Press releases Monday 20 July to Friday 24 July 2009
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(1) Serious concerns over methods used to allocate scarce healthcare resources
(2) Repeated verbal encouragement fails to increase physical activity after stroke
(3) Camera phones can help doctors diagnose uncommon problems
(1) Serious concerns over methods used to allocate scarce healthcare resources
(Research: Comparison of direct and indirect methods of estimating health state utilities for resource allocation: review and empirical analysis)
http://www.bmj.com/cgi/doi/10.1136/bmj.b2688
(Analysis: Valuing health directly)
http://www.bmj.com/cgi/doi/10.1136/bmj.b2577
Two papers published on bmj.com today raise serious concerns over the methods used to put a value on the benefits of different treatments in order to set healthcare priorities.
Most rationing decisions are based on what people think they might feel rather than the experiences of people with real diseases. Both papers show that these two approaches provide very different results.
To make resource allocation decisions, health economists and policy makers use utility values for different conditions or health states. This approach assigns a value between 0 (for death) and 1 (for full health) to each condition or health state and then multiplies that value by how long the state lasts.
Measuring such values is not straightforward and can be controversial but, broadly speaking, there are two groups of methods. The first is to obtain the values directly (usually from patients), and the second, which is used more often, obtains them indirectly by using a quality of life questionnaire, the results of which are converted to utilities using "weights" (tariffs) obtained from the general public.
In the first paper, researchers at the Universities of Birmingham and Cardiff analysed 32 studies, involving 4,688 respondents, which compared direct and indirect methods for a wide range of diseases.
Each study was classified according to whether the respondents were "current patients" (with direct experience of a certain condition) or "hypothetical patients" (asked to imagine the experience of the condition).
They found that indirect methods produce consistently lower utilities (worse recorded health) than the direct group of methods. As such, they warn that any reliance on indirect methods will result in fewer resources being allocated to life saving treatments than if direct methods were used. Because direct and indirect methods can lead to such noticeable differences in elicited utilities, the authors conclude that priority setting institutions should avoid using a mixture of methods for different decisions. In the second paper, Paul Dolan and colleagues from Imperial College London look at how the National Institute for Health and Clinical Excellence (NICE) values health.
NICE values health in terms of gains in quality adjusted life years (QALYs). To measure these values, NICE advocates methods that ask members of the general public to think about how many years of life they would be willing to trade to avoid different states of health.
But the authors argue that these hypothetical preferences often bear little relation to the real experiences of those who have the condition.
They propose an alternative approach - measuring subjective well-being - to help direct resources to treatments in proportion to the real suffering they alleviate.
Measuring subjective well-being in this way involves asking those directly affected by a condition (parents, carers, relatives etc) to rate their daily moods and overall life satisfaction. This information is then analysed with other factors known to be linked with subjective well-being, such as income and marital status.
Most of us recognise that NICE has to take account of quality of life and length of life gains when judging the relative cost effectiveness of different interventions, say the authors. Subjective well-being provides us with a means of valuing the real reduction in suffering that health technologies bring in the wider context and experience of people's lives.
Contacts:
Richard Lilford, Professor of Clinical Epidemiology, School of Health and Population Sciences, University of Birmingham, UK
Email: r.j.lilford@bham.ac.uk
Paul Dolan, Professor of Economics, Imperial College Business School, London, UK
Email: paul.dolan@imperial.ac.uk
Repeated encouragement and verbal instruction do not motivate stroke survivors to be physically active, and other more intensive strategies need to be found, concludes a study published on bmj.com today.
It is well known that even moderate physical activity can reduce the risk of cardiovascular disease and first stroke and physical exercise is also recommended for stroke survivors. Counselling on physical activity can motivate some elderly sedentary people to improve their level of physical activity, and previous studies have shown that physical activity can improve balance, walking ability and fitness in stroke patients.
But little is known about which interventions to promote physical activity in stroke survivors are effective.
So Professor Gudrun Boysen and her team carried out a randomised trial to examine if the low-cost intervention of repeated encouragement and verbal instructions on how to exercise could persuade stroke patients to be more physically active in the long-term.
They recruited 314 stroke patients aged 40 years or older from four stroke centres in Denmark, China, Poland, and Estonia and randomised them to receive either an instructed training programme from a physiotherapist to promote physical activity prior to discharge and at six follow-up visits, or to follow-up visits with no instructions about physical activity.
Levels of physical activity were measured using the Physical Activity Scale for the Elderly (PASE) including walking, light sport, housework and working. A higher score represented a higher level of activity.
Findings showed that repeated encouragement and verbal instruction did not result in a measurable increase in physical activity. Mean PASE scores were 69.1 in the intervention group and 64.0 in the control group. In addition, the intervention had no significant effect on death, recurrent stroke, heart attacks, or falls or fractures.
Our results show that stroke patients are: "Inclined to low levels of physical activity - and more intensive strategies seem to be needed to promote physical activity after ischaemic stroke," conclude the authors.
Contact:
Professor Gudrun Boysen, Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
Email: gb01@bbh.regionh.dk
Taking photographs or video of unusual symptoms on an ordinary camera phone can help doctors diagnose uncommon problems, say researchers in an article published on bmj.com today.
For example, doctors in Norway describe the case of a 25 year old pregnant woman who reported frequent episodes of severe nipple pain.
The pain came whenever her fingers, toes or nipples got cold, such as when walking barefoot on a cold floor or taking a shower, and typically lasted between five and 15 minutes and was so painful as to bring her to tears.
Along with the pain, the colour of the nipples also changed; first white combined with a tingling pain ("tightening a vice screw"), then blue with a burning pain ("pouring acid"), and finally a red phase combined with numbness as the pain decreased. After the birth of her baby, the pain became so intense that she considered giving up breastfeeding.
She presented three photographs from her camera phone showing the colour changes of a typical episode.
With the help of these photographs, doctors diagnosed Raynaud's phenomenon of the nipple. The patient was given treatment, her symptoms completely resolved within one week, and she was able to continue breastfeeding with no side effects.
Raynaud's phenomenon is possibly an underdiagnosed case of nipple pain, conclude the authors, partly because primary health care workers are often not aware of this condition, and partly because the symptoms have vanished before the patient reaches the GP surgery.
Contact:
Oddgeir Holmen, Foundation House Officer, Department of Obstetrics and Gynecology, St Olav's University Hospital, Trondheim, Norway
Email: oddgeir.lingaas.holmen@gmail.com
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