Contralateral knee effect on self-reported knee-specific function and global functional assessment: data from the Osteoarthritis Initiative.

OBJECTIVE: To analyze the effect of contralateral knee pain on sensitivity of patient-reported outcomes and objectively measured functional performance tests in subjects with knee osteoarthritis (OA). METHODS: Subjects with discordant knee pain status (i.e., 1 knee being painful [≥4 on a numeric pain rating scale (NPRS)], with the contralateral knee being pain free [NPRS 0]) were selected from the Osteoarthritis Initiative and matched to subjects with bilaterally pain-free and painful knees by age, sex, body mass index, and radiographic knee OA. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function score, the global Physical Activity Scale for the Elderly (PASE), and objective functional performance tests were cross-sectionally compared in a matched case-control design. RESULTS: A total of 378 subjects with discordant knee pain status were matched to 359 controls with bilaterally pain-free knees and to 323 controls with bilaterally painful knees. WOMAC scores in pain-free knees of discordant knee pain cases significantly differed compared to scores of bilaterally pain-free knees (P = 0.003). Likewise, scores in painful knees of discordant knee pain cases significantly differed compared to scores of bilaterally painful knees (P < 0.001). PASE levels between these groups were not significantly different (P > 0.68). Functional performance tests differed in subjects with discordant knee pain compared to subjects with bilaterally pain-free knees and when compared to subjects with bilaterally painful knees, with the chair stand test showing the strongest effect size (standardized response mean 0.28 and 0.33, respectively). CONCLUSION: The WOMAC physical function score, although knee specific, is impacted by the contralateral knee pain status. The repeated chair stand test appears to be the most sensitive assessment in differentiation between groups with different status of knee pain.

[Factors influencing the decision of future psychiatrists to practice establishment. Results from a survey of young physicians in Germany]. / Prädiktoren für die Niederlassungsabsicht angehender Psychiater. Ergebnisse einer postalischen Befragung junger Ärzte in Deutschland.

OBJECTIVE: Office based psychiatrists are playing a decisive role regarding the provision and coordination of community based, continuous mental health care. Although the estimated need for office based psychiatrists and neurologists is covered to 125 % in Germany, a physician shortage is emerging in some regions. Therefore, the present study aimed to investigate factors influencing the decision of future psychiatrists to a practice establishment. METHODS: 14,939 young physicians aged under 40 without completed specialist medical training were contacted by mail using databases of five state chambers of physicians (Lower Saxony, Westfalen-Lippe, Saxony, Saxony-Anhalt, Mecklenburg-Western Pomerania). The physicians were asked to answer questions regarding socio-demographic characteristics, the aspired medical speciality, their purpose to establish a practice, and an 18-items questionniare regarding important aspects for the latter decision. As revealed in a former study, the 18 items are related to six factors for practice establishment. The answers of 5,053 respondents were eligible for data analysis. RESULTS: 4.3 % of the examined physicians aspired a medical specialist training in psychiatry, 44 % of them plan to establish a practice. Future psychiatrists as well as other physicians valued the surrounding conditions for family as most important factor regarding a practice establishment, followed by professional duties (e. g. on-call duty) and financial conditions. The quality of life in the surrounding area had least importance. CONCLUSIONS: The results point on measures which could be suited making a practice establishment for young physicians attractive.

The role of monetary and nonmonetary incentives on the choice of practice establishment: a stated preference study of young physicians in Germany.

INTRODUCTION: The study aimed to quantify the preferences of young physicians for different attributes relevant to practice establishment in Germany. METHODS: Qualitative in-depth interviews of 22 physicians were conducted to identify relevant practice attributes. Based on this information, a questionnaire was developed containing a discrete choice experiment comprised of a "best-worst scaling" (BWS) task. It was mailed to a representative sample of 14,939 young physicians who were close to making a decision regarding practice establishment. Regression analysis was used to estimate utility weights quantifying physicians' preferences for practice attributes. RESULTS: Qualitative interviews identified six attributes: "professional cooperation,""income,""career opportunities of the partner,""availability of child care,""leisure activities," and "on-call duties." For the BWS task, 5,026 returned questionnaires were analyzed. Results indicated that a change in income led to the largest utility change compared with changes in other attributes. Additional net income to compensate the disutility of a rural practice as compared with an urban practice was 9,044euro/months (U.S.$ 11,938). Yet, nonmonetary attributes such as on-site availability of childcare and fewer on-call duties would decrease the additional income required to compensate the disutility of a rural practice. DISCUSSION: The results offer quantifiable information about young physicians' preferences in establishing a practice. It can assist health policy makers in developing tailored incentive-based interventions addressing urban-rural inequalities in physician coverage.

Utility assessment in patients with mental disorders: validity and discriminative ability of the time trade-off method.

BACKGROUND: Preference-based health-state values, also referred to as utility scores, are considered an important measure of outcome in the evaluation of healthcare. A common approach to elicit utility scores is the use of the time trade-off (TTO) method; however, the data on TTO utility scores in patients with mental disorders are scarce. OBJECTIVE: To analyse the TTO method in patients with mental disorders in terms of discriminative ability, validity and the refusal to trade life time (zero trade). METHODS: In patients with affective (n = 172), schizophrenia spectrum (n = 166) and alcohol-related (n = 160) mental disorders, TTO utilities were administered through a standardized interview. Measures of quality of life (QOL) EQ-5D, WHOQOL-BREF, subjective (SCL-90R) and objective (CGI-S) psychopathology, and functioning (GAF, GARF, SOFAS, HoNOS) provided comparison. Discriminative ability was analysed by assessing frequency distributions of TTO utilities. Validity was analysed by assessing the correlation of TTO utilities with all other scores. The association of a patient's QOL, sociodemographic and disease-related variables with zero trade was analysed by logistic regression. RESULTS: Of patients with affective/schizophrenic/alcohol-related mental disorders, 153/143/145 (89/86/91%), respectively, completed the TTO elicitation; 29/43/28% of the respondents were zero traders. The mean TTO utility was 0.66/0.75/0.61 and the median was 0.85/0.95/0.75. TTO utility scores discriminated well among more impaired mental health states, but discrimination was limited among less impaired health states. In patients with affective and alcohol-related mental disorders, TTO utility scores were significantly correlated (mostly moderate: 0.3 < r < 0.5) with all other scores. However, in schizophrenic patients, TTO utility scores were only a little correlated with other subjective measures and not correlated with objective measures. QOL was significantly associated with zero trade; the influence of the other variables on zero trade was negligible. CONCLUSIONS: TTO utility scores in patients with affective or alcohol-related mental disorders were reasonably valid, but discriminative ability was compromised by a ceiling effect due to zero trade. In schizophrenic patients, validity of TTO utility scores was not demonstrated.

The responsiveness of EQ-5D utility scores in patients with depression: A comparison with instruments measuring quality of life, psychopathology and social functioning.

INTRODUCTION: The EQ-5D provides preference weights (utilities) for health-related quality of life to be used for calculating quality-adjusted life years (QALYs) in cost-utility analysis. The aim of this study was to compare differences in EQ-5D utility scores with differences in quality of life, psychopathology, and social functioning scores. METHODS: In an observational longitudinal cohort study, EQ-5D utilities (EQ visual analogue scale (EQ VAS), EQ-5D indices of the United Kingdom (EQ-5D index-UK) and Germany (EQ-5D index-D)) were compared with scores of the WHOQOL-BREF, CGI, and GAF at baseline and at 18 months (N=104). The patients' health status at follow-up was categorized as "worse", "stable", or "better" using the EQ-5D transition question (patient-based anchor) and the Bech-Rafaelsen melancholy scale (clinician-based anchor). Effect sizes (ES) were used to compare differences in scores within each group over time; regression analysis was used to derive meaningful difference scores in health status associated with a shift from "stable" to "better" health status. RESULTS: The most responsive instrument was the CGI (patient-based anchor: ES=|0.98|; clinician-based anchor: ES=|1.35|); responsiveness was large in EQ VAS (patient-based anchor: ES=|0.84|; clinician-based anchor: ES=|1.19|), but rather small to medium for EQ-5D index-UK (patient-based anchor: ES=|0.55|; clinician-based anchor: ES=|0.65|) and EQ-5D index-D (patient-based anchor: ES=|0.41|; clinician-based anchor: ES=|0.45|). Compared with the other instruments, the shift to a "better health status" was smaller if elicited by the EQ-5D indices. DISCUSSION: Both EQ-5D indices were less responsive and need larger patient samples to detect meaningful differences compared with EQ VAS and the other instruments.

Responsiveness of EQ-5D utility indices in alcohol-dependent patients.

INTRODUCTION: The EQ-5D provides community-based preference weights (utilities) for calculating quality adjusted life years (QALYs) in cost-utility analysis. This study aimed to analyze the responsiveness of EQ-5D-based utilities in patients with alcohol dependence. METHODS: In an observational longitudinal cohort study of alcohol-dependent patients (N=52), three different EQ-5D-based utilities (EQ-Index United Kingdom, United States, and Germany) were calculated and compared with the scores of the WHOQOL-BREF (mental domain), HoNOS (total score), and GAF at baseline and at 18 months. Patients were categorized with more/same/less problems according to their self reported consumption of alcohol (patient-based anchor) and their problem status due to alcohol consumption using a question of the HoNOS scale (clinician-based anchor). Effect sizes (ES) were used to compare longitudinal changes in scores within each group; regression analysis was used to derive difference scores in health status associated with a shift from "same" to "less" problems according to the two anchors. RESULTS: ES were rather trivial to medium for all EQ-5D indices (ranging from |0.10| to |0.59|) related to a shift from "same" to "less" problems in the two anchors. Differences in scores of the EQ-5D indices revealing a shift from "same" to "less" problems according to the two anchors were not significant. CONCLUSIONS: These results suggest that the EQ-5D indices are less responsive and require larger patient samples to detect meaningful clinical differences compared to the other used instruments. Additional research is needed to compare societal and clinical views on relevant change in health status in this patient group.

[The burden of depressive disorders in Germany - results from the European Study of the Epidemiology of Mental Disorders (ESEMeD)]. / Die Krankheitslast von depressiven Erkrankungen in Deutschland - Ergebnisse aus dem Projekt European Study of the Epidemiology of Mental Disorders (ESEMeD).

OBJECTIVE: The purpose of this study was to estimate and compare the disease burden of depression in Germany using preference-based valuations of depressive health states. METHODS: The data came from the European Study of the Epidemiology of Mental Disorders (ESEMeD) in which a representative sample of 3555 non-institutionalised adults aged 18 years or older was interviewed in Germany. Computer assisted personal interviews included EQ-5D, SF-12, time trade-off (TTO) and contingent valuation (willingness-to-pay, WTP). Respondents in whom 12-month prevalence for a depressive disorder according to DSM-IV was identified, were compared to respondents without depressive disorders (controls). Disease burden was measured in terms of loss of quality-adjusted life years (QALYs) and loss of monetary benefit due to depression per year. Valuations of health-related quality of life (HRQL) were derived from EQ-5D (EQ VAS and EQ-5D Index), SF-12 (SF-6D Index) and TTO. Disease burden was estimated by calculating the difference between individual valuation of HRQL/WTP for full health of cases and mean valuation/WTP of controls matched by age and gender. Results were extrapolated to the total population. RESULTS: Depending on the valuation method, the loss of QALYs per year due to depression in Germany was 144,886 (TTO), 239,152 (EQ-5D Index VAS), 265,085 (EQ-5D Index TTO), 307,139 (EQ VAS) and 403,373 (SF-6D Index). The additional WTP for full health amounted to 4.3 billion Euro. CONCLUSIONS: Depressive disorders caused a substantial disease burden. Subjects affected by depression showed lower preference-based scores compared to subjects without depression. However, calculated QALY losses varied strongly by valuation method.

[Discriminative ability, construct validity and sensitivity to change of the EQ-5D quality of life questionnaire in paranoid schizophrenia]. / Diskriminationsvermögen, Konstruktvalidität und Veränderungssensitivität des EQ-5D Lebensqualitätsfragebogens bei paranoider Schizophrenie.

OBJECTIVE: To analyze the discriminative ability, construct validity and sensitivity to change of the EQ-5D in paranoid schizophrenia (ICD-10 F20.0). METHODS: Data of 408 patients was analyzed in a longitudinal study by comparing EQ-5D with SF-36, CGI-S, PANSS, and GAF. RESULTS: EQ-5D showed considerable discriminative ability in the patient sample when compared to a representative population sample. If a measure used for comparison and a EQ-5D dimension were theoretically corresponding, the measure's mean score differed significantly between EQ-5D answer levels, with largest effect sizes for SF-36 scales (0.34<|d|<1.76), but rather small values for CGI-S, PANSS and GAF (|d|<0.5). EQ-5D VAS (mean 61.3) and German EQ-5D index (mean 0.84) showed rather moderate correlations with most other scales (0.18<|r|<0.62). ROC-analysis indicated a very low sensitivity to change of EQ VAS and German EQ-5D index (0.50

Decision makers' and scientists' opinion about contingent valuation and choice experiments for measuring willingness to pay in health care: results from a survey in Germany.

OBJECTIVES: Assessment of willingness to pay (WTP) by contingent valuation (CV) and choice experiments (CE) is increasingly performed in economic evaluation of health care. However, the question of whether the methods for measuring WTP are acceptable to decision makers and scientists has remained largely unacknowledged. The aim of this study was to learn more about decision makers' and scientists' opinion concerning these methods. METHODS: An expert group developed a questionnaire consisting of key items that may influence the opinion about CV and CE according to the constructs "attitude toward behavior," "subjective norm," and "behavioral intention" as defined by the Theory of Reasoned Action by Ajzen and Fishbein. In a survey, seventy-seven decision makers representing key institutions in the German healthcare system and forty-two scientists in health economics completed the questionnaire. RESULTS: Scientists and decision makers in particular did not show a high intention to use methods for measuring WTP. Skepticism regarding precision of the methods and subjects' capability to imagine paying an amount of money for a certain health commodity were stated along with the assertion that the hypothetical decision-making scenario was rather a distant reality. Nevertheless, the majority of scientists and decision makers did not state rejection of the methods. CONCLUSIONS: Increasing the probability of using methods for measuring WTP in health care, the hypothetical scenarios should be made more realistic and payment vehicles should be used to help patients relate payment to a real health benefit. Moreover, an intensive discussion on the potential usefulness of CV/CE without excluding ethical concerns in comparison to existing alternatives has to be resumed.