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.

Breeding Low Chill high quality stonefruit

Breeding Low Chill high quality stonefruit.

Improving avocado fruit quality and market potential by pre and post harvest factors

Improving avocado fruit quality and market potential by pre and post harvest factors.

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.

A tilling approach to develop high quality tropical and sub-tropical pasture gra

This project aims to develop high quality kikuyu pasture grass via chemical mutagenesis, followed by screening for mutations in lignin biosynthesis genes.

Variety quality management in strawberry, using DNA genotyping as a tool

Quality management strawberry, DNA genotyping.

Impact of Stem Defect Agent Defects on Hardwood Wood Quality

Queensland's hardwood plantation industry is producing increasing volumes of sawlog, veneer and poles. Wood quality can sometimes be impaired in some plantation hardwoods when the growing trees are attacked by insect borers. Susceptibility to borer damage varies with the species as well as site conditions or location. The risk model developed from this project will enable the plantation industry to match tree species with appropriate growing conditions in Queensland.

Management of fruit quality and pest infestations of mango and mangosteen for Market access requirements

Management of fruit quality and pest infestations of mango and mangosteen for Market access requirements.

Improving fruit quality and profitability of 'Honey Gold' mango

Honey Gold mango is a new Australian variety owned by a Queensland company, and in high demand because of very good flavour and appearance. It develops under skin browning (USB) when grown in hot areas. It appears after packing and the fruit need to be re-sorted at the markets to remove affected fruit. Production and postharvest treatments will be developed to reduce USB and increase profitability. Other production and harvest factors causing quality loss will be also be identified through a commercial downgrade analysis program in the packhouse. Grower training will reduce downgrades and improve the percentage of fruit in premium grade.

Agronomic Packages for Improved Yield and Quality in the Australian Peanut Industry

Monitoring aflatoxin and developing improved peanut drying practices, cadmium management and web based irrigation decision support systems.

Developing agronomic solutions to improve barley yield and grain quality

The main aim of this project is to develop variety management packages to help tailor commercial malt and feed barley production in the Northern GRDC Region to commercial malt and feed barley specifications. Field trials are designed to give information.

DAN00106 Developing agronomic solutions to improve barley yield and grain quality

Producing management packages for new northern barley varieties. Evaluating silage barley varieties.

Enhancing supplies of high quality barley to meet pork industry demands

Producing barley varieties that have incrased grain yield and consistent or higher energy for pigs, as well as resistance to the major diseases of barley.