Cost-analysis and quality of life after laparoscopic and robotic ventral mesh rectopexy for posterior compartment prolapse: a randomized trial.

BACKGROUND: The aim of this study was to assess, whether robotic-assistance in ventral mesh rectopexy adds benefit to laparoscopy in terms of health-related quality of life (HRQoL), cost-effectiveness and anatomical and functional outcome. METHODS: A prospective randomized study was conducted on patients who underwent robot-assisted ventral mesh rectopexy (RVMR) or laparoscopic ventral mesh rectopexy (LVMR) for internal or external rectal prolapse at Oulu University Hospital, Finland, recruited in February-May 2012. The primary outcomes were health care costs from the hospital perspective and HRQoL measured by the 15D-instrument. Secondary outcomes included anatomical outcome assessed by pelvic organ prolapse quantification method and functional outcome by symptom questionnaires at 24 months follow-up. RESULTS: There were 30 females (mean age 62.5 years, SD 11.2), 16 in the RVMR group and 14 in the LVMR group. The surgery-related costs of the RVMR were 1.5 times higher than the cost of the LVMR. At 3 months the changes in HRQoL were 'much better' (RVMR) and 'slightly better' (LVMR) but declined in both groups at 2 years (RVMR vs. LVMR, p > 0.05). The cost-effectiveness was poor at 2 years for both techniques, but if the outcomes were assumed to last for 5 years, it improved significantly. The incremental cost-effectiveness ratio for the RVMR compared to LVMR was €39,982/quality-adjusted life years (QALYs) at 2 years and improved to €16,707/QALYs at 5 years. Posterior wall anatomy was restored similarly in both groups. The subjective satisfaction rate was 87% in the RVMR group and 69% in the LVMR group (p = 0.83). CONCLUSIONS: Although more expensive than LVMR in the short term, RVMR is cost-effective in long-term. The minimally invasive VMR improves pelvic floor function, sexual function and restores posterior compartment anatomy. The effect on HRQoL is minor, with no differences between techniques.

The effectiveness of a preventive health program and vitamin D status in improving health-related quality of life of older Canadians.

PURPOSE: To assess the effectiveness of a preventive health program and vitamin D status in improving the health-related quality of life (HRQOL) of older residents of Canada. DESIGN: We analyzed baseline and follow-up data of 2119 volunteers of a community program that promotes healthy lifestyles and encourages vitamin D supplementation. We examined the program effect on each of the five dimensions of the EQ-5D-5L, HRQOL score, and quality-adjusted life years (QALYs) using multivariable regression methods. We further examined the specific contribution of vitamin D status as quantified by serum 25-hydroxyvitamin D (25(OH)D). RESULTS: Problems with mobility, usual activities, pain/discomfort, and depression/anxiety were reported less during follow-up compared to baseline. On average, participants' HRQOL had improved by 0.018 units at 6 months and 0.025 units at 1 year of follow-up. Improvements in vitamin D status were independently associated with improvements in HRQOL and in QALYs. As per 25 nmol/L increase in 25(OH)D, there was a 0.002 increase in HRQOL and a 0.001 increase in QALYs. CONCLUSIONS: This study documents the benefits of a real-world preventive health program to HRQOL. It is the first to reveal that improvements in vitamin D status parallel improvements in HRQOL among healthy community dwellers. The study further suggests that the preventive health program and supplementation with vitamin D are cost-effective interventions.

Assessment of children's own health status using visual analogue scale and descriptive system of the EQ-5D-Y: linkage between two systems.

OBJECTIVES: The objective of the study is to derive a scoring system for the EQ-5D child-friendly version (EQ-5D-Y) from a population-based sample of children based on their own health state assessments on the descriptive system and the visual analogue scale (VAS). METHODS: We used data from the 2008 and 2010 Raising Healthy Eating and Active Living Kids in Alberta surveys of grade five students aged primarily 10-11 years and their parents in the Canadian province of Alberta. We applied a random split sample approach. Two-thirds of the sample (modeling sample) was used for the estimation of the EQ-5D-Y VAS. The remaining one-third sample (validation sample) was used for the examination of the prediction accuracy of the estimation model. Multilevel linear regression was used to estimate EQ-5D-Y VAS score and produce EQ-5D-Y index values from the children's self-rated states described in the EQ-5D-Y and the accompanying VAS values. RESULTS: The mean EQ-5D-Y VAS-based index value was 0.891 (SD 0.133) in the modeling sample and 0.885 (SD 0.134) in the validation sample. The own VAS-based index generally showed logical consistency, with lower values for health states that were logically worse. There was no statistically significant difference between the observed and the predicted VAS values in this sample. CONCLUSIONS: This study elicited a value set for health states defined by the EQ-5D-Y that is based on respondents' own VAS ratings from a large representative sample of Canadian children. Future study is needed to validate this type of value set among different age groups of children.

Vitamin D and health-related quality of life in a community sample of older Canadians.

PURPOSE: To assess how vitamin D status is associated with health-related quality of life (HRQOL) among older residents of Canada. DESIGN: We analysed baseline data of 1,493 Canadians aged 50 years and over in Alberta on HRQOL (EQ-5D-5L) and serum 25-hydroxyvitamin D (25(OH)D) as a measure of vitamin D status. We applied multivariable regression methods to examine the association between vitamin D status and each of the five dimensions and the summary index of the EQ-5D-5L. RESULTS: Participants with higher serum 25(OH)D levels were significantly less likely to report problems with mobility, usual activities, and depression and anxiety. Specifically, age- and gender-adjusted odds ratios for reporting problems with mobility, usual activities, and depression and anxiety were 0.58 (95 % confidence interval 0.44-0.78), 0.67 (0.50-0.89), and 0.67 (0.51-0.88) per 100 nmol/L increase in 25(OH)D, respectively. No significant associations were observed for problems with self-care and with pain and discomfort. HRQOL scores combining the responses of each of the five dimensions increased significantly with increasing serum 25(OH)D levels. CONCLUSIONS: This is the first study to reveal the importance of vitamin D for the five dimensions of HRQOL in a community-based sample. The observed associations of vitamin D and HRQOL call for intervention studies to strengthen the evidence of the potential benefits of vitamin D supplementation for HRQOL among older adults.

Sociodemographic and neighbourhood determinants of health-related quality of life among grade-five students in Canada.

OBJECTIVES: To describe the health-related quality of life (HRQOL) of grade-five students in Alberta, Canada, and to assess how this correlates with sociodemographic and neighbourhood characteristics. METHODS: In 2008, we conducted a comprehensive population-based survey among 3,421 grade-five students aged primarily 10-11 years from 148 schools and their parents that included questions on sociodemographic and neighbourhood factors. The HRQOL of the students was assessed using the EQ-5D Canadian English child version (EQ-5D-Y). We applied multilevel multivariable linear regression to examine the independent importance of sociodemographic and neighbourhood factors for the EQ-5D-Y index and EQ-5D-Y Visual Analogue Scale (VAS) score. RESULTS: In five EQ-5D-Y dimensions, problems with 'walking', 'looking after myself', 'usual activities', 'pain or discomfort' and 'worried, sad or unhappy' were reported by 8.1% (n = 288), 6.5% (n = 215), 11.8% (n = 431), 46.0% (n = 1600), and 37.7% (n = 1292) of students, respectively. Their mean EQ-5D-Y index was 0.86 and mean EQ-5D-Y VAS was 80.4. Children from families reporting higher educational attainment reported higher HRQOL both in terms of a higher EQ-5D-Y index and in terms of a higher EQ-5D-Y VAS. Also, children residing in neighbourhood characterized as providing good satisfaction and facilities reported higher HRQOL. CONCLUSIONS: Public health initiatives to improve HRQOL among children are suggested to take into account the influence of different sociodemographic and neighbourhood characteristics such that priority is given to those residing in towns, rural areas and dissatisfying neighbourhoods with poor access to recreational facilities and stores for fresh products.

A new population-based measure of the economic burden of mental illness in Canada.

This paper presents a comprehensive measure of the incremental economic burden of mental illness in Canada which incorporates the use of medical resources and productivity losses due to long-term and short-term disability, as well as reductions in health-related quality of life (HRQOL), for the diagnosed and undiagnosed population with mental illness. The analysis was based on the population-based Canadian Community Health Survey Cycle 2.1 (2003). For all persons, we measured all health services utilization, longterm and short-term work loss, and health-related quality of life and their dollar valuations, with the economic burden being the difference in dollar measures between the populations with and without mental health problems. In total, the economic burden was $51 billion in 2003. Over one-half was due to reductions in HRQOL. The current accepted practice in economic assessments is to include changes in medical resource use, work loss, and reductions in HRQOL.

Cost-effectiveness analysis of nimodipine treatment after aneurysmal subarachnoid hemorrhage and surgery.

OBJECTIVE: To assess the cost-effectiveness ratio of nimodipine administration after aneurysmal subarachnoid hemorrhage (SAH) and surgery. METHODS: One hundred twenty-seven patients of both sexes who had a ruptured aneurysm (verified using angiography), who presented with Hunt and Hess Grades I to III on admission, who underwent an operation within the first week after SAH, and who had participated in a randomized prospective clinical trial of nimodipine medication were enrolled in the study. The efficiency (cost-effectiveness) of nimodipine treatment was evaluated by incremental cost-effectiveness analysis. The cost-effectiveness ratio was evaluated for two groups: patients treated with nimodipine and patients given placebo. The cost was estimated as direct hospitalization costs, and the patient outcome was measured as life years gained. RESULTS: The incremental cost-effectiveness ratio for nimodipine treatment was $223 per life year gained on the basis of 1996 monetary values and contemporary management of SAH. Patients in the nimodipine group had an average of 3.46 years longer life expectancy (incremental effectiveness) than those in the placebo group. There was a significant difference in 3-month follow-up mortality and a slight difference in sickness pensions during the 10 years after SAH. Nimodipine treatment was associated with a significant decrease in mortality. There were no statistically significant differences between the treatment groups in the length of hospital stay. There were no statistically significant differences between the treatment groups in sickness pensions. CONCLUSION: Nimodipine is cost-effective. Therefore, its use in the management of patients with SAH seems economically justified because it increases patient life years at very low incremental cost.

Comparison of Finnish and U.S.-based visual analog scale valuations of the EQ-5D measure.

The EQ-5D is a multiattribute health status measure that can be used to derive preference-based index scores for health-related quality-of-life (HRQOL) assessment. Valuations for EQ-5D health states using different techniques have been obtained in a number of countries. It is not clear how valuations from different countries compare. Using an ordinary least-squares regression, visual analog scale valuations for EQ-5D health states obtained in postal surveys in Finland and the United States were compared. The regression model estimates indicated that Finnish and U.S. respondents did provide different preference valuations for different levels of health. However, the country-specific differences were not large and depended on the dimension and the level of problem on that dimension. Differences in health-state valuations are unlikely to have important implications when using the EQ-5D in international studies.

Cost effectiveness of periradicular infiltration for sciatica: subgroup analysis of a randomized controlled trial.

STUDY DESIGN: A subgroup analysis of a prospective, randomized controlled trial was performed. OBJECTIVE: To describe the cost effectiveness of periradicular infiltration with steroid in subgroups of patients with sciatica. SUMMARY OF BACKGROUND DATA: A recent trial on periradicular infiltration indicated that a methylprednisolone-bupivacaine combination had a short-term effect, as compared with that of saline. This report describes the efficacy and cost effectiveness of steroid in subgroups of patients with sciatic. METHODS: This study involved 160 patients with unilateral sciatica. Outcome assessments were leg pain (100-mm visual analog scale), disability on the Oswestry Low Back Disability Questionnaire, and the Nottingham Health Profile. Data on medical costs and sick leaves also were gathered. Patients were randomized for periradicular infiltration with either methylprednisolone-bupivacaine or saline. The adjusted between-group treatment differences at each follow-up assessment, the number of patients free of leg pain (responders, cutoff 75%), and efficacy by the area-under-the-curve method were calculated. For the cost-effectiveness estimate, the total costs were divided by the number of responders. The rate of operations in different subgroups was evaluated by Kaplan-Meier analysis. RESULTS: In the case of contained herniations, the steroid injection produced significant treatment effects and short-term efficacy in leg pain and in Nottingham Health Profile emotional reactions. For symptomatic lesions at L3-L4-L5, steroid was superior to saline for leg pain, disability, and straight leg raising in the short term. By 1 year, steroid seemed to have prevented operations for contained herniations, costing $12,666 less per responder in the steroid group (P < 0.01). For extrusions, steroid seemed to increase the operation rate, and the steroid infiltration was more expensive, costing $4445 per responder (P < 0.01). CONCLUSIONS: In addition to short-term effectiveness for contained herniations and lesions at L3-L4-L5, steroid treatment also prevented surgery for contained herniations. However, steroid was countereffective for extrusions. The results of the subgroup analyses call for a verification study.

Periradicular infiltration for sciatica: a randomized controlled trial.

STUDY DESIGN: A randomized, double-blind trial was conducted. OBJECTIVES: To test the efficacy of periradicular corticosteroid injection for sciatica. SUMMARY OF BACKGROUND DATA: The efficacy of epidural corticosteroids for sciatica is controversial. Periradicular infiltration is a targeted technique, but there are no randomized controlled trials of its efficacy. METHODS: In this study 160 consecutive, eligible patients with sciatica who had unilateral symptoms of 1 to 6 months duration, and who never underwent surgery were randomized for double-blind injection with methylprednisolone bupivacaine combination or saline. Objective and self-reported outcome parameters and costs were recorded at baseline, at 2 and 4 weeks, at 3 and 6 months, and at 1 year. RESULTS: Recovery was better in the steroid group at 2 weeks for leg pain (P = 0.02), straight leg raising (P = 0.03), lumbar flexion (P = 0.05), and patient satisfaction (P = 0.03). Back pain was significantly lower in the saline group at 3 and 6 months (P = 0.03 and 0.002, respectively), and leg pain at 6 months (13.5, P = 0.02). Sick leaves and medical costs were similar for both treatments, except for cost of therapy visits and drugs at 4 weeks, which were in favor of the steroid injection (P = 0.05 and 0.005, respectively). By 1 year, 18 patients in the steroid group and 15 in the saline group underwent surgery. CONCLUSIONS: Improvement during the follow-up period was found in both the methylprednisolone and saline groups. The combination of methylprednisolone and bupivacaine seems to have a short-term effect, but at 3 and 6 months, the steroid group seems to experience a "rebound" phenomenon.

The use of videoconferencing for telepsychiatry in Finland.

Some of the first telepsychiatry experiments in Finland were carried out at the Department of Psychiatry of the University of Oulu, where videoconferencing has been used for family therapy, occupational counselling, consultation and teaching. In 1996 videoconferencing was used for a total of 249 hours, which increased to 434 hours in 1997. During 1997, 45% of the time was used for teaching, 26% for occupational counselling, consultations and therapies, 23% for training and 6% for administration (mainly testing the connections). In a survey, 37 participants rated aspects of the quality of the videoconferences on a scale from 4 (poor) to 10 (excellent). The audio quality had a mean value of 8.0 (SD 0.9), the picture quality 7.5 (SD 1.5), and the general value of the videoconference was rated 7.5 (SD 1.0). Preliminary results with telepsychiatry in Finland have been promising. Interactive videoconferencing provides an easy, fast and relatively inexpensive method of providing psychiatric services over long distances.

Psychiatric inpatient care planning via telemedicine.

We assessed the costs of psychiatric inpatient care-planning consultations to remote areas using videoconferencing, instead of the conventional face-to-face consultations at a hospital. The data were collected from all wards at the department of psychiatry of Oulu University Hospital over 11 months. A total of 14 videoconferences were conducted with two primary-care centres located 220 km and 160 km from Oulu. During the same period, 20 conventional consultations at the Oulu University Hospital were also assessed. A questionnaire was completed by a total of 124 patients, relatives and health-care personnel; the response rate was about 90%. Of the respondents, 90% were satisfied with the quality of communication afforded by videoconferencing. At a workload of 20 patients per year, the cost of the videoconferences was FM2510 per patient; the cost of the conventional alternative was FM4750 per patient. At 50 care consultations per year, a remote municipality would save about FM117,000.

The feasibility of telemedicine for orthopaedic outpatient clinics--a randomized controlled trial.

We investigated the use of videoconferencing in the examination of orthopaedic outpatients. A consecutive sample of orthopaedic outpatients was randomized to examination either via videoconferencing (n = 76) while attending a primary-care unit or at a conventional hospital outpatient clinic 160 km away (n = 69). Videoconferencing was found to be feasible and the equipment functioned well technically. There were somewhat more problems in examining the telemedicine patients than the clinic patients. The two patient groups were equally satisfied with the specialist service. The telemedicine patients were more willing to have their next visit by videoconferencing than the conventional patients. Videoconferencing between primary and secondary care can be used in the examination of orthopaedic patients whenever no demanding imaging technology is needed.

The socio-economic impact of telehealth: a systematic review.

We reviewed the socio-economic impact of telehealth, focusing on nine main areas: paediatrics, geriatrics, First Nations (i.e. indigenous peoples), home care, mental health, radiology, renal dialysis, rural/remote health services and rehabilitation. A systematic search led to the identification of 4646 citations or abstracts; from these, 306 sources were analysed. A central finding was that telehealth studies to date have not used socio-economic indicators consistently. However, specific telehealth applications have been shown to offer significant socio-economic benefit, to patients and families, health-care providers and the health-care system. The main benefits identified were: increased access to health services, cost-effectiveness, enhanced educational opportunities, improved health outcomes, better quality of care, better quality of life and enhanced social support. Although the review found a number of areas of socio-economic benefit, there is the continuing problem of limited generalizability.

The association between childhood overweight and obesity and otitis media.

OBJECTIVE: The objective of this study was to examine the association between otitis media and childhood obesity in a population-based sample of elementary school children in the Canadian province of Nova Scotia. METHODS: The study design is a prospective cohort study, linking data from a population-based survey of Grade 5 students (aged 10-11 years) in the Canadian province of Nova Scotia in 2003 with Nova Scotia administrative health data. Measured body mass index was used to define weight status based on the age- and gender-specific cut-off points of the International Obesity Task Force. Health administration data for each child was linked via Health Card numbers. The primary outcome was healthcare utilization (physician visits and costs) for suppurative otitis media (International Classification of Diseases [ICD]9: 382; ICD10: H65-66) with no previous diagnosis of otitis in the last 30 days. RESULTS: Relative to normal weight children, obese children had more healthcare provider contacts for otitis media (adjusted incidence rate ratio 2.03, 95% confidence interval [CI] 1.66-2.49), incurred more costs per otitis media-related visit ($47 vs. $24, P = 0.0001) and had higher odds to have repeated otitis media (adjusted odds ratio 2.27, 95% CI 1.54-3.35). Socioeconomic factors, a history of breastfeeding, presence of an allergic disorder or chronic adenoid/tonsil disorder did not change the association between obesity and otitis media. CONCLUSION: There is a clear association between childhood obesity and otitis media that cannot be explained by confounding by socioeconomic factors or clinically associated disorders.

Assessing telemedicine: a systematic review of the literature.

BACKGROUND: To clarify the current status of telemedicine, we carried out a systematic review of the literature. We identified controlled assessment studies of telemedicine that reported patient outcomes, administrative changes or economic assessments and assessed the quality of that literature. METHODS: We carried out a systematic electronic search for articles published from 1966 to early 2000 using the MEDLINE (1966-April 2000), HEALTHSTAR (1975-January 2000), EMBASE (1988-February 2000) and CINALH (1982-January 2000) databases. In addition, the HSTAT database (Health Services/Technology Assessment Text, US National Library of Medicine), the Database of Abstracts of Reviews of Effectiveness (DARE, NHS Centre for Reviews and Dissemination, United Kingdom), the NHS Economic Evaluation Database and the Cochrane Controlled Trials Register were searched. We consulted experts in the field and did a manual search of the reference lists of review articles. RESULTS: A total of 1124 studies were identified. Based on a review of the abstracts, 133 full-text articles were obtained for closer inspection. Of these, 50 were deemed to represent assessment studies fulfilling the inclusion criteria of the review. Thirty-four of the articles assessed at least some clinical outcomes; the remaining 16 were mainly economic analyses. Most of the available literature referred only to pilot projects and short-term outcomes, and most of the studies were of low quality. Relatively convincing evidence of effectiveness was found only for teleradiology, teleneurosurgery, telepsychiatry, transmission of echocardiographic images, and the use of electronic referrals enabling e-mail consultations and video conferencing between primary and secondary health care providers. Economic analyses suggested that teleradiology, especially transmission of CT images, can be cost-saving. INTERPRETATION: Evidence regarding the effectiveness or cost-effectiveness of telemedicine is still limited. Based on current scientific evidence, only a few telemedicine applications can be recommended for broader use.

Elements for assessment of telemedicine applications.

OBJECTIVES: As an initiative of the International Network of Agencies for Health Technology Assessment, an approach to assessment of telemedicine applications was prepared to assist decision makers who are considering introduction and use of this technology. METHODS: Review and commentary drawing on published assessment frameworks and reports of primary evaluations of telemedicine, with particular reference to experience in Finland and Canada. RESULTS: Elements of the approach included development of a business case (considering population and services, personnel and consumers, delivery arrangements, specifications and costs); subsequent evaluation of the telemedicine application; and follow-up (covering the domains of technical assessment, effectiveness, user assessment of the technology, costs of telemedicine, trials, economic evaluation methods, and sensitivity analysis). CONCLUSIONS: Decision makers should link introduction of new and often costly technology to appraisal of its feasibility, followed by evaluation of the application, including longer term consideration of its sustainability and impact on the healthcare system. As the effectiveness and efficiency of telemedicine applications will often be strongly influenced by local issues, results of assessments may not be generalizable.