摘要：Objectives. We sought to assess the difference in a preference-based measure of health among adults reporting maltreatment as a child versus those reporting no maltreatment. Methods. Using data from a study of adults who reported adverse childhood experiences and current health status, we matched adults who reported childhood maltreatment (n = 2812) to those who reported no childhood maltreatment (n = 3356). Propensity score methods were used to compare the 2 groups. Health-related quality-of-life data (or “utilities”) were imputed from the Medical Outcomes Study 36-Item Short Form Health Survey using the Short Form–6D preference-based scoring algorithm. Results. The combined strata-level effects of maltreatment on Short Form–6D utility was a reduction of 0.028 per year (95% confidence interval=0.022, 0.034; P <.001). All utility losses for the childhood-maltreatment versus no-childhood-maltreatment groups by age group were significantly different: 18–39 years, 0.042; 40–49 years, 0.038; 50–59 years, 0.023; 60–69 years, 0.016; 70 or more years, 0.025. Conclusions. Persons who experienced childhood maltreatment had significant and sustained losses in health-related quality of life in adulthood relative to persons who did not experience maltreatment. These data are useful for asessing the cost-effectiveness of interventions designed to prevent child maltreatment in terms of cost per quality-adjusted life years saved. There is increasing evidence that exposure to childhood maltreatment can lead to greater susceptibility to lifelong physical and mental heath problems, including cardiovascular disease, hypertension, diabetes, anxiety disorders, depression, substance abuse, and perpetration of future violence. 1 – 7 Childhood maltreatment can be defined as any act or series of acts of commission or omission by a parent or other caregiver, in the context of a relationship of responsibility, trust, or power, that results in harm, potential for harm, or threat of harm to a child’s health, survival, development, or dignity. 8 , 9 Childhood maltreatment poses a substantial risk for long-term health for many reasons. First, recurrent exposure to the stress associated with maltreatment can lead to potentially irreversible changes in the interrelated brain circuits and hormonal systems that regulate stress. 10 – 12 Changes in these brain systems can lead to a premature physiological aging of the body that increases vulnerability to disease over the life course. 11 , 12 Second, childhood maltreatment increases the risk of behavioral problems such as smoking, substance abuse, obesity, and sexual promiscuity. 1 , 13 Third, a related body of evidence indicates that early adverse childhood experiences have a profound effect on a range of cognitive, social, and emotional competencies that lay the foundation for successful learning, coping, and subsequent economic productivity. 13 – 16 This broad range of childhood maltreatment’s impact on health suggests that it may also have an impact on victims’ life expectancy and long-term health-related quality of life (HRQoL). When assessed together, these outcomes provide information on the effect that childhood maltreatment has on victims’ remaining quality-adjusted life years (QALYs), which is a composite measure of health typically used in economic evaluations of health interventions such as cost-effectiveness analyses. 17 – 21 Assessment of the impact of childhood maltreatment on the first of the 2 components of the QALY—life expectancy—is relatively straightforward. It requires good epidemiological data on mortality outcomes associated with the acute and chronic phases of childhood maltreatment. Assessment of the impact of childhood maltreatment on the second component, HRQoL, is more complicated. When following national guidelines for conducting cost-effectiveness analyses, 17 , 22 , 23 measures of HRQoL should reflect relative desirability of different health outcomes under consideration for the population of interest. Preference-based measures provide a summary value for a respondent’s valuation of the quality of life of a particular health state, incorporating all positive and negative aspects of a health state into a single number. A commonly used approach for valuing preferences in health is “utility.” A utility weight is typically scaled between 1, representing perfect health, and 0, representing a health state judged equivalent to being dead. Decrements in HRQoL, as measured by utility weights on this scale, are then multiplied by length of life to estimate the QALYs associated with and without the intervention under consideration. These preferences, or utilities, can be directly elicited from the affected population or can be indirectly derived through the use of well-developed, generally accepted, and widely used generic HRQoL indexes whose valuation is based on general population samples. 24 – 28 For health outcomes resulting from physical abuse, sexual abuse, psychological abuse, neglect, or any combination thereof, few if any studies have either directly or indirectly elicited utilities. The paucity of data, particularly for health states associated with childhood maltreatment, is most likely because of a variety of practical and methodological challenges. 29 These include the difficulty in defining an average health state for acute or ongoing violent episodes, the cognitive challenges in eliciting preferences for health outcomes from children, proxy issues concerning parents or caregivers who are often the perpetrators of maltreatment, and other reasons associated with development of the field of childhood maltreatment prevention and priorities for research. 30 , 31 Only a few studies have assessed the long-term impact of childhood maltreatment on HRQoL, 32 – 35 but these have included summary measures of health that are not preference based. One summary measure of health, the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36), 36 is a commonly used health-state classification instrument. Edwards et al. compared self-reports of health on the SF-36 in an adult population to an index measure of the number of adverse exposures, including childhood maltreatment, experienced during childhood (the adverse childhood experiences [ACE] score). 32 The authors found an inverse relationship between ACE score (on which the more adverse experiences, the higher the score) and the SF-36 overall summary measure. However, the summary measure derived from the SF-36 measures health on a scale from 0 (worst health) to 100 (best health) but does not explicitly incorporate preferences into its scoring algorithm and, therefore, cannot be used to obtain preference weights for constructing the QALY. Alternatively, preference-based measures of HRQoL reflect relative desirability of a score (or index on a scale) based on tradeoffs that one would make on life expectancy to achieve better HRQoL. 23 Fortunately, new methods have been developed that enable one to translate summary measures of HRQoL into preference-based measures of HRQoL for use in cost-effectiveness analyses. This represents an exciting advance in methodology, particularly as it is applied to health outcomes associated with violence that have received such little attention in terms of eliciting preference-based measures of HRQoL. We sought to derive preference-based values for childhood maltreatment outcomes derived from summary measures of health defined by adults self-reporting maltreatment outcomes during childhood. These results, when incorporated with epidemiological data on life expectancy, will provide a means for assessing lifetime losses in QALYs and for conducting cost-effectiveness analyses of interventions designed to prevent childhood maltreatment.
