Value in Health最新文献

Objective: To examine the determinants of unmet transcatheter aortic valve replacement (TAVR) needs and their impact on patient survival among Medicare beneficiaries with aortic stenosis.

Study setting and design: We developed a county-level mismatch score measuring the gap between actual TAVR procedures performed and expected need based on population differences. Counties were classified as metropolitan, semi-urban, or rural. Factors associated with larger mismatches were identified, and mortality rates among AS patients were examined in relation to mismatch scores.

Data sources and analytic sample: We analyzed Medicare data from 2016-2022 across 3,129 US counties. The mismatch score was developed to account for population differences and county urbanicity classification. Statistical analyses identified factors associated with TAVR mismatch and its relationship to mortality outcomes.

Principal findings: We found substantial geographic variation in TAVR delivery. Counties with higher TAVR mismatch scores showed associations with fewer TAVR-providing hospitals, less market concentration, higher AS prevalence, and lower household incomes. Counties with greater gaps between needed and actual TAVR procedures were also associated with higher mortality rates. This relationship between mismatch and mortality was particularly strong in semi-urban counties.

Conclusions: Our findings identify associations between TAVR access gaps and patient outcomes, as well as factors linked to these access patterns. Counties with higher TAVR mismatch scores showed correlations with healthcare capacity constraints, geographic location, and socioeconomic factors. These associations suggest that mismatches may be addressed through targeted approaches based on local needs to improve care delivery for patients with AS in regions currently experiencing access challenges.

Background: A combination of two herbal compounds, curcumin and QingDai (CurQD), has recently been proposed as an effective treatment for patients with active ulcerative colitis (UC), based on both randomized controlled and real-world evidence. However, no cost-effectiveness analysis for this nutraceutical is currently available.

Methods: A Markov model was generated to simulate the progression of patients with moderate-to-severe UC, by separate analysis for a cohort of advanced therapy-naïve and advanced therapy-experienced patients. Medication costs were derived from the published average wholesale price (AWP) in the US. Efficacy data were modeled by synthesizing efficacy reports from randomized, placebo-controlled trials and real-world cohort studies of all FDA-approved drugs for UC, and each was compared with CurQD. The model employed a 54-week time horizon. A threshold of $50,000 per quality-adjusted life year (QALY) was chosen, and a one-way sensitivity analysis was performed to assess the robustness of the study.

Results: The comparison of CurQD with the FDA-approved advanced therapies for UC yielded an estimated incremental cost-effectiveness ratio (ICER) of over 200,000$/QALY for all comparisons. Differences ranged from -0.05 to a slight gain of 0.07 QALY in bio-experienced patients and from -0.1 to 0.04 QALY in bio-naïve patients. The one-way sensitivity analysis proved the robustness of the study.

Conclusion: The present analysis suggests that the markedly reduced cost and demonstrated efficacy of CurQD provide a significant cost-effectiveness benefit over advanced therapies for active UC, including over anti-TNF biosimilars.

Objectives: This study identified and synthesised validation evidence on healthcare utilisation questionnaires (HUQs) in adult populations.

Methods: A systematic review retrieved validation studies of HUQs from five databases from January 1990 to May 2024. Study characteristics, instrument features, and validation evidence were extracted. Measurement properties and methodological quality were assessed using Consensus-based Standards for Selection of Health Measurement Instruments.

Results: Out of 5626 records screened, 112 articles were included, predominantly from European and North-American countries and non-institution settings (>80%). Eighty-eight HUQs were identified, with 90.9% being originally designed, 64.8% targeting specific conditions, and >50% being self or remotely administered. Over 90% HUQs measured medical care, while <50% addressed social care, productivity loss or family care. Validation evidence was dispersed across instruments and individual items. Criterion validity was most frequently evaluated in 52 (59.1%) HUQs, followed by cross-cultural validity/ measurement invariance (44.3%), content validity (42.0%), construct validity (34.1%) and reliability (20.5%). Thirty-four HUQs demonstrated acceptable criterion validity with quality evidence; fewer for construct validity (16), content validity (13), cross-cultural/ measurement invariance (8), and reliability (7).

Conclusions: Although numerous HUQs exist, most are original instruments with insufficient validation on measurement properties; only eleven met the minimum criteria for content validity and criterion validity or internal consistency. Selection of HUQs should comprehensively consider target population and disease, service scope, measurement property, and healthcare setting. Future efforts should prioritize rigorous scale development, validation against nonmedical resource, and applicability across diverse populations and settings, to support robust cross-context analyses and enhance study comparability at macro-levels.

Background: Inequalities represent a major challenge on the path toward universal health coverage in low- and middle-income countries. The design of essential benefits packages (EBP) creates an opportunity in selecting priority interventions through established criteria including equity considerations. We examine the distributional health and financial protection impact of interventions to be selected in an EBP for Ethiopia.

Methods: We sourced data on health benefits and program costs of priority interventions from the Ethiopian Essential Health Services Package database. Population and disease prevalence estimates were extracted from the Global Burden of Disease study, household surveys, and the literature. Health benefits of interventions were distributed across income quintiles using a risk index combining disease prevalence and intervention coverage inputs. Financial protection was estimated in terms of cases of catastrophic health expenditures (CHE) averted. For each of 30 priority interventions, we estimated the distributional health and financial protection benefits resulting from an incremental coverage annual increase of 10 percentage points.

Results: A total of 390,000 health-adjusted life years would be gained and 65,000 CHE cases averted. 22% and 20% of health benefits would accrue among the poorest and the richest income quintiles, respectively. A third of CHE cases would be averted among the poorest.

Conclusions: Despite current coverage gaps, access to certain interventions would improve overall health, equity, and financial protection, with differing impacts across those dimensions depending on the intervention. Examining the trade-offs and weighing each outcome will enable tailored prioritization of interventions in the EBP.

Objectives: To help address the youth mental health crisis affecting many countries, there is an opportunity for planners to use formalized priority-setting frameworks and sophisticated modeling tools to guide their investment decisions. The objective of this study was to explore how different types of system constraints affected the optimal configuration of existing services and new interventions and to estimate the downstream health and cost consequences for each of the scenarios.

Methods: Constrained optimization analysis was used within a system dynamics modeling framework to systematically test the cost effectiveness of seven scenarios varying existing mental health services capacity growth, new interventions targeted at youths, and budget constraints on the amount of investment funds available for new interventions. Incremental net monetary benefit was the outcome selected to be optimized. Both healthcare and societal perspectives were adopted, and costs were in 2020 to 2021 Australian dollars.

Results: Allowing existing services to expand beyond their long-run average growth rates and implementing 5 of the interventions resulted in the following outcomes accumulated over 11 years compared with business as usual: 16 139 quality-adjusted life-years gained, 294 (13%) suicide deaths avoided, 41 663 (30%) mental-health related emergency department presentations avoided, and 5869 (17%) self-harm hospitalizations avoided. Combined with an investment of AUD$36.6 million in new interventions, total cost savings (societal perspective) were AUD$731.3 million, and incremental net monetary benefit (ie, overall economic value, societal perspective) was AUD$2.07 billion.

Conclusions: The estimates of overall economic value provide a rationale and support for greater investments in mental health and guidance for the implementation of regional mental health system reform.

Objectives: Evidence on the impact of respiratory tract infections (RTIs) on pediatric health-related quality of life (HRQL) remains limited. This study aimed to evaluate the psychometric properties of HRQL measurement instruments for children with RTIs using longitudinal assessments.

Methods: HRQL was assessed in children younger than 16 years with RTIs using proxy-reported versions of EuroQol 5-Dimension Youth version, 3-Level (EQ-5D-Y-3L), the experimental EuroQol Toddler and Infant Populations v2.0 (EQ-TIPS), and the Pediatric Quality of Life Inventory (PedsQL). The PedsQL score was collected weekly for 7 weeks after symptom onset, whereas the EQ-5D-Y-3L or EQ-TIPS-3L score was collected daily for the first 14 days and then weekly until 7 weeks after onset. Changes in quality-adjusted life-days were calculated using EQ-5D-Y-3L based on the Japanese-specific utility value set. The changes in the total score of PedsQL and level sum score of EQ-TIPS-3L were also calculated.

Results: Presymptomatic HRQL data were obtained from 423 participants. The total PedsQL, EQ-5D-Y-3L, and EQ-TIPS-3L scores demonstrated moderate to large responsiveness in capturing differences in HRQL between presymptomatic and first-week symptomatic phases. The known-group validity to differentiate hospitalized and nonhospitalized cases was low in all instruments. The median change in quality-adjusted life-days for all RTIs was -3.0 [interquartile range -6.5, -1.1].

Conclusions: This study assessed responsiveness and validity for the PedsQL, EQ-5D-Y-3L, and EQ-TIPS-3L in measuring HRQL changes following RTIs. The known-group validity score was lower in EQ-TIPS-3L than that in EQ-5D-Y-3L.

Objectives: During consultations on development of the EuroQol 5-Dimension Youth version (EQ-5D-Y) value set, Canadian stakeholders recommended that preferences be directly elicited from children and adolescents using discrete choice experiments (DCEs). Our objective was to assess the feasibility of eliciting health state preferences from adolescents using DCE.

Methods: A convergent parallel mixed-methods study was conducted among a purposive sample of Canadian youth (13-18 years). First, the participants completed an online survey with the EQ-5D-Y-5L, 13 DCE tasks using EQ-5D-Y-5L health states (all participants), and 3 DCE with duration (15-18 years only). Then, they engaged in a focus group discussion. Quantitative data on DCE feasibility (incompletion, speeding, flatlining, and violation of dominant choice task) were analyzed using descriptive statistics. Qualitative focus group data were analyzed using content analysis. Qualitative and quantitative data were integrated using a joint display.

Results: A total of 36 adolescents (n = 6 per focus group) participated. The average time to complete DCE tasks was 7 minutes (range 3-12). No incomplete tasks, speeding, flatlining, or wrong answers to the dominant choice task were observed. All participants reported understanding the instructions and had minimal issues with engagement or use of the online survey. Most issues were differences in interpretation because of the presentation of information, participants' abilities to conceptualize and/or differentiate between health states or framing of DCE tasks.

Conclusions: Although the use of DCE is feasible among adolescents, participants' experience completing the DCEs varied in ways that could affect their responses to the valuation tasks. These findings will inform the EQ-5D-Y-5L valuation study in Canada.

Objectives: To examine how using binary rather than continuous adjustments for health-related quality of life (HRQOL) influences the estimated magnitude of social inequality in lifetime health and to explore the implications for equity weighting in distributional cost-effectiveness analysis.

Methods: We used 2018 Health Survey for England and ONS mortality and population data to compare health distributions in quality-adjusted life expectancy at birth (QALE, EQ-5D-5L, 2018 value set), disability-free life expectancy (DFLE, limiting long-term illness) and healthy life expectancy (HLE, self-assessed health), across neighbourhood deprivation quintiles. Indirect equity weights were derived using Atkinson inequality aversion parameters, and implied mean HRQOL scores were cross-tabulated by age and deprivation to understand discrepancies.

Results: Continuous adjustment yielded substantially smaller inequality gaps between the most and least deprived quintile groups than binary adjustments: QALE gap 11.25, DFLE gap 16.00, HLE gap 18.53. Equity weights based on binary adjustments were substantially higher, especially at higher levels of health inequality aversion (four times higher at Atkinson parameter 10). Social group HRQOL differences reflected both increased prevalence of morbidity and increased HRQOL burden of morbidity. However, the morbidity prevalence differential between groups was larger than the HRQOL differential.

Conclusions: Disability-free and healthy life expectancy yield larger estimated magnitudes of health inequality than quality-adjusted life expectancy. This is due to their binary scaling, which implicitly assigns a HRQOL value of zero (as bad as death) to disability or non-good health. A simple adjustment to narrow both ends of the binary scale renders the two approaches more comparable.

Objectives: Timely follow-up after discharge can prevent hospital readmission, making telehealth (TH) a valuable modality for ensuring access and continuity of care. We quantify variation in TH reimbursement after hospital discharge across payers, providers, and market characteristics, and examine whether gaps in TH reimbursement narrowed or persisted in the post-COVID era.

Methods: Using a large postdischarge cohort (N = 276 922 TH visits; 167 922 unique patients), we estimated allowed payments for TH encounters via generalized linear models. Furthermore, to assess dynamics over time, we applied autoregressive integrated moving average models.

Results: Commercial payers reimbursed consistently more than Medicare (avg $130.85 vs $83.62), surgeons more than physicians and nonphysicians ($138.64 vs $126.12 vs $108.61), and metropolitan areas more than nonmetro areas ($128.07 vs $85.77). Reimbursement was highest in least socially vulnerable areas ($123.29 vs $110.92 in highly vulnerable areas) and for audio-video visits ($132.10 vs $65.67 for audio-only visits). Heterogeneity analyses showed payer-provider and payer-modality gaps persisted across various subgroups. Time-series models revealed largely parallel or divergent trajectories after the pandemic, indicating persistent rather than converging disparities; robustness checks confirmed Medicaid payments were uniformly subject to lowest reimbursement.

Conclusions: Intra-TH reimbursement gaps observed in this study appear consistent with structural fee schedules and contracting arrangements, rather than temporary fluctuations. Without targeted adjustments, such as geographic add-ons, modality floor rates, or specialty-neutral pricing, TH expansion could risk contributing to inequities in postdischarge care. Although our analysis is descriptive, the patterns observed here suggest that structural factors, rather than short-term shocks, may underlie these reimbursement differences.

Health technology assessment (HTA) must increasingly incorporate environmental sustainability (ES) to ensure digital health technologies (DHTs) deliver true value for both population and planetary health. Existing HTA frameworks inadequately capture the upstream and downstream environmental implications of DHTs, overlooking critical factors such as energy consumption, data storage, water usage, and electronic waste. Using a few examples on telehealth platforms, electronic health records, and artificial intelligence-driven diagnostic tools, we illustrate how these technologies can reduce carbon emissions and other pollutants by limiting patient travel and optimizing resource use. We review current HTA frameworks, identify ongoing initiatives, and highlight gaps and challenges in integrating ES into value assessment. Traditional HTA models provide limited guidance for incorporating broad environmental factors, risking underestimation of DHTs' environmental impacts and potentially undermining health systems' net-zero commitments by 2050. To address these issues, in this commentary, we propose targeted investment in frameworks, streamlined environmental data collection, and stronger cross-sector collaboration. Systemic inclusion of ES can reduce inequalities, support ethical supply chains, and incentivize developers to design lower-impact technologies, positioning HTA as a driver of sustainable digital health innovation. By embedding environmental metrics, health systems can better balance clinical benefits, economic efficiency, and ecological responsibility, thereby advancing both human and planetary health.