Impact of hip and vertebral fractures on quality-adjusted life years.

The objective of the study was to estimate the impact of hip and vertebral fractures on quality of life in postmenopausal women using a preference-based health measure that is appropriate for economic evaluations and to investigate correlates of health outcome. Interviews to assess health-related quality of life, which also documented other health conditions and characteristics, were undertaken in women age 50 years and older without osteoporotic fractures compared with women with hip and/or vertebral fracture(s). Health status was characterized by self-reported physical limitations and the mental and physical component summary scores of the SF-36. Quality-adjusted life years (QALYs), which reflect each individual's assessment of her overall health utility, were estimated with time tradeoff values. Regression methods were used to examine QALY correlates (e.g. time since fracture) for each fracture group and to estimate differences in QALYs between fracture and non-fracture subjects after accounting for other patient characteristics. Among 382 women ages 50-96 years, fracture subjects were significantly older, less likely to use hormone replacement therapy and more likely to report physical limitations than non-fracture subjects. On the QALY scale, where 1 represents perfect health and 0 represents death, mean QALY values were 0.82 (95% CI: 0.76, 0.87) among 114 women with one or more vertebral fractures and 0.63 (95% CI: 0.52, 0.74) among 67 with hip fracture compared with 0.91 (95% CI: 0.88, 0.94) among 201 women without fracture. No significant correlates of QALYs were identified among women with vertebral fracture alone. Among hip fracture subjects, time since hip fracture and presence of a vertebral fracture were significant correlates of QALYs. In multiple regression analyses, estimated QALY differences (fracture minus non-fracture subjects) ranged from -0.05 to -0.55 and were equivalent to losses of 20-58 days, 23-65 days and 115-202 days per year for vertebral fracture (p = 0.001), hip fracture (p = 0.009) and hip plus vertebral fracture (p<0.001) subjects, respectively, depending on age. Thus to adequately assess the cost-effectiveness of osteoporosis treatment, the negative impact of vertebral fractures on QALYs, even among women who have survived a hip fracture, must be considered.

Measuring health state preferences in women with breast hypertrophy.

The purpose of this article is to introduce the measurement of utilities, or patient preferences, to the plastic surgery community. Specifically, the study demonstrated the development and validation of a utility measure for estimating the health-related quality of life in women with breast hypertrophy. Two self-administered instruments were developed, a Wheel and a Table. All subjects completed the utility assessments for their "current health" and again for "breast-related symptoms." The reliability of the instruments was assessed in repeat (test-retest) interviews of 47 women within 10 to 18 days. Utilities obtained with the new instruments were also compared with the performance of other validated utility assessment instruments, including a visual analogue scale, a computer-based instrument (U-Titer), and a preference classification system (EuroQol). Of the 47 women in the test-retest reliability study, 21 had experienced breast hypertrophy (13 had not had reduction surgery and 8 had undergone reduction mammaplasty). Mean utility values for breast-related symptoms among women with breast hypertrophy (n = 13) were: Table, 0.85; Wheel, 0.90; and U-Titer, 0.66. Current health utility scores were significantly lower for women with breast hypertrophy (n = 13), as measured by all instruments except the Wheel. The Table had good reliability and distinguished women with breast hypertrophy from those without. Although the Table provided higher utility values for the same health state compared with the computer-based interview (U-Titer), it is much less costly to implement. The Table is recommended as a reasonable alternative for use in multicenter studies of women with breast hypertrophy. The reported utility value for breast hypertrophy of 0.86 is much lower than predicted. It is comparable with the reported burden of living with other health conditions, such as moderate angina (0.90) and a kidney transplant (0.84).

Has the impact of hormone replacement therapy on health-related quality of life been undervalued?

Previous economic evaluations of hormone replacement therapy (HRT) have restricted positive effects to alleviation of postmenopausal symptoms and negative effects to drug side effects. We studied the association between HRT use and postmenopausal women's valuation of both health-related quality of life and potential treatment side effects. Postmenopausal women with either a documented first vertebral fracture within the past 5 years or no history of osteoporotic fractures were recruited from Olmsted County, Minnesota, and from Dartmouth-Hitchcock Medical Center in New Hampshire to participate in a study to assess quality of life and women's attitudes toward osteoporosis prevention. Women's valuations of their current health and potential HRT-related side effects were quantified as quality-adjusted life years (QALYs) assessed by an automated utility assessment instrument (U-Titer) and the time tradeoff technique, by a vertical rating scale, and by estimated quality of well-being (QWB) scores. Health status was measured using the Medical Outcomes Study SF-36. Regression methods were used to assess the impact of current HRT use on health-related quality of life and valuation of side effects. There were 106 women with vertebral fracture and 180 with no history of hip, wrist, or vertebral fractures. Altogether, 116 (40.6%) women were currently taking HRT, 64 (22.2%) had taken HRT in the past, and 106 (37.1%) women had never taken HRT. Current HRT users had higher time tradeoff QALYs than never and past HRT users, with gains ranging from 15.0 to 83.7 days per year for current users relative to the others. Benefits were largest for women with a vertebral fracture and limitations in activities. The secondary QALY measures also showed significantly higher values for current HRT users compared with other women, as did SF-36 subscales for general health, physical function, role-emotional function, and vitality. There was substantial variability in women's perceptions of HRT side effects. Overall, the proportion of women willing to trade time to avoid bleeding was largest, at 95.5%, followed by breast tenderness, weight gain, and endometrial biopsy at 90.4%, 87.4%, and 82.7%, respectively. Current HRT users had higher health-related quality of life than past or never users according to all measures studied. Women's perceptions of potential side effects were highly variable and should be considered by physicians when prescribing an HRT regimen. If, as our results suggest, postmenopausal therapy has positive effects beyond the immediate postmenopausal years, previous economic studies may have underestimated the value of HRT.

Health-related quality of life in economic evaluations for osteoporosis: whose values should we use?

OBJECTIVE: To determine whether the source of preference scores has an impact on the cost-effectiveness of osteoporosis interventions. METHODS: Three groups of subjects aged > or =50 years--199 women without fractures and 183 women with osteoporotic fractures-were studied at two major medical centers. Medical history and comorbidity data were obtained from review of medical records. Health status was measured using the Medical Outcomes Study SF-36. Two preference-classification systems (i.e., quality of well-being scores estimated from SF-36 subscales and the Health Utilities Index) were also used. Preferences for current health and for hypothetical health states were assessed using a time tradeoff and implemented with a computer-based utility instrument (U-Titer). Wilcoxon's rank-sum and signed-rank tests were used to compare preferences for current health among women with osteoporotic fractures with 1) directly assessed preferences for osteoporosis health states delineated by outcome descriptions and 2) preference scores obtained from the preference-classification systems. The potential impact of the source of the preference scores was estimated using a Markov state-transition model. RESULTS: The preference scores for hypothetical osteoporosis health states of the non-fracture subjects were approximately 50% lower than those of the women who had actually experienced the health state. Differences of this magnitude would change the estimated cost-effectiveness of a 15-year intervention (which for approximately $280 per year prevents hip fracture about as well as hormone-replacement therapy) from $25,000 per QALY gained when non-fracture subjects' preferences were used to $94,000 per QALY gained when fracture subjects' preferences were used. Preferences estimated using the Health Utilities Index and those directly measured in fracture subjects using the time tradeoff did not differ significantly. CONCLUSIONS: The Health Utilities Index preference-classification system may provide an efficient and inexpensive alternative to direct utility assessment in this patient group. However, there are important differences in the valuation of health states by women who have experienced osteoporotic fractures compared with women who have not. Cost-utility analyses based solely on fracture patients' preferences for osteoporotic health states may undervalue prevention.

Assessing the preferences of patients with psoriasis. A quantitative, utility approach.

BACKGROUND AND DESIGN: Patient preferences for health outcomes can be explicitly assessed and expressed in quantitative terms known as utilities. Three standard methods for utility assessment have been used to quantify patient preferences, but these methods have not previously been applied to skin disease. Eighty-seven patients with psoriasis from a tertiary medical center were interviewed, using an interactive, computer-based utility assessment questionnaire, U-Titer. Utilities for three categories of psoriasis severity and potential adverse outcomes of methotrexate therapy were assessed by the vertical rating scale, time trade-off, and standard gamble. RESULTS: Patients assigned a broad range of utilities for each of the health states. Utilities obtained by the vertical rating scale did not correlate well with utilities obtained by standard gamble or time trade-off methods. However, utilities assessed by standard gamble and time trade-off were not significantly different. Patient characteristics such as age, gender, and education were not correlated with utility and did not explain the variation. Indicators of the patients' disease severity were not predictive of utilities for the assessed health states. The relatively high utility for liver biopsy suggests that there is less patient aversion to the procedure than suspected. CONCLUSIONS: Utilities, or quantitative measures of patient preferences for health states, are measurable and vary widely for mild, moderate, and severe psoriasis and possible adverse outcomes of methotrexate treatment. The process of elucidating individual patient utilities for various health outcomes can be used to incorporate patient preferences into the process of clinical decision making. Guidelines that are based solely on severity of symptoms, without input from patients on how they value such symptoms, must be questioned.

Variation in patient utilities for outcomes of the management of chronic stable angina. Implications for clinical practice guidelines. Ischemic Heart Disease Patient Outcomes Research Team.

OBJECTIVE: Although practice guidelines sometimes make recommendations based on symptom severity, they rarely account for how patients feel about their symptoms. To investigate the possible importance of patient preferences in treatment of ischemic heart disease, we assessed attitudes toward symptoms in patients with angina pectoris. DESIGN: Case series. SETTING: Ambulatory cardiology clinics at two tertiary care medical centers. PATIENTS: A total of 220 subjects were selected from 589 patients with chronic stable angina referred from cardiologists to achieve patients samples balanced for sex, race, and angina severity. MAIN OUTCOME MEASURES: We measured patients' attitudes toward their angina using the rating scale, time trade-off, and standard gamble utility metrics. Reliability of measurements was evaluated by repeating the assessments 2 weeks later on 50 willing patients. RESULTS: While the mean responses followed the expected patterns (those with more severe Canadian Cardiovascular Society scores chose lower utilities), attitudes toward symptoms varied substantially among patients with similarly severe angina. For example, there was a 33% chance that a patient with class II angina had a time trade-off utility that was lower (ie, more bothered by symptoms) than a patient with more severe angina (class III/IV). This variation in utilities was not due to random error in the assessments. CONCLUSIONS: Angina patients with similar functional limitation vary considerably in their tolerance for their symptoms, as measured by utilities. Our findings suggest that guidelines for the management of ischemic heart disease should be based on the preferences of the individual patient rather than on symptom severity alone.

Classroom shared governance.

As shared governance increases in organizations that employ nurses, it becomes an essential element of professional socialization and preservice education. Framing a course in concepts of shared governance offers students experiential learning in uses of power, accountability, organizational decision making, and peer negotiation. The authors present concepts and examples of classroom shared governance from student and teacher perspectives.