The History and Future of the “ISPOR Value Flower”: Addressing Limitations of Conventional Cost-Effectiveness Analysis

ObjectivesSince its publication as part of the 2018 ISPOR Special Task Force (STF) on US Value Assessments, the “ISPOR value flower,” with its petals highlighting elements that may be overlooked or underappreciated in conventional drug value assessments, has been discussed and debated. We review the history of the value flower, describe recent developments, and consider implications for future value assessments.MethodsWe discuss various antecedents to the value flower, as well as conceptual and empirical articles published in the past 4 years.ResultsSince the publication of the ISPOR STF report, researchers have provided more rigorous theoretical and mathematical foundations for certain novel value elements (eg, severity of illness, value of insurance, value of hope) through “generalized risk-adjusted cost-effectiveness analysis,” which incorporates risk aversion in people’s preferences and uncertainty in treatment outcomes. Empirical estimates are also emerging to support key elements, such as insurance value, real option value, value of hope, and value of knowing. Although health technology assessment bodies have applied or are considering certain elements (eg, severity modifiers to cost-effectiveness thresholds), other elements have yet to gain traction.ConclusionsFive years after the STF began its work, the development of novel value measures continues to evolve. Although it is encouraging to see supporting empirical studies emerging, more are needed. Additional efforts are also needed to illustrate how the estimates can be used in the deliberative processes that are integral to health technology assessments.     

Development of an EQ-5D Value Set for India Using an Extended Design (DEVINE) Study: The Indian 5-Level Version EQ-5D Value Set

ObjectivesThis study aimed to develop the Indian 5-level version EQ-5D (EQ-5D-5L) value set, which is a key input in health technology assessment for resource allocation in healthcare.MethodsA cross-sectional survey using the EuroQol Group’s Valuation Technology was undertaken in a representative sample of 3548 adult respondents, selected from 5 different states of India using a multistage stratified random sampling technique. The participants were interviewed using a computer-assisted personal interviewing technique. This study adopted a novel extended EuroQol Group’s Valuation Technology design that included 18 blocks of 10 composite time trade-off (c-TTO) tasks, comprising 150 unique health states, and 36 blocks of 7 discrete choice experiment (DCE) tasks, comprising 252 DCE pairs. Different models were explored for their predictive performance. Hybrid modeling approach using both c-TTO and DCE data was used to estimate the value set.ResultsA total of 2409 interviews were included in the analysis. The hybrid heteroscedastic model with censoring at ?1 combining c-TTO and DCE data yielded the most consistent results and was used for the generation of the value set. The predicted values for all 3125 health states ranged from ?0.923 to 1. The preference values were most affected by the pain/discomfort dimension.ConclusionsThis is the largest EQ-5D-5L valuation study conducted so far in the world. The Indian EQ-5D-5L value set will promote the effective conduct of health technology assessment studies in India, thereby generating credible evidence for efficient resource use in healthcare.     

政策反馈理论视域：中国医疗卫生政策钟摆式变迁及其逻辑

新中国成立以来,党和国家不断强化医疗卫生建设,70余年来医疗卫生政策演进呈钟摆式变迁的特征,即从公益导向的福利性医疗卫生政策摆向效率导向的市场化政策,再摆向公益为主兼顾效率的民生导向政策,在公益与效率间发生三次摆动。本文借助政策反馈理论分析医疗卫生政策钟摆式变迁的内在逻辑,发现政策变迁过程中原有政策通过资源效应、解释效应、演化效应和学习效应影响新政策的制定,使得新政策留有原政策的烙印,呈现出摆动式变迁而非剧烈或范式变迁。政策反馈理论为医疗卫生政策制定提供新视角,制定医疗卫生政策需注重原政策的历史影响力,以公共价值引领医疗医保医药政策,从多重政策反馈效应视角出发优化卫生政策的制定。     

雌孕激素序贯用药治疗流产术后宫腔残留患者的临床价值分析

目的分析雌孕激素序贯用药治疗流产术后宫腔残留患者的临床价值。方法选取2017年1月至2019年12月我站收治的人工流产患者60例,按治疗方式不同分为对照组(28例)和观察组(32例)。对照组采用刮宫治疗,观察组于人工流产术后第7 d行B超检查,观察宫腔残留情况后采用药物治疗。比较两组的临床疗效、并发症。结果两组的总有效率比较无统计学差异(P>0.05)。观察组的腹痛发生率低于对照组,出血时间短于对照组(P <0.05)。结论雌孕激素序贯用药治疗能够有效清除宫腔残留,缩短出血时间,减轻腹痛,有利于重新建立正常的月经周期,促进子宫功能修复,避免再次刮宫对子宫内膜的损伤及手术对患者造成的不良身心应激,具有较高的临床推广价值。     

肿瘤M2型丙酮酸激酶检测在结肠癌诊断中的临床价值

目的探究肿瘤M2型丙酮酸激酶检测在结肠癌诊断中的临床价值。方法选取本院经病理诊断确诊为结肠癌的50例患者与结肠腺瘤的60例患者分别设为结肠癌组与结肠腺瘤组,选择90例健康人设为正常组,分别使用ELISA、化学发光法(CL)检测血浆M2-PK数值及癌胚抗原(CEA)水平。结果结肠癌组及Dukes C、D期肿瘤M2-PK水平与结肠腺瘤组、正常组及Dukes A、B期相比更高(P<0.05),肿瘤M2-PK结肠癌诊断敏感性与CEA相比更高。结论肿瘤M2型丙酮酸激酶检测在结肠癌诊断中具有较高的临床价值,且肿瘤M2-PK的敏感性高于CEA,与肿瘤分期之间具有十分密切的联系,能够有效应用于结肠癌的筛查与诊断工作当中。     

医疗绩效管理中实施PDCA循环的效果分析

目的对比分析实施PDCA循环前后医疗绩效管理的效果。方法医院每季度进行一次绩效管理考核,分为核心制度、病历质量、用药情况、耗材情况和医疗效率5个维度。2019年第一季度绩效管理开始引入PDCA循环,以第一季度各维度得分作为基础值,对比分析引入PDCA循环前后各维度得分,以手术科室为例,进行统计分析。结果核心制度、病历质量、耗材情况维度得分比较,均P<0.05,差异具有统计学意义;用药情况、医疗效率维度得分比较,均P>0.05,但各季度得分相比基础值均逐渐升高,第四季度与基础值比较差异具有统计学意义(P<0.05)。结论医疗绩效管理中实施PDCA循环,能有效提升管理水平,促进医疗质量螺旋上升。     

Smoking Cessation and Quality of Life: Insights From Analysis of Longitudinal Australian Data,an Application for Economic Evaluations

ObjectivesA number of studies have shown an association between smoking habit and quality of life, but these have mainly involved cross-sectional data. This study takes advantage of longitudinal panel data to estimate the effect of the transition from “smoker” to “ex-smoker” status (smoking cessation) on health-related quality of life (HRQoL), measured by SF-36, in an Australian general population sample.MethodsPanel data from 13 waves (2001-2013) of a nationally representative longitudinal survey of Household Income and Labour Dynamics of Australia (HILDA) were used; 1858 respondents (5% of total HILDA sample) who experienced only 1 cessation event in their HILDA life were selected. HRQoL trajectories elicited by SF-36 (0-100 scale, worst to best health) were modeled before and after cessation events using a piecewise (segmented) 2-way fixed-effect linear regression, adopted to capture within-person differences. This enabled measurement of changes of regression slopes and intercept while controlling time-invariant characteristics (eg, country of birth, gender) and time-varying changes in health status.ResultsAnnual pre-post intervention improvements were estimated for the following dimensions: role physical 0.65 (95% CI 0.62-1.24), bodily pain 0.48 (95% CI 0.10-0.86), general health 0.55 (95% CI 0.2-0.9), and the physical component summary score 0.22 (95% CI 0.01-0.04). Immediate effects (discontinuity at the time of cessation) of smoking cessation existed for bodily pain –1.5 (95% CI –2.52 to –0.40) and general health 1.82 (95% CI 1.01-2.62). The effects for mental health domains were not significant.ConclusionsAdjusting for all unmeasured time-invariant confounders and controlling the effect of time, this study revealed the varied effects of smoking cessation on HRQoL; it has positive effect on physical and general health but nonsignificant effect on mental aspects. Preference-based utility measures based on SF-6D capture changes that can be measured in several of the domains of the SF-36.     

Toward Better Data Dashboards for US Drug Value Assessments

ObjectivesTo explore the use of data dashboards to convey information about a drug’s value, and reduce the need to collapse dimensions of value to a single measure.MethodsReview of the literature on US Drug Value Assessment Frameworks, and discussion of the value of data dashboards to improve the manner in which information on value is displayed.ResultsThe incremental cost per quality-adjusted life-year ratio is a useful starting point for conversation about a drug’s value, but it cannot reflect all of the elements of value about which different audiences care deeply. Data dashboards for drug value assessments can draw from other contexts. Decision makers should be presented with well-designed value dashboards containing various metrics, including conventional cost per quality-adjusted life-year ratios as well as measures of a drug’s impact on clinical and patient-centric outcomes, and on budgetary and distributional consequences, to convey a drug’s value along different dimensions.ConclusionsThe advent of US drug value frameworks in health care has forced a concomitant effort to develop appropriate information displays. Researchers should formally test different formats and elements.     

微酸性电解水实验室微生物杀灭效果研究

 目的 研究某微酸性电解水实验室微生物杀灭效果。方法 选取某次氯酸水发生器现制微酸性电解水,测定不同有效氯含量、不同作用时间其对细菌繁殖体、芽孢以及真菌的杀灭效果。结果 该微酸性电解水有效氯含量为34.3~118 mg/L,有机干扰物牛血清白蛋白浓度为3.0%和0.3%时,分别作用1.0、3.0、5.0、10.0 min,对金黄色葡萄球菌、大肠埃希菌、铜绿假单胞菌的平均杀灭对数值均>5.00,对白假丝酵母菌的平均杀灭对数值均>4.00;有效氯含量为101~118 mg/L,牛血清白蛋白浓度为0.3%时,分别作用5.0、10.0、30.0 min,对枯草杆菌黑色变种芽孢的平均杀灭对数值均>5.00。结论 在特定实验条件下,该微酸性电解水对细菌的繁殖体、芽孢以及真菌均达到消毒剂消毒合格标准。     

脊柱术后感染病原菌及CD64和中性粒细胞百分比的早期预测价值

目的分析脊柱术后医院感染患者病原菌分布特征及中性粒细胞64(CD64)和中性粒细胞百分比(NEU%)表达情况。方法选取2017年6月-2019年6月天津市天津医院收治的脊柱术后医院感染患者51例为感染组,并选取同期于医院就诊的脊柱术后未发生感染患者51例为未感染组。分析感染组患者病原菌情况,检测患者NEU和CD64水平;ROC曲线分析CD64和NEU%指标水平预测感染的诊断价值。结果 51例感染患者共培养分离病原菌78株,其中革兰阴性菌42株(53.85%)、革兰阳性菌33株(42.31%)、真菌3株(3.85%),以铜绿假单胞菌及金黄色葡萄球菌为主。术后7 d,感染组体温、WBC、中性粒细胞计数、CRP、ESR分别为(38.47±0.52)℃、(8.34±2.17)×109/L、(5.98±1.94)×109/L、(54.52±19.93)mg/L、(51.74±21.88)mm/h均高于非感染组(P<0.05)。术后7 d,感染组CD64、NEU%分别为(8.87±2.13)%、(84.93±13.39)高于非感染组(P<0.05)。CD64指数与NEU%水平诊断ROC曲线下面积分别为0.922、0.826。结论脊柱术后医院感染以革兰阴性菌为主,CD64及NEU%水平有助于脊柱术后医院感染的早期诊断。