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Introduction: Coverage decisions in publicly funded healthcare systems require a formal, systematic and transparent assessment process for policies related to distribution of resources. The process is complex and employs multiple types of information, such as clinical effectiveness, costs and health utility scores which are used to produce quality-adjusted life years. The purpose of this study was to create health utility scores for CKD patients within the Canadian population. Methods: This is a cross-sectional study of CKD patients. We administered the Short-Form 36 Quality of Life Questions to all participants and employed the Short-Form 6 Dimension index to create health utility scores which were created using a set of parametric preference weights, nonparametric preference weights and ordinal health state valuation techniques obtained from a sample of the general population. Results: Utility values in the dialysis group were lower than in the non-dialysis group. There was a significant relationship between age and health utility scores: As age increases, health utility scores decrease. Diabetes was associated with lower health utility scores in dialysis patients, whereas other covariates did not reach levels of statistical significance in our stepwise regression models. The parametric Bayesian model and standard gamble approach yielded the same results, while the correlation between the nonparametric and parametric methods was above 0.9. Conclusion: Health utility scores were low relative to the general population norm in our study cohort. Longitudinal assessment of CKD patients to capture possible fluctuations in health utility scores may add useful information. [ABSTRACT FROM AUTHOR]

Background: Pulmonary vein isolation (PVI) forms the basis of catheter ablation strategies for atrial fibrillation (AF). Ablation of additional sites has been used to increase the efficacy of ablation procedures in restoring and maintaining normal sinus rhythm. Objective: The aim of this paper was to compare the effectiveness of PVI versus PVI plus adjuvant atrial ablations (PVI+) in patients with AF. Methods: A systematic search using bibliographic databases and gray literature was undertaken. Randomized and non-randomized controlled trials evaluating clinical efficacy, effectiveness, or safety of ablation procedures in adults with AF were included in this review. Results: Of 3,204 potential citations identified by the original search, 21 randomized controlled trials and three non-randomized trials were included. Meta-analysis results reveal that in the first year after ablation, AF patients who underwent PVI+ strategies had a significantly higher rate of maintaining sinus rhythm than those who underwent PVI alone (RR 1.10, 95 % CI 1.02, 1.17). However, a subgroup meta-analysis was statistically significant for only PVI+ left atrial (LA) linear ablations (RR 1.16, 95 % CI 1.04, 1.29). The pooled success rates were higher in PVI+ group for both paroxysmal (RR 1.14, 95 % CI 1.06, 1.24) and non-paroxysmal AF (RR 1.53, 95 % CI 1.10, 2.14). Conclusion: PVI+ strategies, particularly PVI+ LA ablations, appear to result in higher success rates than PVI alone in the first year after the procedure. Studies of longer duration are needed to evaluate the long-term benefits and safety of different adjunctive ablation approaches for rhythm control in AF patients. [ABSTRACT FROM AUTHOR]

Objectives: The goal of this study was to analyze health-related quality of life (HRQL) data from a Canadian population with type 2 diabetes in order to estimate the disutility associated with experiencing a diabetes-related complication. Methods: The EQ-5D, a standardized instrument for use as a measure of health outcome, was administered to 1,147 patients in Hamilton, Ontario, with type 2 diabetes. After controlling for age, gender, and duration of diabetes, changes in utility values were estimated by regressing the EQ-5D scores onto binary indicators for the presence of an event. The primary method of analysis was Ordinary Least Squares (OLS) and due to concerns over non-Normality, bootstrap standard errors (SE) were calculated. Results: The analysis included 1,143 participants. Based on the OLS model, reductions in HRQL were associated with duration of diabetes (−0.0015, SE = 0.0006), experiencing a myocardial infarction (MI) (−0.059, SE = 0.017), amputation (−0.063, SE = 0.059), stroke (−0.046, SE = 0.023), and kidney failure (−0.102, SE = 0.047). Conclusion: This study estimated the reductions in HRQL associated with several important complications commonly experienced in patients with diabetes. The greatest impacts on HRQL were associated with kidney failure and MI. The utility values calculated here can be used to assess the outcome of interventions that reduce these diabetes-related complications and will have a useful impact on future economic evaluations of diabetes management strategies in Canada. [ABSTRACT FROM AUTHOR]

Diabetes mellitus is a major healthcare concern from both a treatment and a funding perspective. Although decision makers frequently rely on models to evaluate the long-term costs and consequences associated with diabetes interventions, no recent article has reviewed the methods used in long-term cost-effectiveness models of diabetes treatment. The following databases were searched up to April 2008 to identify published economic models evaluating treatments for diabetes mellitus: OVID MEDLINE, EMBASE and the Thomson's Biosis Previews, NHS EED via Wiley's Cochrane Library, and Wiley's HEED database. Identified articles were reviewed and grouped according to unique models. When a model was applied in different settings (e.g. country) or compared different treatment alternatives, only the original publication describing the model was included. In some cases, subsequent articles were included if they provided methodological advances from the original model. The following data were captured for each study: (i) study characteristics; (ii) model structure; (iii) long-term complications, data sources, methods reporting and model validity; (iv) utilities, data sources and methods reporting; (v) costs, data sources and methods reporting; (vi) model data requirements; and (vii) economic results including methods to deal with uncertainty. A total of 17 studies were identified, 12 of which allowed for the conduct of a cost-effectiveness analysis and a cost-utility analysis. Although most models were Markov-based microsimulations, models differed with respect to the number of diabetes-related complications included. The majority of the studies used a lifetime time horizon and a payer perspective. The DCCT for type 1 diabetes and the UKPDS for type 2 diabetes were the trial data sources most commonly cited for the efficacy data, although several non-randomized data sources were used. While the methods used to derive the efficacy data were commonly reported, less information was given regarding the derivation of the utilities or the costs. New interventions were generally deemed cost effective based on ten studies presenting results. Authors relied mostly on univariate sensitivity analyses to test the robustness of their models. Although diabetes is a complex disease, several models have been developed to predict the long-term costs and consequences associated with diabetes treatment. Combined with previous findings, this review supports the development of a reference case that could be used for any new diabetes models. Models could be enhanced if they had the capacity to deal with both first- and second-order uncertainty. Future research should continue to compare economic models for diabetes treatment in terms of clinical outcomes, costs and QALYs when applicable. [ABSTRACT FROM AUTHOR]

A response by Ron Goeree and colleagues to a letter to the editor about the article regarding the arguments of Amiram Gafni and Stephen Birch on the decision-making processes for healthcare systems in Ontario.