Providing more balanced information on the harms and benefits of cervical cancer screening: A randomized survey among US and Norwegian women.

We aimed to identify how additional information about benefits and harms of cervical cancer (CC) screening impacted intention to participate in screening, what type of information on harms women preferred receiving, from whom, and whether it differed between two national healthcare settings. We conducted a survey that randomized screen-eligible women in the United States (n = 1084) and Norway (n = 1060) into four groups according to the timing of introducing additional information. We found that additional information did not significantly impact stated intentions-to-participate in screening or follow-up testing in either country; however, the proportion of Norwegian women stating uncertainty about seeking precancer treatment increased from 7.9% to 14.3% (p = 0.012). Women reported strong system-specific preferences for sources of information: Norwegians (59%) preferred it come from a national public health agency while Americans (59%) preferred it come from a specialist care provider. Regression models revealed having a prior Pap-test was the most important predictor of intentions-to-participate in both countries, while having lower income reduced the probabilities of intentions-to-follow-up and seek precancer treatment among U.S. women. These results suggest that additional information on harms is unlikely to reduce participation in CC screening but could increase decision uncertainty to seek treatment. Providing unbiased information would improve on the ethical principle of respect for autonomy and self-determination. However, the clinical impact of additional information on women's understanding of the trade-offs involved with CC screening should be investigated. Future studies should also consider country-specific socioeconomic barriers to screening if communication re-design initiatives aim to improve CC screening participation.

Using novel biomarkers to triage young adult women with minor cervical lesions: a cost-effectiveness analysis.

OBJECTIVE: To evaluate the short-term consequences and cost-effectiveness associated with the use of novel biomarkers to triage young adult women with minor cervical cytological lesions. DESIGN: Model-based economic evaluation using primary epidemiological data from Norway, supplemented with data from European and American clinical trials. SETTING: Organised cervical cancer screening in Norway. POPULATION: Women aged 25-33 years with minor cervical cytological lesions detected at their primary screening test. METHODS: We expanded an existing simulation model to compare 12 triage strategies involving alternative biomarkers (i.e. reflex human papillomavirus (HPV) DNA/mRNA testing, genotyping, and dual staining) with the current Norwegian triage guidelines. MAIN OUTCOME MEASURES: The number of high-grade precancers detected and resource use (e.g. monetary costs and colposcopy referrals) for a single screening round (3 years) for each triage strategy. Cost-efficiency, defined as the additional cost per additional precancer detected of each strategy compared with the next most costly strategy. RESULTS: Five strategies were identified as cost-efficient, and are projected to increase the precancer detection rate between 18 and 57%, compared with current guidelines; however, the strategies did not uniformly require additional resources. Strategies involving HPV mRNA testing required fewer resources, whereas HPV DNA-based strategies detected >50% more precancers, but were more costly and required twice as many colposcopy referrals compared with the current guidelines. CONCLUSION: Strategies involving biomarkers to triage younger women with minor cervical cytological lesions have the potential to detect additional precancers, yet the optimal strategy depends on the resources available as well as decision-makers' and women's acceptance of additional screening procedures. TWEETABLE ABSTRACT: Women with minor cervical lesions may be triaged more accurately and effectively using novel biomarkers.

The predicted lifetime costs and health consequences of calcium and vitamin D supplementation for fracture prevention-the impact of cardiovascular effects.

UNLABELLED: Some studies indicate that calcium supplementation increases cardiovascular risk. We assessed whether such effects could counterbalance the fracture benefits from supplementation. Accounting for cardiovascular outcomes, calcium may cause net harm and would not be cost-effective. Clinicians may do well considering cardiovascular effects when prescribing calcium supplementation. INTRODUCTION: Accounting for possible cardiovascular effect of calcium and vitamin D supplementation (CaD), the aims of this study were to assess whether CaD on balance would improve population health and to evaluate the cost-effectiveness of such supplementation. METHODS: We created a probabilistic Markov simulation model that was analysed at the individual patient level. We analysed 65-year-old Norwegian women with a 2.3 % 10-year risk of hip fracture and a 9.3 % risk of any major fracture according to the WHO fracture risk assessment tool (FRAX®). Consistent with a recent Cochrane review, we assumed that CaD reduces the risk of hip, vertebral, and wrist fractures by 16, 11, and 5 %, respectively. We included the increased risk of acute myocardial infarction (AMI) and stroke under a no-, medium-, and high-risk scenario. RESULTS: Assuming no cardiovascular effects, CaD supplementation produces improved health outcomes resulting in an incremental gain of 0.0223 quality-adjusted life years (QALYs) and increases costs by €322 compared with no treatment (cost-effectiveness ratio €14,453 per QALY gained). Assuming a Norwegian cost-effectiveness threshold of €60,000 per QALY, CaD is likely to be considered a cost-effective treatment alternative. In a scenario with a medium or high increased risk of cardiovascular events, CaD produces net health losses, respectively, -0.0572 and -0.0784 QALY at additional costs of €481 and €1033. CONCLUSIONS: We conclude that the magnitude of potential cardiovascular side effects is crucial for the effectiveness and cost-effectiveness of CaD supplementation in elderly women.

Cost and health consequences of treatment of primary biliary cirrhosis with ursodeoxycholic acid.

BACKGROUND: Long-term use of ursodeoxycholic acid (UDCA) is the recommended therapy in primary biliary cirrhosis (PBC). The lifetime effectiveness and cost-effectiveness of UDCA in PBC have, however, not been assessed. AIM: To estimate the health outcomes and lifetime costs of a Norwegian cohort of PBC patients on UDCA. METHODS: Norwegian PBC patients (n = 182) (90% females; mean age 56.3 ± 8.9 years; Mayo risk score 4.38) who were included in a 5-year open-label study of UDCA therapy were subsequently followed up for up to 11.5 years. The lifetime survival was estimated using a Weibull survival model. The survival benefit from UDCA was based on a randomised clinical trial from Canada, comparing the effect of non-UDCA and UDCA. Survival and costs of standard care vs. standard care plus UDCA were simulated in a Markov model with death and liver transplantation as major events, invoking transition of a patient's state in the model. RESULTS: The gain in life expectancy for a PBC patient on UDCA compared with standard care was 2.24 years (1.19 years discounted). The lifetime treatment costs were EUR 151,403 and EUR 157,741 (EUR 102,912 and EUR 115,031 discounted) for patients with and without UDCA respectively. A probabilistic sensitivity analysis indicated an 82% probability that UDCA entails both greater life expectancy and lower costs than standard care. CONCLUSIONS: The results of this study indicate that UDCA therapy is a dominant strategy as it confers reduced morbidity and mortality, as well as cost savings, compared with standard therapy.

Cost-effectiveness of supplementing a broth-enriched culture test with the Xpert meticillin-resistant Staphylococcus aureus (MRSA) assay for screening inpatients at high risk of MRSA.

BACKGROUND: Meticillin-resistant Staphylococcus aureus (MRSA) represents a considerable challenge for health care in terms of complications and costs. Whilst bacteriological culture remains the most common method for detecting MRSA, the polymerase-chain-reaction-based Xpert MRSA assay was introduced to Ullevål Oslo University Hospital, Norway in 2009. AIM: To estimate the cost-effectiveness of supplementing a broth-enriched culture test with the Xpert MRSA assay in comparison with using the culture test alone as part of an active surveillance strategy. METHODS: A decision-tree model was developed to compare the current strategy (broth-enriched culture test) with two new strategies using the Xpert MRSA assay (daytime and 24 h). Costs and outcomes (length of pre-emptive isolation, number of unavailable room-hours, quality of life) were measured. FINDINGS: The current strategy was more expensive (NOK16,984 per patient) than the daytime Xpert strategy and 24 h Xpert strategy (NOK7360 and NOK3690 per patient, respectively). The new strategies reduced the length of pre-emptive isolation per patient (by 43.9 h and 57.5 h for the daytime Xpert strategy and 24 h Xpert strategy, respectively), and also the number of unavailable room-hours per case (by 57.1 h and 77.7 h, respectively). The improvement in patients' quality-adjusted life years (QALYs) was nominal (2.4*10(-4) and 3.0*10(-4) QALYs per patient for the daytime Xpert strategy and 24 h Xpert strategy, respectively). The sensitivity analyses indicated that these results were robust to reasonable changes in the model parameters. CONCLUSIONS: The 24 h Xpert strategy appears to be the best strategy for active surveillance as it reduces costs and unfavourable outcomes compared with the other strategies, while improving favourable outcomes under reasonable assumptions.

Cost-effectiveness of cervical cancer screening with primary human papillomavirus testing in Norway.

BACKGROUND: New screening technologies and vaccination against human papillomavirus (HPV), the necessary cause of cervical cancer, may impact optimal approaches to prevent cervical cancer. We evaluated the cost-effectiveness of alternative screening strategies to inform cervical cancer prevention guidelines in Norway. METHODS: We leveraged the primary epidemiologic and economic data from Norway to contextualise a simulation model of HPV-induced cervical cancer. The current cytology-only screening was compared with strategies involving cytology at younger ages and primary HPV-based screening at older ages (31/34+ years), an option being actively deliberated by the Norwegian government. We varied the switch-age, screening interval, and triage strategies for women with HPV-positive results. Uncertainty was evaluated in sensitivity analysis. RESULTS: Current cytology-only screening was less effective and more costly than strategies that involve switching to primary HPV testing in older ages. For unvaccinated women, switching at age 34 years to primary HPV testing every 4 years was optimal given the Norwegian cost-effectiveness threshold ($83,000 per year of life saved). For vaccinated women, a 6-year screening interval was cost-effective. When we considered a wider range of strategies, we found that an earlier switch to HPV testing (at age 31 years) may be preferred. CONCLUSIONS: Strategies involving a switch to HPV testing for primary screening in older women is expected to be cost-effective compared with current recommendations in Norway.

Cost-effectiveness of screening for abdominal aortic aneurysm in the Netherlands and Norway.

BACKGROUND: The aim of this study was to determine the cost-effectiveness of ultrasound screening for abdominal aortic aneurysm (AAA) in men aged 65 years, for both the Netherlands and Norway. METHODS: A Markov model was developed to simulate life expectancy, quality-adjusted life-years, net health benefits, lifetime costs and incremental cost-effectiveness ratios for both screening and no screening for AAA. The best available evidence was retrieved from the literature and combined with primary data from the two countries separately, and analysed from a national perspective. A threshold willingness-to-pay (WTP) of €20,000 and €62,500 was used for data from the Netherlands and Norway respectively. RESULTS: The additional costs of the screening strategy compared with no screening were €421 (95 per cent confidence interval 33 to 806) per person in the Netherlands, and the additional life-years were 0·097 (-0·180 to 0·365), representing €4340 per life-year. For Norway, the values were €562 (59 to 1078), 0·057 (-0·135 to 0·253) life-years and €9860 per life-year respectively. In Norway the results were sensitive to a decrease in the prevalence of AAA in 65-year-old men to 1 per cent, or lower. Probabilistic sensitivity analyses indicated that AAA screening has a 70 per cent probability of being cost-effective in the Netherlands with a WTP threshold of €20,000, and 70 per cent in Norway with a threshold of €62,500. CONCLUSION: Using this model, screening for AAA in 65-year-old men would be highly cost-effective in both the Netherlands and Norway.

Cost-effectiveness analyses of elective orthopaedic surgical procedures in patients with inflammatory arthropathies.

OBJECTIVE: To examine the costs per quality-adjusted life year (QALY) gained for surgical interventions in patients with inflammatory arthropathies, and to compare the costs per QALY gained for replacement versus non-replacement surgical interventions. METHODS: In total, 248 patients [mean age 57 (SD 13) years, 77% female] with inflammatory arthropathies underwent orthopaedic surgical treatment and responded to mail surveys at baseline and during follow-up (3, 6, 9, and 12 months). Questionnaires included the quality-of-life EuroQol-5D (EQ-5D) and Short Form-6D (SF-6D) utility scores. The health benefit from surgery was subsequently translated into QALYs. The direct treatment costs in the first year were, for each patient, derived from the hospital's cost per patient accounting system (KOSPA). The costs per QALY were estimated and future costs and benefits were discounted at 4%. RESULTS: Improvement in utility at 1-year follow-up was 0.10 with EQ-5D and 0.03 with SF-6D (p < 0.05). The estimated 10-year cost per QALY gained was EUR 5000 for hip replacement surgery (EUR18 600 using SF-6D) and EUR 10 500 (EUR 48 500 using SF-6D) for all replacement procedures. The 5-year cost per QALY was EUR 17 800 for non-replacement surgical procedures measured by EQ-5D (SF-6D: EUR 67 500). CONCLUSIONS: Elective orthopaedic surgery in patients with inflammatory arthropathies was cost-effective when measured with EQ-5D, and some procedures were also cost-effective when SF-6D was used in the economic evaluations. Hip replacement surgery was most cost-effective, irrespective of the method of analysis.

HPV mRNA tests for the detection of cervical intraepithelial neoplasia: a systematic review.

OBJECTIVE: Perform a systematic review to determine the test performance of HPV mRNA testing compared to DNA testing using CIN2+ as the target condition. METHODS: We searched bibliographic databases (MEDLINE, EMBASE and Cochrane Library) from January 1996 through August 2010 using a predefined search strategy. The reference standard used to diagnose precancerous lesions was histologically confirmed cervical intraepithelial neoplasia 2+ (CIN2+). Two reviewers independently assessed study eligibility, extracted data, and assessed risk of bias. Sensitivity, specificity, positive and negative likelihood ratios and diagnostic odds ratios were calculated for each study. In addition, we fitted a series of summary receiver operating characteristics (SROC) curves. A subgroup analysis was performed according to specific inclusion covariates. RESULTS: Out of 3179 potentially relevant citations, 12 publications (11 studies) met our inclusion criteria. The included studies were of varying methodological quality, and were predominately performed in a secondary screening setting. Eight studies investigated the performance of the PreTect Proofer/NucliSENS EasyQ, two studies investigated the performance of the APTIMA assay and one study investigated both mRNA tests on the same patient samples. Due to few studies and considerable clinical heterogeneity, pooling of data was not possible. Instead, we compiled a 'best evidence synthesis' for E6/E7 mRNA HPV testing. Sensitivities ranged from 0.41 to 0.86 and from 0.90 to 0.95 for the PreTect Proofer/Easy Q and APTIMA assay, respectively. Specificities ranged from 0.63 to 0.97 and from 0.42 to 0.61 for the PreTect Proofer/Easy Q and APTIMA assay, respectively. The SROC curves for both mRNA tests were to the left of the diagonal and the APTIMA assay performed closest to the DNA tests. CONCLUSION: The review suggests that mRNA tests have diagnostic relevance, but additional studies and economic evaluations must be conducted in order to make a solid conclusion regarding the clinical applicability of HPV mRNA testing.

Health-related quality of life in diabetes: The associations of complications with EQ-5D scores.

BACKGROUND: The aim of this study was to describe how diabetes complications influence the health-related quality of life of individuals with diabetes using the individual EQ-5D dimensions and the EQ-5D index. METHODS: We mailed a questionnaire to 1,000 individuals with diabetes type 1 and 2 in Norway. The questionnaire had questions about socio-demographic characteristics, use of health care, diabetes complications and finally the EQ-5D descriptive system. Logistic regressions were used to explore determinants of responses in the EQ-5D dimensions, and robust linear regression was used to explore determinants of the EQ-5D index. RESULTS: In multivariate analyses the strongest determinants of reduced MOBILITY were neuropathy and ischemic heart disease. In the ANXIETY/DEPRESSION dimension of the EQ-5D, "fear of hypoglycaemia" was a strong determinant. For those without complications, the EQ-5D index was 0.90 (type 1 diabetes) and 0.85 (type 2 diabetes). For those with complications, the EQ-5D index was 0.68 (type 1 diabetes) and 0.73 (type 2 diabetes). In the linear regression the factors with the greatest negative impact on the EQ-5D index were ischemic heart disease (type 1 diabetes), stroke (both diabetes types), neuropathy (both diabetes types), and fear of hypoglycaemia (type 2 diabetes). CONCLUSIONS: The EQ-5D dimensions and the EQ-5D seem capable of capturing the consequences of diabetes-related complications, and such complications may have substantial impact on several dimensions of health-related quality of life (HRQoL). The strongest determinants of reduced HRQoL in people with diabetes were ischemic heart disease, stroke and neuropathy.

Health and cost consequences of surgical versus conservative treatment for a comminuted proximal humeral fracture in elderly patients.

OBJECTIVE: This study aims to evaluate the costs and health outcome for surgical and conservative treatment of displaced proximal humeral fractures. DESIGN: This study is a randomised controlled trial. PARTICIPANTS: This study included 50 patients aged 60 or older admitted to hospital with a severely displaced three- or four-part fracture. INTERVENTIONS: The patients were treated surgically with an angular stable interlocking implant (25 patients) or conservative treatment (25 patients). MAIN OUTCOME MEASURE: The outcomes measured included quality-adjusted life years (QALYs) and societal costs. RESULTS: At 12 months' follow-up, the mean difference in the number of QALYs was 0.027 (95% confidence interval (CI)=-0.025, 0.078) while the mean difference in total health-care costs was 597 euro in favour of surgery (95% CI=-5291, 3777). CONCLUSION: There was no significant difference in QALYs or costs between surgical and conservative treatment of severe displaced proximal humeral fractures.

Fluctuating functions related to quality of life in advanced Parkinson disease: effects of duodenal levodopa infusion.

OBJECTIVE: To assess fluctuations in quality of life (QoL) and motor performance in patients with advanced Parkinson disease (PD) treated with continuous daytime duodenal levodopa/carbidopa infusion or conventional therapy. METHODS: Of 18 patients completing a 6-week trial (DIREQT), 12 were followed for up to 6 months and assessed using electronic diaries and the PD Questionnaire-39 (PDQ-39). RESULTS: During the trial and follow-up, major diurnal fluctuations were observed, especially for hyperkinesia, 'off' time, ability to walk and depression. Duodenal infusion was associated with significantly more favourable outcomes compared with conventional treatment for satisfaction with overall functioning, 'off' time and ability to walk, with improved outcomes with PDQ-39. CONCLUSIONS: Relative to conventional treatment, infusion therapy may stabilize and significantly improve motor function and patient's QoL. The potential for daily fluctuation in PD symptoms means single measures of treatment effectiveness can result in bias in effect estimates and hence repeated measures are recommended.

Costs and health consequences of chlamydia management strategies among pregnant women in sub-Saharan Africa.

OBJECTIVES: Chlamydia is the most common bacterial sexually transmitted infection worldwide and a major cause of morbidity-particularly among women and neonates. We compared costs and health consequences of using point-of-care (POC) tests with current syndromic management among antenatal care attendees in sub-Saharan Africa. We also compared erythromycin with azithromycin treatment and universal with age-based chlamydia management. METHODS: A decision analytical model was developed to compare diagnostic and treatment strategies, using Botswana as a case. Model input was based upon (1) a study of pregnant women in Botswana, (2) literature reviews and (3) expert opinion. We expressed the study outcome in terms of costs (US$), cases cured, magnitude of overtreatment and successful partner treatment. RESULTS: Azithromycin was less costly and more effective than erythromycin. Compared with syndromic management, testing all attendees on their first visit with a 75% sensitive POC test increased the number of cases cured from 1500 to 3500 in a population of 100,000 women, at a cost of US$38 per additional case cured. This cost was lower in high-prevalence populations or if testing was restricted to teenagers. The specific POC tests provided the advantage of substantial reductions in overtreatment with antibiotics and improved partner management. CONCLUSIONS: Using POC tests to diagnose chlamydia during antenatal care in sub-Saharan Africa entails greater health benefits than syndromic management does-and at acceptable costs-especially when restricted to younger women. Changes in diagnostic strategy and treatment regimens may improve people's health and even reduce healthcare budgets.

Cost-effectiveness of antenatal screening for neonatal alloimmune thrombocytopenia.

OBJECTIVES: To estimate the costs and health consequences of three different screening strategies for neonatal alloimmune thrombocytopenia (NAIT). DESIGN: Cost-utility analysis on the basis of a decision tree that incorporates the relevant strategies and outcomes. SETTING: Three health regions in Norway encompassing a 2.78 million population. POPULATION: Pregnant women (n = 100,448) screened for human platelet antigen (HPA) 1a and anti-HPA 1a antibodies, and their babies. METHOD: Decision tree analysis. In three branches of the decision tree, pregnant women entered a programme while in one no screening was performed. The three different screening strategies included all HPA 1a negative women, only HPA 1a negative, HLA DRB3*0101 positive women or only HPA 1a negative women with high level of anti-HPA 1a antibodies. Included women underwent ultrasound examination and elective caesarean section 2-4 weeks before term. Severely thrombocytopenic newborn were transfused immediately with compatible platelets. MAIN OUTCOME MEASUREMENTS: Quality-adjusted life years (QALYs) and costs. RESULTS: Compared with no screening, a programme of screening and subsequent treatment would generate between 210 and 230 additional QALYs among 100,000 pregnant women, and at the same time, reduce health care costs by approximately 1.7 million euros. The sensitivity analyses indicate that screening is cost effective or even cost saving within a wide range of probabilities and costs. CONCLUSION: Our calculations indicate that it is possible to establish an antenatal screening programme for NAIT that is cost effective.

Young patients with hip fracture: a population-based study of bone mass and risk factors for osteoporosis.

INTRODUCTION: Hip fracture in young patients is rare. The present study was aimed to clarify the comorbidity pattern and reveal relevant risk factors for osteoporosis and fracture in this patient group. MATERIALS AND METHODS: Using electronic diagnosis registers and lists of the operating theatres for the Oslo hospitals, patients with new hip fracture during two 1-year periods from May 1994 through April 1995 and from May 1996 through April 1997 were identified. All patients age 20-49 years at the time of fracture were included (n=49), and a detailed medical history was recorded. Thirty-two of the patients volunteered for examination and completed a questionnaire and interview to reveal risk factors for osteoporosis. Data from the Oslo Health Study served as reference material. Bone mineral density (BMD) was measured using dual x-ray absorptiometry, and Z-scores were calculated using healthy subjects from Oslo as reference. RESULTS: Of the patients identified, the median age was 40 years (range 25-49), and 63% were men. In 65% of the patients, the fracture occurred after a fall at the same level, in 16% it occurred after a fall from a higher level, and in 18% it occurred in a traffic accident. Twenty percent of the patients had a history of alcohol or drug abuse, 39% had neuromuscular diseases, and 12% had endocrine diseases. The patients examined had significantly more risk factors for osteoporosis than the reference population. The BMD expressed as Z-score for L2-4 was -1.0+/-0.9 (mean +/- SD; p<0.001), for femoral neck was -1.5+/-1.0 (p<0.001), and for total body was -1.3+/-1.1 (p<0.001). BMD was significantly lower than in controls for patients sustaining low-energy and high-energy trauma. There was a negative correlation between the total number of risk factors and BMD for lumbar spine (r=-0.35, p<0.05), femoral neck (r=-0.37, p=0.04), and total body (r=-0.55, p=0.001), respectively. CONCLUSIONS: The majority of the young patients with hip fracture have a history of low-energy trauma, comorbidity predisposing for falls or decreased bone strength, as well as several risk factors for osteoporosis. The BMD was significantly lower than in the reference population regardless of the trauma mechanism.

Local and national electronic databases in Norway demonstrate a varying degree of validity.

OBJECTIVE: The aim of the present study was to examine the validity of local and national electronic databases using medical records as gold Standard. STUDY DESIGN AND SETTING: All hospital admissions with ICD 9-code 820.X (hip fracture) in a 1-year period were identified in the electronic discharge registers of the hospitals in Oslo and in the national electronic database (The Norwegian Patient Register). Medical records for all patients identified by the discharge registers and the logbooks of the operating theater of the hospitals were retrieved, and the diagnosis was verified. RESULTS: Compared with the total number of fractures confirmed in medical records, the electronic discharge register of one of the hospitals underestimated the number of fractures by 46%, whereas the two other overestimated the number by 17% and 19%. For the national electronic database, an overall overestimation of 19% was found. CONCLUSION: The present findings question the validity of electronic databases and thus have implications for epidemiologic studies.

Influence of number needed to treat, costs and outcome on preferences for a preventive drug.

BACKGROUND: The number needed to treat (NNT) has been widely recommended for communicating benefits from risk reductions. It has been claimed that NNT is easily understood and that it has intuitive meaning. There are, however, only few studies of lay people's understanding of NNT. OBJECTIVE: The objective of this study was to explore whether lay people are sensitive to the magnitude of treatment effectiveness as expressed in terms of NNT, and whether the sensitivity is influenced by variation in the type of health outcome, variation in patients' payment for the treatment or variation in the type of side effects. METHODS: In total, 2326 non-institutionalized Danes aged 18-91 years were interviewed face to face and asked whether they would consent to a treatment against a somewhat increased risk of death or heart attack. The respondents were allocated to different levels of effectiveness of treatment expressed as NNT of 10, 100, 200 or 400, different costs and different descriptions of adverse effects. RESULTS: The odds for consenting to therapy were little influenced by the magnitude of NNT, but were greater among married respondents and among those who had side effects presented in terms of headache and constipation. CONCLUSION: In this study, the respondents' choice of treatment was largely insensitive to the magnitude of NNT independently of variations in type of health outcome and costs. NNT may not be easily understood by lay people.

Consequences of hip fracture on activities of daily life and residential needs.

The aim of this study was to describe the consequences of hip fracture with respect to changes in residential needs and the ability to perform activities of daily life. Patients 50 years and older admitted to the two largest hospitals of Oslo with a hip fracture during the period May 1996 through April 1997 were identified. In November 1997 a questionnaire on residential needs, activities of daily life, hip pain and health status was sent to the patients still alive (n = 767). After reminders, the questionnaires of 593 patients (77%) were included. Logistic regression analysis was applied to assess items associated with functional limitation and need for residential care. The proportion of patients living in nursing homes increased from 15% before to 30% after the hip fracture, and men were twice as likely to move into a nursing home than women. Of the patients living in their own homes before the hip fracture, 6% of those < 75 years compared with 33% of those > 85 years had to move to nursing home after hip fracture. The proportion of patients walking without any aid decreased from 76 to 36%, and 43% of the patients lost their prefracture ability to move outside on their own. More than a fourth of the patients (28%) lost their ability to cook their own dinner after sustaining hip fracture. The probability of these events increased with increasing age. The probability of reporting inferior health status and for having hip pain that affected sleep after the fracture was unrelated to age. Many patients sustaining a hip fracture, and in particular the oldest patients, have reduced ability to perform activities of daily life.

Association of time preference for health with age and disease severity.

This study assessed the relationship between time preference for health and age and disease severity. An implicit time preference for health was inferred in 59 patients with chronic obstructive pulmonary disease (COPD) using the time tradeoff method with 10-year and 30-year perspectives. The preference rate was calculated by solving the resulting nonlinear equation, solvable for 50 patients.Among the resulting rates, 4 were negative, 8 zero, and 38 positive. The time preference rate ranged from -10.8% to 75.0%, with a median of 6.6%, and a mean of 11.5%. In correlation analysis, the implicit time preference rate was associated with age;however, there was little association with markers of disease severity. In multivariate analysis, only age was a significant predictor of time preference rate after controlling for the other variables in the model.

Criteria for TNF-targeted therapy in rheumatoid arthritis: estimates of the number of patients potentially eligible.

Tumour necrosis factor (TNF) antagonists or blocking agents represent a major advance in the treatment of rheumatoid arthritis (RA), but their use raises economic concerns because of the high drug cost. Population-based patient registers with clinical data allow the estimation of the proportion of patients with RA who are eligible for TNF antagonist therapy according to recent consensus statements on TNF-targeted therapy. Data were derived from a representative county-based (500,000 population) register of patients with RA. Of 894 patients aged between 18 and 70 years, 636 (71%) [females 80%, mean (SD) age 53.6 (12.2) years and mean (SD) disease duration 12.2 (9.3) years] had a clinical and radiographic examination. The eligibility for TNF-targeted therapy was estimated from the following criteria: (i) previous or current therapy with at least one disease-modifying antirheumatic agent (DMARD); and (ii) active disease. Disease activity criteria were set to 28-swollen joint count (28-SJC) > or = 6, 28-tender joint count > or = 6, and erythrocyte sedimentation rate (ESR) > or = 28 mm/hour or C-reactive protein (CRP) > or = 20 mg/L. Sensitivity analyses were performed varying some of these disease activity parameters. Of the 636 patients, as many as 526 (83%) had previously or were currently using DMARDs and 98 (15%) fulfilled both the DMARD and activity criteria, thus being the maximum number of patients considered for TNF-targeted therapy. If the most stringent criteria were used (ever DMARD, 28-SJC > or = 12 and ESR > or = 50 mm/hour or CRP > or = 40 mg/L) only 15 of the 626 (2%) would be candidates for TNF-targeted therapy. In a population of 1 million, assuming a prevalence of 2000 patients with RA under the age of 70 years, the number of candidates for TNF-targeted therapy would be 40 to 300, depending on the disease activity criteria. Stringent ESR and CRP criteria would lead to a major reduction in the number of eligible patients. These utilisation data imply annual drug costs in the range of $US 480,000 to $US 3,600,000 for TNF antagonists for RA per 1 million population. Further economic evaluations are needed to determine for which groups such treatment is warranted from a health economics perspective.