Choosing who shall not be treated in the NHS. Estimation of loss of quality-adjusted life expectancy (QALE) for patients with operable versus inoperable lung cancer: adjusting quality-of-life and lead-time bias for utility of surgery. Tests of Preferential Independence in the QALY Model The Minimally Clinically Important Difference in Generic Utility-Based Measures Quality adjusted life years in older adults with depressive symptoms and chronic medical disorders. Quality of life and cost-effectiveness of a 3-year trial of lifestyle intervention in primary health care. Cost-effectiveness of rehabilitation after an acute coronary event: a randomised controlled trial. Lifestyle behaviours and quality-adjusted life years in middle and older age. Psychometric assessment of the Quality of Life Index. Health-Related Quality of Life Consequences of Implantable Cardioverter Defibrillators: Results From MADIT II Individual quality of life in patients undergoing hip replacement Measurement of Health-Related Quality of Life in the Early Follow-Up of Colon and Rectal Cancer Life quality vs the 'quality of life': assumptions underlying prospective quality of life instruments in health care planning. Can Utility-Weighted Health-Related Quality-of-Life Estimates Capture Health Effects of Quality Improvement for Depression? Validity of the Assessment of Quality of Life (AQoL) utility instrument in patients with operable and inoperable lung cancer. Health-related quality of life before and after gastrointestinal surgery. Quality of Care Is Associated with Survival in Vulnerable Older Patients
In the face of severe re source constraints , health care systems are seeking both to control costs and to ensure maximum benefits for the re sources consumed . The use of  Quality Adjusted Life Years ( QALYs )  is becoming more widely advocated as a decision aid in the solution of re source allocation problems . The QALY combines two dimensions of health outcome --the quantity of life and its quality --in such a way that choices between different services with different purpose s can be made using comparisons based on common units of measurement . The combination of these two dimensions allows comparisons between services with different objectives , such as curing and caring services . The QALY , however , lacks a third dimension which is vital to the decision-making process to which it is intended to contribute : the worth of a specific life relative to others . This paper presents results based on interviews of 719 residents of Cardiff drawn at r and om from the electoral register . The results suggest that further development of the novel methodology used to establish the relative value placed on various human lives is worthwhile . Evidence is given which indicates that the public consider lives to be of unequal worth . The results also show that these values are consistent for different types of choices phrased in different ways on a large number of control variables , implying the existence of a cultural stable value system which is a necessary prerequisite if consensus values of human life are to be used to assist decision-making in non-private health care systems . ( ABSTRACT TRUNCATED AT 250 WORDS OBJECTIVES This study attempts to quantify the difference in loss of quality -adjusted life expectancy ( QALE ) for patients with operable and inoperable non-small-cell lung cancer ( NSCLC ) . PATIENTS AND METHODS A cohort consisting of 1652 pathologically verified NSCLC patients with performance status 0 - 1 was monitored for 7 years ( 2005 - 2011 ) to obtain the survival function . This was further extrapolated to lifetime , based on the survival ratios between patients and age- and sex-matched referents simulated from the life tables of the National Vital Statistics of Taiwan . Between 2011 and 2012 , EuroQol 5-dimension question naires were used to prospect ively measure the quality -of-life ( QoL ) of a 518 consecutive , cross-sectional sub sample . We adjusted the lifetime survival function by the utility values of QoL for the cancer cohort to obtain the QALE , while that for the age and sex-matched referents were adjusted to the values collected from the 2009 National Health Interview Survey , and the difference between them was the loss-of-QALE . RESULTS The QALE for patients with operable and inoperable NSCLC were 11.66±0.18 and 1.43±0.05 quality -adjusted life year ( QALY ) , with the corresponding loss-of-QALE of 5.25±0.18 and 14.24±0.05 QALY , respectively . The lifetime utility difference for patients with operable and inoperable NSCLC was 9.00±0.18 QALY , after adjustment for QoL and lead-time bias . CONCLUSION The utility gained from surgical operation for operable lung cancer is substantial , even after adjustment for lead-time bias . Future studies should compare screening programs with treatment strategies when carrying out cost-utility assessment s to improve patients ' values The author presents evidence for the descriptive adequacy of the  quality -adjusted life years ( QALY ) model as applied to health profiles . One important assumption of the model is preferential independence : if two profiles have the same health state during year X , then preference between them does not switch if the level of health changes during year X. In experiment 1 , 30-year health profiles were used to perform 27 em pirical tests of independence with 98 subjects .  Independence was reliably satisfied in all 27 tests . In experiment 2 , 15 additional tests were conducted . These tests had been specifically design ed to be more sensitive to independence violations , but indepen dence was still mostly satisfied . In both experiments , the conclusions about indepen dence hold regardless of what discount rate is used . These results act as a " lower bound " on the validity of the QALY model for health profiles . Key words : quality -ad justed life years ; QALY model ; health profiles ; preferential independence . ( Med Decis Making 1998;18:418 - 428 Purpose : To evaluate the use of utility-based generic quality of life measures for establishing the minimally clinical ly important difference ( MCID ) . Background : Utility-based quality of life measures place levels of wellness on a continuum anchored by death ( 0.00 ) and optimum function ( 1.00 ) . Preference measurement studies are used to define the meaning of points along the continuum . Health states that differ by less than 0.03 units can not be discriminated by panels of judges as different from one another . Thus , 0.03 is a reasonable MCID for these measures . Method : Three published studies of patients with Chronic Obstructive Pulmonary Disease ( COPD ) reported data on the Quality of Well-being Scale ( QWB ) before and after pulmonary rehabilitation . One of the studies also r and omly assigned patients to lung volume reduction surgery or to maximal medical therapy . These patients were followed for an average of 29 months . Results : All three evaluations of pulmonary rehabilitation showed changes on the QWB in excess of the proposed 0.03 MCID . QWB changes for patients assigned to lung volume reduction surgery were close to the MCID threshold at one year but grew stronger in subsequent years . Using Norman 's 0.50 st and ard deviation method , all three estimates of rehabilitation effectiveness and the outcomes one year following surgery fall below the MCID . Conclusion : Different methods for estimating MCID lead to different conclusions about the meaning of quality of life changes following pulmonary rehabilitation and lung volume reduction surgery . The preference scaling system in generic utility-based quality of life measures provides a metric that is directly interpretable and avoids many of the criticisms of MCID measures . The method is sensitive enough to suggest clinical ly meaningful benefits of rehabilitation and surgery . Further , quality adjusted life years offer a valuable metric for policy analysis . Utility-based measures of health related quality of life should gain greater use in COPD outcomes research We used data from a 4-year prospect i ve study of 2,558 primary care patients age 65 and older in a large staff model health maintenance organization to examine the association of clinical ly significant depressive symptoms and eight other chronic medical conditions with quality adjusted life years ( QALYs ) . We developed linear regression models to examine the association of clinical ly significant depressive symptoms as defined by a score of 16 or greater on the Center for Epidemiological Studies Depression Scale and eight common chronic medical disorders at baseline with QALYs over the 4-year study period . Estimates of QALYs were derived from Quality of Well-Being Scale scores at baseline , at 2-year follow-up , and at 4-year follow-up . Individuals with clinical ly significant depressive symptoms at baseline had significantly lower QALYs over the 4-year study period than nondepressed subjects , even after adjusting for differences in age , gender , and the eight other chronic medical conditions . In terms of the entire study population , only arthritis and heart disease were more strongly associated with QALYs than depression BACKGROUND Lifestyle interventions reduce cardiovascular risk and risk of diabetes mellitus , but reports on long-term effects on quality of life ( QOL ) and health care utilization are rare . We investigated the impact of a primary health care-based lifestyle intervention program on QOL and cost-effectiveness over 3 years . METHODS A total of 151 men and women , aged 18 to 65 years , at moderate to high risk for cardiovascular disease , were r and omly assigned to either lifestyle intervention with st and ard care or st and ard care alone . Intervention consisted of supervised exercise sessions and diet counseling for 3 months , followed by regular group meetings over a 3-year period . Change in QOL was measured with EuroQol ( 5-dimensional EuroQol-5D [ EQ-5D ] and EuroQol-VAS [ EQ-VAS ] ) , the 36-Item Short-Form Health Survey ( SF-36 ) , and the 6-dimensional Short-Form 6D ( SF-6D ) . The health economic evaluation was performed from a societal view and a treatment perspective . In a cost-utility analysis , the costs , gained quality -adjusted life-years ( QALYs ) , and savings in health care were considered . Cost-effectiveness was also described using the net monetary benefit method . RESULTS Significant differences between the groups over the 3-year period were shown in the EQ-VAS ( P = .002 ) , SF-6D ( P = .01 ) , and SF-36 ( P = .04 ) physical component summary but not in the EQ-5D ( P = .24 ) or SF-36 ( P = .37 ) mental component summary . The net savings were $ 47 per participant . Costs per gained QALY , savings not counted , were $ 1668 to $ 4813 . Probabilities of cost-effectiveness were 89 % to 100 % when the amount of $ 50,000 was used as stakeholder 's threshold of willingness to pay for a gained QALY . CONCLUSION Lifestyle intervention in primary care improves QOL and is highly cost-effective in relation to st and ard care . Trial Registration clinical trials.gov Identifier : NCT00486941 OBJECTIVE To estimate the incremental effects on cost and quality of life of  cardiac rehabilitation after an acute coronary syndrome . DESIGN Open r and omised controlled trial with 1 year 's follow-up . Analysis was on an intention-to-treat basis . SETTING Two tertiary hospitals in Sydney . INTERVENTION 18 sessions of comprehensive exercise-based outpatient cardiac rehabilitation or conventional care as provided by the treating doctor . PARTICIPANTS 113 patients aged 41 - 75 years who were self-caring and literate in English . Patients with uncompensated heart failure , uncontrolled arrhythmias , severe and symptomatic aortic stenosis or physical impairment were excluded . MAIN OUTCOME MEASURES Costs ( hospitalisations , medication use , outpatient visits , investigations , and personal expenses ) ; and measures of quality of life . Incremental cost per quality -adjusted life year ( QALY ) saved at 1 year ( this estimate combines within- study utility effects with reported 1-year risk of survival and treatment effects of rehabilitation on mortality ) . Sensitivity analyses around a base case estimate included alternative assumptions of no treatment effect on survival , 3 years of treatment effect on survival and variations in utility . RESULTS The estimated incremental cost per QALY saved for  rehabilitation  relative to st and ard care was 42,535 US dollars when modelling included the reported treatment effect on survival . This increased to 70,580 US dollars per QALY saved if treatment effect on survival was not included . The results were sensitive to variations in utility and ranged from 19,685 US dollars per QALY saved to rehabilitation not being cost-effective . CONCLUSIONS The effects on quality of life tend to reinforce treatment advantages on survival for patients having postdischarge rehabilitation after an acute coronary syndrome . The estimated base case incremental cost per QALY saved is consistent with those historically accepted by decision making authorities such as the Pharmaceutical Benefits Advisory Committee OBJECTIVE to examine the relationship between combined lifestyle behaviours  and quality -adjusted life years ( QALYs ) in a general population . METHODS a population -based study was conducted in 13,358 men and women who participated in the European Prospect i ve Investigation into Cancer (EPIC)-Norfolk ( baseline 1993 - 97 ) . A score of 1 was given to each of non-smoking , physically not inactive , moderate alcohol consumption ( 1 - 14 units ) and consumption of at least five portions of fruit and vegetables ( vitamin C level ≥50 µmol/l ) . Short-Form Six-Dimension ( SF-6D ) health utility index scores were derived from the SF-36 . QALYs were estimated up to follow-up ( July 2007 ) . RESULTS a total of 13,358 men and women were eligible to be included in the study ( aged 40 - 79 years at baseline ) . A total of 12,921 people were alive at follow-up ( 117 , 784 person-years  ) . Mean follow-up period was ∼11.5 years . 437 ( 4.4 % of men and 2.4 % of women ) died . The death rate was 6.5 times higher in people with health behaviour score 0 compared with those who scored 4 ( 8.4 versus 1.3 % ) . People with higher scores had significantly higher QALYs . CONCLUSION our findings support the view that modifiable lifestyle factors are an important component in health improvement The purpose of this study was to examine the psychometric properties of the  Quality of Life Index  ( QLI ) ( Ferrans & Powers , 1985a ) . The sample consisted of 349 patients selected r and omly from the adult , in-unit hemodialysis patient population of Illinois . Factor analysis was used to examine the underlying factor structure . A four-factors solution best fit the data , indicating that there were four dimensions underlying the QLI : health and functioning , socioeconomic , psychological/spiritual , and family . Factor analysis of the four primary factors revealed one higher order factor , representing quality of life . Construct validity also was supported by the contrasted groups approach . As predicted , it was found that those who had higher incomes had significantly higher quality of life scores on the social and economic subscale . Support for convergent validity was provided by a strong correlation ( r = .77 ) between scores from the QLI and an assessment of life satisfaction . Findings supported the internal consistency reliability of the entire QLI ( alpha = .93 ) and the four subscales ( alphas = .87 , .82 , .90 , .77 ) Background : Implantable cardioverter defibrillators ( ICDs ) improve survival and extend lives of patients with severe heart disease . Objective : We sought to evaluate the impact of ICDs on health-related quality of life ( HRQOL ) during the first 3 years after implantation . Subjects : A total of 1089 patients from the Multicenter Automatic Defibrillator Implantation Trial II ( MADIT II ) were r and omized to an ICD or medical treatment only . Measures : Health Utility Index ( HUI3 ) at baseline , 3 , 12 , 24 , and 36 months following r and omization ; survival data . Research Design : We constructed mean profiles of HRQOL for living patients , estimated overall quality -adjusted life years ( QALYs ) , separately by treatment arm , and calculated cumulative QALY gains/losses as the difference between the areas under the treatment specific HRQOL profiles . Multivariate fixed effect regression models were developed to impute the missing HRQOL data using baseline patient characteristics ( age , gender , treatment , HUI3 score , diabetes , diuretics use , and NYHA class ) . Bootstrapped st and ard errors were calculated for the estimated differences in HRQOL gains/losses between treatment arms . Similarly , we performed subgroup analyses ( by gender , age , and baseline NYHA class , blood urine nitrogen , ejection fraction , and QRS ) . Results : There were no differences in QALYs loss for living patients by treatment group ( −0.037 , P = 0.64 ) or in overall QALYs loss by treatment group ( 0.043 , P = 0.37 ) over 3 years . In subgroup analysis , female subjects demonstrated a trend towards greater survival benefit ( 0.298 , P = 0.07 ) and overall QALYs ( 0.261 , P = 0.14 ) . Conclusions : Adverse effects of the ICD on HRQOL together with lower HRQOL among survivors may offset the 3-year survival benefits of ICDs Quality of life ( QoL ) assessment is becoming increasingly important for measuring the impact of illnesses , diseases , and their treatment and for deciding priorities when allocating re sources . We developed a novel method to measure QoL from the perspective of the individual patient . The schedule for the evaluation of individual quality of life ( SEIQoL ) was devised from the technique known as judgment analysis to measure patients ' level of functioning in five self-nominated facets of life and the relative weight or importance attached to these areas . We applied this method , together with traditional measures of health status , in a prospect i ve intervention study of 20 patients undergoing unilateral total hip-replacement surgery with six-month follow-up by comparison with matched , non-patient controls .  Health status was significantly improved by hip replacement on the McMaster health index question naire ( p less than 0.001 ) and the arthritis impact measurement scales ( p less than 0.001 ) . Individually measured QoL was significantly increased after surgery when measured by SEIQoL ( p less than 0.02 ) . The individual nature of QoL was reflected in the variety of life areas nominated as important by individual patients , the differences in relative weights attached to these areas , and the complex nature of the changes that occurred postoperatively . Our data not only highlight such individuality but also show that SEIQoL provides a means by which this can be assessed scientifically Purpose Little is known about factors that affect health-related quality of life during the early follow-up of colorectal cancer . This study was design ed to identify the factors that contribute to poor health-related quality of life after six weeks of follow-up and to compare the relative performance of instruments best suited to measure it . Methods A single-center , prospect i ve study was design ed to examine health-related quality of life after  potentially curative surgery for colorectal cancer .  Two condition-specific and two generic instruments ( QLQ-C30 , FACT-C , SF12 and EQ-5D ) measured quality  of life six weeks after discharge . Univariate and multivariate analyses were used to assess the impact of 16 treatment factors , demographic variables , and symptoms on seven global health-related quality of life scores . Results Question naires were obtained from 201 consecutive patients . Five factors were associated with poor health-related quality of life scores at six-week follow-up in the multivariate analysis : reduced preoperative performance status , stomas , diarrhea , constipation , and younger than aged 65 years . No instrument out performed the others . However , condition-specific instruments and those in which patients subjectively rated their overall health-related quality of life were better suited to detect health-related quality of life differences relating to the effects of colorectal cancer treatment . Conclusions Younger patients , those with stomas , and those suffering from diarrhea or constipation are more likely to report poor health-related quality of life at six-week follow-up . The routine measurement of health-related quality of life using an instrument that includes a patient-rated scale together with condition-specific items could be used to detect patients at risk of poorer short-term health-related quality of life outcomes Quality of  Life is a broad construct used in health planning , health economics , and medical decision-making . It is also a term that has a long currency in social and sociological literature s. This paper considers the assumptions underlying prospect i ve QL instruments in an historical and contemporary context . It argues that as a tool in health planning and in clinical decision making life quality as a measurement has its origins in the early eugenics literature and the social policies that derived from it in first North America , the primary focus of this paper , and later in Europe . Reference to narrative and social literature s , as well as those involving coping and adaptation , are then used to critique the assumptions underlying this class of QL instruments . It concludes that to the degree now current prospect i ve instruments reflect a purely physical perspective of " disease burden " irrespective of social conditions they create a context that works against life quality , and in some cases , the continuance of persons with physical differences Background .Utility methods that are responsive to changes in desirable outcomes are needed for cost-effectiveness ( CE ) analyses and to help in decisions about re source allocation . Objectives .Evaluated is the responsiveness of different methods that assign utility weights to subsets of SF-36 items to average improvements in health result ing from quality improvement ( QI ) interventions for depression . Design .A group level , r and omized , control trial in 46 primary care clinics in six managed care organizations . Clinics were r and omized to one of two QI interventions or usual care . Subjects . One thous and one hundred thirty-six patients with current depressive symptoms and either 12-month , lifetime , or no depressive disorder identified through screening 27,332 consecutive patients . Measures .Utility weighted SF-12 or SF-36 measures , probable depression , and physical and mental health-related quality of life scores . Results .Several utility-weighted measures showed increases in utility values for patients in one of the interventions , relative to usual care , that paralleled the improved health effects for depression and emotional well being . However , QALY gains were small . Directly elicited utility values showed a paradoxical result of lower utility during the first year of the study for intervention patients relative to controls . Conclusions .The results raise concerns about the use of direct single-item utility measures or utility measures derived from generic health status measures in effectiveness studies for depression . Choice of measure may lead to different conclusions about the benefit and CE of treatment . Utility measures that capture the mental health and non-health outcomes associated with treatment for depression are needed There have been few longitudinal studies of quality of life in patients with all stages of lung cancer , particularly those that have included measures of utility . The purpose of this study was to examine the psychometric properties of the Assessment of Quality of Life instrument ( AQoL )  in patients with lung cancer . The AQoL is a health-related quality of life question naire and provides a descriptive system for a multi-attribute utility instrument ( MAU ) , so that scores can be used in cost-utility evaluations . In the present study the reliability ( internal consistency ) of the AQoL was examined and the concurrent validity was assessed using the Medical Outcomes 36-item Short Form Health Survey ( SF-36 ) as the comparator instrument . The sensitivity to different health states of the AQoL and the responsiveness to change over time was also examined . A prospect i ve , non-experimental cohort study was undertaken . Ninety-two participants with all stages of lung cancer were recruited from a tertiary multi-disciplinary lung cancer clinic . Ninety participants had non-small cell lung cancer ( NSCLC ) and two had limited stage small cell lung cancer . The  AQOL and SF-36 surveys  were administered concurrently at baseline . In patients with NSCLC the surveys were then repeated 3 and 6 months later . Correlations between the baseline AQoL summary scales and SF-36 summary scales support the divergent and convergent validity of the AQoL.  Reliability was also found to be sufficient ( Cronbach 's Alpha=0.76 ) . In addition , in patients with inoperable NSCLC , baseline AQoL scores were found to be predictive of survival at 6 months in Cox proportional hazards multivariate analysis . However , the physical components summary score of the SF-36 was more sensitive to differences in health states between patients with different stages of NSCLC at 6 months of follow-up and more responsive to change over time in both operable and inoperable patients with NSCLC than the AQoL. The findings support the construct validity and reliability of the  AQoL  in this population . However , there remains some uncertainty about whether the AQoL has sufficient sensitivity to different health states in this population . Further studies using other MAU instruments may determine whether alternative instruments are more sensitive to different health states in individuals with lung cancer OBJECTIVE To assess the impact of surgical treatment on health-related quality of life ( QoL ) and its various dimensions in four common gastrointestinal diseases , to compare it with that of the general population , and to assess the relationship between the patient 's and the surgeon 's satisfaction . DESIGN Prospect i ve , observational study . SETTING Tertiary care centre , Finl and . PATIENTS 131 patients , of whom 77 had cholecystectomy , 20 fundoplication , 20 incisional herniorrhaphy , 12 large bowel resection , and 2 construction of a stoma only because of unresectable colorectal cancer . INTERVENTIONS Routine operative treatment of four gastrointestinal diseases . MAIN OUTCOME MEASURES QoL measured by a  generic 15-dimensional instrument .  RESULTS The health-related QoL improved postoperatively in the entire group . Discomfort , symptoms , and vitality were all reduced at 2 months , whereas bowel movements , eating , and usual activities had been restored at 12 months . The health related QoL was comparable with that of the general population at 12 months except for breathing and sleeping . The pattern of recovery varied among diagnostic subgroups , being most improved in patients operated on for biliary disease , those aged 60 years or younger , women and otherwise previously healthy patients . There was a close agreement between the patient 's and the surgeon 's opinion of outcome . CONCLUSIONS Gastrointestinal surgery improves quality of life . Separating a generic health-related QoL measure into dimensions allows a more appropriate estimation of quality of life than a single index score . Because some dimensions were made worse soon after operation and some were restored slowly , a minimum 12-month follow-up may be needed to assess the effect of gastrointestinal surgery on health- related Context Quality -of-care evaluation often focuses on how often patients receive certain tests or treatments . Theoretically , the content of care should predict patient survival , but the evidence is inconclusive . Contribution This study used 207 criteria to assess good care in 372 vulnerable elderly patients . When care did not meet these st and ards , patients were more likely to die during the 3 years of follow-up . Implication s In vulnerable older patients , the content of care is associated with mortality . This finding supports the use of process measures in the evaluation of quality of care and shows that good care may prolong life . The Editors As clinicians , the public , and health systems become more aware that many Americans do not receive necessary care , the importance of measuring and improving quality of care has gained increasing attention ( 1 - 3 ) . Although quality of care can theoretically be measured by outcomes ( what happens to patients ) , process ( what providers do ) is often preferred ( 3 - 5 ) because process is under relatively greater control of providers , needs a shorter time frame , can directly inform improvement , and may not require statistical adjustment for severity of illness ( 6 , 7 ) . Typically , process measures evaluate the proportion of eligible patients who receive care as recommended ( for example , the proportion of patients 65 years of age receiving pneumococcal vaccine ) . To be a meaningful measure of quality , a process of care must be related to improved patient outcomes . For many quality indicators , this relationship is based on evidence of efficacy from r and omized , controlled trials , usually among a select patient population . However , the relationship between performance on  process of care quality indicators  and better health outcomes remains a largely untested assumption for general population s of patients receiving care in community setting s. The lack of a demonstrated relationship between performance on process quality measures and outcome advantage in a cohort of patients has hindered the acceptance of quality indicators as a way to measure and improve health outcomes ( 8) . The Assessing Care of Vulnerable Elders ( ACOVE ) project developed a set of process quality criteria  that were judged by clinical experts to improve patient outcomes on the basis of clinical evidence and professional opinion ( 9 - 11 ) . Combined with mortality information available through the National Death Index , our study evaluated the process outcome relationship . While the development method conferred content validity on the process measures , we aim ed to assess the predictive validity of the quality measurement system by examining the relationship between the quality of care received by sample d participants and their subsequent survival . Methods The ACOVE Project The ACOVE project developed and implemented a set of quality indicators that focuses on process of care for clinical conditions important in the care of vulnerable older patients . Details of the methods of selecting conditions and developing quality indicators have been described in previous reports ( 9 , 10 ) 12 ) . We selected quality indicators by using systematic review s of the medical literature followed by deliberations by several panels of clinical experts using formal consensus methods to assess the validity of quality indicators . This process result ed in 236 quality indicators covering 22 clinical areas ( continuity of care , dementia , depression , diabetes mellitus , end-of-life care , falls and mobility problems , hearing loss , heart failure , hospital care , hypertension , ischemic heart disease , malnutrition , medication management , osteoarthritis , osteoporosis , pain management , pneumonia , pressure ulcer , screening and prevention , stroke and atrial fibrillation , urinary incontinence , and vision care ) across the continuum of care , including prevention , diagnosis , treatment , and follow-up . Each quality indicator contains an if clause that defines the patient who is eligible to receive it and a then clause that describes what care is recommended ( for example : If a vulnerable elder has had a myocardial infa rct ion , then he or she should be offered a -blocker ) . If the medical record describes a contraindication to the recommended care , the patient is not eligible for the quality indicator . Furthermore , we explicitly defined certain indicators as being not applicable , and therefore not included , when assessing the care of patients with advanced dementia or poor prognosis ( 13 ) . We applied the ACOVE quality indicators to a sample of vulnerable older patients in 2 large managed care organizations , 1 in the northeastern United States and the other in the southwestern United States ( 11 ) . Each managed care plan had more than 20000 senior members and contracted with a network of providers for delivery of care . Eligibility criteria included continuous enrollment in the managed care organization with no out-of-network care during the 13-month study period and no active treatment for malignant conditions except for nonmelanoma skin cancer . We identified vulnerable older persons by telephone interview using the Vulnerable Elders Survey-13 ( VES-13 ) ( 14 ) . The VES-13 is a 13-item question naire that produces a vulnerability score ranging from 0 to 10 based on age , self-reported health , and function . Patients with scores of 3 or higher are at 4 times the risk for death or functional decline over the next 2 years and are therefore defined as vulnerable . We excluded nonEnglish- language speakers because interviews were available only in English . Among 3207 community-dwelling patients 65 years of age and older who were r and omly selected from the 2 managed care plans , we conducted screening interviews with 2278 patients ( 9 % through proxies ) and identified 475 ( 21 % ) patients as vulnerable . Among them , 420 ( 88 % ) patients consented to participate in the study and 372 ( 78 % ) patients had medical records for the 13-month period from 1 July 1998 to 31 July 1999 that were able to be abstract ed . We collected all participants ' medical records , including those for inpatient care , outpatient care , nursing home care , home care , and mental health care . Trained nurses abstract ed charts to apply quality indicators . A senior nurse review er assessed completed abstract ions , and physician overreaders review ed them for clinical assessment . We evaluated inter-rater reliability by re abstract ion of 10 % of the medical records , which contained 698 quality indicators . Agreement was 97 % for quality indicator eligibility and 95 % for overall quality score . We collected patient characteristics , including age , sex , cognitive function measured by the Blessed OrientationMemoryConcentration test ( 15 ) , and mental health score derived from Medical Outcomes Study Short Form-36 items ( 16 ) , at the time of the recruitment telephone interview . The R AND institutional review board approved the study protocol . Among the 236 ACOVE quality indicators , 207 could be implemented in the field trial either by medical record  ( 183 indicators ) or patient interview  ( 24 indicators ) . Because some patients died before the interview was conducted , we used only quality indicators for which information was available in medical records . Among these , 160 quality indicators had at least 1 eligible patient ; 43 focused on prevention , 42 on diagnosis , 47 on treatment , and 28 on follow-up care . These 160 quality indicators covered all 22 conditions . The Appendix Table contains the list of quality indicators used in our report , the number of eligible patients , and the pass rate for each indicator . Appendix Table . Quality Indicators Using Medical Records as the Information Source , Eligible Patients , and Pass Rates Statistical Analysis We calculated quality scores for each patient on the basis of the percentage of ACOVE quality indicators for which an eligible patient received recommended care . We obtained death , date , and cause-of-death data for ACOVE participants from the National Death Index during 3 years after the quality measurement period ( from August 1999 to September 2002 ) . We used both unadjusted and adjusted analyses to examine the link between patient survival and quality score . For the unadjusted analysis , we first divided the sample in half on the basis of quality score ( that is , median and < median ) and examined the difference in survival curves between patients with higher quality and patients with lower quality by using the log-rank test . Second , we calculated survival for 10 equal intervals of quality score from the lowest quality score to the highest quality score in the sample and graphically assessed the grade d relationship between quality score and survival . We used the Cox proportional hazards survival model in adjusted analyses . Because the proportional hazards assumption for the multivariate survival analysis did not hold for the entire observation period , we used a piecewise model that allowed the coefficients for quality to vary between 500 days or less and more than 500 days , as suggested by the KaplanMeier survival curve in the unadjusted analysis . Covariates included sex , VES-13 score ( including age ) , mental health , number of hospitalizations and office visits during the quality measurement period , and number of conditions that patients had during the quality measurement period among 13 comorbid conditions ( dementia , depression , diabetes mellitus , heart failure , hypertension , ischemic heart disease , osteoarthritis , osteoporosis , pressure ulcer , atrial fibrillation , urinary incontinence , chronic obstructive pulmonary disease , and chronic renal failure ) . The mental health score ranged from 1 to 6 , and we created 3 categories on the basis of the score ( < 2 , very good ; 2 to 3 , good ; and > 3 , fair ) . An indicator variable design ated patients who were not interviewed for mental health items because of cognitive impairment . To further examine a plausible mechanism for the quality survival link , we examined the relationship between survival and
It was found that individual preferences over health are influenced by the duration of health states and their sequence .
However , although there is much variation across individual respondents , the assumptions tend to hold much better when valuations are aggregated across respondents , which is encouraging for economic evaluations that rely on using average ( mean or median ) values
The numbers of quality -adjusted life years ( QALYs ) gained are increasingly being used to represent the gains in individual utility from treatment .
This requires that the value of a health improvement to an individual is a simple product of gains in quality of life and length of life .
The article reports on a systematic review of the literature on 2 issues : whether the value of a state is affected by how long the state lasts , and by states that come before or after it .