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Background Previous studies have summarized evidence on health-related quality of life for older people, identifying a range of measures that have been validated, but have not sought to present results by degree of frailty. Furthermore, previous studies did not typically use quality-of-life measures that generate an overall health utility score. Health utility scores are a necessary component of quality-adjusted life-year calculations used to estimate the cost-effectiveness of interventions. Methods We calculated normative estimates in mean and standard deviation for EQ-5D-5L, short-form 36-item health questionnaire in frailty (SF-36), and short-form 6-dimension (SF-6D) for a range of established frailty models. We compared response distributions across dimensions of the measures and investigated agreement using Bland-Altman and interclass correlation techniques. Results The EQ-5D-5L, SF-36, and SF-6D scores decrease and their variability increases with advancing frailty. There is strong agreement between the EQ-5D-5L and SF-6D across the spectrum of frailty. Agreement is lower for people who are most frail, indicating that different components of the 2 instruments may have greater relevance for people with advancing frailty in later life. There is a greater risk of ceiling effects using the EQ-5D-5L rather than the SF-6D. Conclusions We recommend the SF-36/SF-6D as an appropriate measure of health-related quality of life for clinical trials if fit older people are the planned target. In trials of interventions involving older people with increasing frailty, we recommend that both the EQ-5D-5L and SF36/SF6D are included, and are used in sensitivity analyses as part of cost-effectiveness evaluation.

The level and distribution of patient waiting times for elective treatment are a major concern in publicly funded health care systems. Strict targets, which have specified maximum waiting times, have been introduced in the NHS over the last decade and have been criticised for distorting existing clinical priorities in scheduling hospital treatment. We demonstrate the usefulness of conditional density estimation (CDE) in the evaluation of the reform using data for Scotland for 2002 and 2007. We develop a modified goodness of fit test to discriminate between models with different numbers of bins. We document a change in prioritisation between different patient groups with longer waiting patients benefiting at the expense of those who previously waited less. Our results contribute to understanding the response of publicly funded health systems to enforced targets for maximum waiting times.

The main challenge for patients and payers is the principal–agent problem caused by the asymmetry of information on the provider's efforts. This is particularly acute in the case of quality. The agent must specify incentives for providers to deliver quality and can do so using various forms of comparative performance evaluation. A key choice is the comparator, which could be the agent's own historical performance or the historical or contemporaneous performance of other agents. In practice, payers have steadily increased their use of comparative performance evaluation. Initially this focused on appealing to intrinsic motivation. Later attempts to link comparative performance evaluation to financial incentives have highlighted the uncertainties of the evidence base.