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.

Options for biogas cleaning and use on-farm

This project follows on from and utilises a floating cover currently being installed on the primary effluent pond at a southern piggery.

Validation and development of PigBal model

This project involves validating and upgrading the PigBal model to improve the accuracy of manure production predictions from intensive piggery operations.

Queensland sedimentation and evaporation pond system (SEPS) trial

The Sedimentation and Evaporation Pond System (SEPS) is a low-capital effluent management system based primarily on shallow pond sedimentation of effluent solids and annual evaporation of the liquid to retrieve dried solids.

New genetic loci link adipose and insulin biology to body fat distribution

Body fat distribution is a heritable trait and a well-established predictor of adverse metabolic outcomes, independent of overall adiposity. To increase our understanding of the genetic basis of body fat distribution and its molecular links to cardiometabolic traits, here we conduct genome-wide association meta-analyses of traits related to waist and hip circumferences in up to 224,459 individuals. We identify 49 loci (33 new) associated with waist-to-hip ratio adjusted for body mass index (BMI), and an additional 19 loci newly associated with related waist and hip circumference measures (P < 5 × 10−8). In total, 20 of the 49 waist-to-hip ratio adjusted for BMI loci show significant sexual dimorphism, 19 of which display a stronger effect in women. The identified loci were enriched for genes expressed in adipose tissue and for putative regulatory elements in adipocytes. Pathway analyses implicated adipogenesis, angiogenesis, transcriptional regulation and insulin resistance as processes affecting fat distribution, providing insight into potential pathophysiological mechanisms.

Genetic studies of body mass index yield new insights for obesity biology

Obesity is heritable and predisposes to many diseases. To understand the genetic basis of obesity better, here we conduct a genome-wide association study and Metabochip meta-analysis of body mass index (BMI), a measure commonly used to define obesity and assess adiposity, in up to 339,224 individuals. This analysis identifies 97 BMI-associated loci (P < 5 × 10−8), 56 of which are novel. Five loci demonstrate clear evidence of several independent association signals, and many loci have significant effects on other metabolic phenotypes. The 97 loci account for ~2.7% of BMI variation, and genome-wide estimates suggest that common variation accounts for >20% of BMI variation. Pathway analyses provide strong support for a role of the central nervous system in obesity susceptibility and implicate new genes and pathways, including those related to synaptic function, glutamate signalling, insulin secretion/action, energy metabolism, lipid biology and adipogenesis.

Validation and development of PigBal model - Stage 2

The proposed project involves validate and upgrading the PigBal model to improve the accuracy of manure and GHG production predictions.

Methane Recovery and use at Grantham Piggery

This report describes the outcomes from the Australian Methane to Markets in Agriculture (AM2MA) research project PRJ-005672 ‘Methane recovery and use at a piggery – Grantham’. This project involved upgrading the biogas extraction system originally installed in conjunction with a partial floating cover, retro-fitted to the primary anaerobic pond at the QNPH Grantham piggery under an earlier AM2MA project (Project No. PRJ-003003), as described by Skerman et al (2011). Following the system upgrade, this project also included installing a biogas reticulation pipeline to supply biogas from the extraction system, to a water heating system used to heat water circulated through underfloor heating pads in the piggery farrowing sheds. This biogas fired water heating system has the potential to significantly reduce on-farm energy costs by replacing a significant proportion of the Liquid Petroleum Gas (LPG) previously used for farrowing shed heating. Further monitoring of the biogas system performance has also been carried out. This report describes the work undertaken and outlines the monitoring results, implications, conclusions and recommendations arising from this work.

Biogas production by covered lagoons; Part 1 - piggery, QNPH

Establish a greenhouse gas pond cover and collection system providing data on methane and CO2 emissions.

Evaluation of APFIP (apple) varieties

Evaluation of APFIP (apple) varieties.

FTO genotype is associated with phenotypic variability of body mass index

There is evidence across several species for genetic control of phenotypic variation of complex traits1, 2, 3, 4, such that the variance among phenotypes is genotype dependent. Understanding genetic control of variability is important in evolutionary biology, agricultural selection programmes and human medicine, yet for complex traits, no individual genetic variants associated with variance, as opposed to the mean, have been identified. Here we perform a meta-analysis of genome-wide association studies of phenotypic variation using ~170,000 samples on height and body mass index (BMI) in human populations. We report evidence that the single nucleotide polymorphism (SNP) rs7202116 at the FTO gene locus, which is known to be associated with obesity (as measured by mean BMI for each rs7202116 genotype)5, 6, 7, is also associated with phenotypic variability. We show that the results are not due to scale effects or other artefacts, and find no other experiment-wise significant evidence for effects on variability, either at loci other than FTO for BMI or at any locus for height. The difference in variance for BMI among individuals with opposite homozygous genotypes at the FTO locus is approximately 7%, corresponding to a difference of ~0.5 kilograms in the standard deviation of weight. Our results indicate that genetic variants can be discovered that are associated with variability, and that between-person variability in obesity can partly be explained by the genotype at the FTO locus. The results are consistent with reported FTO by environment interactions for BMI8, possibly mediated by DNA methylation9, 10. Our BMI results for other SNPs and our height results for all SNPs suggest that most genetic variants, including those that influence mean height or mean BMI, are not associated with phenotypic variance, or that their effects on variability are too small to detect even with samples sizes greater than 100,000.

Life history and host range of Alagoasa extrema (Coleoptera: Chrysomelidae: Alticinae), a potential biological control agent of Lantana spp. (Verbenaceae) in Australia

The life history and host range of the lantana beetle, Alagoasa extrema, a potential biocontrol agent for Lantana spp. were investigated in a quarantine unit at the Alan Fletcher Research Station, Brisbane, Australia. Adults feed on leaves and females lay batches of about 17 eggs on the soil surface around the stems of plants. The eggs take 16 days to hatch and newly emerged larvae move up the stem to feed on young leaves. Larvae feed for about 23 days and there are three instars. There is a prepupal non-feeding stage that lasts about 12 days and the pupal stage, which occurs in a cocoon in the soil, lasts 16 days. Teneral adults remain in the cocoon for 3 days to harden prior to emergence. Males live for about 151 days while females live for about 127 days. The pre-oviposition period is 19 days. In no-choice larval feeding trials, nine plant species, representing three families, supported development to adult. Three species, Aloysia triphylla, Citharexylum spinosum and Pandorea pandorana were able to support at least two successive generations. These results confirm those reported in South Africa and suggest that A. extrema is not sufficiently specific for release in Australia. Furthermore, it is not recommended for release in any other country which is considering biological control of lantana.

Meta-analysis identifies 13 new loci associated with waist-hip ratio and reveals sexual dimorphism in the genetic basis of fat distribution

Waist-hip ratio (WHR) is a measure of body fat distribution and a predictor of metabolic consequences independent of overall adiposity. WHR is heritable, but few genetic variants influencing this trait have been identified. We conducted a meta-analysis of 32 genome-wide association studies for WHR adjusted for body mass index (comprising up to 77,167 participants), following up 16 loci in an additional 29 studies (comprising up to 113,636 subjects). We identified 13 new loci in or near RSPO3, VEGFA, TBX15-WARS2, NFE2L3, GRB14, DNM3-PIGC, ITPR2-SSPN, LY86, HOXC13, ADAMTS9, ZNRF3-KREMEN1, NISCH-STAB1 and CPEB4 (P = 1.9 × 10−9 to P = 1.8 × 10−40) and the known signal at LYPLAL1. Seven of these loci exhibited marked sexual dimorphism, all with a stronger effect on WHR in women than men (P for sex difference = 1.9 × 10−3 to P = 1.2 × 10−13). These findings provide evidence for multiple loci that modulate body fat distribution independent of overall adiposity and reveal strong gene-by-sex interactions.

Young people's perceptions of the wood products industry : a relational view

The basis for this study was in poor attractiveness of the wood products industry among young people as a field to study and work in. The purpose was to produce new information of how to improve the relationship between young people and the wood products industry in order to better attract young people with different relational orientation. A survey was conducted among students of comprehensive schools and students of wood industry at vocational schools selected by systematic cluster sampling. The final sample consisted of 613 students. The study combined the theories and concepts of relationships, communication and trust of several disciplines. In addition, it applied theories of relationship marketing, stakeholders, publics, involvement and concepts of reputation and values. It studied the central relational elements in the form of antecedents, relationship state and its consequences. The study examined, how young people with different background and level of interest perceive wood industry as a field to study and work in from relational point of view, what are the central deficiencies in perceived relational elements and what are the public relations activities enhancing the relationship between wood industry and young people with less and high interest in the sector. The results indicate poor visibility of the wood industry among young people: unfamiliarity with the industry and unawareness of the opportunities to study in the field. It appeared that instead of increasing only information sharing, interactive communication in different forms is needed. The study also suggests that behaviors of the industry sector advancing perceived trustworthiness are of crucial importance. Moreover, the wood industry needs to pay attention to its behaviors and communication also among other stakeholder groups, especially the media, as reputation plays an important role in building up trust and satisfaction between young people and the sector. Finally, the less and highly interested young people were found to assess the relationship partly through different relational elements. In order to develop the relationship with highly interested young people they should be regarded clearly as future employees of the wood industry through activities affirming that they are desired and valued employees in the sector. Further, openness of information disclosure, whether concerning current situation or future prospects, seems to increase credibility and attractiveness of the wood industry. Highly interested young people were also found to appreciate socially responsible activities. The less interested young people seem to be insecure about the reliability of the wood industry as an employer, as well as, its ability and interest to invest in young people s skills. In addition,involvement in issues relevant for young people was found crucial in enhancing the relationship with the less interested young people.The conclusions of the study provide tools for enhancing the attractiveness of the wood industry among young people not only to the industry itself, but also to its advocates, teachers and student counselors of comprehensive and vocational schools, authorities and policy makers.

Läksi puut ylenemähän : Metsien hoidon historia Suomessa keskiajalta metsäteollisuuden läpimurtoon 1870-luvulla

Tutkimuksen tavoitteena on historiantutkimuksen menetelmiä käyttäen selvittää metsänhoidon teorian sekä käytännön metsänhoidon kehitysvaiheet ja näihin vaikuttaneet tekijät, keskiajalta lähtien 1870-luvulla tapahtuneeseen metsäteollisuuden läpimurtoon saakka. Tutkimus tarkastelee Suomen metsiä, niiden käyttöä ja metsänhoidon alkuvaiheita Ruotsin ja Venäjän vallan aikoina. Vastauksia haetaan erityisesti seuraaviin pääkysymyksiin: - miten eri metsänkäyttömuodot ja -käyttäjät vaikuttivat metsiin ja metsänhoidon edistymiseen? - millä tavoin maanomistuksen kehitys vaikutti metsien käyttöön ja hoitoon? - millaisiin päämääriin ja yhteiskunnallisiin taustatekijöihin metsien käytön julkinen ohjaus perustui? - mitä käytännön vaikutuksia valtion metsäpolitiikalla ja ohjauksella oli metsänhoidon kehitykseen? - missä ja miten kehittyivät Suomessa sovellettu metsänhoidon teoria ja käytännön menetelmät? - mitkä tekijät säätelivät metsänhoidon teorioiden soveltamista käytäntöön? - mikä oli naapurimaiden metsänhoidon sekä kansainvälisten yhteyksien merkitys metsänhoidon kehitykselle Suomessa? - miten vuosisatainen pelko metsien ja puun loppumisesta vaikutti metsänhoidon kehitykseen? - millainen merkitys puun arvon kehityksellä oli metsänhoidon alkuun saattamiselle ja edistymiselle? Suomessa harjoitettiin 1870-luvulle saakka pääasiassa talonpoikaista metsänkäyttöä. Maaseudun väestö hankki toimeentulonsa metsistä eränkäynnin, kaskiviljelyn, laiduntamisen, rakennushirsien valmistamisen, tervantuotannon ja paikoin myös potaskan tai sysien valmistamisen avulla. Erityisesti rannikkoseuduilla tuotettiin "isorakennuksen puita", lehtereitä, mastopuita ja muuta erikoispuutavaraa. Lautojen ja lankkujen sahaus laajeni vähitellen, saavuttaen 1800-luvun lopulla hallitsevan aseman myyntiin tarkoitettujen metsäntuotteiden tuotannossa. Polttopuun sekä muun kotitarvepuun kulutus säilyi suurimpana puunkäytön ryhmänä pitkälle 1900-luvulle saakka. Mainituista metsänkäyttömuodoista erityisesti kaskeaminen ja sitä seuraava laiduntamisvaihe sekä tervaspuiden koloaminen "autioittivat" laajoja metsäalueita. Tiheimmin asutuilla seuduilla esiintyi pulaa poltto- ja rakennuspuusta myöhäiskeskiajalta alkaen. Nämä ongelmat sekä laivanrakennuksen ja vuoriteollisuuden puunsaannin turvaamisen tarve johtivat 1600-luvun puolivälissä pysyvään metsänkäytön julkiseen ohjaukseen. Tuolloin Ruotsin valtakunnan metsälainsäädännön kivijalaksi tuli kestävyyden periaate, josta kruunu kylläkin joutui tinkimään moneen otteeseen. Valtion jatkuva rahantarve oli käytännössä metsäpolitiikan tärkein taustavoima sekä Ruotsin vallan että autonomian aikana. Jo 1600-luvulla ruvettiin vaatimaan talonpoikien yhteismaiden jakamista omistajilleen vastuullisemman metsänkäytön nimissä. Isoajakoa saatiin Suomessa odottaa 1770-luvulle saakka. Etelä-Suomessa se valmistui melko nopeasti, 1800-luvun puoliväliin mennessä. Sillä olikin myönteinen, metsien säästävämpään käsittelyyn johtava vaikutus. Valtiosta tuli isonjaon myötä erityisesti Pohjois-Suomessa merkittävä metsänomistaja 1800-luvun jälkipuoliskolla. Valtion metsähallinto, jota maaherrat ja sivistyneistö vaativat perustettavaksi jo 1700-luvun puolivälissä, aloitti toimintansa maanlaajuisesti 1860-luvulla. Se oli ensimmäinen merkittävä metsänhoidon organisaatio, ja vasta sen myötä metsänkäyttöä ohjaavilla säädöksillä ja ohjeilla alkoi olla käytännön merkitystä. Yksityismetsiä varten ei tällaista organisaatiota vielä perustettu, niitä rasittivat pahoin nousevan sahateollisuuden määrämittahakkuut pitkälle 1900-luvun puolelle. Turun Akatemiassa tehtiin mittavaa metsänhoidon menetelmiä koskevaa sekä myös metsäpoliittista tutkimustyötä 1700-luvun jälkipuoliskolla. Tulokset eivät vielä sanottavasti siirtyneet käytäntöön, lähinnä puun alhaisen arvon ja tarvittavien organisaatioiden puuttumisen takia. Kun valtion metsähallintoa ja Suomen omaa metsäopetusta ryhdyttiin perustamaan 1800-luvun puolivälissä, haettiin metsänhoidon mallia alan johtavaksi maaksi kehittyneestä Saksasta. Tultaessa 1870-luvulle, oli Evolla jo käynnissä voimakas kehitystyö maamme olosuhteisiin soveltuvien menetelmien luomiseksi saksalaisen teorian pohjalta. Metsänhoidon tiedot ja taidot olisivat jo tässä vaiheessa riittäneet kestävän metsätalouden harjoittamiseen kaikkien omistajaryhmien metsissä, jos tarvittavat organisaatiot olisi kyetty perustamaan ja metsäammattilaisia olisi koulutettu tarpeeksi. Metsänhoidon kehitystä hidastivat 1800-luvun lopulla lähinnä valtion heikko talous ja poliittiset näkemyserot. Metsäteollisuuden 1870-luvulta alkanut voimakas kasvu ja lisääntyvä puuntarve pakottivat kuitenkin valtiovallan pitämään huolta puuntuotannon jatkuvuudesta. Metsäteollisuuden kasvavan viennin kautta lisääntyvät verotulot ja kan-santalouden myönteinen kehitys antoivat vähitellen mahdollisuuden metsänhoidon edistämiseen ammattilaisten koulutuksen, kansalaisten neuvonnan, lainsäädännön ja viranomaisten toiminnan kautta. Tämä tutkimus lähestyy aihettaan metsähistorian, taloushistorian, yhteiskuntahistorian ja ympäristöhistorian näkökulmista. Ajankohtaista merkitystä sillä on kehitysmaiden sekä Itä-Euroopan siirtymätalouksien metsänhoidon edistämiselle, missä suomalaiset metsäammattilaiset ovat mukana lukuisten kehityshankkeiden asiantuntijoina. Kymmenissä maissa metsätalous kamppailee samanlaisten ongelmien kanssa kuin Suomessa ja naapurimaissa 100 - 300 vuotta sitten. Meidän kokemuksistamme on näille kansantalouksille hyötyä valtion- ja yksityismetsätalouden metsänhoito-organisaatioita sekä metsälainsäädäntöä kehitettäessä.