Generating Utilities for the Château-Santé Base: A Novel, Generic, and Patient-Centered Health-Outcome Measure.

OBJECTIVES: We have developed a new patient-centered, preference-based generic health-outcome measure, Château-Santé Base (CS-Base), which is based on a novel multiattribute preference response (MAPR) measurement framework. This study aimed to generate a first utility set for the CS-Base, making it suitable for use in health-economic evaluations. METHODS: CS-Base comprises 12 health attributes: mobility, vision, hearing, cognition, mood, anxiety, pain, fatigue, social functioning, daily activities, self-esteem, and independence, each with 4 levels. Our methodology to generate utilities for the CS-Base was 2-fold. First, we derived coefficients from patient MAPR data to calculate CS-Base values. Subsequently, these were normalized to a 0.0 to 1.0 utility scale, in which 0.0 signifies dead. The dead position was estimated using general population data from a discrete choice experiment (discrete choice experiment + dead), using a division-value strategy, which localize the position of states better or worse than dead. RESULTS: We analyzed MAPR data from 3222 patients and discrete choice experiment + dead data from 1995 respondents. All MAPR coefficients were negative, logically ordered, and significantly different from the reference level. The dead position was denoted by a division value of -148.385. Utility values spanned from -0.071 to 1.0, and only 53 of 16 777 216 states were deemed worse than dead. CONCLUSIONS: This study introduced the first CS-Base utility set, underlining a 2-step utility derivation method. This method, blending societal and patient views, surpasses traditional preference-based approaches, yielding firmer results. However, improvement of the normalization procedure is expected. Estimating CS-Base utilities is an ongoing process that gains precision over time.

Health Status of US Patients With One or More Health Conditions: Using a Novel Electronic Patient-reported Outcome Measure Producing Single Metric Measures.

BACKGROUND: Most existing research studying health status impacted by morbidity has focused on a specific health condition, and most instruments used for measuring health status are neither patient-centered nor preference-based. This study aims to report on the health status of patients impacted by one or more health conditions, measured by a patient-centered and preference-based electronic patient-reported outcome measure. METHODS: A cross-sectional study was conducted among patients with one or more health conditions in the United States. A novel generic, patient-centered, and preference-based electronic patient-reported outcome measure: Château Santé-Base, was used to measure health status. Individual health state was expressed as a single metric number (value). We compared these health-state values between sociodemographic subgroups, between separate conditions, between groups with or without comorbidity, and between different combinations of multimorbidity. RESULTS: The total sample comprised 3913 patients. Multimorbidity was present in 62% of the patients. The most prevalent health conditions were pain (50%), fatigue/sleep problems (40%), mental health problems (28%), respiratory diseases (22%), and diabetes (18%). The highest (best) and lowest health-state values were observed in patients with diabetes and mental health problems. Among combinations of multimorbidity, the lowest values were observed when mental health problems were involved, the second lowest values were observed when fatigue/sleep problems and respiratory diseases coexisted. CONCLUSIONS: This study compared health status across various single, and multiple (multimorbidity and comorbidity) health conditions directly, based on single metric health-state values. The insights are valuable in clinical practice and policy-making.

From simple to even simpler, but not too simple: a head-to-head comparison of the Better-Worse and Drop-Down methods for measuring patient health status.

BACKGROUND: We recently developed a novel, preference-based method (Better-Worse, BW) for measuring health status, expressed as a single metric value. We have since expanded it by developing the Drop-Down (DD) method. This article presents a head-to-head comparison of these two methods. We explored user feasibility, interpretability and statistics of the estimated coefficients, and distribution of the computed health-state values. METHODS: We conducted a cross-sectional online survey among patients with various diseases in the USA. The BW and DD methods were applied in the two arms of the study, albeit in reverse order. In both arms, patients first performed a descriptive task (Task 1) to rate their own health status according to the 12 items (each with 4 levels) in the CS-Base health-outcome instrument. They then performed Task 2, in which they expressed preferences for health states by the two methods. We then estimated coefficients for all levels of each item using logistic regression and used these to compute values for health states. RESULTS: Our total sample comprised 1,972 patients. Completion time was < 2 min for both methods. Both methods were scored as easy to perform. All DD coefficients were highly significant from the reference level (P < 0.001). For BW, however, only the second-level coefficient of "Cognition" was significantly different (P = 0.026). All DD coefficients were more precise with narrower confidence intervals than those of the BW method. CONCLUSIONS: Both the BW and DD are novel methods that are easy to apply. The DD method outperformed the BW method in terms of the precision of produced coefficients. Due to its task, it is free from a specific distorting factor that was observed for the BW method.

Validity and reliability of the adapted Dutch version of the Brace Questionnaire (BrQ).

BACKGROUND AND PURPOSE: The Brace Questionnaire (BrQ) is a disease-specific health-related quality of life (HRQOL) instrument for measuring perceived health status of scoliosis patients undergoing brace treatment. The purpose of this study is to evaluate the validity and reliability of a translated and culturally adapted Dutch version of the BrQ. PATIENTS AND METHODS: The original Greek BrQ was translated into Dutch and a cross-cultural adaptation and validation processes were conducted. Subsequently, 80 adolescent idiopathic scoliosis (AIS) patients undergoing active brace treatment were included from 4 scoliosis centers to evaluate the validity and reliability of the Dutch version of the BrQ. The questionnaire's floor and ceiling effects, internal consistency, and test-retest reliability were assessed. Concurrent validity was evaluated by comparing the BrQ with the revised Scoliosis Research Society 22-item questionnaire (SRS-22r) scores. RESULTS: The mean total BrQ score was 75.9 (standard deviation [SD] 11.3) and the mean domain scores varied between 3.4 (SD 0.9) and 4.2 (SD 0.7) for the domains "vitality" and "bodily pain," respectively. There were no floor and ceiling effects for the total BrQ score. The BrQ showed satisfactory internal consistency in most subdomains with a Cronbach's α ranging between 0.35 for the domain "general health perception" and 0.89 for the domain "self-esteem and aesthetics." Excellent test-retest reproducibility was observed for the total BrQ score (ICC 0.91), and the BrQ was successfully validated against the SRS-22r. CONCLUSION: The translated and culturally adapted Dutch version of the BrQ is a valid and reliable HRQOL instrument for AIS patients undergoing brace treatment.

Comparing the EQ-5D-3 L and EQ-5D-5 L: studying measurement and scores in Indonesian type 2 diabetes mellitus patients.

BACKGROUND: The EuroQoL five-dimensional instrument (EQ-5D) is the favoured preference-based instrument to measure health-related quality of life (HRQoL) in several countries. Two versions of the EQ-5D are available: the 3-level version (EQ-5D-3 L) and the 5-level version (EQ-5D-5 L). This study aims to compare specific measurement properties and scoring of the EQ-5D-3 L (3 L) and EQ-5D-5 L (5 L) in Indonesian type 2 diabetes mellitus (T2DM) outpatients. METHODS: A survey was conducted in a hospital and two primary healthcare centres on Sulawesi Island. Participants were asked to complete the two versions of the EQ-5D instruments. The 3 L and 5 L were compared in terms of distribution and ceiling, discriminative power and test-retest reliability. To determine the consistency of the participants' answers, we checked the redistribution pattern, i.e., the consistency of a participant's scores in both versions. RESULTS: A total of 198 T2DM outpatients (mean age 59.90 ± 11.06) completed the 3 L and 5 L surveys. A total of 46 health states for 3 L and 90 health states for 5 L were reported. The '11121' health state was reported most often: 17% in the 3 L and 13% in the 5 L. The results suggested a lower ceiling effect for 5 L (11%) than for 3 L (15%). Regarding redistribution, only 6.1% of responses were found to be inconsistent in this study. The 5 L had higher discriminative power than the 3 L version. Reliability as reflected by the index score was 0.64 for 3 L and 0.74 for 5 L. Pain/discomfort was the dimension mostly affected, whereas the self-care dimension was the least affected. CONCLUSIONS: This study suggests that the 5 L-version of the EQ-5D instrument performs better than the 3 L-version in T2DM outpatients in Indonesia, regarding measurement and scoring properties. As such, our study supports the use of the 5 L as the preferred health-related quality of life measurement tool. We did not do a trial but this study was approved by the Medical Ethics Committee of Universitas Gadjah Mada Yogyakarta, Indonesia (document number KE/FK/1188/EC, 12 November 2014, amended 16 March 2015).

'Diabetes is a gift from god' a qualitative study coping with diabetes distress by Indonesian outpatients.

BACKGROUND: More than two-thirds of patients diagnosed with type 2 diabetes mellitus (T2DM) in Indonesia encounter medical-related problems connected to routine self-management of medication and the social stigma related to T2DM. The current study aims to explore distress and coping strategies in Indonesian T2DM outpatients in a Primary Healthcare Centre (PHC) in Surabaya, East Java, Indonesia. METHODS: We conducted a qualitative study using two different data collection methods: focus group discussions and in-depth interviews. The guideline of interviews and discussions were developed based on seventeen questions derived from the DDS17 Bahasa Indonesia (a Bahasa Indonesia version of the Diabetes Distress Scale questionnaire), which covered physician distress domain, emotional burden domain, regimen distress domain and interpersonal distress domain. RESULTS: The majority of the 43 participants were females and aged 50 or older. Our study discovered two main themes: internal and external diabetes distress and coping strategies. Internal diabetes distress consists of disease burden, fatigue due to T2DM, fatigue not due to T2DM, emotional burden (fear, anxiety, etc.) and lack of knowledge. Internal coping strategies comprised spirituality, positive attitude, acceptance and getting more information about T2DM. External diabetes distress was evoked by distress concerning healthcare services, diet, routine medication, monthly blood sugar checks, interpersonal distress (family) and financial concern. External coping strategies included healthcare support, traditional medicine, vigilance, self-management, social and family support and obtaining information about health insurance. CONCLUSION: Our study shows that for Indonesian T2DM-patients, spirituality and acceptance are the most common coping mechanisms for reducing DD. Furthermore, our study revealed an overall positive attitude towards dealing with T2DM as well as a need for more information about T2DM and potential coping strategies. Finally, an important finding of ours relates to differences in DD between males and females, potential DD associated with health services provision and the specific challenges faced by housewives with T2DM.

Exploring patient satisfaction after operative and nonoperative treatment for midshaft clavicle fractures: a focus group analysis.

BACKGROUND: There is no consensus on the optimal treatment for displaced midshaft clavicle fractures. Several studies indicate superior patient satisfaction in favour of operative reconstruction. It is unknown what drives superior satisfaction in this treatment group. The aim of this study was to explore patient satisfaction and identify contributors to patient satisfaction after operative and nonoperative treatment for displaced midshaft clavicle fractures in adults using a focus group approach. METHODS: Four face-to-face and two web-based focus groups were hosted. A total of 24 participants who were treated nonoperatively (n = 14) or operatively (n = 10) agreed to participate. Participants were selected using purposive sampling, ensuring variation in gender, age, treatment complications and outcomes. A question script was developed to systematically explore patient expectations, attitudes and satisfaction with different dimensions of care. All focus groups were voice-recorded and transcribed at verbatim. Thematic analysis was conducted on all face-to-face and web-based transcripts. RESULTS: The main emerging themes across treatment groups were; need for more information, functional recovery, speed of recovery and patient-doctor interaction. There was no difference in themes observed between operative and nonoperative focus groups. The lack of information was the most important complaint in dissatisfied patients. CONCLUSION: Our study shows that informing patients about their injury, treatment options and expectations for recovery is paramount for overall patient satisfaction after treatment for a displaced midshaft clavicle fracture. LEVEL OF EVIDENCE: Level III, focus group study.

Valuing Health Status in the First Year of Life: The Infant Health-Related Quality of Life Instrument.

OBJECTIVES: Efforts to evaluate HRQoL and calculate quality-adjusted life years (QALYs) for infants less than 12 months of age are hampered by the lack of preference-based HRQoL instruments for this group. To fill this gap, we developed the Infant Quality of life Instrument (IQI), which is administered through a mobile application. This article explains how weights were derived for the 4 levels of each health item. METHODS: The IQI includes 7 health items: sleeping, feeding, breathing, stooling/poo, mood, skin, and interaction. In an online survey, respondents from the general population (n = 1409) and primary caregivers (n = 1229) from China, the United Kingdom, and the United States were presented with 10 discrete choice scenarios. Coefficients for the item levels were obtained with a conditional logit model. RESULTS: The highest coefficients were found for sleeping, feeding, and breathing. All coefficients for these items were negative and logically ordered, meaning that more extreme levels were less preferred. Stooling, mood, skin, and interaction showed some irregularities in the ordering of coefficients. Results for caregivers and the general population were about the same. CONCLUSIONS: The IQI is the first generic instrument to assess overall HRQoL in infants up to 1 year of age. It is short and easy to administer through a mobile application. We demonstrated how to derive values for infant health states with a discrete choice methodology. Our next step will be to normalize these values into utilities ranging from 0 (dead) to 1 (best health state) and to collect IQI values in a clinical population.

Patient-Centered Item Selection for a New Preference-Based Generic Health Status Instrument: CS-Base.

OBJECTIVES: To develop patient-centered health content for a novel generic instrument (Château Santé Base [CS-Base]) that is suitable to generate values for health status. METHODS: Candidate items were drawn from existing health frameworks of generic health status instruments and placed in a diagram (HealthFANTM, Zeist, the Netherlands). Through an online survey, patients with a wide range of diseases were asked to select the 9 items that were most important to them. The importance of the items for the whole study group was determined by means of frequency distributions. RESULTS: After handling duplicates and overlap, the remaining set of 47 items was placed in the HealthFAN. Among the 2256 Dutch patients who started the survey, the most common diagnoses were neck and back pain, diabetes, and asthma/chronic obstructive pulmonary disease. The 5 health items mentioned most frequently as most important were pain, personal relationships, fatigue, memory, and vision. Hearing and vision, anxiety and depression, and independence and self-esteem seemed highly intertwined, so we chose to pair these items. CONCLUSIONS: A total of 12 health items were included in CS-Base. Its content is largely based on patient input and enables classification of patients' health status. CS-Base can be administered by means of an app on a mobile phone, which makes it a convenient and attractive tool for patients and researchers.

Health-related quality of life in Indonesian type 2 diabetes mellitus outpatients measured with the Bahasa version of EQ-5D.

OBJECTIVES: To present EuroQol-5D (EQ-5D) index scores in Indonesian type 2 diabetes mellitus (T2DM) outpatients and to investigate the associations between EQ-5D and socio-demographic characteristics and clinical condition. METHODS: Socio-demographic data were collected by interviewing participants, clinical data were obtained from treating physicians and self-reporting. Participants originated from primary and secondary care facilities in the Java and Sulawesi regions. Ordinal regression analysis was conducted with the quintiles of the EQ-5D index scores as the dependent variable to investigate the multivariate association with the participants' socio-demographic characteristics and clinical condition. RESULTS: 907 participants completed the five-level Indonesian version of the EQ-5D. The mean age of the participants was 59.3 (SD 9.7), and 57% were female. The overall EQ-5D index score was 0.77 (0.75-0.79). Male participants had a higher EQ-5D index score compared to females, and the highest percentage of self-reported health problems was in the pain/discomfort dimension (61%). Factors identified as being significantly associated with lower EQ-5D index scores were: (i) treatment in secondary care, (ii) lower educational level, (iii) dependency on caregivers, (iv) not undergoing T2DM therapy, and (v) being a housewife. CONCLUSION: This study provides estimates of EQ-5D index scores that can be used in health economic evaluations. As housewives were found to experience more T2DM-related pain/discomfort and anxiety/depression, targeted approaches to reduce these problems should be aimed specifically at this group of patients. Potential approaches could involve disease-specific-counselors (health literacy partners) who provide routine monitoring of T2DM therapy as well as improved health promotion among T2DM communities.

Evaluation of the psychometric properties of the endoscopic endonasal sinus and skull base surgery questionnaire (EES-Q) in a prospective cohort study.

OBJECTIVES: The patients' perspective on health has become increasingly important when assessing treatment outcomes. Recently, the Endoscopic Endonasal Sinus and Skull Base Surgery Questionnaire (EES-Q) was developed to determine the impact of endoscopic endonasal surgery on health-related quality of life (HRQoL). The aim of this study was to evaluate the test-retest reliability, construct validity and responsiveness of the EES-Q. DESIGN: Prospective cohort study. SETTING: University Medical Center Groningen, tertiary referral hospital, the Netherlands. PARTICIPANTS: One hundred patients who underwent endoscopic endonasal surgery because of sinus or anterior skull base pathology. MAIN OUTCOME MEASURES: Test-retest reliability, construct validity and responsiveness. RESULTS: The EES-Q domains exhibited good test-retest reliability (ICC > 0.90). Construct validity was corroborated by significant positive and negative correlations between the EES-Q and the Sino-Nasal Outcome Test-22 (SNOT-22) and postoperative health status (P < 0.01) respectively. The correlation between the social EES-Q domain and the ability to move and perform usual activities (EuroQol-5D-3L [EQ-5D-3L]) was significant positive (P < 0.01). In patients with paranasal sinus pathology, the EES-Q was responsive to clinical change (Cohen's d = 0.6). CONCLUSION: The EES-Q is a reliable and acceptable responsive disease-specific HRQoL instrument. The expected construct validity of the EES-Q is supported by the results in this study. Inconveniences in social functioning had the greatest negative impact on postoperative health status rating. This reflects the importance of a multidimensional HRQoL assessment after EES. The results indicate that the EES-Q is a promising disease-specific tool for the HRQoL assessment after endoscopic endonasal sinus or anterior skull base surgery.

Does Inclusion of Interactions Result in Higher Precision of Estimated Health State Values?

BACKGROUND: Most preference-based instruments producing overall values for health states are devised on the simplifying assumption that the overall effect of distinct health-related quality of life domains (attributes) of the instrument equals the sum of the attributes. Nevertheless, health attributes are often inter-related and depend on each other. OBJECTIVES: To investigate whether inclusion of second-order interactions in the three-level EuroQol five-dimensional questionnaire (EQ-5D-3L) value function would result in better fit and lead to different health state values than a model with main effects only. METHODS: Using an efficient design, 400 pairs of EQ-5D-3L health states were generated in a pairwise choice format. We analyzed responses of 4000 people from the general population using a conditional logit model, and we tested goodness of fit using pseudo R2, Akaike information criterion, differences in log-likelihood, and likelihood ratio. We compared accuracies of models' predictions based on root mean square error and mean absolute error. RESULTS: The interaction-effects model showed systematically lower values than the main-effects model. Inclusion of interactions resulted only in a slightly better model fit. Interactions comprising mobility and self-care were the most salient. CONCLUSIONS: For the EQ-5D-3L, a value function based on interactions produces systematically lower values than a main-effects model, meaning that the effect of two or more health problems combined is stronger than the sum of the individual main effects.

A preference-based item response theory model to measure health: concept and mathematics of the multi-attribute preference response model.

BACKGROUND: A new patient-reported health measurement model has been developed to quantify descriptions of health states. Known as the multi-attribute preference response (MAPR) model, it is based on item response theory. The response task in the MAPR is for a patient to judge whether hypothetical health-state descriptions are better or worse than his/her own health status. METHODS: In its most simple form MAPR is a Rasch model where for each respondent on the same unidimensional health scale values are estimated of their own health status and values of the hypothetical comparator health states. These values reflect the quality or severity of the health states. Alternatively, the respondents are offered health-state descriptions that are based on a classification system (e.g., multi-attribute) with a fixed number of health attributes, each with a limited number of levels. In the latter variant, the weights of the levels of the attributes in the descriptive system, which represents the range of the health states, are estimated. The results of a small empirical study are presented to illustrate the procedures of the MAPR model and possible extensions of the model are discussed. RESULTS: The small study that we conducted to illustrate the procedure and results of our proposed method to measure the quality of health states and patients' own health status showed confirming results. CONCLUSIONS: This paper introduces the typical MAPR model and shows how it extends the basic Rasch model with a regression function for the attributes of the health-state classification system.

Value judgment of health interventions from different perspectives: arguments and criteria.

BACKGROUND: The healthcare sector is evolving while life expectancy is increasing. These trends put greater pressure on healthcare resources, prompt healthcare reforms, and demand transparent arguments and criteria to assess the overall value of health interventions. There is no consensus on the core criteria by which to value and prioritize interventions, and individual stakeholders might value specific elements differently. The present study is based on a literature review that retrieved the most widely recognized arguments and criteria used in decision-making. The aim was to compile a smaller set of arguments and criteria that would seem most relevant to different stakeholders. METHODS: A literature review was performed in Medline and EMBASE. The initial search retrieved over 2000 articles and documents of relevant committees. A selection was made based on their reference to healthcare, policy issues, or social justice. Finally, 84 papers were included. Data extraction took place after appraisal of the articles. A full table was made, including all arguments and criteria found; next, identical or largely overlapping arguments were excluded. The remaining arguments and criteria were assessed for relevance and a reduced set was compiled. RESULTS: The final set included 25 arguments and criteria, categorized by type (clinical, social justice, ethical, and policy). For each argument and criterion, relevance to stakeholders was scored on three levels (not, partly, and completely relevant). CONCLUSIONS: Many arguments and criteria play a role in making value judgments on health interventions, but not all are relevant to all interventions. Moreover, they may interact with each other. A viable way to deal with interacting and possibly conflicting arguments and criteria might be to arrange public discussions that would evoke different stakeholders' perspectives.

Measurement properties of the EQ-5D across four major geriatric conditions: Findings from TOPICS-MDS.

BACKGROUND: As populations age, chronic geriatric conditions linked to progressive organ failure jeopardize health-related quality of life (HRQoL). Thus, this research assessed the validity and applicability of the EQ-5D (a common HRQoL instrument) across four major chronic geriatric conditions: hearing issues, joint damage, urinary incontinence, or dizziness with falls. METHODS: The study sample comprised 25,637 community-dwelling persons aged 65 years and older residing in the Netherlands (Data source: TOPICS-MDS, www.topics-mds.eu ). Floor and ceiling effects were examined. To assess convergent validity, random effects meta-correlations (Spearman's rho) were derived between individual EQ-5D domains and related survey items. To further examine construct validity, the association between sociodemographic characteristics and EQ-5D summary scores were assessed using linear mixed models. Outcomes were compared to the overall study population as well as a 'healthy' subgroup reporting no major chronic conditions. RESULTS: Whereas ceiling effects were observed in the overall study population and the 'healthy' subgroup, such was not the case in the geriatric condition subgroups. The majority of hypotheses regarding correlations between survey items and sociodemographic associations were supported. EQ-5D summary scores were lower in respondents who were older, female, widowed/single, lower educated, and living alone. Increasing co-morbidity had a clear negative effect on EQ-5D scores. CONCLUSION: This study supported the construct validity of the EQ-5D across four major geriatric conditions. For older persons who are generally healthy, i.e. reporting few to no chronic conditions, the EQ-5D confers poor discriminative ability due to ceiling effects. Although the overall dataset initially suggested poor discriminative ability for the EQ-5D, such was not the case within subgroups presenting with major geriatric conditions.

A Simple and Practical Index to Measure Dementia-Related Quality of Life.

BACKGROUND: Research on new treatments for dementia is gaining pace worldwide in an effort to alleviate this growing health care problem. The optimal evaluation of such interventions, however, calls for a practical and credible patient-reported outcome measure. OBJECTIVES: To describe the refinement of the Dementia Quality-of-life Instrument (DQI) and present its revised version. METHODS: A prototype of the DQI was adapted to cover a broader range of health-related quality of life (HRQOL) and to improve consistency in the descriptions of its domains. A valuation study was then conducted to assign meaningful numbers to all DQI health states. Pairs of DQI states were presented to a sample of professionals working with people with dementia and a representative sample of the Dutch population. They had to repeatedly select the best DQI state, and their responses were statistically modeled to obtain values for each health state. RESULTS: In total, 207 professionals working with people with dementia and 631 members of the general population completed the paired comparison tasks. Statistically significant differences between the two samples were found for the domains of social functioning, mood, and memory. Severe problems with physical health and severe memory problems were deemed most important by the general population. In contrast, severe mood problems were considered most important by professionals working with people with dementia. DISCUSSION: The DQI is a simple and feasible measurement instrument that expresses the overall HRQOL of people suffering from dementia in a single meaningful number. Current results suggest that revisiting the discussion of using values from the general population might be warranted in the dementia context.

Understanding drug preferences, different perspectives.

AIMS: To compare the values regulators attach to different drug effects of oral antidiabetic drugs with those of doctors and patients. METHODS: We administered a 'discrete choice' survey to regulators, doctors and patients with type 2 diabetes in The Netherlands. Eighteen choice sets comparing two hypothetical oral antidiabetic drugs were constructed with varying drug effects on glycated haemoglobin, cardiovascular risk, bodyweight, duration of gastrointestinal complaints, frequency of hypoglycaemia and risk of bladder cancer. Responders were asked each time which drug they preferred. RESULTS: Fifty-two regulators, 175 doctors and 226 patients returned the survey. Multinomial conditional logit analyses showed that cardiovascular risk reduction was valued by regulators positively (odds ratio 1.98, 95% confidence interval 1.11-3.53), whereas drug choices were negatively affected by persistent gastrointestinal problems (odds ratio 0.24, 95% confidence interval 0.14-0.41) and cardiovascular risk increase (odds ratio 0.49, 95% confidence interval 0.27-0.87). Doctors and patients valued these effects in a similar manner to regulators. The values that doctors attached to large changes in glycated haemoglobin and that both doctors and patients attached to hypoglycaemia and weight gain also reached statistical significance. No group's drug choice was affected by a small absolute change in risk of bladder cancer when presented in the context of other drug effects. When comparing the groups, the value attached by regulators to less frequent hypoglycaemic episodes was significantly smaller than by patients (P = 0.044). CONCLUSIONS: Regulators may value major benefits and risks of drugs for an individual diabetes patient mostly in the same way as doctors and patients, but differences may exist regarding the value of minor or short-term drug effects.

Do individuals with and without depression value depression differently? And if so, why?

PURPOSE: Health state valuations, used to evaluate the effectiveness of healthcare interventions, can be obtained either by the patients or by the general population. The general population seems to value somatic conditions more negatively than patients, but little is known about valuations of psychological conditions. This study examined whether individuals with and without depression differ in their valuations of depression and whether perceptions regarding depression (empathy, perceived susceptibility, stigma, illness perceptions) and individual characteristics (mastery, self-compassion, dysfunctional attitudes) bias valuations of either individuals with or without depression. METHODS: In an online study, a general population sample used a time-trade-off task to value 30 vignettes describing depression states (four per participant) and completed questionnaires on perceptions regarding depression and individual characteristics. Participants were assigned to depression groups (with or without depression), based on the PHQ-9. A generalized linear mixed model was used to assess discrepancies in valuations and identify their determinants. RESULTS: The sample (N = 1268) was representative of the Dutch population on age, gender, education and residence. We found that for mild depression states, individuals with depression (N = 200) valued depression more negatively than individuals without depression (N = 1068) (p = .007). Variables related to perceptions of depression and individual characteristics were not found to affect valuations of either individuals with or individuals without depression. CONCLUSION: Since the general population values depression less negatively, using their perspective might result in less effectiveness for interventions for mild depression. Perceptions of depression or to individual characteristics did not seem to differentially affect valuations made by either individuals with or without depression.

Motives of Dutch persons aged 50 years and older to accept vaccination: a qualitative study.

BACKGROUND: Elderly in several European countries are currently being vaccinated against influenza and pneumococcal disease, and various reasons have been put forward to expand these programs. To successfully immunize the older adult population, however, it is crucial for the target group to accept such interventions. This study aims to elucidate the motives of Dutch persons aged ≥ 50 years for accepting vaccination. METHODS: Thirteen focus groups were composed with persons aged 50 years and older. A semi-structured topic list with open-ended questions was used to guide the focus groups. The transcripts were analyzed according the principles of thematic survey. By an inductive process, the main themes and related subthemes were extracted from the responses. RESULTS: Eight themes were found to play an important role in accepting vaccination: healthy aging; usefulness of vaccination in older age; risk of getting an infectious disease; vaccine characteristics; severity of the disease and its implications; the experiences of previous vaccinations; the influence of healthcare workers and other people; and the need for information. CONCLUSIONS: This qualitative study reveals that acceptance of vaccination is not based on a single argument. The most important one appears to be the risk of getting an infectious disease. In that light, vaccination campaigns may emphasize the susceptibility of older adults. It is also advisable to consider the usefulness of vaccination in older age as an overall argument. A tailored approach to offering vaccination may be considered. Further research would be needed to determine the relative importance of the factors identified in this study.

Attitudes of Dutch general practitioners towards vaccinating the elderly: less is more?

BACKGROUND: In many European countries, vaccinations are offered to the elderly. Expanding the programme to include routine vaccination against pneumococcal disease, herpes zoster, and pertussis, for example, could reduce disease burden amongst the growing population of persons aged 50 years and older. Since most countries involve general practitioners (GPs) in the programmes, the potential success of such new vaccinations depends on the attitude of GPs towards these vaccinations. This qualitative study explores Dutch GPs' attitudes regarding vaccination in general, and their attitudes regarding the incorporation of additional vaccines in the current Dutch influenza vaccination programme. METHODS: Interviews were held with ten Dutch GPs (five men and five women) that worked either in an academic hospital, in a practice based in a health center, or in individual practice. All interviews were recorded with a digital voice recorder and transcribed verbatim. Transcripts were analysed according to thematic analysis. RESULTS: GPs perceived prevention as part as their job and believed vaccination to be effective for preventing infectious diseases. However, influenza vaccination was not always perceived as effective. Doubts regarding the usefulness of additional vaccinations were identified. If additional vaccines would be offered, this should be based on scientific evidence and the severity of the infectious disease. Selection of patients for vaccination should not be based solely on age, but more on risk factors. The GP should be the central point of contact for new vaccination campaigns; however, high workload was seen as a concern. Several GPs questioned their ability to refuse to distribute the vaccinations. CONCLUSIONS: A positive attitude towards implementing additional vaccinations is not apparent. Achieving the most health benefits seems to be the most important consideration of Dutch GPs regarding vaccinating older adults. Questions regarding the usefulness of vaccinating older adults should be taken into consideration. More research is necessary to confirm the results among a wider range of Dutch GPs.