Tosteson A N, Gabriel S E, Kneeland T S, Moncur M M, Manganiello P D, Schiff I, Ettinger B, Melton L J
Department of Medicine, Dartmouth Medical School, Hanover, New Hampshire, USA.
J Womens Health Gend Based Med. 2000 Mar;9(2):119-30. doi: 10.1089/152460900318614.
Previous economic evaluations of hormone replacement therapy (HRT) have restricted positive effects to alleviation of postmenopausal symptoms and negative effects to drug side effects. We studied the association between HRT use and postmenopausal women's valuation of both health-related quality of life and potential treatment side effects. Postmenopausal women with either a documented first vertebral fracture within the past 5 years or no history of osteoporotic fractures were recruited from Olmsted County, Minnesota, and from Dartmouth-Hitchcock Medical Center in New Hampshire to participate in a study to assess quality of life and women's attitudes toward osteoporosis prevention. Women's valuations of their current health and potential HRT-related side effects were quantified as quality-adjusted life years (QALYs) assessed by an automated utility assessment instrument (U-Titer) and the time tradeoff technique, by a vertical rating scale, and by estimated quality of well-being (QWB) scores. Health status was measured using the Medical Outcomes Study SF-36. Regression methods were used to assess the impact of current HRT use on health-related quality of life and valuation of side effects. There were 106 women with vertebral fracture and 180 with no history of hip, wrist, or vertebral fractures. Altogether, 116 (40.6%) women were currently taking HRT, 64 (22.2%) had taken HRT in the past, and 106 (37.1%) women had never taken HRT. Current HRT users had higher time tradeoff QALYs than never and past HRT users, with gains ranging from 15.0 to 83.7 days per year for current users relative to the others. Benefits were largest for women with a vertebral fracture and limitations in activities. The secondary QALY measures also showed significantly higher values for current HRT users compared with other women, as did SF-36 subscales for general health, physical function, role-emotional function, and vitality. There was substantial variability in women's perceptions of HRT side effects. Overall, the proportion of women willing to trade time to avoid bleeding was largest, at 95.5%, followed by breast tenderness, weight gain, and endometrial biopsy at 90.4%, 87.4%, and 82.7%, respectively. Current HRT users had higher health-related quality of life than past or never users according to all measures studied. Women's perceptions of potential side effects were highly variable and should be considered by physicians when prescribing an HRT regimen. If, as our results suggest, postmenopausal therapy has positive effects beyond the immediate postmenopausal years, previous economic studies may have underestimated the value of HRT.
以往对激素替代疗法（HRT）的经济学评估将其积极作用局限于缓解绝经后症状，消极作用局限于药物副作用。我们研究了HRT的使用与绝经后女性对健康相关生活质量及潜在治疗副作用的评价之间的关联。在明尼苏达州奥姆斯特德县以及新罕布什尔州达特茅斯-希区柯克医疗中心招募了过去5年内有首次椎体骨折记录或无骨质疏松性骨折病史的绝经后女性，参与一项评估生活质量及女性对骨质疏松预防态度的研究。通过自动效用评估工具（U-Titer）、时间权衡技术、垂直评分量表以及估计的幸福质量（QWB）评分，将女性对自身当前健康状况及HRT相关潜在副作用的评价量化为质量调整生命年（QALY）。使用医学结局研究简明健康调查问卷（SF-36）来测量健康状况。采用回归方法评估当前使用HRT对健康相关生活质量及副作用评价的影响。有106名椎体骨折女性和180名无髋部、腕部或椎体骨折病史的女性。总共有116名（40.6%）女性当前正在服用HRT，64名（22.2%）女性过去曾服用过HRT，106名（37.1%）女性从未服用过HRT。当前HRT使用者的时间权衡QALY高于从未使用过和过去使用过HRT的使用者，相对于其他使用者，当前使用者每年的获益为15.0至83.7天。对于有椎体骨折且活动受限的女性，获益最大。次要的QALY测量指标也显示，与其他女性相比，当前HRT使用者的值显著更高，SF-36的一般健康、身体功能、角色-情感功能和活力子量表也是如此。女性对HRT副作用的认知存在很大差异。总体而言，愿意用时间来避免出血的女性比例最高，为95.5%，其次是乳房压痛、体重增加和子宫内膜活检，分别为90.4%、87.4%和82.7%。根据所有研究指标，当前HRT使用者的健康相关生活质量高于过去使用者或从未使用者。女性对潜在副作用的认知差异很大，医生在开HRT方案时应予以考虑。如果正如我们的结果所示，绝经后治疗的积极作用超出绝经后的直接阶段，那么以往的经济学研究可能低估了HRT的价值。
