Estimating Cost-Effectiveness Using Alternative Preference-Based Scores and Within-Trial Methods: Exploring the Dynamics of the Quality-Adjusted Life-Year Using the EQ-5D 5-Level Version and Recovering Quality of Life Utility Index

ObjectivesThis study aimed to explore quality-adjusted life-year (QALY) and subsequent cost-effectiveness estimates based on the more physical health–focused EQ-5D 5-level version (EQ-5D-5L) value set for England or cross-walked EQ-5D 3-level version UK value set scores or more mental health recovery-focused Recovering Quality of Life Utility Index (ReQoL-UI), when using alternative within-trial statistical methods. We describe possible reasons for the different QALY estimates based on the interaction between item scores, health state profiles, preference-based scores, and mathematical and statistical methods chosen.MethodsQALYs are calculated over 8 weeks from a case study 2:1 (intervention:control) randomized controlled trial in patients with anxiety or depression. Complete case and with missing cases imputed using multiple-imputation analyses are conducted, using unadjusted and regression baseline-adjusted QALYs. Cost-effectiveness is judged using incremental cost-effectiveness ratios and acceptability curves. We use previously established psychometric results to reflect on estimated QALYs.ResultsA total of 361 people (241:120) were randomized. EQ-5D-5L crosswalk produced higher incremental QALYs than the value set for England or ReQoL-UI, which produced similar unadjusted QALYs, but contrasting baseline-adjusted QALYs. Probability of cost-effectiveness <£30 000 per QALY ranged from 6% (complete case ReQoL-UI baseline-adjusted QALYs) to 64.3% (multiple-imputation EQ-5D-5L crosswalk unadjusted QALYs). The control arm improved more on average than the intervention arm on the ReQoL-UI, a result not mirrored on the EQ-5D-5L nor condition-specific (Patient-Health Questionnaire-9, depression; Generalized Anxiety Disorder-7, anxiety) measures.ConclusionsReQoL-UI produced contradictory cost-effectiveness results relative to the EQ-5D-5L. The EQ-5D-5L’s better responsiveness and “anxiety/depression” and “usual activities” items drove the incremental QALY results. The ReQoL-UI’s single physical health item and “personal recovery” construct may have influenced its lower 8-week incremental QALY estimates in this patient sample.     

Frequency of blood lactate elevation following esophagectomy and its association to postoperative complications

Background

Esophagectomy is a major surgical intervention and a cornerstone in the treatment of esophageal cancer. There is clinical experience that blood lactate concentration often is elevated in the period following esophagectomy, but the incidence and clinical consequences are sparsely studied.

Methods

We extracted data from all patients undergoing esophagectomy at Karolinska University Hospital 2016–2018, n = 153. Most were performed with minimally invasive technique, n = 130. Blood lactate values directly after surgery, highest value during the first night, and morning level on postoperative day one were recorded. Primary outcome was hospital length of stay and secondary outcome was a composite of postoperative infection, additional surgery, or intensive care during the hospital stay. Development of anastomotic leak was analyzed separately.

Results

Postoperative hyperlactatemia was common as 93% of patients had peak lactate concentration >1.6 mmol/L and 27% >3.5 mmol/L in the first night following operation. Median hospital length of stay was 14 days. Blood lactate showed a weak correlation to hospital stay and intensive care the morning following surgery, but not at arrival to postoperative ward. There were no statistical differences between those with and without anastomotic leak at any of the time points. Elevated lactate in the first 12–16 h postoperatively was related to surgical factors (open technique, surgery time, and perioperative bleeding) but not to patient related factors (ASA-class, Charlson comorbidity index, sex, age) or cumulative fluid balance.

Conclusion

In conclusion, elevated blood lactate in the immediate time following esophagectomy showed a weak association to intensive care and length of stay but not anastomotic leak.     

Validation of an on-screen application-based measurement of shoulder range of motion over telehealth medium

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飞秒激光辅助超声乳化联合Ahmed青光眼引流阀植入术治疗合并难治性青光眼的白内障

目的：评估飞秒激光辅助超声乳化联合Ahmed青光眼引流阀植入术治疗合并难治性青光眼的白内障的有效性和安全性。

方法：回顾性病例对照研究。2019-10/2021-10入院合并难治性青光眼的白内障患者53例53眼，依据自愿选择分为飞秒激光辅助白内障超声乳化(FLACS)组26例26眼和常规白内障超声乳化(CPCS)组27例27眼。两组分别行FLACS和CPCS联合Ahmed青光眼引流阀植入术。比较两组患者术中超声乳化能量释放量(CDE)、有效超声时间(EPT)的差异和术前与术后抗青光眼药物数量的变化，以及术后观察不同时期(1d，1wk，1、3mo)在提高最佳矫正视力(BCVA)，降低眼压、角膜内皮细胞损伤程度和手术并发症及成功率状况。

结果：FLACS组术中CDE和EPT明显低于CPCS组(t=8.50、5.16； P<0.01、=0.001)。两组术后抗青光眼药物较术前均明显减少(t=9.12、7.76； P=0.011、0.016)，但两组间无差异(t=1.79，P=0.082)。两组术后BCVA均较术前改善，眼压均较术前降低(P<0.05)。FLACS组在术后早期(1d，1wk)BCVA的改善较CPCS组更显著(t=9.74、8.49； P=0.008、0.012)，但在术后1、3mo的BCVA改善程度并无不同(t=0.62、0.44； P=1.415、2.021)。CPCS组在术后随访不同时期的角膜内皮细胞损伤较FLACS组更明显(P<0.05)。术后随访的不同时期FLACS组和CPCS组在控制眼压方面无差异(F_组间=0.64，P_组间=0.421)。FLACS组的手术并发症发生率27%(7/26)较CPCS组89%(24/27)低(χ²=20.95，P<0.01)，其中角膜水肿(8% vs 41%)、前囊撕裂(0 vs 11%)在FLACS组中明显低于CPCS组，后囊破裂(0 vs 7%)、玻璃体脱出(0 vs 4%)及人工晶状体偏位(0 vs 7%)也均发生在CPCS组。但两组的治疗总成功率相近(P=28.718)。

结论：飞秒激光辅助超声乳化联合Ahmed青光眼引流阀植入术可充分发挥联合手术的精准微创可控优势，帮助合并难治性青光眼的白内障患者有效降低眼压及更早获得视力恢复。