Routine Measurement of Health-Related Quality of Life in Assessing Cost-Effectiveness in Secondary Health Care

Aims: The aims of this study were 1) to identify and describe health economic studies that have used quality-adjusted life years (QALYs) based on actual measurements of patients' health-related quality of life (HRQoL); 2) to test the feasibility of routine collection of health-related quality of life (HRQoL) data as an indicator of effectiveness of secondary health care; and 3) to establish and compare the cost-utility of three large-volume surgical procedures in a real-world setting in the Helsinki University Central Hospital, a large referral hospital providing secondary and tertiary health-care services for a population of approximately 1.4 million. Patients and methods: So as to identify studies that have used QALYs as an outcome measure, a systematic search of the literature was performed using the Medline, Embase, CINAHL, SCI and Cochrane Library electronic databases. Initial screening of the identified articles involved two reviewers independently reading the abstracts; the full-text articles were also evaluated independently by two reviewers, with a third reviewer used in cases where the two reviewers could not agree a consensus on which articles should be included. The feasibility of routinely evaluating the cost-effectiveness of secondary health care was tested by setting up a system for collecting HRQoL data on approximately 4 900 patients' HRQoL before and after operative treatments performed in the hospital. The HRQoL data used as an indicator of treatment effectiveness was combined with diagnostic and financial indicators routinely collected in the hospital. To compare the cost-effectiveness of three surgical interventions, 712 patients admitted for routine operative treatment completed the 15D HRQoL questionnaire before and also 3-12 months after the operation. QALYs were calculated using the obtained utility data and expected remaining life years of the patients. Direct hospital costs were obtained from the clinical patient administration database of the hospital and a cost-utility analysis was performed from the perspective of the provider of secondary health care services. Main results: The systematic review (Study I) showed that although QALYs gained are considered an important measure of the effectiveness of health care, the number of studies in which QALYs are based on actual measurements of patients' HRQoL is still fairly limited. Of the reviewed full-text articles, only 70 reported QALYs based on actual before after measurements using a valid HRQoL instrument. Collection of simple cost-effectiveness data in secondary health care is feasible and could easily be expanded and performed on a routine basis (Study II). It allows meaningful comparisons between various treatments and provides a means for allocating limited health care resources. The cost per QALY gained was 2 770 for cervical operations and 1 740 for lumbar operations. In cases where surgery was delayed the cost per QALY was doubled (Study III). The cost per QALY ranges between subgroups in cataract surgery (Study IV). The cost per QALY gained was 5 130 for patients having both eyes operated on and 8 210 for patients with only one eye operated on during the 6-month follow-up. In patients whose first eye had been operated on previous to the study period, the mean HRQoL deteriorated after surgery, thus precluding the establishment of the cost per QALY. In arthroplasty patients (Study V) the mean cost per QALY gained in a one-year period was 6 710 for primary hip replacement, 52 270 for revision hip replacement, and 14 000 for primary knee replacement. Conclusions: Although the importance of cost-utility analyses has during recent years been stressed, there are only a limited number of studies in which the evaluation is based on patients own assessment of the treatment effectiveness. Most of the cost-effectiveness and cost-utility analyses are based on modeling that employs expert opinion regarding the outcome of treatment, not on patient-derived assessments. Routine collection of effectiveness information from patients entering treatment in secondary health care turned out to be easy enough and did not, for instance, require additional personnel on the wards in which the study was executed. The mean patient response rate was more than 70 %, suggesting that patients were happy to participate and appreciated the fact that the hospital showed an interest in their well-being even after the actual treatment episode had ended. Spinal surgery leads to a statistically significant and clinically important improvement in HRQoL. The cost per QALY gained was reasonable, at less than half of that observed for instance for hip replacement surgery. However, prolonged waiting for an operation approximately doubled the cost per QALY gained from the surgical intervention. The mean utility gain following routine cataract surgery in a real world setting was relatively small and confined mostly to patients who had had both eyes operated on. The cost of cataract surgery per QALY gained was higher than previously reported and was associated with considerable degree of uncertainty. Hip and knee replacement both improve HRQoL. The cost per QALY gained from knee replacement is two-fold compared to hip replacement. Cost-utility results from the three studied specialties showed that there is great variation in the cost-utility of surgical interventions performed in a real-world setting even when only common, widely accepted interventions are considered. However, the cost per QALY of all the studied interventions, except for revision hip arthroplasty, was well below 50 000, this figure being sometimes cited in the literature as a threshold level for the cost-effectiveness of an intervention. Based on the present study it may be concluded that routine evaluation of the cost-utility of secondary health care is feasible and produces information essential for a rational and balanced allocation of scarce health care resources.

NIRS calibrations for predicting the nutritional quality of feed

NIRS calibrations for predicting the nutritional quality of feed.

Improving the quality of kikuyu by reducing the lignin content

Development of improved pasture grass via chemical mutagenesis and selection of mutations in lignin genes.

DAQ00104 Sponge and dough bread quality of Australian wheat germplasm

The main grade of wheat targeted for the export sponge and dough (S&D) market is Australian prime hard (APH). By association, protein should be a key parameter relating to S&D quality, specifically loaf volume (LV). Surprisingly, the project revealed a low level of correlation between total protein content and LV. It appears that protein composition may be the key to understanding S&D quality, as the glutenin Glu D1 5+10 subunit contributed to the highest LVs. The current varieties KennedyA and SunzellA, together with several breeding lines, provided a consistently high quality over a number of seasons. These varieties performed as well as, if not better than, North American S&D varieties.

Measuring route passenger load diversity for capacity and quality of service assessment

This paper develops theory that quantifies transit route passenger-relative load factor and distinguishes it from occupancy load factor. The ratio between these measures is defined as the load diversity coefficient, which as a single measure characterizes the diversity of passenger load factor between route segments according to the origin-destination profile. The relationship between load diversity coefficient and route coefficient of variation in occupancy load factor is quantified. Two tables are provided that enhance passenger capacity and quality of service (QoS) assessment regarding onboard passenger load. The first expresses the transit operator’s perspective of load diversity and the passengers’ perspective of load factor relative to the operator’s, across six service levels corresponding to ranges of coefficient of variation in occupancy load factor. The second interprets the relationships between passenger average travel time and each of passenger-relative load factor and occupancy load factor. The application of this methodology is illustrated using a case study of a premium radial bus route in Brisbane, Australia. The methodology can assist in benchmarking and decision making regarding route and schedule design. Future research will apply value of time to QoS measurement, reflecting perceived passenger comfort through crowding and average time spent aboard. This would also assist in transit service quality econometric modeling.

Measuring route passenger load diversity for capacity and quality of service assessment

This poster introduces Passenger Relative Load Factor for a route or individual bus service as a capacity and quality of service measure, distinguishing it from Occupancy Load Factor. It introduces Load Diversity Coefficient as the ratio of Passenger Relative Load Factor to Occupancy Load Factor, and relates Load Diversity Coefficient to Coefficient of Variation in Occupancy Load Factor. It qualifies the operator’s and passengers’ perspectives of load factor based on Coefficient of Variation in Occupancy Load Factor along a route. A case study using weekday Automatic Fare Collection (AFC) data on a premium bus line in Brisbane, Australia illustrates the methodology. The compendium paper also qualifies the operator’s and passengers’ perspectives of these load factors along with Passengers’ Average Travel Time for capacity and quality of service assessment.

Microbial quality of hemp (Cannabis sativa L.) and flax (Linum usitatissimum L.) from plants to thermal insulation

Flax and hemp have traditionally been used mainly for textiles, but recently interest has also been focused on non-textile applications. Microbial quality throughout the whole processing chain of bast fibres has not previously been studied. This study concentrates on the microbial quality and possible microbial risks in the production chain of hemp and flax fibres and fibrous thermal insulations. In order to be able to utilize hemp and flax fibres, the bast fibres must be separated from the rest of the plant. Non-cellulosic components can be removed with various pretreatment processes, which are associated with a certain risk of microbial contamination. In this study enzymatic retting and steam explosion (STEX) were examined as pretreatment processes. On the basis of the results obtained in this study, the microbial contents on stalks of both plants studied increased at the end of the growing season and during the winter. However, by processing and mechanical separation it is possible to produce fibres containing less moulds and bacteria than the whole stem. Enzymatic treatment encouraged the growth of moulds in fibres. Steam explosion reduced the amount of moulds in fibres. Dry thermal treatment used in this study did not markedly reduce the amount of microbes. In this project an emission measurement chamber was developed which was suitable for measurements of emissions from both mat type and loose fill type insulations, and capable of interdisciplinary sampling. In this study, the highest amounts of fungal emissions were in the range of 10^3 10^5 cfu/m^3 from the flax and hemp insulations at 90% RH of air. The fungal emissions from stone wool, glass wool and recycled paper insulations were below 10^2 cfu/m^3 even at 90% RH. Equally low values were obtained from bast fibrous materials in lower humidities (at 30% and 80% RH of air). After drying of moulded insulations at 30% RH, the amounts of emitted moulds were in all cases higher compared to the emissions at 90% RH before drying. The most common fungi in bast fibres were Penicillium and Rhizopus. The widest variety of different fungi was in the untreated hemp and linseed fibres and in the commercial loose-fill flax insulation. Penicillium, Rhizopus and Paecilomyces were the most tolerant to steam explosion. According to the literature, the most common fungi in building materials and indoor air are Penicillium, Aspergillus and Cladosporium, which were all found in some of the bast fibre materials in this study. As organic materials, hemp and flax fibres contain high levels of nutrients for microbial growth. The amount of microbes can be controlled and somewhat decreased by the processing methods presented.

Role of heat treatment in the processing and quality of oat flakes

This thesis reports on investigations into the influence of heat treatment on the manufacturing of oat flakes. Sources of variation in the oat flake quality are reviewed, including the whole chain from the farm to the consumer. The most important quality parameters of oat flakes are the absence of lipid hydrolysing enzymes, specific weight, thickness, breakage (fines), water absorption. Flavour, colour and pasting properties are also important, but were not included in the experimental part of this study. Of particular interest was the role of heat processing. The first possible heat treatment may occur already during grain drying, which in Finland generally happens at the farm. At the mill, oats are often kilned to stabilise the product by inactivating lipid hydrolysing enzymes. Almost invariably steaming is used during flaking, to soften the groats and reduce flake breakage. This thesis presents the use of a material science approach to investigating a complex system, typical of food processes. A combination of fundamental and empirical rheological measurements was used together with a laboratory scale process to simulate industrial processing. The results were verified by means of industrial trials. Industrially produced flakes at three thickness levels (nominally 0.75, 0.85 and 0.90 mm) were produced from kilned and unkilned oat groats, and the flake strength was measured at different moisture contents. Kilning was not found to significantly affect the force required to puncture a flake with a 2mm cylindrical probe, which was taken as a measure of flake strength. To further investigate how heat processing contributes to flake quality, dynamic mechanical analysis was used to characterise the effect of heat on the mechanical properties of oats. A marked stiffening of the groat, of up to about 50% increase in storage modulus, was observed during first heating at around 36 to 57°C. This was also observed in tablets prepared from ground groats and extracted oat starch. This stiffening was thus attributed to increased adhesion between starch granules. Groats were steamed in a laboratory steamer and were tempered in an oven at 80 110°C for 30 90 min. The maximum force required to compress the steamed groats to 50% strain increased from 50.7 N to 57.5 N as the tempering temperature was increased from 80 to 110°C. Tempering conditions also affected water absorption. A significantly higher moisture content was observed for kilned (18.9%) compared to unkilned (17.1%) groats, but otherwise had no effect on groat height, maximum force or final force after a 5 s relaxation time. Flakes were produced from the tempered groats using a laboratory flaking machine, using a roll gap of 0.4 mm. Apart from specific weight, flake properties were not influenced by kilning. Tempering conditions however had significant effects on the specific weight, thickness and water absorption of the flakes, as well as on the amount of fine material (<2 mm) produced during flaking. Flake strength correlated significantly with groat strength and flake thickness. Trial flaking at a commercial mill confirmed that groat temperature after tempering influenced water absorption. Variation in flake strength was observed , but at the groat temperatures required to inactivate lipase, it was rather small. Cold flaking of groats resulted in soft, floury flakes. The results presented in this thesis suggest that heating increased the adhesion between starch granules. This resulted in an increase in the stiffness and brittleness of the groat. Brittle fracture, rather than plastic flow, during flaking could result in flaws and cracks in the flake. These would be expected to increase water absorption. This was indeed observed as tempering temperature increased. Industrial trials, conducted with different groat temperatures, confirmed the main findings of the laboratory experiments. The approach used in the present study allowed the systematic study of the effect of interacting process parameters on product quality. There have been few scientific studies of oat processing, and these results can be used to understand the complex effects of process variables on flake quality. They also offer an insight into what happens as the oat groat is deformed into a flake.

Quality of life after early enteral feeding versus standard care for proven or suspected advanced epithelial ovarian cancer: Results from a randomised trial

Background Malnutrition is common in patients with advanced epithelial ovarian cancer (EOC), and is associated with impaired quality of life (QoL), longer hospital stay and higher risk of treatment-related adverse events. This phase III multi-centre randomised clinical trial tested early enteral feeding versus standard care on postoperative QoL. Methods From 2009 to 2013, 109 patients requiring surgery for suspected advanced EOC, moderately to severely malnourished were enrolled at five sites across Queensland and randomised to intervention (n = 53) or control (n = 56) groups. Intervention involved intraoperative nasojejunal tube placement and enteral feeding until adequate oral intake could be maintained. Despite being randomised to intervention, 20 patients did not receive feeds (13 did not receive the feeding tube; 7 had it removed early). Control involved postoperative diet as tolerated. QoL was measured at baseline, 6 weeks postoperatively and 30 days after the third cycle of chemotherapy. The primary outcome measure was the difference in QoL between the intervention and the control group. Secondary endpoints included treatment-related adverse event occurrence, length of stay, postoperative services use, and nutritional status. Results Baseline characteristics were comparable between treatment groups. No significant difference in QoL was found between the groups at any time point. There was a trend towards better nutritional status in patients who received the intervention but the differences did not reach statistical significance except for the intention-to-treat analysis at 7 days postoperatively (11.8 intervention vs. 13.8 control, p 0.04). Conclusion Early enteral feeding did not significantly improve patients' QoL compared to standard of care but may improve nutritional status.

Author responsibilities in improving the quality of peer reviews: A rejoinder to Iivari (2016)

In this rejoinder to Iivari (2016), I discuss authors’ responsibilities in the process of ensuring quality reviews. I argue that one overlooked element in quality peer reviewing is authors’ unconstrained right to submit manuscripts in whatever form or quality they desire. As such, I suggest adding some constraints and offering more freedom to reviewers to maintain viability of the scholarly publication system. I offer three responses to Iivari’s suggestions and add two further suggestions for change.

Barley genotype expressing "stay-green"-like characteristics maintains starch quality of the grain during water stress condition

The identification of "stay-green" in sorghum and its positive correlation with yield increases has encouraged attempts to incorporate "stay-green"-like traits into the genomes of other commercially important cereal crops. However, knowledge on the effects of "stay-green" expression on grain quality under extreme physiological stress is limited. This study examines impacts of "stay-green"-like expression on starch biosynthesis in barley (Hordeum vulgare L.) grain under mild, severe, and acute water stress conditions induced at anthesis. The proportions of long amylopectin branches and amylose branches in the grain of Flagship (a cultivar without "stay-green"-like characteristics) were higher at low water stress, suggesting that water stress affects starch biosynthesis in grain, probably due to early termination of grain fill. The changes in long branches can affect starch properties, such as the rates of enzymatic degradation, and hence its nutritional value. By contrast, grain from the "stay-green"-like cultivar (ND24260) did not show variation in starch molecular structure under the different water stress levels. The results indicate that the cultivar with "stay-green"-like traits has a greater potential to maintain starch biosynthesis and quality in grain during drought conditions, making the "stay-green"-like traits potentially useful in ensuring food security. (C) 2013 Elsevier Ltd. All rights reserved.

Physical activity and health related quality of life

Background Research on the relationship between Health Related Quality of Life (HRQoL) and physical activity (PA), to date, have rarely investigated how this relationship differ across objective and subjective measures of PA. The aim of this paper is to explore the relationship between HRQoL and PA, and examine how this relationship differs across objective and subjective measures of PA, within the context of a large representative national survey from England. Methods Using a sample of 5,537 adults (40–60 years) from a representative national survey in England (Health Survey for England 2008), Tobit regressions with upper censoring was employed to model the association between HRQoL and objective, and subjective measures of PA controlling for potential confounders. We tested the robustness of this relationship across specific types of PA. HRQoL was assessed using the summary measure of health state utility value derived from the EuroQol-5 Dimensions (EQ-5D) whilst PA was assessed via subjective measure (questionnaire) and objective measure (accelerometer- actigraph model GT1M). The actigraph was worn (at the waist) for 7 days (during waking hours) by a randomly selected sub-sample of the HSE 2008 respondents (4,507 adults – 16 plus years), with a valid day constituting 10 hours. Analysis was conducted in 2010. Results Findings suggest that higher levels of PA are associated with better HRQoL (regression coefficient: 0.026 to 0.072). This relationship is consistent across different measures and types of PA although differences in the magnitude of HRQoL benefit associated with objective and subjective (regression coefficient: 0.047) measures of PA are noticeable, with the former measure being associated with a relatively better HRQoL (regression coefficient: 0.072). Conclusion Higher levels of PA are associated with better HRQoL. Using an objective measure of PA compared with subjective shows a relatively better HRQoL.

Quality of ALICE SSD modules revealed by electrical tests

ALICE (A Large Ion Collider Experiment) is an experiment at CERN (European Organization for Nuclear Research), where a heavy-ion detector is dedicated to exploit the unique physics potential of nucleus-nucleus interactions at LHC (Large Hadron Collider) energies. In a part of that project, 716 so-called type V4 modules were assembles in Detector Laboratory of Helsinki Institute of Physics during the years 2004 - 2006. Altogether over a million detector strips has made this project the most massive particle detector project in the science history of Finland. One ALICE SSD module consists of a double-sided silicon sensor, two hybrids containing 12 HAL25 front end readout chips and some passive components, such has resistors and capacitors. The components are connected together by TAB (Tape Automated Bonding) microcables. The components of the modules were tested in every assembly phase with comparable electrical tests to ensure the reliable functioning of the detectors and to plot the possible problems. The components were accepted or rejected by the limits confirmed by ALICE collaboration. This study is concentrating on the test results of framed chips, hybrids and modules. The total yield of the framed chips is 90.8%, hybrids 96.1% and modules 86.2%. The individual test results have been investigated in the light of the known error sources that appeared during the project. After solving the problems appearing during the learning-curve of the project, the material problems, such as defected chip cables and sensors, seemed to induce the most of the assembly rejections. The problems were typically seen in tests as too many individual channel failures. Instead, the bonding failures rarely caused the rejections of any component. One sensor type among three different sensor manufacturers has proven to have lower quality than the others. The sensors of this manufacturer are very noisy and their depletion voltage are usually outside of the specification given to the manufacturers. Reaching 95% assembling yield during the module production demonstrates that the assembly process has been highly successful.