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Shanlian Hu,1 Depei Wu,2 Jing Wu,3 Yabing Zhang,4 Mette Bøgelund,5 Johannes Pöhlmann,6 Richard F Pollock6 1School of Public Health, Fudan University, Shanghai, People’s Republic of China; 2First Affiliated Hospital of Soochow University, Soochow University, Suzhou, People’s Republic of China; 3School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, People’s Republic of China; 4Shanghai Institute of Technology, Shanghai, People’s Republic of China; 5Incentive Partners ApS, Holte, Denmark; 6Covalence Research Ltd, Harpenden, United KingdomCorrespondence: Richard F Pollock, Covalence Research Ltd, Rivers Lodge, West Common, Harpenden, AL5 2JD, United Kingdom, Tel +44 20 8638 6525, Email pollock@covalence-research.comPurpose: Treatment process attributes can affect health state utilities associated with therapy. For intravenous iron, used to treat iron deficiency and iron deficiency anemia, research into process attributes is still lacking. This study estimated utilities associated with process attributes for intravenous iron infusions.Methods: An online survey including seven health state vignettes and time trade-off tasks was administered to participants, who were not patients living with iron deficiency or iron deficiency anemia, from a Chinese online panel. Vignettes used an identical description of iron deficiency and iron deficiency anemia but differed in the annual number of infusions, infusion duration, and infusion-associated risk of hypophosphatemic osteomalacia. Disutilities and their rate of change as the number of infusions increased were examined using a power model.Results: The survey was completed by 1091 participants. The highest utilities were observed for one annual infusion of 15– 30 minutes or 30– 60 minutes, without risk of hypophosphatemic osteomalacia (0.754 and 0.746, respectively). In comparison, more infusions and infusions with a risk of hypophosphatemic osteomalacia were associated with lower utilities. Utility continued to decrease, but at a diminishing rate, as the annual number of infusions increased, with utility decrements of 0.006 and 0.002, respectively, when going from zero to one and from four to five infusions per year. All marginal disutilities were small (values < 0.01).Conclusion: This study suggested that treatment attributes of intravenous iron infusions affect health state utilities. Using intravenous iron formulations that allow for fewer and shorter infusions without the risk of hypophosphatemic osteomalacia can reduce the number of visits required and increase patients’ quality of life.Plain Language Summary: A lack of iron in the body can be treated successfully using intravenous infusions of iron, but it is not yet known how different intravenous iron formulations affect patients’ quality of life.Intravenous iron formulations differ in how often and for how long (per infusion) they need to be administered; for example, while one available intravenous iron formulation allows most iron deficits to be corrected in a single visit, others can require several visits. Formulations also seem to differ in the risk of complications relating to low phosphate and bone softening.This study presented descriptions of treatment options, differing in the number and duration of infusions as well as in risk, to more than 1000 Chinese respondents. Based on their answers, the differences between intravenous iron administration regimes could be valued and linked to quality of life. Intravenous iron treatment with fewer, shorter infusions and without risk of bone softening was found to come with a better quality of life. Each additional infusion reduced quality of life, but less so if treatment already involved several infusions. These findings can help patients and physicians to make clinical decisions that focus not only on efficacy and safety but also on the quality of life.Keywords: China, disutility, health-related quality of life, intravenous iron, iron deficiency, time trade-off

Mike Tankersley,1,2 Tonya Winders,3,4 Mark Aagren,5 Henrik Brandi,5 Mikkel Hasse Pedersen,6 Anne Sofie Ledgaard Loftager,6 Mette Bøgelund6 1Departments of Medicine, Pediatrics and Otolaryngology, University of Tennessee Health Science Center, Memphis, TN, USA; 2The Tankersley Clinic, Memphis, TN, USA; 3Allergy & Asthma Network, Vienna, VA, USA; 4Global Allergy & Airways Patient Platform, Vienna, Austria; 5Department of Global Market Access & Public Affairs, ALK, Hørsholm, Denmark; 6Incentive Denmark, Holte, DenmarkCorrespondence: Mette Bøgelund Tel +45 2916 1222Email mb@incentive.dkBackground: People with allergic rhinitis (AR) who are not controlled on conventional therapy can be treated using allergy immunotherapy (AIT) administered as tablets, injections or drops. In the US, the use of sublingual immunotherapy as tablets (SLIT-tablets) is limited in comparison to subcutaneous immunotherapy (SCIT).Objective: This study investigated patients’ preference for SLIT-tablets vs monthly or weekly SCIT from a US patient perspective.Methods: We carried out a discrete choice experiment (DCE) consisting of two blocks with eight choice sets. Adults and caregivers of children with moderate-to-severe AR were included if they had not previously or were not currently receiving AIT. Three attributes were included in the design: the mode and frequency of administration, the risk of systemic reactions and the co-payment.Results: A total of 724 adults with AR and 665 caregivers of children with AR were included in the study. Both adults and caregivers had a significant preference for SLIT-tablets compared with both weekly and monthly injections and for less risk of anaphylactic shock. Caregivers were more risk-averse than adults when choosing their treatment, and the younger the child, the more risk-averse the caregiver. The preference for SLIT-tablets was found for both monoallergic and polyallergic adults and caregivers of monoallergic and polyallergic children. Respondents not wanting AIT for free were more risk-averse than those indicating that they wanted AIT for free.Conclusion: Our findings suggest that SLIT-tablets is the preferred route of administration for AIT among adults and caregivers of children with AR.Keywords: allergic rhinitis, allergy immunotherapy, discrete choice experiment, patient preferences, subcutaneous immunotherapy, sublingual immunotherapy

Andrei Krassioukov,1,2 Yasuhiko Igawa,3 Márcio Augusto Averbeck,4 Helmut Madersbacher,5 Andrew J Lloyd,6 Mette Bøgelund,7 Nikesh Thiruchelvam8 1University of British Columbia, International Collaboration On Repair Discoveries (ICORD), Vancouver, British Columbia, Canada; 2Division of Physical Medicine and Rehabilitation, Department of Medicine, G.F. Strong Rehabilitation Centre, Vancouver, British Columbia, Canada; 3Department of Continence Medicine, The University of Tokyo, Graduate School of Medicine, Tokyo, Japan; 4Head of Neuro-Urology Unit, Moinhos de Vento Hospital, Porto Alegre, Brazil; 5Department of Neurology, Medical University Innsbruck, Innsbruck, Austria; 6Bladon Associates Ltd., Oxford, UK; 7Incentive Partners ApS, Holte, Denmark; 8Department of Urology, Cambridge University Hospitals NHS Trust, Cambridge, UK Purpose: To estimate gains in health utility for two different catheter features and a support service related to urinary catheters used for intermittent catheterization. Patients and methods: Two internet-based time trade-off (TTO) surveys were undertaken to value vignettes describing two innovative catheter features and a support service. The first TTO survey “Size and Service” included catheters with compact design and the availability of a support service for users; the second TTO survey “Phthalates” included avoidance of potentially harmful phthalates in the material of the catheters. All participants were from the UK; they traded health states against a time horizon that matched their total life expectancy. Sensitivity analyses were done to estimate the impact of extreme values on disutilities. Results: The participants (n=890) estimated the incremental value of 0.031 (95% CI: 0.024–0.039), 0.009 (95% CI: 0.003–0.015), and 0.037 (95% CI: 0.027–0.046), respectively, for catheters with compact design, availability of support service, and catheters not containing phthalates. Conclusions: Participants valued all three improvements in catheter design. To capture the impact of such design improvements on quality of life and utilities, vignette-based approaches can be a useful supplement to the conventional, generic tools. Keywords: intermittent catheterization, time trade-off, vignette-based approach, health-related quality of life, QALY

Stewart B Harris,1 Kamlesh Khunti,2 Mona Landin-Olsson,3 Claus B Galbo-Jørgensen,4 Mette Bøgelund,4 Barrie Chubb,5 Jens Gundgaard,6 Marc Evans71Schulich School of Medicine and Dentistry, Western University, London, ON, Canada; 2Diabetes Research Unit, University of Leicester, Leicester, UK; 3Department of Medicine, Helsingborg Hospital, Lund University, Lund, Sweden; 4Incentive, Holte Stationsvej, Holte, Denmark; 5EU Health Economics and Outcomes Research, Novo Nordisk Ltd, Crawley, UK; 6Health Economics and HTA, Novo Nordisk A/S, Søborg, Denmark; 7Department of Diabetes, University Hospital Llandough, Cardiff, UKAims: We sought to develop descriptions of health states associated with daytime and nocturnal hypoglycemia in a structured fashion from the patient's perspective under different combinations of severity and frequency of hypoglycemic events.Methods: An expert meeting followed by two patient focus groups was used to develop comprehensive descriptions of acute consequences of severe and non-severe, daytime and nocturnal hypoglycemia. Patients with diabetes (type 1 = 85, type 2 = 162) from a survey panel then validated these descriptions and assessed how often they worried and took different actions to prevent hypoglycemia. Severity and frequency of hypoglycemia were compared with respect to how often people worried and took actions to prevent an event. The effect of hypoglycemia on 35 different life activities was quantitatively compared for patients who had and had not experienced a severe hypoglycemic event.Results: At least 95% of respondents agreed that the detailed patient-level descriptions of health states accurately reflected their experience of severe and non-severe, daytime and nocturnal hypoglycemia, thereby validating these descriptions. Respondents who had experienced a severe hypoglycemic event were generally more adversely affected in their worries and actions and life events than those who experienced only non-severe events; those who experienced nocturnal events were more affected than those who experienced only daytime events.Conclusion: The negative psychosocial consequences and undesirable compensatory behaviors arising from hypoglycemia underscore the importance of preventing severe episodes, particularly severe nocturnal episodes. These validated descriptions for hypoglycemia from the patient's perspective may also help inform future qualitative and quantitative research.Keywords: hypoglycemia, health states, diabetes, quality of life

Aims The aim of this study was to investigate associations between HbA1c recall by patients with Type 2 diabetes and self-management behaviours, patient activation, perception of care and diabetes distress. Methods In a cross-sectional survey, 993 patients with Type 2 diabetes reported their latest HbA1c. Validated scales measured self-management behaviours, patient activation, perception of care and diabetes distress. Self-reported HbA1c was compared with latest measured HbA1c. Using logistic regressions, associations between HbA1c recall and the variables of interest were investigated. Results Sixty-four per cent of patients recalled their latest HbA1c. Poor HbA1c recall was significantly associated with unhealthy eating behaviour, low level of exercise, low level of patient activation, poor glycaemic control, not knowing target HbA1c level, low educational level and being female. There were no associations between recall of HbA1c and diabetes distress or perceived care. Conclusions Recall of HbA1c level may increase patient activation and health-promoting behaviours. However, low educational level may be a barrier for using HbA1c as a motivator for health-promoting behaviours. This study indicates a need for studies of causal relationships, as well as mechanisms and challenges in using patient awareness of HbA1c as a driver for health-promoting behaviours. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine preferences among patients with type 2 diabetes for content and format of patient education. METHODS: Using discrete choice methods, we surveyed patients about their preferences for patient education. We investigated preferred content and format regarding education on living well with diabetes, preventing complications, healthy eating, exercising, and psychosocial issues related to diabetes. RESULTS: We obtained usable responses from 2187 patients with type 2 diabetes. Acquiring competencies to live a fulfilling life with diabetes, adjust diet and exercise habits, and prevent complications was significantly more highly valued than was simply being informed about these topics. Patients preferred to be involved in the planning of their diabetes care and valued individually tailored content higher than prescheduled content. Women and younger patients found diet and exercise significantly more important than did men, and patients with poorly controlled diabetes valued all education and support more highly than did patients in better control. CONCLUSION: Patients with type 2 diabetes prefer to be actively involved in educational activities, to develop competencies to prevent and manage complications, and to involve their social network in supporting them. PRACTICE IMPLICATIONS: Future patient education should enhance participation and competence development and include relatives. [ABSTRACT FROM AUTHOR]

Introduction: Diabetes is associated with a number of complications, particularly if glycaemic targets are not achieved. Glycaemic control is highly linked to treatment persistence and adherence. To understand the burden of poor persistence and adherence, this systematic literature review identified existing evidence regarding basal insulin adherence/non-adherence and persistence/non-persistence among people with diabetes in Western Europe (defined as the UK, France, Spain, Switzerland, the Netherlands, Ireland, Austria, Portugal, Denmark, Norway, Sweden, Finland, Italy, Germany, Iceland and Belgium)., Methods: Eligible studies were systematically identified from two databases, Medline and Embase (published between 2012 and June 2022). Conference abstracts from ISPOR and EASD were manually included. Identified studies were screened by two independent reviewers in a two-step blinded process. The eligibility of studies was decided on the basis of pre-established criteria. A proportional meta-analysis and comparative narrative analyses were conducted to analyse the included studies., Results: Twelve studies were identified. Proportions of adherence/non-adherence and persistence/non-persistence varied across studies. Pooled rates of non-persistence at 6, 12 and 18 months were 20.3% (95% CI 13.8; 27.8), 33.8% (95% CI 24.1; 44.3) and 36.5% (95% CI 33.6; 39.4), respectively. In the literature, the proportion of adherent people ranged from 41% to 64% (using the outcome measure medication possession ratio (MPR) > 80%), with a pooled rate of 55.6% (95% CI 45.3; 65.6), suggesting that approximately 44% of people with type 2 diabetes (T2D) are non-adherent., Conclusion: The results highlight that almost half of patients with T2D in Western Europe have poor adherence to insulin therapy and, at 18 months, one in three patients do not persist on treatment. These findings call for new basal insulin therapies and diabetes management strategies that can improve treatment persistence and adherence among people with T2D., (© 2024. The Author(s).)

Atopic dermatitis is a chronic, inflammatory skin disease. A variety of systemic treatments are available for patients with moderate-to-severe atopic dermatitis. The efficacy, safety and administration profile of these treatments vary, and determining the optimal treatment strategy may require weighing the benefits and drawbacks of therapies with diverse characteristics. This study used an online discrete choice experiment survey to investigate treatment preferences among adults with atopic dermatitis from Denmark, France, the UK, or Canada. Participants were identified through existing online panels. The survey included questions regarding different treatment attributes, defined based on currently approved treatments for moderate to severe atopic dermatitis. Treatment preferences were measured as the relative importance of different treatment attributes. A total of 713 respondents met the inclusion criteria and completed the survey. The discrete choice experiment identified a significant preference for avoiding the risk of severe adverse events, and for oral pill every day compared with biweekly injections. The time to full effect was not rated as being important. These findings suggest that patients with moderate-to-severe atopic dermatitis prioritize safety as most important, followed by ease of administration in their treatment preferences, while time to full effect and monitoring requirements were the least important attributes.

Aim: Weight bias, stigma and discrimination are pervasive in the health care system and society and may result in biased treatment of people living with obesity (PwO). We aimed to identify perceptions, attitudes and potential barriers that exist between people with obesity and health care professionals (HCPs) in Denmark., Methods: The ACTION-DK survey was a cross-sectional, non-interventional, descriptive study conducted in Denmark. The cohort included 879 PwO (body mass index ≥30.0 kg/m 2 ) based on self-reported height and body weight, and 100 HCPs from the primary and secondary sectors who frequently encountered PwO., Results: Several discrepancies between PwO and HCPs were identified, including recognition of obesity as a chronic disease (PwO: 49% vs. HCPs: 84%) and whether PwO were responsible for their weight loss (PwO: 81% vs. HCPs: 17%). Among PwO, 46% were motivated to lose weight, but only 28% of HCPs shared this perception. Untimely initiation of obesity care consultations was also identified as a potential barrier to proper obesity care, as PwO waited 7 years, on average, from their initial decision to lose weight before having their first obesity care consultation. In addition, only 24% of PwO had a follow-up consultation after the initial obesity care discussion. Almost half of HCPs (46%) considered weight loss medication effective, but only 10% brought up this possibility during an obesity care discussion., Conclusions: Our findings suggest that it is pivotal to improve obesity care in Denmark by ensuring a better follow-up and alignment of the perceptions and attitudes toward obesity between PwO and HCPs., (© 2023 The Authors. Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd.)

Objectives: The glucagon-like peptide-1 agonist semaglutide and the dual glucose-dependent insulinotropic polypeptide tirzepatide have proven to significantly reduce glucose levels in people with type 2 diabetes. However, the costs needed to achieve a sustained decrease in HbA1c level and disease control with semaglutide and tirzepatide, respectively, are unclear. Therefore, this study aimed to compare the cost of treatment with semaglutide with the cost of treatment with tirzepatide for type 2 diabetes in Austria, the Netherlands, Lithuania, and the United Arab Emirates in order to determine their respective value for money., Methods: The primary outcome of this analysis was the cost in euros needed to achieve disease control in one person with type 2 diabetes based on the composite endpoint of HbA1c <7%, ≥5% weight loss, and no hypoglycemic events. In addition, analyses regarding the cost needed to reach relevant HbA1c endpoints were performed. Clinical data were obtained from the SURPASS 2 trial, registered at clinicaltrials.gov (NCT03987919), and drug cost was based on wholesale acquisition cost or pharmacy purchase prices from public domains obtained in Q1 of 2023., Results: The cost needed to achieve disease control in one person with type 2 diabetes (HbA1c <7%, ≥5% weight loss, and no hypoglycemic events) was up to three times lower using semaglutide compared with all three doses of tirzepatide in most markets. In the HbA1c analyses, semaglutide was also found to be the least expensive treatment option., Conclusion: Semaglutide provides better value for money than tirzepatide for HbA1c-lowering endpoints.

We used the Danish National Health Registers to conduct a study on the prevalence of obesity-related comorbidities in Danish citizens who have been diagnosed with obesity at a Danish hospital. This was a retrospective observational study with a population comprising all Danish citizens (≥18 years) who have been registered with a specific obesity class diagnosis in the Danish National Patient Register between 2002 and 2018. A total of 86 980 persons with hospital-diagnosed obesity were included in the study population. To investigate how the risk of having comorbidities varies with the degree of obesity, we applied adjusted logistic regression to estimate the odds ratio of having one of the following predefined comorbidities for people with a BMI in obesity classes II and III compared with people with a BMI in obesity class I: type 2 diabetes, ischaemic heart disease, non-alcoholic steatohepatitis and non-alcoholic fatty liver disease, hip and knee osteoarthritis, obstructive sleep apnoea and asthma. Comorbidities were defined from ICD-10 diagnosis codes and prescription medication utilization. The odds ratio for obstructive sleep apnoea (OR 1.86 and OR 3.0), type 2 diabetes (OR 1.68 and OR 2.26), hip and knee osteoarthritis (OR 1.29 and OR 1.54) and asthma (OR1.13 and OR 1.25) increased significantly with obesity class (obesity class II relative to I and III relative to I, respectively). The odds ratio of having had at least one comorbidity was estimated to be 1.52 for people with a BMI in obesity class II and 2.10 for people with a BMI in obesity class III compared with people in obesity class I. The risk of obstructive sleep apnoea, type 2 diabetes, hip and knee osteoarthritis, and asthma increased significantly with increasing BMI, highlighting the importance of preventing further weight gain even in individuals who are already living with obesity., (© 2022 The Authors. Clinical Obesity published by John Wiley & Sons Ltd on behalf of World Obesity Federation.)

Introduction: The Danish national health registers were used to investigate the economic burden of obesity, associated costs of comorbidities and a breakdown into direct and indirect costs., Methods: The study population comprised all Danish adult citizens registered with a hospital diagnosis of obesity in the Danish National Patient Register between 2002 and 2018. Cases were matched with five controls via the Danish Civil Registration System. We estimated the difference in total healthcare costs and indirect costs between cases and controls and the difference in healthcare resource utilization. In a sub-analysis, we estimated total healthcare costs for persons who had been registered with one or more of 11 predefined comorbidities., Results: People with obesity experienced a statistically significant twofold increase in average direct healthcare costs per year (EUR 5,934), compared with controls (EUR 2,788) and had statistically significantly higher indirect costs compared to controls. Total healthcare costs for people with obesity and one or more of the 11 comorbidities were 91.7%-342.8% higher than total healthcare costs of the population with obesity but none of the 11 comorbidities., Conclusion: Obesity was associated with an increase in both direct and indirect costs. The presence of comorbidities was associated with additional healthcare costs., Key Points: Obesity is associated with an increase in direct and indirect costs in Denmark.Comorbidities are associated with additional healthcare costs.

Purpose: We aimed to estimate the total cost of bariatric surgery in Denmark., Materials and Methods: The study population included all Danish citizens ≥ 18 years who had received bariatric surgery, identified in the Danish National Patient Register in the period from 2002 to 2018. Patients who had received bariatric surgery were matched with three controls on gender, year of birth, and region of residence. A difference-in-difference approach was used to estimate the healthcare costs attributable to bariatric surgery from 3 years before to 5 years after surgery., Results: Total healthcare costs for cases receiving bariatric surgery during the first 5 years following surgery amounted to EUR 32,899, and EUR 16,651 for their matched controls. Thereby, the difference in total healthcare costs (EUR 16,248) between persons receiving bariatric surgery and their matched controls was 2.2 times the DRG rate for the surgery itself (EUR 7387). Moreover, the results suggest that receiving bariatric surgery led to a total increase in gross earnings of EUR 5970 (5%) and a total reduction in receipt of transfer payments of EUR 4488 (12%) in the period up until 5 years after surgery., Conclusion: The results showed a significant and persistent increase in healthcare costs for people with obesity receiving bariatric surgery during the first 5 years after surgery. We also found that bariatric surgery was associated with increased attachment to the labor market., (© 2022. The Author(s).)