Surgery, Limb Edema and Health-related Quality of Life: A Prospective Follow-up Study on Patients With Cutaneous Malignant Melanoma.

BACKGROUND/AIM: The latest developments in oncological therapies for malignant melanoma, and the discovery that complete lymph node dissection offers no survival benefit, are changing the landscape of melanoma surgery. There is a need for more information on health-related quality of life (HRQoL) consequences of melanoma surgery. PATIENTS AND METHODS: This longitudinal cohort study was carried out from 2004 to 2009 in the Helsinki and Uusimaa Hospital District and patients were followed-up at 6, 12 and 24 months. The patients were asked to fill in the generic 15D questionnaire and the cancer-specific European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-30). In addition, they were asked selected questions from the EORTC Item Library regarding upper and lower limb edema. RESULTS: A total of 169 (64.5%) patients with local or locally advanced melanoma referred for surgical treatment responded, of whom 161 were included in the final analysis. For the whole patient group, distress, depression and emotional function improved over time. Worse HRQoL in some of the dimensions were associated with female sex, skin transplant versus direct wound closure and complications 30 days or more after surgery, but none was associated with worse overall HRQoL. Postoperative complications, type of wound closure or lymph node surgery had no effect on overall HRQoL. Patient-reported limb edema was associated with worse overall HRQoL at baseline and during follow-up by both instruments. Patients reporting limb edema reported worse mobility and more pain throughout the study. CONCLUSION: Patient-reported limb edema, regardless of the cause, seems to be an important predictor of worse HRQoL among patients with melanoma.

Where does the money go to? Cost analysis of gynecological patients with a benign condition.

OBJECTIVES: The impact of benign gynecological conditions on life of women and on costs for the society is high. The purpose of this study is to gain knowledge and understanding of costs of the treatment of these disorders in order to be able to improve the clinical care processes, gain insight into feasible savings opportunities and to allocate funds wisely. METHODS: The healthcare processes of 311 women attending university or community hospitals in the Helsinki and Uusimaa Hospital District between June 2012 and August 2013 due to a benign gynecological condition were followed up for two years and treatment costs analysed. RESULTS: Total direct hospital costs averaged 689€ at six months and 2194€ at two years. The most expensive treatment was that of uterine fibroids in the short term and that of endometriosis and fibroids later on. Costs did not depend on hospital size. Surgical operations caused nearly half of hospital costs. Productivity loss caused biggest expenses outside of the hospital. LNG-IUD (levonorgestrel-releasing intrauterine device) accounted for the largest pharmaceutical costs for patients. Hospital treatment was associated with a reduced need for outpatient services during follow-up. CONCLUSIONS: A majority of direct hospital costs arise over time. This stresses the need for prolonged healthcare management. To control costs, the need for repetitive doctors' appointments, monitoring tests, and ward treatments should be carefully evaluated. Procedures not needing an operation theatre (for example hysteroscopy for polypectomy), should be done ambulatorily.

The health-related quality of life of patients with a benign gynecological condition: a 2-year follow-up.

Aim: To assess health-related quality of life (HRQoL) of patients with benign gynecological disorders. Materials & methods: Prospective 2-year follow-up with the 15D HRQoL-instrument of 311 women treated in Helsinki-area hospitals in 2012-2013. Results: The initially impaired HRQoL regarding excretion, discomfort and symptoms, and vitality and sexual activity improved after treatment. However, only sexual activity reached similar levels as in the general population. Treatment of endometriosis, fibroids and polyps resulted in best and that of unspecific pelvic pain and bleeding disorders in worst HRQoL scores. Results were independent of hospital size. Conclusion: The impaired HRQoL dimensions were improved by treatment but HRQoL still remained poorer than in the general female population. Treatment of unspecific pelvic pain and bleeding disorders needs further evaluation.

Tweetable abstract Benign gynecological conditions markedly impact women's quality of life including physical, sexual and mental well-being. Two-year follow-up of patients in this new study found quality of life to be partly improved by treatment, but was still lower than in the general female population.

The use of real-world effectiveness measurements in clinical settings at Helsinki University Hospital: a systematic literature review.

Aim: Patient reported outcomes collected alongside clinical trials do not reflect real-world effectiveness (RWE). This review assessed the use of RWE measurements in routine clinical treatment and the instruments applied to collect that data. Materials & methods: The RWE articles published from HUS (Helsinki University Hospital) were extracted from several databases. Results: Out of 170 eligible articles, generic health-related quality of life instruments were used in 87 (51.2%) and disease-specific health-related quality of life instruments in 58 (34.1%) articles as a primary measurement. Most of the articles pertained to surgery, gynecology and pediatric surgery. Conclusion: The number of articles assessing RWE is very limited compared with all the articles published from HUS. Thus, we still have limited information about the effectiveness of the treatment in real life.

Health-related quality of life and costs of switching originator infliximab to biosimilar one in treatment of inflammatory bowel disease.

Effectiveness, efficacy and safety of biosimilar infliximab (CT-P13) in inflammatory bowel disease (IBD) patients has been shown in previous studies. Limited data exist on health-related quality of life (HRQoL) of switching originator to biosimilar infliximab (IFX) in IBD patients. The objective of this study was to evaluate impact of switching originator to biosimilar IFX on HRQoL, disease activity, and health care costs in IBD maintenance treatment.In this single-center prospective observational study, all IBD patients receiving maintenance IFX therapy were switched to biosimilar IFX. HRQoL was measured using the generic 15D health-related quality of life instrument (15D) utility measurement and the disease-specific Inflammatory Bowel Disease Questionnaire (IBDQ). Crohn Disease Activity Index (CDAI) or Partial Mayo Score (pMayo), and fecal calprotectin (FC) served for evaluation of disease activity. Data were collected at time of switching and 3 and 12 months after switching. Patients' characteristics, clinical background information and costs were collected from patient records and the hospital's electronic database.Fifty-four patients were included in the analysis. No statistically significant changes were observed in 15D, CDAI, pMayo, and FC during 1-year follow-up. IBDQ scores were higher (P = .018) in Crohn disease 3 months after switching than at time of switching. Costs of biosimilar IFX were one-third of costs of originator one. Total costs related to secondary health care (excluding costs of IFX), were similar before and after the onset of biosimilar IFX.HRQoL and disease activity were after switching from originator to biosimilar IFX comparable, but the costs of biosimilar IFX were only one-third of those of the originator one.

Long-Term Quality of Life of Melanoma Survivors Is Comparable to that of the General Population.

BACKGROUND/AIM: There is a growing need for information regarding the Health-Related Quality of Life (HRQoL) of cancer survivors. This study aimed to assess the HRQoL of patients treated for cutaneous malignant melanoma between 1980 and 2004 in the Helsinki and Uusimaa Hospital district and compare the results to the general population. MATERIALS AND METHODS: HRQoL of 981 cutaneous melanoma patients (aged 13 to 97 years, 56.1% female) was assessed using the generic 15D instrument and compared to the general population. The association between demographic and clinical factors and HRQoL was analyzed using oneway ANOVA, student's t-test and multivariate regression. RESULTS: The mean 15D score of melanoma patients was slightly lower (0.904) than that of the general population (0.911, p=0.027), but the difference was not statistically significant. HRQoL deteriorates with age and metastatic disease and improves with time. CONCLUSION: No evidence was found that long-term HRQoL of melanoma survivors was worse than the general population.

Treatment of gynecological malignancies: long-term follow-up of health-related quality of life and healthcare costs.

Aim: To assess long-term health-related quality of life (HRQoL) and treatment-related costs in gynecological cancer patients, and to compare HRQoL between cancer types and to age-standardized general female population. Materials & methods: A prospective 8-10-year follow-up of 218 patients treated in Helsinki University Hospital in 2002-2004. Results: The most common malignancies were uterine, ovarian and cervical cancers. The mean HRQoL scores were 0.880 (baseline), 0.885 (6 months) and 0.884 for survivors in the end of the study. Depression, vitality and sexual activity were impaired at baseline but improved during follow-up. Total secondary healthcare costs during the follow-up averaged EUR 41342. Conclusion: The long-term HRQoL of surviving gynecological cancer patients was good and similar to that of age-standardized general female population.

Long-term clinical outcomes, health-related quality of life, and costs in different treatment modalities of stable coronary artery disease.

Aims: This study is a prospective, observational 8-year follow-up of 300 stable unselected coronary artery disease patients entering elective coronary angiography in 2002-03. Recorded were clinical outcomes, health-related quality of life (HRQoL), and secondary care costs after coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention (PCI), or medical therapy (MT). Methods and results: HRQoL was measured by the 15D instrument at baseline, 6 months, and 8 years. Regression techniques with an adjustment for relevant baseline characteristics were used to compare the 8-year survival and change in HRQoL between the groups. At baseline, all groups had statistically significantly impaired HRQoL compared with age- and gender-standardized general population. Six months after invasive interventions the mean HRQoL score had improved in a statistically significant and clinically important manner. This improvement was maintained at 8 years as the HRQoL no longer differed from that of the general population, whereas MT patients were still worse off. However, after adjustment for baseline characteristics, the groups no longer differed regarding 8-year survival or change in HRQoL among survivors. Mean 8-year secondary care costs were without (with) adjustment for baseline characteristics: €17 498 (16 730) for CABG, €7245 (6920) for PCI, and €4514 (4580) for MT, respectively. Conclusion: When adjusted for baseline characteristics, no statistically significant differences were found between the patient groups in 8-year survival or change in HRQoL among survivors. The 8-year mean secondary care costs of CABG were over two-fold and almost four-fold, even after adjustment for baseline characteristics, compared with those of PCI and MT.

Cost-effectiveness of anorexia nervosa in QALYs.

BACKGROUND: The costs of treating eating disorders are often considered high. AIMS: The objective was to perform a cost-utility analysis to estimate the cost-effectiveness of treatment of anorexia nervosa (AN). METHODS: Thirty-nine patients entering treatment of AN completed the 15D health-related quality-of-life (HRQoL) questionnaire before and 2 years after the start of treatment. Direct hospital costs were obtained. Quality-adjusted life years (QALYs) gained were calculated and cost-utility assessed. RESULTS: Patients' baseline HRQoL was severely impaired. During follow-up, mean HRQoL improved statistically significantly. The cost per QALY gained was €5296 (best-case scenario) or €64 440 (base-case scenario) (€11 559 or €71 600 discounted 3%) depending on the assumptions used in the analysis. CONCLUSIONS: The cost per QALY was in the same range as that of many other interventions provided in specialized medical care and within the limits usually considered acceptable, indicating that the treatment of AN is cost-effective.

Long-term health-related quality of life in eating disorders.

OBJECTIVE: There is limited evidence on the long-term development of health-related quality of life (HRQoL) in eating disorders and its relation to eating disorder symptoms. Our objective was to measure long-term change in the HRQoL of eating disorder patients and compare it to normal population. METHODS: Fifty-four bulimia nervosa (BN) and forty-seven anorexia nervosa (AN) patients (ICD-10 diagnosis) entering treatment completed the 15D HRQoL questionnaire and the Eating Disorder Inventory (EDI) before and approximately 8 years after the start of treatment. RESULTS: Baseline HRQoL was severely impaired in the patients. During follow-up, mean HRQoL, body mass index (BMI) and EDI improved statistically significantly in both groups. BMI of AN patients reached normal values, but HRQoL was still severely impaired in both AN and BN compared to general population. CONCLUSIONS: The long-term HRQoL after treatment continues to improve, but is still after 8 years poor. Eating disorders are very serious conditions with long-lasting impact on quality of life even after symptom remission.

Bayesian prediction of treatment outcome in anorexia nervosa: a preliminary study.

BACKGROUND: Knowledge of the prognostic factors predicting treatment outcome in anorexia nervosa (AN) measured with health-related quality of life (HRQoL) is limited. AIMS: We performed a novel statistical analysis to identify factors predicting treatment outcome in AN. METHODS: 39 patients entering treatment of an ICD-10-defined AN completed the 15D HRQoL survey, the Eating Disorder Inventory (EDI) and a questionnaire evaluating self reported health status and eating habits before and 2 years after the start of treatment. The analysis was based on a Bayesian approach, which allows analyses of small data sets, and was performed using a naïve Bayes classifier. RESULTS: An impaired follow-up HRQoL score was associated with three baseline risk factors: low self-reported vitality, high scores in eating control and a poor reported health status. Low baseline body mass index (BMI) and a high score in the eating dimension of the 15D predicted low follow-up BMI. CONCLUSIONS: In our preliminary study, we identified a set of variables predicting poor HRQoL in AN. An effort to treat these symptoms effectively in the beginning of AN treatment may influence the outcome.

Estimating the minimum important change in the 15D scores.

PURPOSE: To facilitate the interpretation of empirical results produced by the 15D, a generic, preference-based instrument for measuring health-related quality of life (HRQoL), a subjective five-category global assessment scale (GAS) was used as an external anchor to determine the minimum important change (MIC) in the 15D scores. METHODS: Altogether 4,903 hospital patients representing sixteen disease entities and having the 15D score at baseline repeated the HRQoL assessment at 6 months after treatment and answered the question: compared to the situation before treatment, my overall health status is now (1) much better, (2) slightly better, (3) much the same, (4) slightly worse, (5) much worse. Regression analysis was used to estimate the MIC for improvement/deterioration, defined as the lower/upper limit of 99.9 % confidence interval of the regression coefficient, standardized for baseline HRQoL, for categories (2) and (4), respectively, and confirmed by ROC curve analysis. RESULTS: The limits or intervals for classifying the changes of 15D scores into GAS categories were >.035 for (1), .015-.035 for (2),>-.015 and<.015 for (3), -.035--.015 for (4) and <-.035 for (5). The lower/upper limits of ±.015 for categories (2) and (4) can be regarded as the generic MIC thresholds for improvement/deterioration, respectively. CONCLUSIONS: The generic MICs for the change of 15D scores are ±.015. Follow-up studies using the 15D should report the mean change in the 15D score, its statistical significance, relationship to the MIC, and the distribution of the changes of the 15D scores into the five categories.

Cost-effectiveness of hysterectomy for benign gynecological conditions: a systematic review.

The objective of this study was to assess the cost-effectiveness of hysterectomy performed for benign indications. Hysterectomy remains the most common major gynecological operation in the Western world. Rates of hysterectomy have not declined as expected with the introduction of new treatment options. Furthermore, use of laparoscopic techniques varies widely within the Nordic countries. We designed a systematic review in a University Central Hospital. The sample included all published studies regarding the cost-effectiveness of hysterectomy performed for benign indications (n = 1666). Medline, Cochrane Library, PsycINFO, CINAHL, and Nursing databases were searched. Inclusion criteria were the availability of pre- and post-intervention health-related quality of life measures (HRQoL) and data on costs. HRQoL, costs, and cost-effectiveness of treatment were the main outcome measures. Studies (n = 24) focused on treatment of symptomatic fibroids (n = 8), treatment of heavy menstrual bleeding (n = 10), various surgical techniques (n = 5) and the effect of various indications for hysterectomy (n = 2). Follow-up periods varied from 4 months to over 10 years. SF/RAND-36 or EQ-5D measures and societal cost perspective were most commonly used. Only 11 studies used individual patient data. HRQoL following hysterectomy was generally good but costs were high. The cost-effectiveness depended on indication, age, and duration of follow-up. The cost-effectiveness of hysterectomy has been surprisingly poorly studied. Conclusions are difficult to draw due to different study designs, indications, follow-up times, and HRQoL instruments used. Rates of hysterectomy have declined less than expected with the introduction of new treatment modalities. Costs of surgery are high. Laparoscopic hysterectomy seems to be the least cost-effective, although further data from original patient cohorts with long-term follow-up are needed.

The effectiveness of urinary incontinence treatments measured using the 15D Health-Related Quality of Life instrument.

INTRODUCTION AND HYPOTHESIS: The health-related quality of life (HRQoL) is significantly impaired among urinary incontinent women and the effectiveness of urinary incontinence (UI) treatment should be measured using an HRQoL instrument. METHODS: A prospective, observational study evaluating the HRQoL of 178 non-selected UI patients referred for routine treatment at the Helsinki University Central Hospital between the years 2004 and 2010. HRQoL was assessed using the generic 15D questionnaire on four occasions: before treatment, 6 and 18 months after treatment, and after a median follow-up of 5 years. The HRQoL of the patients was compared with that of an age-standardized Finnish female population. RESULTS: Compared with the general population, the baseline total HRQoL score of the patients was significantly impaired (p < 0.001). It was worse among the urge or mixed (UUI (±SUI)) incontinence patients than among the stress incontinence (SUI) patients (p = 0.035). During follow-up, HRQoL improved and the improvement was more substantial among the operatively than among the conservatively treated patients (p = 0.027). Statistically significant improvement was only seen in the SUI group (Δ + 0.021, 95 % CI 0.005-0.036), but clinically relevant improvement was also found in the operatively treated UUI (±SUI) group. The maximum benefit of treatment was reached between at 2 and 3 years. CONCLUSIONS: 15D is a sensitive tool for monitoring the change in HRQoL and could be implemented into clinical practice. Operative treatment of UI is effective when measured by improved HRQoL. Not only SUI patients, but also selected patients with an urgency component may benefit from surgery.

Quality-adjusted life-years for the estimation of effectiveness of screening programs: a systematic literature review.

OBJECTIVES: The aim of this study was to identify and characterize studies that have used quality-adjusted life-years (QALYs) based on measurements of patients' health-related quality of life (HRQoL) as an indicator of effectiveness of screening programs. METHODS: Systematic search of the literature until March 2010, using several electronic databases. Initial screening of articles based on abstracts, and evaluation of full-text articles were done by at least two of the authors. RESULTS: The search identified 1,610 articles. Based on review of abstracts, 431 full-text articles were obtained for closer inspection and, of these, 81 reported QALYs based on patient-derived data using a valid HRQoL assessment. The most frequently used method to assess HRQoL was Time Trade-Off (55 percent) followed by EQ-5D (26 percent). The most frequently studied medical conditions were malignant diseases (23 percent) followed by cardiovascular diseases (19 percent). All studies employed some kind of modeling with the Markov model being the most prevalent type (65 percent). Majority of the articles (59 percent) concluded that the screening program studied was cost-effective. CONCLUSIONS: The use of QALYs in the evaluation of screening programs has expanded during the last few years. However, only a minority of studies have used HRQoL data derived from patients, using direct or indirect valuation. Further investigation and harmonization of the methodology in evaluation of screening programs is needed to ensure better comparability across different screening programs.

The cost utility of reduction mammaplasty at medium-term follow-up: a prospective study.

PURPOSE: The effects of reduction mammaplasty (RM) have been proved in several randomised trials. However, publications regarding cost utility are infrequent and lacking with regard to medium-term follow-up. Therefore, we decided to assess the cost utility of RM at 2-5 years' follow-up, when later costs and possible re-operations have been incurred. METHODS: A total of 73 patients had bilateral RM between January 2005 and March 2007 in the Hospital District of Helsinki and Uusimaa, Finland. Health-related quality of life was measured with the 15D. Preoperative data were collected with an interview at an appointment and follow-up data by means of a postal survey. Direct hospital costs were obtained from the Ecomed(®) clinical patient administration database (Datawell Ltd., Espoo, Finland). RESULTS: A total of 62 (85%) patients agreed to participate in the study and returned the follow-up questionnaire. The mean follow-up time was 4.0 years (SD 0.53, range 2.3-4.6 years). The mean improvement in the 15D score change was 0.083 (SD 0.081). The mean number of quality-adjusted life years (QALYs) gained was 3.052 (SD 3.167, range 2.561-17.553). The mean hospital costs of the intervention were €3601 (SD 1321), and the mean cost per QALY gained was €1180. Roughly 76% of the costs were due to the hospital stay during the operation. Eight percent of the costs were incurred more than 6 months after the hospital stay. CONCLUSIONS: The cost per QALY gained by RM is low, even when considering later costs caused by possible re-operations, and compares favourably with a number of other surgical procedures.

Effect of health-related quality-of-life instrument and quality-adjusted life year calculation method on the number of life years gained in the critical care setting.

OBJECTIVES: Health-related quality of life (HRQoL) and quality-adjusted life-years (QALYs) gained are basic elements in the cost-utility evaluations of health care. Different HRQoL instruments produce different scores for the same patient, and thus also a different number of QALYs. We examined the effect of these factors on the number of QALYs gained and the cost per QALY in the critical care setting. METHODS: In 937 patients having been treated in the critical care setting in the Helsinki University Central Hospital the HRQoL scores were measured by the EQ-5D and 15D 6 and 12 months after start of treatment, and QALYs were calculated using four different sets of assumptions regarding recovery from disease. RESULTS: The mean number of QALYs gained during the first year after treatment ranged from 0.178 ± 0.206 to 0.550 ± 0.508 and the consequent cost per QALY from €38,405 to €118,668 depending on HRQoL instrument and assumptions used in the calculations regarding recovery from disease. CONCLUSIONS: The HRQoL instrument and the assumptions employed regarding recovery from disease have a great influence on the results of cost-utility analyses and should, therefore, be explicitly described in studies reporting QALYs. Furthermore, a common consensus on which calculation method should be used within critical care would be urgently needed.

Cost of a quality-adjusted life year in liver transplantation: the influence of the indication and the model for end-stage liver disease score.

Cost issues in liver transplantation (LT) have received increasing attention, but the cost-utility is rarely calculated. We compared costs per quality-adjusted life year (QALY) from the time of placement on the LT waiting list to 1 year after transplantation for 252 LT patients and to 5 years after transplantation for 81 patients. We performed separate calculations for chronic liver disease (CLD), acute liver failure (ALF), and different Model for End-Stage Liver Disease (MELD) scores. For the estimation of QALYs, the health-related quality of life was measured with the 15D instrument. The median costs and QALYs after LT were €141,768 and 0.895 for 1 year and €177,618 and 3.960 for 5 years, respectively. The costs of the first year were 80% of the 5-year costs. The main cost during years 2 to 5 was immunosuppression drugs (59% of the annual costs). The cost/QALY ratio improved from €158,400/QALY at 1 year to €44,854/QALY at 5 years, and the ratio was more beneficial for CLD patients (€42,500/QALY) versus ALF patients (€63,957/QALY) and for patients with low MELD scores versus patients with high MELD scores. Although patients with CLD and MELD scores > 25 demonstrated markedly higher 5-year costs (€228,434) than patients with MELD scores < 15 (€169,541), the cost/QALY difference was less pronounced (€59,894/QALY and €41,769/QALY, respectively). The cost/QALY ratio for LT appears favorable, but it is dependent on the assessed time period and the severity of the liver disease.

Comparison of two utility instruments, the EQ-5D and the 15D, in the critical care setting.

PURPOSE: Reliable measures are required for proper cost-utility analysis after critical care. No gold standard is available, but the EQ-5D health-related quality of life instrument (HRQoL) has been proposed. Our aim was to compare the EQ-5D with another utility measure, the 15D, after critical illness. METHODS: A total of 929 patients filled in both the EQ-5D and 15D HRQoL instruments 6 and 12 months after treatment at an intensive care or high-dependency unit. The difference in the medians and distributions of the scores of the instruments was tested with Wilcoxon signed-rank test and their association with Spearman rank correlation. Discriminatory power was compared by the ceiling effect and agreement between the instruments regarding the direction of the minimal clinically important change in the HRQoL scores between 6 and 12 months was tested with the McNemar-Bowker test and Cohen's kappa. RESULTS: The utility scores produced by the instruments and their distributions were different. Agreement between the instruments was only moderate. The 15D appeared more sensitive than the EQ-5D both in terms of discriminatory power and responsiveness to clinically important change. CONCLUSION: The agreement between the two utility measures was only moderate. The choice of the instrument may have a substantial effect on cost-utility results. Our results suggest that the 15D performs well after critical illness, but further large cohort studies comparing different utility instruments in this patient population are warranted before the gold standard for utility measurement can be announced.

Cost-utility of molecular adsorbent recirculating system treatment in acute liver failure.

AIM: To determine the short-term cost-utility of molecular adsorbent recirculating system (MARS) treatment in acute liver failure (ALF). METHODS: A controlled retrospective study was conducted with 90 ALF patients treated with MARS from 2001 to 2005. Comparisons were made with a historical control group of 17 ALF patients treated from 2000 to 2001 in the same intensive care unit (ICU) specializing in liver diseases. The 3-year outcomes and number of liver transplantations were recorded. All direct liver disease-related medical expenses from 6 mo before to 3 years after ICU treatment were determined for 31 MARS patients and 16 control patients. The health-related quality of life (HRQoL) before MARS treatment was estimated by a panel of ICU doctors and after MARS using a mailed 15D (15-dimensional generic health-related quality of life instrument) questionnaire. The HRQoL, cost, and survival data were combined and the incremental cost/quality-adjusted life years (QALYs) was calculated. RESULTS: In surviving ALF patients, the health-related quality of life after treatment was generally high and comparable to the age- and gender-matched general Finnish population. Compared to the controls, the average cost per QALY was considerably lower in the MARS group (64,732 euros vs 133,858 euros) within a timeframe of 3.5 years. The incremental cost of standard medical treatment alone compared to MARS was 10,928 euros, and the incremental number of QALYs gained by MARS was 0.66. CONCLUSION: MARS treatment combined with standard medical treatment for ALF in an ICU setting is more cost-effective than standard medical treatment alone.