analyses showed that results were sensitive to uncertainty. In conclusion, the multifaceted implementation strategy was cost saving when compared with the usual strategy for implementing LBP clinical practice guidelines in general practice. Furthermore, there was no significant difference in effect, and the estimate was sensitive to uncertainty.

Mapping CHU9D Utility Scores from the PedsQLTM 4.0 SF-15.

BACKGROUND: The Pediatric Quality of Life Inventory™ 4.0 Short Form 15 Generic Core Scales (hereafter the PedsQL) and the Child Health Utility-9 Dimensions (CHU9D) are two generic instruments designed to measure health-related quality of life in children and adolescents in the general population and paediatric patient groups living with specific health conditions. Although the PedsQL is widely used among paediatric patient populations, presently it is not possible to directly use the scores from the instrument to calculate quality-adjusted life-years (QALYs) for application in economic evaluation because it produces summary scores which are not preference-based. OBJECTIVE: This paper examines different econometric mapping techniques for estimating CHU9D utility scores from the PedsQL for the purpose of calculating QALYs for cost-utility analysis. METHODS: The PedsQL and the CHU9D were completed by a community sample of 755 Australian adolescents aged 15-17 years. Seven regression models were estimated: ordinary least squares estimator, generalised linear model, robust MM estimator, multivariate factorial polynomial estimator, beta-binomial estimator, finite mixture model and multinomial logistic model. The mean absolute error (MAE) and the mean squared error (MSE) were used to assess predictive ability of the models. RESULTS: The MM estimator with stepwise-selected PedsQL dimension scores as explanatory variables had the best predictive accuracy using MAE and the equivalent beta-binomial model had the best predictive accuracy using MSE. CONCLUSIONS: Our mapping algorithm facilitates the estimation of health-state utilities for use within economic evaluations where only PedsQL data is available and is suitable for use in community-based adolescents aged 15-17 years. Applicability of the algorithm in younger populations should be assessed in further research.

A multifaceted implementation strategy versus passive implementation of low back pain guidelines in general practice: a cluster randomised controlled trial.

BACKGROUND: Guidelines are often slowly adapted into clinical practice. However, actively supporting healthcare professionals in evidence-based treatment may speed up guideline implementation. Danish low back pain (LBP) guidelines focus on primary care treatment of LBP, to reduce referrals from primary care to secondary care. The primary aim of this project was to reduce secondary care referral within 12 weeks by a multifaceted implementation strategy (MuIS). METHODS: In a cluster randomised design, 189 general practices from the North Denmark Region were invited to participate. Practices were randomised (1:1) and stratified by practice size to MuIS (28 practices) or a passive implementation strategy (PaIS; 32 practices). Included were patients with LBP aged 18 to 65 years who were able to complete questionnaires, had no serious underlying pathology, and were not pregnant. We developed a MuIS including outreach visits, quality reports, and the STarT Back Tool for subgrouping patients with LBP. Both groups were offered the usual dissemination of guidelines, guideline-concordant structuring of the medical record, and a new referral opportunity for patients with psycho-social problems. In an intention-to-treat analysis, the primary and secondary outcomes pertained to the patient, and a cost-effectiveness analysis was performed from a healthcare sector perspective. Patients and the assessment of outcomes were blinded. Practices and caregivers delivering the interventions were not blinded. RESULTS: Between January 2013 and July 2014, 60 practices were included, of which 54 practices (28 MuIS, 26 PaIS) included 1101 patients (539 MuIS, 562 PaIS). Follow-up data for the primary outcome were available on 100 % of these patients. Twenty-seven patients (5.0 %) in the MuIS group were referred to secondary care vs. 59 patients (10.5 %) in the PaIS group. The adjusted odds ratio (AOR) was 0.52 [95 % CI 0.30 to 0.90; p = 0.020]. The MuIS was cost-saving £-93.20 (£406.51 vs. £499.71 per patient) after 12 weeks. Conversely, the MuIS resulted in less satisfied patients after 52 weeks (AOR 0.50 [95 % CI 0.31 to 0.81; p = 0.004]). CONCLUSIONS: Using a MuIS changed general practice referral behaviour and was cost effective, but patients in the MuIS group were less satisfied. This study supports the application of a MuIS when implementing guidelines. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01699256.

Systematic review of the cost-effectiveness of implementing guidelines on low back pain management in primary care: is transferability to other countries possible?

OBJECTIVE: The primary aim is to identify, summarise and quality assess the available literature on the cost-effectiveness of implementing low back pain guidelines in primary care. The secondary aim is to assess the transferability of the results to determine whether the identified studies can be included in a comparison with a Danish implementation study to establish which strategy procures most value for money. DESIGN: Systematic review. DATA SOURCES: The search was conducted in Embase, PubMed, Cochrane Library, NHS Economic Evaluation Database, Scopus, CINAHL and EconLit. No restrictions were made concerning language, year of publication or publication type. The bibliographies of the included studies were searched for any studies not captured in the literature search. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: To be included, a study must be: (1) based on a randomised controlled trial comparing implementation strategies, (2) the guideline must concern treatment of low back pain in primary care and (3) the economic evaluation should contain primary data on cost and cost-effectiveness. RESULTS: The title and abstract were assessed for 308 studies; of these, three studies were found eligible for inclusion. The Consensus Health Economic Criteria (CHEC) list showed that the 3 studies were of moderate methodological quality while application of Welte's model showed that cost results from two studies could, with adjustments, be transferred to a Danish setting. It was questionable whether the associated effects could be transferred. CONCLUSIONS: Despite the resemblance of the implementation strategies, the 3 studies report conflicting results on cost-effectiveness. This review showed that transferring the results from the identified studies is not straightforward and underlines the importance of transparent reporting. Future research should focus on transferability of effects, for example, development of a supplement to Welte's model.

Adjustment of foreign EQ-5D-3L utilities can increase their transferability.

BACKGROUND: Foreign utilities of the EQ-5D-3L (3-level version of the EuroQol-5 Dimension of health questionnaire) are not readily transferrable to economic evaluations conducted from a national perspective. It has been advised to avoid transferring mean utilities from one country to another without adjusting them; yet no such method exists. PURPOSE: The present study aimed to develop a method for adjusting mean utilities to increase their transferability from one country to another. METHODS: Seven datasets containing EQ-5D-3L answers were valued using value sets from four countries: the UK, the Netherlands, Germany, and Spain. Hereby, seven mean utility values were obtained for each country. This allowed for three pairwise comparisons: 1) UK mean values vs Dutch mean values; 2) UK mean values vs German mean values; and 3) UK mean values vs Spanish mean values. For each of these three comparisons, a regression model was fitted using the mean UK utilities as the dependent variable and the other country's mean utilities as the independent variable. The coefficients from the three regression models were validated using results from a published article containing mean utilities obtained by valuing the EQ-5D-3L data using all four value sets. RESULTS: The findings suggested that adjustment of foreign utilities may increase transferability between countries where value sets are not comparable. It was possible to adjust the mean utilities valued by the Dutch and German value sets to make them reflect mean UK utilities as there were substantial differences between these value sets. Transferability of the Spanish mean utility values was not improved as the Spanish and UK value sets are sufficiently similar. CONCLUSION: It is feasible to adjust foreign mean utilities of the EQ-5D-3L to make them reflect national preferences for health.

Study protocol of an economic evaluation of an extended implementation strategy for the treatment of low back pain in general practice: a cluster randomised controlled trial.

BACKGROUND: In Denmark, guidelines on low back pain management are currently being implemented; in association with this, a clinical trial is conducted. A health economic evaluation is carried out alongside the clinical trial to assess the cost-effectiveness of an extended implementation strategy to increase the general practitioners' adherence to the guidelines. In addition to usual dissemination, the extended implementation strategy is composed of visits from a guideline facilitator, stratification tools, and feedback on guideline adherence. The aim of this paper is to provide the considerations on the design of the health economic evaluation. METHODS/DESIGN: The economic evaluation is carried out alongside a cluster randomised controlled trial consisting of 60 general practices in the North Denmark Region. An expected 1,200 patients between the age of 18 and 65 years with a low back pain diagnosis will be enrolled. The economic evaluation comprises both a cost-effectiveness analyses and a cost-utility analysis. Effectiveness measures include referral to secondary care, health-related quality of life measured by EQ-5D-5L, and disability measured by the Roland Morris disability questionnaire. Cost measures include all relevant additional costs of the extended implementation strategy compared to usual implementation. The economic evaluation will be performed from both a societal perspective and a health sector perspective with a 12-month time horizon. DISCUSSION: It is expected that the extended implementation strategy will reduce the number of patients referred to secondary care. It is hypothesised that the additional upfront cost of extended implementation will be counterbalanced by improvements in clinical practice and patient-related outcomes, thereby rendering the extended implementation strategy cost-effective. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01699256.

In Denmark kidney transplantation is more cost-effective than dialysis.

INTRODUCTION: Approximately 5,000 Danish patients are being treated for end-stage renal disease, for which the two treatment options are dialysis and transplantation. The objective of this study was to estimate the cost-effectiveness of kidney transplantation versus dialysis from a public health-care perspective. MATERIAL AND METHODS: A cost-utility analysis was conducted using a decision analytic model. The model was designed as a Markov model in which all relevant costs and effects of the two alternative treatments were included. Deterministic data were used alongside the best available evidence from the literature. To estimate the overall uncertainty concerning the incremental cost-effectiveness ratio (ICER), a probabilistic sensitivity analysis with second-order Monte Carlo simulations was carried out on a hypothetical cohort of 10,000 patients. RESULTS: The cost per quality-adjusted life year (QALY) was 1,032,934 DKK for dialysis compared with 810,516 DKK for transplantation. When comparing kidney transplantation with dialysis, kidney transplantation was cost-saving and resulted in additional QALYs. When taking the overall uncertainty associated with the ICER into account, an incremental cost-effectiveness scatter plot supported that transplantation was dominating and that the results were robust. In addition, a cost-effectiveness acceptability curve showed that transplantation had a 99.93% likelihood of being cost-effective at a willingness-to-pay value of 0 DKK. CONCLUSION: The cost-effectiveness ratio was favourable for kidney transplantation when compared with dialysis. In view of this, it was concluded that transplantation is preferable to dialysis when treating patients with end-stage renal disease. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Enhanced implementation of low back pain guidelines in general practice: study protocol of a cluster randomised controlled trial.

BACKGROUND: Evidence-based clinical practice guidelines may improve treatment quality, but the uptake of guideline recommendations is often incomplete and slow. Recently new low back pain guidelines are being launched in Denmark. The guidelines are considered to reduce personal and public costs. The aim of this study is to evaluate whether a complex, multifaceted implementation strategy of the low back pain guidelines will reduce secondary care referral and improve patient outcomes compared to the usual simple implementation strategy. METHODS/DESIGN: In a two-armed cluster randomised trial, 100 general practices (clusters) and 2,700 patients aged 18 to 65 years from the North Denmark region will be included. Practices are randomly allocated 1:1 to a simple or a complex implementation strategy. Intervention practices will receive a complex implementation strategy, including guideline facilitator visits, stratification tools, and quality reports on low back pain treatment. Primary outcome is referral to secondary care. Secondary outcomes are pain, physical function, health-related quality of life, patient satisfaction with care and treatment outcome, employment status, and sick leave. Primary and secondary outcomes pertain to the patient level. Assessments of outcomes are blinded and follow the intention-to-treat principle. Additionally, a process assessment will evaluate the degree to which the intervention elements will be delivered as planned, as well as measure changes in beliefs and behaviours among general practitioners and patients. DISCUSSION: This study provides knowledge concerning the process and effect of an intervention to implement low back pain guidelines in general practice, and will provide insight on essential elements to include in future implementation strategies in general practice. TRIAL REGISTRATION: Registered as NCT01699256 on ClinicalTrials.gov.

Is dabigatran considered a cost-effective alternative to warfarin treatment: a review of current economic evaluations worldwide.

OBJECTIVE: Dabigatran was the first of a new generation of anticoagulation drugs for the indication of non-valvular atrial fibrillation (AF) to be approved. Evidence show that dabigatran 150 mg twice daily significantly reduces the risk of stroke and systemic embolism (RR = 0.65; p < 0.001) and shows a comparable rate of major bleedings (RR = 0.93; p = 0.32), whereas dabigatran 110 mg twice daily was associated with a comparable rate of stroke and systemic embolism (RR = 0.90; p = 0.30) and a significantly lower rate of major bleedings compared to warfarin treatment (RR = 0.80; p = 0.003). The purpose is to review current economic evaluations of these alternatives for healthcare professionals to include these findings in their decision-making. METHODS: A systematic literature search identified 43 economic evaluations, of which 10 were included and evaluated according to the Consensus Health Economic Criteria list (CHEC-list) and the Oxford model. RESULTS: Six economic evaluations concluded that dabigatran was a cost-effective alternative to warfarin. One evaluation concluded the same except when quality in warfarin treatment was excellent, with a mean time in therapeutic range (TTR) > 73%. Three evaluations concluded that dabigatran was a cost-effective alternative to warfarin in patient sub-groups; TTR ≤ 64%, congestive heart failure, hypertension, age ≥ 75, diabetes mellitus, prior stroke or transient ischemic attack (CHADS2 score) ≥3, or a CHADS2 score = 2 unless international normalized ratio (INR) control was excellent, and with high risk of stroke or in a low-quality warfarin treatment. Dabigatran 110 mg twice daily was in general dominated by dabigatran 150 mg twice daily. LIMITATIONS: The evaluations were not fully homogeneous, as some did not include loss of productivity, costs of dyspepsia, and annual costs of dabigatran patient management. CONCLUSIONS: In the majority of the economic evaluations, dabigatran is a cost-effective alternative to warfarin treatment. In some evaluations dabigatran is only cost-effective in sub-groups, such as patients with a low TTR-value in warfarin treatment and a CHADS2 score ≥2.

Cost-effectiveness and cost-benefit analyses of a multidisciplinary intervention compared with a brief intervention to facilitate return to work in sick-listed patients with low back pain.

STUDY DESIGN: Randomized clinical trial of 2 interventions in 351 employees sick listed due to low back pain (LBP) and a subsequent validation study (n = 120) to validate results from subgroup analyses in the original study. OBJECTIVE: To compose health economic analyses (cost-effectiveness- and cost-benefit analyses) of multidisciplinary versus brief intervention by calculating health care sector costs and sick leave benefits. SUMMARY OF BACKGROUND DATA: Both brief and multidisciplinary interventions have been reported to be superior relative to usual care when comparing intervention costs with saved costs for sick leave benefits. We reported similar return to work rates in a brief and a multidisciplinary intervention group, but different return to work rates in subgroups. METHODS: The brief intervention comprised clinical examination and reassuring advice. The multidisciplinary intervention was conducted by a case manager and a team of specialists. The costs of medicine, health care services, and sick leave benefits were calculated on the basis of registers. RESULTS: The mean intervention cost per patient was € 1377 higher in the multidisciplinary intervention (n = 176) than in the brief intervention group (n = 175), and sick leave was not averted. However, sick leave was averted in a subgroup receiving the multidisciplinary intervention and the mean incremental intervention cost for 1 saved sick leave week in this subgroup (n = 60) of patients, who thought they were at risk of losing their job or had little influence on their work situation was € 217. The latter finding was verified in the validation study (n = 28). CONCLUSION: The brief intervention resulted in fewer sick leave weeks and was less expensive than the multidisciplinary intervention. The multidisciplinary intervention only outperformed the brief intervention in terms of costs in a subgroup of sick-listed employees who thought they were at risk of losing their job or had little influence on their work situation. LEVEL OF EVIDENCE: 2.

Factors influencing quality of life in asthmatics--a case-control study.

INTRODUCTION: The quality of life (QOL) in persons with asthma is reduced and different factors such as demography, asthma severity and psychiatric comorbidity play an influential role. However, little is known about the interplay of these factors. OBJECTIVE: To describe QOL in relation to asthma and analyse for the relative impact of asthma severity, psychiatric comorbidity, lifestyle (smoking and obesity) and demographic determinants on QOL in persons with asthma. METHODS: One thousand one hundred sixty-one subjects from an earlier cohort with and without asthma were sent an asthma screening questionnaire and a generic QOL measuring instrument (15D). RESULTS: Seven hundred seventy-eight valid responses (67%). QOL was significantly reduced in persons with asthma compared with controls (P = 0.001), almost on all domains of 15D. In the adjusted regression model, asthma severity, depression, female gender and smoking were associated with reduced QOL, suggesting that these factors play an independent role on lowering QOL. Depression did not inflate the relationship between asthma severity and worse QOL, suggesting that asthma severity plays an independent role on everyday life regardless of psychological state. CONCLUSION: Asthma severity, psychiatric comorbidity, female gender and smoking were identified in this study to be major contributors to decreased QOL in asthmatics. Health professionals should be aware of this complex picture and take these factors into consideration when choosing the proper treatment of asthma patients. Asthma, asthma severity, epidemiology, psychiatric comorbidity, QOL.

Characteristics of patients receiving allergy vaccination: to which extent do socio-economic factors play a role?

BACKGROUND: Little is known about characteristics of patients receiving allergen-specific immunotherapy. Identifying obstacles to appropriate treatment according to guidelines may facilitate the development of strategies aiming at improved treatment of patients with allergic respiratory diseases. The objective of this study was to investigate differences in disease severity, demographic and socioeconomic status between allergic rhinitis patients receiving allergen-specific immunotherapy and allergic rhinitis patients not receiving allergen-specific immunotherapy. METHODS: A total of 366 patients were studied of whom 210 were going to receive subcutaneously administrated immunotherapy (SIT) against grass pollen and/or house dust mite allergy. The severity of rhino-conjunctivitis (hay fever) and/or asthma was classified according to international guidelines. The questionnaires included an EQ-5D visual analogue scale instrument and some socio-economic questions. RESULTS: Severity of disease, young age, high level of education as well as greater perceived impairment of health-related quality of life due to allergic symptoms were significantly associated with use of SIT. Somewhat unexpectedly, household income was not associated with use of SIT. CONCLUSION: Use of SIT was associated with both disease severity measures and educational level, but not income level. These results suggest social inequality as reflected by lower use of SIT among patients with lower educational level may represent an obstacle to treatment with SIT.

Willingness to pay for allergy-vaccination among Danish patients with respiratory allergy.

OBJECTIVE: The aim of this study was to elicit willingness to pay (WTP) for allergen-specific subcutaneous injection immunotherapy (SCIT) in a cohort of respondents suffering from allergic-rhinoconjunctivitis (a-RC)/asthma, and to investigate how patients self-select to SCIT according to need. METHODS: A random sample of the general population was screened for a-RC/asthma and asked if they were willing to consider SCIT. They were asked to state their WTP for SCIT by way of a discrete choice question (DC-q), an open-ended WTP question (o-WTP-q), and questions relating to their sociodemographic background and the severity of their a-RC/asthma. The characteristics of respondents demanding SCIT were compared with the characteristics of respondents who have actually received SCIT to establish possible barriers to demand. RESULTS: Our results suggest that respondents do well in self-selecting themselves to SCIT on the basis of need according to disease burden measured in terms of a-RC classification, number of contacts with a general practitioner, number of sick days, and potential quality-adjusted life-year loss. Mean WTP for SCIT was estimated at 655 euros (median, 267 euros) (o-WTP-q) and 903 euros (95 percent confidence limit, 348-1,459) (DC-q). CONCLUSION: Characteristics of respondents, who consider SCIT and are willing to pay for SCIT, suggest that allergy sufferers select themselves appropriately according to need and not according to other characteristics, such as income or education. There is a significant discrepancy between those who hypothetically consider SCIT and those demanding SCIT in real life. This study suggests that there are barriers to entry related to age and education, but not to income.