Cross-sectional and temporal differences in health-related quality of life of people with and without osteoarthritis: a 10-year prospective study

OBJECTIVE

To describe the impact of OA on health-related quality of life (HRQoL) in the forms of health state utilities (HSUs) and health-dimension scores, and to compare the longitudinal changes in HRQoL for people with and without OA, using an Australian population-based longitudinal cohort.

METHODS

Participants of the Tasmanian Older Adult Cohort with data on OA diagnosis and HRQoL were included [interviewed at baseline (n = 1093), 2.5 years (n = 871), 5 years (n = 760) and 10 years (n = 562)]. HRQoL was assessed using the Assessment of Quality of Life four-dimensions and analysed using multivariable linear mixed regressions.

RESULTS

Compared with participants without OA, HSUs for those with OA were 0.07 (95% confidence interval: 0.09, 0.05) units lower on average over 10 years. HSUs for participants with knee and/or hip OA were similar to those with other types of OA at the 2.5 year follow-up and then diverged, with HSUs of the former being up to 0.09 units lower than the latter. Those with OA had lower scores for psychological wellness, independent living and social relationships compared with those without OA. Independent living and social relationships were mainly impacted by knee and/or hip OA, with the effect on the former increasing over time.

CONCLUSION

Interventions to improve HRQoL should be tailored to specific OA types, health dimensions, and times. Support for maintaining psychological wellness should be provided, irrespective of OA type and duration. However, support for maintaining independent living could be more relevant to knee and/or hip OA patients living with the disease for longer.

What are the health and socioeconomic impacts of allergic respiratory disease in Tasmania?

Objective The aim of this study was to quantify the direct and indirect costs of asthma and allergic rhinitis (AR) for 2018 in Tasmania. Methods We used publicly available data, and Tasmanian-specific values where available, to estimate direct and indirect costs of both diseases. Direct costs included outcomes such as emergency department (ED) presentations, hospitalisations, general practice visits and medication use. Indirect costs included premature mortality and lost productivity. Results Direct health impacts for both conditions combined included 1454 ED presentations, 682 hospitalisations, 72446 general practice visits and 7122 specialist visits. Indirect health impacts included 13 deaths and between 483000 and 2.8 million days of lost productivity. Total costs ranged between A$126.5 million and A$436.7 million for asthma and between A$65.3 million and A$259.7 million for AR. Per-person annual costs ranged between A$1918 and A$6617 for asthma and between A$597 and A$2374 for AR. Conclusions The main financial burden due to asthma and AR was related to productivity losses from presenteeism and absenteeism. The magnitude of the economic impacts of AR and asthma warrants further analysis to produce a national-level assessment. Such analyses could identify cost-effective interventions that produce highest benefits for the management of these conditions in our community. What is known about the topic? Allergic respiratory diseases, and particularly asthma and AR, pose a significant health burden, with effects including asthma-related hospital admissions, significant pharmaceutical expenditure and lost workforce and school education productivity. Australia, and particularly Tasmania, has a high prevalence of these conditions, but no recent studies have appraised or estimated their health impacts and costs. What does this paper add? This paper proposes a unique and transparent costing model that allows the costs of these conditions to be estimated while accounting for restrictions in data availability. The model is used to provide the first comprehensive costings of asthma and AR in Tasmania, Australia. We identified that the estimated health costs are dominated by productivity losses from presenteeism and absenteeism, and that total per person costs are higher for a person with asthma compared to one with AR. What are the implications for practitioners? This analysis has the potential to guide cost-effective interventions by identifying where the highest benefits may be obtained when managing these conditions in our community.

Comorbidity patterns in people with multiple sclerosis: A latent class analysis of the Australian Multiple Sclerosis Longitudinal Study

BACKGROUND AND PURPOSE

This study was undertaken to identify clinically meaningful comorbidity patterns and their associations with the demographic/clinical characteristics of people with multiple sclerosis (MS).

METHODS

We conducted latent class analysis to identify clinically distinct comorbidity patterns in MS using the 15 most common comorbidities among 1518 Australian Multiple Sclerosis Longitudinal Study participants. The associations between demographic/clinical characteristics and comorbidity patterns were examined using log-binomial and multinomial logistic regression.

RESULTS

Five distinct comorbidity patterns were identified: "minimally diseased class" (30.8%), consisting of participants with no or one comorbidity; "metabolic class" (22.7%); "mental health-allergy class" (21.7%); "nonmetabolic class" (7.6%); and "severely diseased class" (7.0%), consisting of participants with higher prevalence of these comorbidities. The relative probabilities of being assigned to comorbidity classes compared to the minimally diseased class were significantly increased for participants who were older (metabolic: relative risk ratio [RRR] = 1.09, 95% confidence interval [CI] = 1.06-1.11; nonmetabolic: RRR = 1.07, 95% CI = 1.04-1.11; severely diseased: RRR = 1.04, 95% CI = 1.01-1.08), female (nonmetabolic: RRR = 5.35, 95% CI = 1.98-14.42; severely diseased: RRR = 2.21, 95% CI = 1.02-4.77), and obese (metabolic: RRR = 4.06, 95% CI = 2.45-6.72; mental health-allergy: RRR = 1.57, 95% CI = 1.00-2.46; severely diseased: RRR = 4.53, 95% CI = 2.21-9.29) and who had moderate disability (mental health-allergy: RRR = 2.32, 95% CI = 1.47-3.64; severely diseased: RRR = 2.65, 95% CI = 1.16-6.04).

CONCLUSIONS

Comorbidity patterns exist in MS. Women, people who were older, people who were obese, and people who had higher disability levels were more likely to be in classes with higher levels of comorbidity. These findings may offer opportunities for designing more personalised approaches to comorbidity prevention and treatment.

The impact of idiopathic pulmonary fibrosis on health state utility values: evidence from Australia

PURPOSE

Idiopathic pulmonary fibrosis (IPF) is a progressive and universally fatal lung disease, characterised by increasing fibrosis of the lung parenchyma. In this study, we aimed to quantify the health state utility values (HSUVs) for Australians with IPF and to identify the factors affecting these HSUVs.

METHODS

Participants of the Australian IPF Registry (AIPFR), with data on EuroQoL five dimension-five level (EQ-5D-5L) profiles were included. Pulmonary function tests (PFTs) were used to assess disease severity using three IPF -based classification systems. Stepwise multivariable linear regression models assessed the relationship between HSUVs and important demographic and clinical parameters.Query RESULTS: A total of 155 participants provided data for the analysis of HSUVs. For our base case, HSUVs ranged from - 0.57 to 1.00. Mean HSUVs for all participants was 0.65 (95% CI 0.61-0.70). In general, HSUVs decreased with increasing disease severity under all disease severity classification systems. Multivariable linear regression demonstrated a negative association between HSUVs, disease severity and having more than 2 comorbidities.

CONCLUSIONS

Our study has shown that EQ-5D-5L has exhibited discriminatory sensitivity for the study population. We have demonstrated that disease severity and having more than two comorbidities was associated with lower HSUVs in Australians with IPF. Our findings support early diagnosis and appropriate evidence-based treatment to slow or prevent IPF progression; and identification and treatment of associated comorbidities to potentially improve health-related quality of life in people with IPF.

A systematic review of cost-effectiveness analyses of continuous versus intermittent renal replacement therapy in acute kidney injury

INTRODUCTION

Though cost-effectiveness analyses (CEAs) have evaluated continuous renal replacement therapy (RRTs) and intermittent RRTs in acute kidney injury (AKI) patients; it is yet to establish which RRT technique is most cost-effective. We systematically reviewed the current evidence from CEAs of CRRT versus IRRT in patients with AKI.

AREAS COVERED

PubMed, EMBASE, and Cochrane databases searched for CEAs comparing two RRTs. Overall, seven CEAs, two from Brazil and one from US, Canada, Colombia, Belgium, and Argentina were included. Five CEAs used Markov model, three reported following CHEERS, none accounted indirect costs. Time horizon varied from 1-year-lifetime. Marginal QALY gain with CRRT compared to IRRT was reported across CEAs. Older CEAs found CRRT to be costlier and not cost-effective than IRRT (ICER 2019 US$: 152,671$/QALY); latest CEAs (industry-sponsored) reported CRRT to be cost-saving versus IRRT (-117,614$/QALY). Risk of mortality, dialysis dependence, and incidence of renal recovery were the key drivers of cost-effectiveness.

EXPERT OPINION

CEAs of RRTs for AKI show conflicting findings with secular trends. Latest CEAs suggested CRRT to be cost-effective versus IRRT with dialysis dependence rate as major driver of cost-effectiveness. Future CEAs, preferably non-industry sponsored, may account for indirect costs to improve the generalizability of CEAs.

A Systematic Review and Narrative Synthesis of Health Economic Evaluations of Hepatocellular Carcinoma Screening Strategies

OBJECTIVES

Many economic evaluations of hepatocellular carcinoma (HCC) screenings have been conducted; however, these vary substantially with regards to screening strategies, patient group, and setting. This review aims to report the current knowledge of the cost-effectiveness of screening and describe the published data.

METHODS

We conducted a search of biomedical and health economic databases up to July 2020. We included full and partial health economic studies if they evaluated the costs or outcomes of HCC screening strategies.

RESULTS

The review included 43 studies. Due to significant heterogeneity in key aspects across the studies, a narrative synthesis was conducted. Most studies reported using ultrasound or alpha fetoprotein as screening strategies. Screening intervals were mostly annual or biannual. Incidence, diagnostic performance, and health state utility values were the most critical parameters affecting the cost-effectiveness of screening. The majority of studies reported HCC screening to be cost-effective, with the biannual ultrasound + alpha fetoprotein standing out as the most cost-effective strategy. However, few studies considered the utilization rate, and none considered the diagnostic performance of ultrasound in the context of central adiposity. Computed tomography and magnetic resonance imaging were also evaluated, but its cost-effectiveness was still controversial.

CONCLUSIONS

Although many studies suggested HCC screening was cost-effective, substantial limitations of the quality of these studies means the results should be interpreted with caution. Future modeling studies should consider the impact of central adiposity on the precision of ultrasound, real-world utilization rates and projections of increased HCC incidence.

The impact of comorbidities on health-related quality of life of people with osteoarthritis over ten years

OBJECTIVE

To investigate the impact of total number and patterns of comorbidities on health-related quality of life (HRQoL) and identify the most prevalent and influential comorbidity patterns in people with osteoarthritis (OA) over ten years.

METHODS

Participants from the Tasmanian Older Adult Cohort aged 50-80 years, with self-reported OA and data on comorbidities and HRQoL were included. Participants were interviewed at baseline (n = 398), 2.5-years (n = 304), 5-years (n = 269) and 10-years (n = 191). Data on the self-reported presence of 10 chronic comorbidities were collected at baseline. HRQoL was assessed using the Assessment of Quality of Life-4-Dimensions. The long-term impacts of the number and of the nine most prevalent combinations of cardiovascular (CVD), non-OA musculoskeletal (Ms), metabolic, and respiratory comorbidities on HRQoL over ten years were analysed using linear mixed regressions.

RESULTS

Compared with comorbidity-free OA participants, the health state utility (HSU) of those with 2 or ≥ 3 comorbidities was respectively -0.07 and -0.13 units lower over ten years, largely driven by reduced scores for independent living, social relationships and psychological wellness. Comorbidity patterns including 'CVD+Ms' were most influential, and associated with up to 0.13 units lower HSU, mostly through negative impacts on independent living (up to -0.12), psychological wellness (up to -0.08) and social relationship (up to -0.06).

CONCLUSION

Having more comorbidities negatively impacted OA patients' long-term HRQoL. OA patients with CVD and non-OA musculoskeletal conditions had the largest HSU impairment, therefore optimal management and prevention of these conditions may yield improvements in OA patients' HRQoL.

Measuring Hypertension Progression With Transition Probabilities: Estimates From the WHO SAGE Longitudinal Study

This paper assessed the transition probabilities between the stages of hypertension severity and the length of time an individual might spend at a particular disease state using the new American College of Cardiology/American Heart Association hypertension blood pressure guidelines. Data for this study were drawn from the Ghana WHO SAGE longitudinal study, with an analytical sample of 1884 across two waves. Using a multistate Markov model, we estimated a seven-year transition probability between normal/elevated blood pressure (systolic ≤ 129 mm Hg & diastolic <80 mm Hg), stage 1 (systolic 130-139 mm Hg & diastolic 80-89 mm Hg), and stage 2 (systolic ≥140mm Hg & diastolic≥90 mm Hg) hypertension and adjusted for the individual effects of anthropometric, lifestyle, and socio-demographic factors. At baseline, 22.5% had stage 1 hypertension and 52.2% had stage 2 hypertension. The estimated seven-year transition probability for the general population was 19.0% (95% CI: 16.4, 21.8) from normal/elevated blood pressure to stage 1 hypertension, 31.6% (95% CI: 27.6, 35.4%) from stage 1 hypertension to stage 2 hypertension, and 48.5% (45.6, 52.1%) for remaining at stage 2. Other factors such as being overweight, obese, female, aged 60+ years, urban residence, low education and high income were associated with an increased probability of remaining at stage 2 hypertension. However, consumption of recommended servings of fruits and vegetables per day was associated with a delay in the onset of stage 1 hypertension and a recovery to normal/elevated blood pressure. This is the first study to show estimated transition probabilities between the stages of hypertension severity across the lifespan in sub-Saharan Africa. The results are important for understanding progression through hypertension severity and can be used in simulating cost-effective models to evaluate policies and the burden of future healthcare.

Ambulatory oxygen for treatment of exertional hypoxaemia in pulmonary fibrosis (PFOX trial): a randomised controlled trial

INTRODUCTION

Interstitial lung diseases are characterised by scarring of lung tissue that leads to reduced transfer of oxygen into the blood, decreased exercise capacity and premature death. Ambulatory oxygen therapy may be used to treat exertional oxyhaemoglobin desaturation, but there is little evidence to support its efficacy and there is wide variation in clinical practice. This study aims to compare the clinical efficacy and cost-effectiveness of ambulatory oxygen versus ambulatory air in people with fibrotic interstitial lung disease and exertional desaturation.

METHODS AND ANALYSIS

A randomised, controlled trial with blinding of participants, clinicians and researchers will be conducted at trial sites in Australia and Sweden. Eligible participants will be randomised 1:1 into two groups. Intervention participants will receive ambulatory oxygen therapy using a portable oxygen concentrator (POC) during daily activities and control participants will use an identical POC modified to deliver air. Outcomes will be assessed at baseline, 3 months and 6 months. The primary outcome is change in physical activity measured by number of steps per day using a physical activity monitor (StepWatch). Secondary outcomes are functional capacity (6-minute walk distance), health-related quality of life (St George Respiratory Questionnaire, EQ-5D-5L and King's Brief Interstitial Lung Disease Questionnaire), breathlessness (Dyspnoea-12), fatigue (Fatigue Severity Scale), anxiety and depression (Hospital Anxiety and Depression Scale), physical activity level (GENEActive), oxygen saturation in daily life, POC usage, and plasma markers of skeletal muscle metabolism, systematic inflammation and oxidative stress. A cost-effectiveness evaluation will also be undertaken.

ETHICS AND DISSEMINATION

Ethical approval has been granted in Australia by Alfred Hospital Human Research Ethics Committee (HREC/18/Alfred/42) with governance approval at all Australian sites, and in Sweden (Lund Dnr: 2019-02963). The results will be published in peer-reviewed scientific journals, presented at conferences and disseminated to consumers in publications for lay audiences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03737409).

Health-related quality of life of patients with idiopathic pulmonary fibrosis: a systematic review and meta-analysis

Idiopathic pulmonary fibrosis (IPF) is one of the most common forms of interstitial lung disease presenting in persons 50 years and older. Through a comprehensive review of available studies, we aimed to assess health-related quality of life (HRQoL) of people living with IPF and the instruments used in this assessment.Searches were conducted up to May, 2020. Quality appraisal and data extraction were performed using pre-designed forms. Narrative synthesis approach was used to report results of the systematic review and a random effects model was used for the meta-analysis. A leave-one-out sensitivity analysis was performed, and a trim and fill method was used to assess publication bias.The review included 134 studies. The most used instruments to measure HRQoL were St George's Respiratory Questionnaire (SGRQ), Short Form 36 (SF36) and EuroQoL (EQ5D). Standardised mean scores (95% confidence interval) for these instruments were as follows: SGRQ total score: 44.72 (42.21-47.22); SF36 physical component score (PCS): 37.00 (34.74-39.26) SF36 mental component score (MCS): 50.18 (48.41-51.95); King's Brief Interstitial Lung Disease questionnaire total score: 58.38 (55.26-61.51); and EQ5D utility: 0.73 (0.68-0.79). Analysis of standardised means for both SGRQ and SF36 demonstrated worse scores in physical health domains as compared to mental health domains.This systematic review confirms that IPF negatively affected HRQoL, mostly impacting the physical health domains. This study also demonstrated that a diverse number of instruments are used to evaluate HRQoL. In view of this diversity, a standardised approach to measurement of HRQoL for IPF is important to ensure that comparisons made are reliable.

A systematic review and meta-analysis of health state utility values for osteoarthritis-related conditions

BACKGROUND

Health state utility values (HSUVs) are a key input in health economic modelling but HSUVs of people with osteoarthritis (OA)-related conditions have not been systematically reviewed and meta-analysed.

OBJECTIVE

To systematically review and meta-analyse the HSUVs for people with OA.

METHODS

Searches within health economic/biomedical databases were performed to identify eligible studies reporting OA-related HSUVs. Data on study design, participant characteristics, affected OA joint sites, treatment type, HSUV elicitation method, considered health states, and the reported HSUVs were extracted. HSUVs for people with knee, hip and mixed OA in pre- and post-treatment populations were meta-analysed using random effects models.

RESULTS

One-hundred and fifty-one studies were included in the systematic review, and 88 in meta-analyses. Of 151 studies, 56% were conducted in Europe, 75% were in people with knee and/or hip OA and 79% were based on the EQ-5D. The pooled mean (95% confidence interval [CI]) baseline HSUVs for knee OA core interventions, medication, injection and primary surgery treatments were 0.64 (0.61-0.66), 0.56 (0.45-0.68), 0.58 (0.50-0.66) and 0.52 (0.49-0.55), respectively. These were 0.71 (0.59-0.84) for hip OA core interventions and 0.52 (0.49-0.56) for hip OA primary surgery. For all knee OA treatments and hip OA primary surgery, pooled HSUVs were significantly higher in the post- than the pre- treatment populations.

CONCLUSION

This study provides a comprehensive summary of OA-related HSUVs and generates a HSUVs database for people with different affected OA joint sites undergoing different treatments to guide HSUV choices in future health economic modelling of OA interventions.

Socio-demographic, behavioural and health-related characteristics associated with active commuting in a regional Australian state: Evidence from the 2016 Tasmanian Population Health Survey

ISSUE ADDRESSED

Physical activity is lower and rates of preventable common diseases are higher in regional/rural than urban Australia. Active commuting (walking/bicycling to get from one place to another) may benefit health through increased physical activity, but most evidence of its correlates come from urban studies. This study aimed to investigate associations between active commuting, socio-demographic characteristics, behaviours, total physical activity and health in a regional/rural Australian state.

METHODS

This study used data from the 2016 Tasmanian Population Health Survey, a representative cross-sectional self-report survey of 6,300 adults in Tasmania, Australia. Logistic regression modelling investigated associations between socio-demographic, behavioural and health characteristics and past week active commuting frequency.

RESULTS

In multivariable models, being younger, having tertiary qualifications, living in a socio-economically advantaged area, being physically active, having a healthy body mass index and good/excellent self-rated health were associated with engaging in more active commuting. Inner regional dwellers were no more likely than outer regional dwellers to actively commute after covariate adjustment.

CONCLUSION

Strategies to promote active commuting in regional/rural areas might consider targeting older adults, those less educated, those living in socio-economically disadvantaged areas, those less physically active, those with poorer health and those with higher body mass index. Research could further investigate why these groups appear to be less active for commuting purposes. SO WHAT?: Increasing physical activity and active commuting may help to reduce rates of preventable common diseases in regional/remote areas.

Feelings of depression, pain and walking difficulties have the largest impact on the quality of life of people with multiple sclerosis, irrespective of clinical phenotype

Background:

The symptoms that have the largest impact on health-related quality of life (HRQoL) in people with multiple sclerosis (MS) may vary by MS phenotype (relapsing-remitting MS (RRMS), secondary progressive MS (SPMS) and primary progressive MS (PPMS)). Knowing these symptoms assists in symptom management.

Objective:

To examine the associations between 13 common MS symptoms and HRQoL in the total sample and stratified by MS phenotype.

Method:

The study included 1985 participants. HRQoL was measured with two multi-attribute utility instruments: assessment of quality of life with eight dimensions (AQoL-8D) and European quality of life with five dimensions and five levels for each dimension (EQ-5D-5L). Multivariable linear regression was used to identify the symptoms that had the largest impact on the HRQoLs.

Results:

Feelings of depression, pain, fatigue, and feelings of anxiety were most strongly associated with AQoL-8D and EQ-5D-5L. Walking difficulties additionally contributed to reduced EQ-5D-5L. The strongest single predictors in the multivariable analyses were feelings of depression or pain for AQoL-8D and walking difficulties for EQ-5D-5L, irrespective of MS phenotype.

Conclusion:

The strongest single predictors for the AQoL-8D and EQ-5D-5L were feelings of depression, pain and walking difficulties, irrespective of MS phenotype. Reducing these symptoms may have the largest impact on improving HRQoL in all MS phenotypes of people with MS.

Risk factors for leaving employment due to multiple sclerosis and changes in risk over the past decades: Using competing risk survival analysis

Background:

No studies have assessed changes in employment survival in multiple sclerosis (MS) populations over recent decades, including the introduction of disease-modifying therapies (DMTs).

Objectives:

To evaluate factors associated with leaving employment due to MS; to assess whether the risk of leaving employment has changed over recent decades in Australia, stratified by MS phenotype.

Methods:

We included 1240 participants who were working before MS diagnosis. Information on employment status, reasons for leaving employment and year of leaving were collected. Data were analysed using competing risk survival analysis.

Results:

Males, progressive MS, lower education level and older age at diagnosis were associated with a higher sub-distribution hazard of leaving employment. Compared to the period before 2010, the sub-distribution hazard during 2010–2016 for relapsing-remitting multiple sclerosis (RRMS) was reduced by 43% (sub-distribution hazard ratio (sHR) 0.67, 95% confidence interval (CI): 0.50 to 0.90), while no significant reduction was seen for primary-progressive multiple sclerosis (PPMS) (sHR 1.25, 95% CI: 0.72 to 2.16) or secondary-progressive multiple sclerosis (SPMS) (sHR 1.37, 95% CI: 0.84 to 2.25).

Conclusion:

Males, people with progressive MS and those of lower education level were at higher risk of leaving employment. The differential changed risk of leaving employment between people with different MS phenotype after 2010 coincides with the increased usage of high-efficacy DMTs for RRMS.

Comorbidities contribute substantially to the severity of common multiple sclerosis symptoms

BACKGROUND

More research is needed to understand the contribution of comorbidities to MS symptomatology.

OBJECTIVES

To examine the dose-response relationship between the number of comorbidities and severity of MS symptoms and to assess the relative contribution of comorbidity groups and individual comorbidities to the severity of each symptom.

METHODS

We surveyed 1223 participants of the Australian MS Longitudinal Study for the presence of 30 comorbidities and the severity of 13 MS symptoms (0-10 scale). The associations between comorbidities and symptoms were assessed using negative binomial regression. The relative contributions of comorbidities to the severity of symptoms were assessed using general dominance analysis.

RESULTS

Higher number of comorbidities was most strongly associated with a higher severity of pain and feelings of anxiety and depression (ratios of means ≥ 0.12 per comorbidity increase). Comorbidities explained between 3.7% (spasticity) and 22.0% (feelings of anxiety) of the total variance of symptom severity. Mental health and musculoskeletal disorders contributed most strongly to the severity of the most common symptoms in MS.

CONCLUSIONS

Our findings support that early recognition and optimal management of comorbidities, particularly of mental health and musculoskeletal disorders, could have a positive impact on the severity of symptoms of people with MS.

Impact of overweight and obesity on life expectancy, quality-adjusted life years and lifetime costs in the adult population of Ghana

INTRODUCTION

Prior studies have revealed the increasing prevalence of obesity and its associated health effects among ageing adults in resource poor countries. However, no study has examined the long-term and economic impact of overweight and obesity in sub-Saharan Africa. Therefore, we quantified the long-term impact of overweight and obesity on life expectancy (LE), quality-adjusted life years (QALYs) and total direct healthcare costs.

METHODS

A Markov simulation model projected health and economic outcomes associated with three categories of body mass index (BMI): healthy weight (18.5≤BMI <25.0); overweight (25.0≤BMI < 30.0) and obese (BMI ≥30.0 kg/m2) in simulated adult cohorts over a 50-year time horizon from age fifty. Costs were estimated from government and patient perspectives, discounted 3% annually and reported in 2017 US$. Mortality rates from Ghanaian lifetables were adjusted by BMI-specific all-cause mortality HRs. Published input data were used from the 2014/2015 Ghana WHO Study on global AGEing and adult health data. Internal and external validity were assessed.

RESULTS

From age 50 years, average (95% CI) remaining LE for females were 25.6 (95% CI: 25.4 to 25.8), 23.5 (95% CI: 23.3 to 23.7) and 21.3 (95% CI: 19.6 to 21.8) for healthy weight, overweight and obesity, respectively. In males, remaining LE were healthy weight (23.0; 95% CI: 22.8 to 23.2), overweight (20.7; 95% CI: 20.5 to 20.9) and obesity (17.6; 95% CI: 17.5 to 17.8). In females, QALYs for healthy weight were 23.0 (95% CI: 22.8 to 23.2), overweight, 21.0 (95% CI: 20.8 to 21.2) and obesity, 19.0 (95% CI: 18.8 to 19.7). The discounted total costs per female were US$619 (95% CI: 616 to 622), US$1298 (95% CI: 1290 to 1306) and US$2057 (95% CI: 2043 to 2071) for healthy weight, overweight and obesity, respectively. QALYs and costs were lower in males.

CONCLUSION

Overweight and obesity have substantial health and economic impacts, hence the urgent need for cost-effective preventive strategies in the Ghanaian population.

Evaluating the Ability of Economic Models of Diabetes to Simulate New Cardiovascular Outcomes Trials: A Report on the Ninth Mount Hood Diabetes Challenge

OBJECTIVES

The cardiovascular outcomes challenge examined the predictive accuracy of 10 diabetes models in estimating hard outcomes in 2 recent cardiovascular outcomes trials (CVOTs) and whether recalibration can be used to improve replication.

METHODS

Participating groups were asked to reproduce the results of the Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG OUTCOME) and the Canagliflozin Cardiovascular Assessment Study (CANVAS) Program. Calibration was performed and additional analyses assessed model ability to replicate absolute event rates, hazard ratios (HRs), and the generalizability of calibration across CVOTs within a drug class.

RESULTS

Ten groups submitted results. Models underestimated treatment effects (ie, HRs) using uncalibrated models for both trials. Calibration to the placebo arm of EMPA-REG OUTCOME greatly improved the prediction of event rates in the placebo, but less so in the active comparator arm. Calibrating to both arms of EMPA-REG OUTCOME individually enabled replication of the observed outcomes. Using EMPA-REG OUTCOME-calibrated models to predict CANVAS Program outcomes was an improvement over uncalibrated models but failed to capture treatment effects adequately. Applying canagliflozin HRs directly provided the best fit.

CONCLUSIONS

The Ninth Mount Hood Diabetes Challenge demonstrated that commonly used risk equations were generally unable to capture recent CVOT treatment effects but that calibration of the risk equations can improve predictive accuracy. Although calibration serves as a practical approach to improve predictive accuracy for CVOT outcomes, it does not extrapolate generally to other settings, time horizons, and comparators. New methods and/or new risk equations for capturing these CV benefits are needed.

Systematic Review of the Evolution of Health-Economic Evaluation Models of Osteoarthritis

OBJECTIVE

To comprehensively synthesize the evolution of health-economic evaluation models (HEEMs) of all osteoarthritis (OA) interventions, including preventions, core treatments, adjunct nonpharmacologic interventions, pharmacologic interventions, and surgical treatments.

METHODS

The literature was searched within health-economic/biomedical databases. Data extracted included OA type, population characteristics, model setting/type/events, study perspective, and comparators; the reporting quality of the studies was also assessed. The review protocol was registered at the International Prospective Register of Systematic Reviews (CRD42018092937).

RESULTS

Eighty-eight studies were included. Pharmacologic and surgical interventions were the focus in 51% and 44% of studies, respectively. Twenty-four studies adopted a societal perspective (with increasing popularity after 2013), but most (63%) did not include indirect costs. Quality-adjusted life years was the most popular outcome measure since 2008. Markov models were used by 62% of studies, with increasing popularity since 2008. Until 2010, most studies used short-to-medium time horizons; subsequently, a lifetime horizon became popular. A total of 86% of studies reported discount rates (predominantly between 3% and 5%). Studies published after 2002 had a better coverage of OA-related adverse events (AEs). Reporting quality significantly improved after 2001.

CONCLUSION

OA HEEMs have evolved and improved substantially over time, with the focus shifting from short-to-medium-term pharmacologic decision-tree models to surgical-focused lifetime Markov models. Indirect costs of OA are frequently not considered, despite using a societal perspective. There was a lack of reporting sensitivity of model outcome to input parameters, including discount rate, OA definition, and population parameters. While the coverage of OA-related AEs has improved over time, it is still not comprehensive.

trips4health: Protocol of a single-blinded randomised controlled trial incentivising adults to use public transport for physical activity gain

Background

Public transport (PT) users typically accumulate more physical activity (PA) than private motor vehicle users yet redressing physical inactivity through transport-related PA (TRPA) interventions has received limited attention. Further, incentive-based strategies can increase leisure-time PA but their impact on TRPA, is unclear. This study's objective is to determine the impact of an incentive-based strategy on TRPA in a regional Australian setting.

Methods

trips4health is a single-blinded randomised controlled trial with a four-month intervention phase and subsequent six-month maintenance phase. Participants will be randomised to: an incentives-based intervention (bus trip credit for reaching bus trip targets, weekly text messages to support greater bus use, written PA guidelines); or an active control (written PA guidelines only). Three hundred and fifty adults (≥18 years) from southern Tasmania will be recruited through convenience methods, provide informed consent and baseline information, then be randomised. The primary outcome is change in accelerometer measured average daily step count at baseline and four- and ten-months later. Secondary outcomes are changes in: measured and self-reported travel behaviour (e.g. PT use), PA, sedentary behaviour; self-reported and measured (blood pressure, waist circumference, height, weight) health; travel behaviour perspectives (e.g. enablers/barriers); quality of life; and transport-related costs. Linear mixed model regression will determine group differences. Participant and PT provider level process evaluations will be conducted and intervention costs to the provider determined.

Discussion

trips4health will determine the effectiveness of an incentive-based strategy to increase TRPA by targeting PT use. The findings will enable evidence-informed decisions about the worthwhileness of such strategies.

Trial registration

ACTRN12619001136190.

Universal trial number

U1111-1233-8050.

Health state utilities for economic evaluation of bariatric surgery: A comprehensive systematic review and meta-analysis

Health state utilities (HSUs) are health economic metrics that capture and assess health-related quality of life (HRQoL). They are essential in health-economic evaluations when calculating quality-adjusted life years. We investigated published studies reporting bariatric surgery-related HSUs elicited through direct or indirect (multiattribute utility instrument [MAUI]) patient-reported methods (PROSPERO registration number: CRD42019131725). Mean HSUs for different time points and HSU changes over time (where feasible) were meta-analysed using random-effects models. Of the 950 potentially relevant identified studies, n = 28 (2004-2018) qualified for data extraction, with n = 85 unique HSUs elicited mainly from the EQ-5D (88%). Most (75%) studies were published after 2013. The follow-up duration varied between studies and was often limited to 12 months. The pooled mean HSU was 0.72 (0.67-0.76) at baseline/presurgery (n = 18) and 0.84 (0.79-0.89) one-year postsurgery (n = 11), indicating a 0.11 (0.09-0.14) utility unit increment. EQ-5D showed the similar results. This positive difference can be partially explained by BMI and/or co-morbidities status improvement. This study provides a valuable summary of HSUs to future bariatric surgery-related cost-utility models. However, more well-designed higher-quality bariatric-related HSU studies are expected for future reviews to improve the available evidence. We suggest that researchers select an MAUI that is preferentially sensitive to the study population.

A Patient-Level Model to Estimate Lifetime Health Outcomes of Patients With Type 1 Diabetes

OBJECTIVE

To develop a patient-level simulation model for predicting lifetime health outcomes of patients with type 1 diabetes and as a tool for economic evaluation of type 1 diabetes treatment based on data from a large, longitudinal cohort.

RESEARCH DESIGN AND METHODS

Data for model development were obtained from the Swedish National Diabetes Register. We derived parametric proportional hazards models predicting the absolute risk of diabetes complications and death based on a wide range of clinical variables and history of complications. We used linear regression models to predict risk factor progression. Internal validation was performed, estimates of life expectancies for different age-sex strata were computed, and the impact of key risk factors on life expectancy was assessed.

RESULTS

The study population consisted of 27,841 patients with type 1 diabetes with a mean duration of follow-up of 7 years. Internal validation showed good agreement between the predicted and observed cumulative incidence of death and 10 complications. Simulated life expectancy was ∼13 years lower than that of the sex- and age-matched general population, and patients with type 1 diabetes could expect to live with one or more complications for ∼40% of their remaining life. Sensitivity analysis showed the importance of preventing renal dysfunction, hypoglycemia, and hyperglycemia as well as lowering HbA_1c in reducing the risk of complications and death.

CONCLUSIONS

Our model was able to simulate risk factor progression and event histories that closely match the observed outcomes and to project events occurring over patients' lifetimes. The model can serve as a tool to estimate the impact of changing clinical risk factors on health outcomes to inform economic evaluations of interventions in type 1 diabetes.

Health Impacts of Ambient Biomass Smoke in Tasmania, Australia

The island state of Tasmania has marked seasonal variations of fine particulate matter (PM2.5) concentrations related to wood heating during winter, planned forest fires during autumn and spring, and bushfires during summer. Biomass smoke causes considerable health harms and associated costs. We estimated the historical health burden from PM2.5 attributable to wood heater smoke (WHS) and landscape fire smoke (LFS) in Tasmania between 2010 and 2019. We calculated the daily population level exposure to WHS- and LFS-related PM2.5 and estimated the number of cases and health costs due to premature mortality, cardiorespiratory hospital admissions, and asthma emergency department (ED) visits. We estimated 69 deaths, 86 hospital admissions, and 15 asthma ED visits, each year, with over 74% of impacts attributed to WHS. Average yearly costs associated with WHS were of AUD$ 293 million and AUD$ 16 million for LFS. The latter increased up to more than AUD$ 34 million during extreme bushfire seasons. This is the first study to quantify the health impacts attributable to biomass smoke for Tasmania. We estimated substantial impacts, which could be reduced through replacing heating technologies, improving fire management, and possibly implementing integrated strategies. This would most likely produce important and cost-effective health benefits.

A new model of care and in-house general practitioners for residential aged care facilities: a stepped wedge, cluster randomised trial

OBJECTIVES

To evaluate whether an alternative model of care in aged care facilities, including in-house general practitioners, influenced health outcomes for residents.

DESIGN

Stepped wedge, cluster randomised controlled trial over 90 weeks (31 December 2012 - 21 September 2014), with a 54-week pre-trial retrospective data period (start: 19 December 2011) and a 54-week post-trial prospective data collection period (to 4 October 2015).

PARTICIPANTS, SETTING

Fifteen residential aged care facilities operated by Bupa Aged Care in metropolitan and regional cities in four Australian states.

INTERVENTION

Residential aged care facilities sought to recruit general practitioners as staff members; care staff roles were redefined to allow registered nurses greater involvement in care plan development.

MAIN (PRIMARY) OUTCOME MEASURES

Numbers of falls; numbers of unplanned transfers to hospital; polypharmacy.

RESULTS

The new model of care could be implemented in all facilities, but four could not recruit in-house GPs at any time during the trial period. Intention-to-treat analyses found no statistically significant effect of the intervention on the primary outcome measures. Contamination-adjusted intention-to-treat analyses identified that the presence of an in-house GP was associated with reductions in the numbers of unplanned hospital transfers (incidence rate ratio [IRR], 0.53; 95% CI, 0.43-0.66) and admissions (IRR, 0.52; 95% CI, 0.41-0.64) and of out-of-hours GP call-outs (IRR, 0.54; 95% CI, 0.36-0.80), but also with an increase in the number of reported falls (IRR, 1.37; 95% CI, 1.20-1.58).

CONCLUSIONS

Recruiting GPs to work directly in residential aged care facilities is difficult, but may reduce the burden of unplanned presentations to hospitals and increase the reporting of adverse events.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry, ACTRN12613000218796 (25 February 2013).

Annual transition probabilities of overweight and obesity in older adults: Evidence from World Health Organization Study on global AGEing and adult health

Overweight/obesity is becoming increasingly prevalent in sub-Saharan Africa including Ghana. However, transition probabilities, an essential component to develop cost-effective measures for weight management is lacking in this population. We estimated annual transition probabilities between three body mass index (BMI) categories: normal weight (BMI ≥18.5 and <25.0 kg/m2), overweight (BMI ≥25.0 and <30.0 kg/m2), and obesity (BMI ≥30.0 kg/m2), among older adults aged ≥50 years in Ghana. Data were used from a nationally representative, multistage sample of 1496 (44.3% females) older adults in both Waves 1 (2007/8) and 2 (2014/15) of the Ghana WHO SAGE. A multistage Markov model was used to estimate annual transition probabilities. We further examined the impact of specific socio-economic factors on the transition probabilities. At baseline, 22.8% were overweight and 11.1% were obese. The annual transition probability was 4.0% (95% CI: 3.4%, 4.8%) from normal weight to overweight, 11.1% (95% CI: 9.5%, 13.0%) from overweight to normal weight and 4.9% (95% CI: 3.8%, 6.2%) from overweight to obesity. For obese individuals, the probability of remaining obese, transitioning to overweight and completely reverting to normal weight was 90.2% (95% CI: 87.7%, 92.3%), 9.2% (95% CI: 7.2%, 11.6%) and 0.6% (95% CI: 0.4%, 0.8%) respectively. Being female, aged 50-65 years, urban residence, having high education and high wealth were associated with increased probability of transitioning into the overweight or obese categories. Our findings highlight the difficulty in transitioning away from obesity, especially among females. The estimated transition probabilities will be essential in health economic simulation models to determine sustainable weight management interventions.

Bariatric surgery is a cost-saving treatment for obesity-A comprehensive meta-analysis and updated systematic review of health economic evaluations of bariatric surgery

Demand for bariatric surgery to treat severe and resistant obesity far outstrips supply. We aimed to comprehensively synthesise health economic evidence regarding bariatric surgery from 1995 to 2018 (PROSPERO registration number: CRD42018094189). Meta-analyses were conducted to calculate the annual cost changes "before" and "after" surgery, and cumulative cost differences between surgical and nonsurgical groups. An updated narrative review also summarized the full and partial health economic evaluations of surgery from September 2015. N = 101 studies were eligible for the qualitative analyses since 1995, with n = 24 studies after September 2015. Quality of reporting has increased, and the inclusion of complications/reoperations was predominantly contained in the full economic evaluations after September 2015. Technical improvements in surgery were also reflected across the studies. Sixty-one studies were eligible for the quantitative meta-analyses. Compared with no/conventional treatment, surgery was cost saving over a lifetime scenario. Additionally, consideration of indirect costs through sensitivity analyses increased cost savings. Medication cost savings were dominant in the before versus after meta-analysis. Overall, bariatric surgery is cost saving over the life course even without considering indirect costs. Health economists are hearing the call to present higher quality studies and include the costs of complications/reoperations; however, indirect costs and body contouring surgery are still not appropriately considered.

Validation of 0-10 MS symptom scores in the Australian multiple sclerosis longitudinal study

BACKGROUND

Multiple sclerosis (MS) symptom measurements often use multiple-item scales per symptom, creating a high burden when multiple symptoms are assessed. We aimed to examine the validity, stability and responsiveness of single-item 0-10 numeric rating MS Symptom Scores (MSSymS).

METHODS

The study included 1,985 participants from the Australian Multiple Sclerosis Longitudinal Study. Thirteen MS symptoms were assessed using the MSSymS, of which we were able to validate six (walking difficulties, fatigue, pain, feelings of anxiety, feelings of depression and vision problems). Comparison measures included Patient Determined Disease Steps (PDDS), Fatigue Severity Scale (FSS), Hospital Anxiety and Depression Scale (HADS), and Assessment of Quality of Life (AQoL). We used spearman rank correlation for concurrent validity, linear regression for predictive validity, intra-class correlations for stability, and percentage change for responsiveness.

RESULTS

We found high correlations between walking difficulties and PDDS (r = 0.82), pain and AQoL-pain (r = 0.77), fatigue and FSS (r = 0.72); moderate correlations between feelings of anxiety and HADS-Anxiety (r = 0.68), feelings of depression and HADS-Depression (r = 0.63); and low correlation between vision and AQoL-vision (r = 0.43) For predictive validity, the graphs with quality of life were largely overlapping and the R² of the regression lines were generally similar. The stability and responsiveness of the MSSymS were adequate.

CONCLUSION

The six assessed symptoms of the MSSymS performed equally well compared to validated comparison measures in terms of concurrent and predictive validity, temporal stability and responsiveness.

Health service utilization and direct healthcare costs associated with obesity in older adult population in Ghana

Obesity is a major risk factor for many chronic diseases and disabilities, with severe implications on morbidity and mortality among older adults. With an increasing prevalence of obesity among older adults in Ghana, it has become necessary to develop cost-effective strategies for its management and prevention. However, developing such strategies is challenging as body mass index (BMI)-specific utilization and costs required for cost-effectiveness analysis are not available in this population. Therefore, this study examines the associations between health services utilization as well as direct healthcare costs and overweight (BMI ≥25.00 and &lt;30.00 kg/m2) and obesity (BMI ≥30.00 kg/m2) among older adults in Ghana. Data were used from a nationally representative, multistage sample of 3350 people aged 50+ years from the World Health Organization’s Study on global AGEing and adult health (WHO-SAGE; 2014/15). Health service utilization was measured by the number of health facility visits over a 12-month period. Direct costs (2017 US dollars) included out-of-pocket payments and the National Health Insurance Scheme (NHIS) claims. Associations between utilization and BMI were examined using multivariable zero-inflated negative binomial regressions; and between costs and BMI using multivariable two-part regressions. Twenty-three percent were overweight and 13% were obese. Compared with normal-weight participants, overweight and obesity were associated with 75% and 159% more inpatient admissions, respectively. Obesity was also associated with 53% additional outpatient visits. One in five of the overweight and obese population had at least one chronic disease, and having chronic disease was associated with increased outpatient utilization. The average per person total costs for overweight was $78 and obesity was $132 compared with $35 for normal weight. The NHIS bore approximately 60% of the average total costs per person expended in 2014/15. Overweight and obese groups had significantly higher total direct healthcare costs burden of $121 million compared with $64 million for normal weight in the entire older adult Ghanaian population. Compared with normal weight, the total costs per person associated with overweight increased by 73% and more than doubled for obesity. Even though the total prevalence of overweight and obesity was about half of that of normal weight, the sum of their cost burden was almost doubled. Implementing weight reduction measures could reduce health service utilization and costs in this population.

Association between fire smoke fine particulate matter and asthma-related outcomes: Systematic review and meta-analysis

BACKGROUND

Asthma-related outcomes are regularly used by studies to investigate the association between human exposure to landscape fire smoke and health. Robust summary effect estimates are required to inform health protection policy for fire smoke exposure.

OBJECTIVE

To conduct a systematic review and meta-analysis to estimate the association between short-term exposure to landscape fire smoke (LFS) fine particulate matter (PM_2.5) and asthma-related outcomes.

METHODS

We conducted a systematic review and meta-analysis following PRISMA guidelines. Four databases (PubMed, Medline, EMBASE and Scopus) and reference lists of recent fire smoke and health reviews were searched. The Newcastle-Ottawa Scale was used to evaluate the quality of case-crossover studies, and a previously validated quality assessment framework was used for observational studies lacking control groups. Publication bias was assessed using funnel plots and Egger's Test. The trim and fill method was used when there was evidence of publication bias. Sensitivity and influence analyses were conducted on all endpoints to test the robustness of estimates. Summary estimates were obtained for hospitalisations and emergency department (ED) visits. A descriptive analysis was conducted for physician visits, medication use, and salbutamol dispensations.

RESULTS

From an initial 181 articles (after duplicate removal), 20 studies were included for quantitative assessment and descriptive synthesis. LFS PM_2.5 levels were positively associated with asthma hospitalisations (RR = 1.06, 95% CI: 1.02-1.09) and emergency department visits (RR = 1.07, 95% CI: 1.04-1.09). Subgroup analyses found that females were more susceptible than males for ED visits, and that there was an increasing association by age groups for hospital admissions and ED visits. High heterogeneity between studies was observed, but results were robust to sensitivity analysis.

CONCLUSIONS

Females and all adults aged over 65 years appear to be the population groups most sensitive to asthma-related outcomes when exposed to LFS PM_2.5. Overall, results were higher than those obtained for a typical PM_2.5 mixture.

Long-Term Inpatient Hospital Utilisation and Costs (2007-2008 to 2015-2016) for Publicly Waitlisted Bariatric Surgery Patients in an Australian Public Hospital System Based on Australia's Activity-Based Funding Model

BACKGROUND

Within the Australian public hospital setting, no studies have previously reported total hospital utilisation and costs (pre/postoperatively) and costed patient-level pathways for primary bariatric surgery and surgical sequelae (including secondary surgery) informed by Australia's Independent Hospital Pricing Authority's activity-based funding (ABF) model.

OBJECTIVE

We aimed to provide our Tasmanian state government partner with information regarding key evidence gaps about the resource use and costs of bariatric surgery (including pre- and postoperatively, types of surgery and comorbidities), the costs of surgical sequelae and policy direction regarding the types of bariatric surgery offered within the Tasmanian public hospital system.

METHODS

Hospital inpatient length of stay (days), episodes of care (number) and aggregated cost data were extracted for people who were waiting for and subsequently received bariatric surgery (for the fiscal years 2007-2008 to 2015-2016) from administrative sources routinely collected, clinically coded/costed according to ABF. Aggregated ABF costs were expressed in 2016-2017 Australian dollars ($A). Sensitivity (cost outliers) and subgroup analyses were conducted.

RESULTS

A total of 105 patients entered the study. Total costs (pre/postoperative over 8 years) for all inpatient episodes of care (n = 779 episodes of care) were $A6,018,349. When the ten cost outliers were omitted from the total cost, this cost reduced to $A4,749,265. Mean costs for primary laparoscopic adjustable gastric band (LAGB) and sleeve gastrectomy (SG) bariatric surgery were $A14,622 and $A15,014, respectively. The average cost/episode of care for people with diabetes decreased in the first year postoperatively, from $A7258 to $A5830/episode of care. In total, 27 LAGB patients (30%) required surgery due to surgical sequelae (including revisional/secondary surgery; n = 58 episodes of care) and 56% of these episodes of care were secondary LAGB device related (mostly port/reservoir related), with a mean cost of $A6267.

CONCLUSIONS

Taking into account our small SG sample size and the short time horizon for investigating surgical sequalae for SG, costs may be mitigated in the Tasmanian public hospital system by substituting LAGB with SG when clinically appropriate due to costs associated with the LAGB device for some patients. At 3 years postoperatively versus preoperatively, episodes of care and costs reduced substantially, particularly for people with diabetes/cardiovascular disease. We recommend that a larger confirmatory study of bariatric surgery including LAGB and SG be undertaken of disaggregated ABF costs in the Tasmanian public hospital system.

The Challenge of Transparency and Validation in Health Economic Decision Modelling: A View from Mount Hood

Transparency in health economic decision modelling is important for engendering confidence in the models and in the reliability of model-based cost-effectiveness analyses. The Mount Hood Diabetes Challenge Network has taken a lead in promoting transparency through validation with biennial conferences in which diabetes modelling groups meet to compare simulated outcomes of pre-specified scenarios often based on the results of pivotal clinical trials. Model registration is a potential method for promoting transparency, while also reducing the duplication of effort. An important network initiative is the ongoing construction of a diabetes model registry (https://www.mthooddiabeteschallenge.com). Following the 2012 International Society for Pharmacoeconomics and Outcomes Research and the Society of Medical Decision Making (ISPOR-SMDM) guidelines, we recommend that modelling groups provide technical and non-technical documentation sufficient to enable model reproduction, but not necessarily provide the model code. We also request that modelling groups upload documentation on the methods and outcomes of validation efforts, and run reference case simulations so that model outcomes can be compared. In this paper, we discuss conflicting definitions of transparency in health economic modelling, and describe the ongoing development of a registry of economic models for diabetes through the Mount Hood Diabetes Challenge Network, its objectives and potential further developments, and highlight the challenges in its construction and maintenance. The support of key stakeholders such as decision-making bodies and journals is key to ensuring the success of this and other registries. In the absence of public funding, the development of a network of modellers is of huge value in enhancing transparency, whether through registries or other means.

Acceptability and perceived feasibility of strategies to increase public transport use for physical activity gain - A mixed methods study

ISSUE ADDRESSED

Public transport (PT) users typically accumulate more physical activity (PA) than motor vehicle users. This mixed methods study aimed to determine acceptability and perceived effectiveness of strategies to increase bus use for PA gain in a regional Australian setting.

METHODS

In a 2017 online survey, Tasmanian adults (n = 1091) rated the likelihood of increasing their bus use according to ten hypothetical strategies (fare-, incentives-, information- or infrastructure-based). Three focus groups and five interviews (n = 31) included infrequent bus users from the survey to determine reasons for strategy preferences and potential impact on PA.

RESULTS

The top three strategies in the survey, with supporting rationale from qualitative data, were: provision of real-time bus information ("…because I can better plan…"); bus-only lanes ("…it just speeds the whole thing up…") and employee incentives/rewards for example bus fare credits ("…it really comes down to money…"). Full-time students favoured cost-saving strategies most and residents in outer suburbs favoured infrastructure-based strategies most. Qualitative data indicated that potential for enhanced certainty, efficiency or cost-savings drove strategy preferences and some strategies may lead to PA gain (eg through the location of Park and Ride facilities).

CONCLUSIONS

Real-time information, bus-only lanes and employee incentives/rewards appear most promising for increasing bus use in this population, but tailoring strategies may be required. Discrete PT enhancement strategies may result in PA gain. SO WHAT?: Increasing PA through transport behaviour has been underexplored. The potential for PA gain through greater PT use and discrete PT use enhancement strategies is an important public health consideration.

Comorbidities are prevalent and detrimental for employment outcomes in people of working age with multiple sclerosis

Background:

More work is needed to understand the burden of comorbidities in people with multiple sclerosis (MS).

Objective:

To assess prevalence of 30 comorbidities and impacts of comorbidities on employment outcomes in a working-aged MS cohort.

Methods:

Participants were from the Australian MS Longitudinal Study ( n = 929). Information on specific comorbidity was obtained (whether or not each was present, doctor-diagnosed, limited their activities and being treated).

Results:

Comorbidities most frequently reported to limit activities were osteoarthritis (51%), migraines (40%), anxiety (33%), depression (29%) and allergies (18%). Mean MS-related work productivity loss in past 4 weeks was 1.3 days for those without comorbidities and 2.5 days for those with any comorbidity. The annual population costs of work productivity loss were highest for people with depression, allergies, anxiety, migraines and osteoarthritis. Higher number of comorbidities was associated with more work productivity loss and a higher likelihood of not working. These associations were substantially reduced after adjustment for MS symptom severity.

Conclusions:

Comorbidities substantially impact employment outcomes and these effects were mainly mediated through MS symptom severity. This suggests that optimal and simultaneous management of comorbidities may be a viable strategy to reduce MS symptom severity, which in turn could improve employment outcomes.

Evaluation of the Association Between Health State Utilities and Obesity in Sub-Saharan Africa: Evidence From World Health Organization Study on Global AGEing and Adult Health Wave 2

BACKGROUND

Obesity is a major public health challenge and its prevalence has increased across the age spectrum from 1980 to date in most parts of the world including sub-Saharan Africa. Studies that derive health state utilities (HSUs) stratified by weight status to support the conduct of economic evaluations and prioritization of cost-effective weight management interventions are lacking in sub-Saharan Africa.

OBJECTIVES

To estimate age- and sex-specific HSUs for Ghana, along with HSUs by weight status. Associations between HSUs and overweight and obesity will be examined.

STUDY DESIGN

Cross-sectional survey of the Ghanaian population.

METHODS

Data were sourced from the World Health Organization Study of Global AGEing and Adult Health (WHO SAGE), 2014 to 2015. Using a "judgment-based mapping" method, responses to items from the World Health Organization Quality-of-Life (WHOQOL-100) used in the WHO SAGE were mapped to EQ-5D-5L profiles, and the Zimbabwe value set was applied to calculate HSUs. Poststratified sampling weights were applied to estimate mean HSUs, and a multivariable linear regression model was used to examine associations between HSUs and overweight or obesity.

RESULTS

Responses from 3966 adults aged 18 to 110 years were analyzed. The mean (95% confidence interval) HSU was 0.856 (95% CI: 0.850, 0.863) for the population, 0.866 (95% CI: 0.857, 0.875) for men, and 0.849 (95% CI: 0.841, 0.856) for women. Lower mean HSUs were observed for obese individuals and with older ages. Multivariable regression analysis showed that HSUs were negatively associated with obesity (-0.024; 95% CI: -0.037, -0.011), female sex (-0.011; 95% CI: -0.020, -0.003), and older age groups in the population.

CONCLUSIONS

The study provides HSUs by sex, age, and body mass index (BMI) categories for the Ghanaian population and examines associations between HSU and high BMI. Obesity was negatively associated with health state utility in the population. These data can be used in future economic evaluations for Ghana and sub-Saharan African populations.

Study protocol for a multicentre, controlled non-randomised trial: benefits of exercise physiology services for type 2 diabetes (BEST)

INTRODUCTION

Controlled trials support the efficacy of exercise as a treatment modality for chronic conditions, yet effectiveness of real-world Exercise Physiology services is yet to be determined. This study will investigate the efficacy and cost-effectiveness of services provided by Accredited Exercise Physiologists (AEPs) for clients with type 2 diabetes (T2D) in clinical practice.

METHODS AND ANALYSIS

A non-randomised, opportunistic control, longitudinal design trial will be conducted at ten Exercise Physiology Clinics. Participants will be individuals with T2D attending one of the Exercise Physiology Clinics for routine AEP services (exercise prescription and counselling) (intervention) or individuals with T2D not receiving AEP services (usual care) (control). The experimental period will be 6 months with measurements performed at baseline and at 6 months. Primary outcome measures will be glycosylated haemoglobin (HbA1c), resting brachial blood pressure (BP), body mass index, waist circumference, 6 min walk test, grip strength, 30 s sit to stand, Medical Outcomes Short-Form 36-Item Health Survey and Active Australia Questionnaire. Secondary outcomes will be medication usage, out-of-pocket expenses, incidental, billable and non-billable health professional encounters and work missed through ill health. Healthcare utilisation will be measured for 12 months prior to, during and 12 months after trial participation using linked data from Medicare Benefits Schedule and Pharmaceutical Benefits Scheme data.

ETHICS AND DISSEMINATION

The study is a multicentre trial comprising: University of Tasmania, University of New South Wales Lifestyle Clinic, University of Canberra, Baker Heart and Diabetes Institute (covered under the ethics approval of University of Tasmania Health and Medical Ethics Committee H0015266), Deakin University (Approval number: 2016-187), Australian Catholic University (2016-304R), Queensland University of Technology (1600000049), University of South Australia (0000035306), University of Western Australia (RA/4/1/8282) and Canberra Hospital (ETH.8.17.170). The findings of this clinical trial will be communicated via peer-reviewed journal articles, conference presentations, social media and broadcast media.

TRIAL REGISTRATION NUMBER

ACTRN12616000264482.

Rapidly increasing prevalence of overweight and obesity in older Ghanaian adults from 2007-2015: Evidence from WHO-SAGE Waves 1 & 2

BACKGROUND

Studies on changes in the prevalence and determinants of obesity in older adults living in sub-Saharan Africa are scarce. We examined recent changes in obesity prevalence and associated factors for older adults in Ghana between 2007/08 and 2014/15.

METHODS

Data on adults aged 50 years and older in Ghana were drawn from the WHO SAGE 2007/08 (Wave 1; n = 4158) and 2014/15 (Wave 2; n = 1663). The weighted prevalence of obesity, overweight, normal weight and underweight, and of high central adiposity were compared in 2007/08 and 2014/15. Multinomial and binomial logistic regressions were used to examine whether the determinants of weight status based on objectively measured body mass index and waist circumference changed between the two time periods.

RESULTS

The prevalence of overweight (2007/08 = 19.6%, 95% CI: 18.0-21.4%; 2014/15 = 24.5%, 95% CI: 21.7-27.5%) and obesity (2007/08 = 10.2%, 95% CI: 8.9-11.7%; 2014/15 = 15.0%, 95% CI: 12.6-17.7%) was higher in 2014/15 than 2007/08 and more than half of the population had high central adiposity (2007/08 = 57.7%, 95% CI: 55.4-60.1%; 2014/15 = 66.9%, 95% CI: 63.7-70.0%) in both study periods. While the prevalence of overweight increased in both sexes, obesity prevalence was 16% lower in males and 55% higher in females comparing 2007/08 to 2014/15. Female sex, urban residence, and high household wealth were associated with higher odds of overweight/obesity and high central adiposity. Those aged 70+ years had lower odds of obesity in both study waves. In 2014/15, females who did not meet the recommended physical activity were more likely to be obese.

CONCLUSION

Over the 7-year period between the surveys, the prevalence of underweight decreased and overweight increased in both sexes, while obesity decreased in males but increased in females. The difference in obesity prevalence may point to differential impacts of past initiatives to reduce overweight and obesity, potential high-risk groups in Ghana, and the need to increase surveillance.

Economic Burden of Gastric Cancer: A Case of Iran

Purpose:

Today, cancers have become a major cause of mortality in developed and developing countries. Among various cancers, gastric cancer imposes a huge economic burden on patients, their families, and on the health-care system. This study aimed to determine the economic burden of gastric cancer in Kohgiluyeh and Boyer Ahmad province of Iran in 2016.

Methods:

This was a cross-sectional cost of illness study conducted in Kohgiluyeh and Boyer Ahmad province of Iran in 2016, using a prevalence-based approach. All patients were studied using the census method (N = 110). The required data on direct medical, direct nonmedical, and indirect costs were collected using a data collection form from the patients’ medical records, tariffs of diagnostic, and therapeutic services approved by the Ministry of Health and Medical Education in 2016.

Results:

The total cost and burden of gastric cancer in Kohgiluyeh and Boyer Ahmad province of Iran in 2016 were $US436 237, among which the majority were direct medical costs (59%). The highest costs among direct medical costs, direct nonmedical costs, and indirect costs were, respectively, related to the costs of medications used by the patients (35%), transportation (31%), and absence of patients’ families from work and daily activities caused by patient care (56%).

Conclusion:

Our study has revealed for the first time high costs of gastric cancer in Iran. To decrease the total costs and burden, the following suggestions can be made: increasing insurance coverage and government subsidies for purchasing necessary medications, providing the required specialized care and services related to cancer diseases such as gastric cancer in other provincial cities rather than just in capital cities, and so on.

Chinese patients' preference for pharmaceutical treatments of osteoporosis: a discrete choice experiment

While adherence to osteoporosis treatment is low, patients' preference for osteoporosis treatment is unknown in Chinese patients. Chinese patients are willing to receive treatments with higher clinical efficacy and lower out-of-pocket cost. In addition, annual intravenous infusion and 6-month subcutaneous injection are preferred over weekly oral tablets.

PURPOSE

This study was performed to elicit Chinese patients' preferences for osteoporosis medication treatment and to investigate the heterogeneities of the preferences in subgroups.

METHODS

A discrete choice experiment comprising 15 choice sets with 4 important attributes was conducted in a Chinese population at risk of osteoporotic fracture. The four attributes were treatment efficacy in reducing the risk of fracture, out-of-pocket cost per year, adverse effects of treatment, and mode of administration. The patients were asked to choose between two hypothetical treatments; they could also choose no treatment. Mixed logit models were used, and any observed heterogeneity in the patients' preferences was further assessed in subgroup analyses.

RESULTS

In total, 267 patients were analysed. On average, the patients preferred to receive treatment rather than no treatment. The patients preferred treatment with higher efficacy in preventing fracture and lower out-of-pocket cost. The least preferred adverse effect of medication was gastrointestinal disorders, followed by flu-like symptoms and finally skin reactions. The most preferred mode of administration was annual intravenous infusion, followed by 6-month subcutaneous injection, a weekly oral tablet, and daily nasal spray; daily oral tablets ranked as the least preferred mode of administration. The differences in the patients' preferences among all attributes were statistically significant (p < 0.05). Patients' age was found to contribute to the observed preference heterogeneity in most of the included attributes.

CONCLUSIONS

This study revealed Chinese patients' preferences for osteoporosis treatments. Annual intravenous infusion and 6-month subcutaneous injection were significantly preferred over weekly oral tablets in this Chinese population.

Change in multiple sclerosis prevalence over time in Australia 2010–2017 utilising disease-modifying therapy prescription data

Objective:

Determine the prevalence of multiple sclerosis (MS) in Australia in 2017 using MS-specific disease-modifying therapy (DMT) prescription data and estimate the change in prevalence from 2010.

Methods:

DMT prescriptions were extracted from Australia’s Pharmaceutical Benefits Scheme (PBS) data for January–December 2017. Percentages of people with MS using DMTs (DMT penetrance) were calculated using data from the Australian MS Longitudinal Study. Prevalence was estimated by dividing the total number of monthly prescriptions by 12 (except alemtuzumab), adjusted for DMT penetrance and Australian population estimates. Prevalences in Australian states/territories were age-standardised to the Australian population. Comparisons with 2010 prevalence data were performed using Poisson regression.

Results:

Overall DMT penetrance was 64%, and the number of people with MS in Australia in 2017 was 25,607 (95% confidence interval (CI): 24,874–26,478), a significant increase of 4324 people since 2010 ( p < 0.001). The prevalence increased significantly from 95.6/100,000 (2010) to 103.7/100,000 (2017), with estimates highest in Tasmania in 2017 (138.7/100,000; 95% CI: 137.2–140.1) and lowest in Queensland (74.6/100,000; 95% CI: 73.5–75.6). From 2010 to 2017 using the median latitudes for each state/territory, the overall latitudinal variation in MS prevalence was an increase of 3.0% per degree-latitude.

Conclusion:

Consistent with global trends, Australia’s MS prevalence has increased; this probably reflecting decreased mortality, increased longevity and increased incidence.

Increasing incidence and mortality related to liver cancer in Australia: time to turn the tide

OBJECTIVE

Assess national and jurisdictional incidence and mortality trends for primary liver cancer in Australia.

METHODS

Analysis of Australian Cancer Incidence and Mortality data published in 2017 by the AIHW. Age-standardised rates (ASR) for 1982 to 2014/2015. Piecewise linear regression was used to assess temporal trends. For the purposes of comparison, data were also extracted for all cancers with greater burdens of disease (lung, colorectal, breast, prostate, pancreatic, and brain cancers and melanoma of the skin).

RESULTS

Since 1982, the average annual percentage change (AAPC) for ASR incidence of liver cancer was 4.858% (95%CI 4.558-5.563). This marked a 306% increase from 1.822/100,000 persons (95%CI 1.586-2.058) in 1982 to 7.396/100,000 persons (95%CI 7.069-7.723) in 2014. AAPC for ASR mortality was 3.013% (95%CI 2.448-3.521): an increase of 184% from 2.323/100,000 persons (95%CI 2.052-2.594) in 1982 to 6.593/100,000 (95%CI 6.290-6.896) in 2015. ASR incidence and mortality were highest in the NT (12.607/100,000 persons), VIC (8.229/100,000) and NSW (7.798/100,000). In comparison to the other selected cancers, higher AAPC for both incidence and mortality of liver cancer were observed.

CONCLUSION

Incidence and mortality associated with liver cancer have increased substantially in the past three decades, in contrast to the improved outcomes observed for many other cancers. Jurisdictional incidence rates reflect higher prevalence of hepatitis B and C. Implications for public health: In the context of Australian cancer prevention and care programs, liver cancer is an outlier. Strategies to mitigate risk factors and improve surveillance of liver health for at-risk groups are urgently required.

Modelling the impact of multiple sclerosis on life expectancy, quality-adjusted life years and total lifetime costs: Evidence from Australia

Objectives:

To quantify life expectancy (LE), quality-adjusted life years (QALYs) and total lifetime societal costs for a hypothetical cohort of Australians with multiple sclerosis (MS).

Methods:

A 4-state Markov model simulated progression from no/mild to moderate and severe disability and death for a cohort of 35-year-old women over a lifetime horizon. Death risks were calculated from Australian life tables, adjusted by disability severity. State-dependent relapse probabilities and associated disutilities were considered. Probabilities of MS progression and relapse were estimated from AusLong and TasMSL MS epidemiological databases. Annual societal (direct and indirect) costs (2017 Australian dollars) and health-state utilities for each state were derived from the Australian MS Longitudinal Study. Costs were discounted at 5% annually.

Results:

Mean (95% confidence interval (CI)) LE from age 35 years was 42.7 (41.6–43.8) years. This was 7.5 years less than the general Australian population. Undiscounted QALYs were 28.2 (26.3–30.0), a loss of 13.1 QALYs versus the Australian population. Discounted lifetime costs were $942,754 ($347,856–$2,820,219).

Conclusion:

We have developed a health economics model of the progression of MS, calculating the impact of MS on LE, QALYs and lifetime costs in Australia. It will form the basis for future cost-effectiveness analyses of interventions for MS.

Microsimulation model for the health economic evaluation of osteoporosis interventions: study protocol

INTRODUCTION

Osteoporosis is a systemic skeletal disease that is characterised by reduced bone strength and increased fracture risk. Osteoporosis-related fractures impose enormous disease and economic burden to the society. Although many treatments and health interventions are proven effective to prevent fractures, health economic evaluation adds evidence to their economic merits. Computer simulation modelling is a useful approach to extrapolate clinical and economic outcomes from clinical trials and it is increasingly used in health economic evaluation. Many osteoporosis health economic models have been developed in the past decades; however, they are limited to academic use and there are no publicly accessible health economic models of osteoporosis.

METHODS AND ANALYSIS

We will develop the Australian osteoporosis health economic model based on our previously published microsimulation model of osteoporosis in the Chinese population. The development of the model will follow the recommendations for the conduct of economic evaluations in osteoporosis by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases and the US branch of the International Osteoporosis Foundation. The model will be a state-transition semi-Markov model with memory. Clinical parameters in the model will be mainly obtained from the Dubbo Osteoporosis Epidemiology Study and the health economic parameters will be collected from the Australian arm of the International Costs and Utilities Related to Osteoporotic Fractures Study. Model transparency and validates will be tested using the recommendations from Good Research Practices in Modelling Task Forces. The model will be used in economic evaluations of osteoporosis interventions including pharmaceutical treatments and primary care interventions. A user-friendly graphical user interface will be developed, which will connect the user to the calculation engine and the results will be generated. The user interface will facilitate the use of our model by people in different sectors.

ETHICS AND DISSEMINATION

No ethical approval is needed for this study. Results of the model validation and future economic evaluation studies will be submitted to journals. The user interface of the health economic model will be publicly available online accompanied with a user manual.

The role of intergenerational educational mobility and household wealth in adult obesity: Evidence from Wave 2 of the World Health Organization's Study on global AGEing and adult health

BACKGROUND

Obesity has emerged as a major risk factor for non-communicable diseases in low and middle-income countries but may not follow typical socioeconomic status (SES)-related gradients seen in higher income countries. This study examines the associations between current and lifetime markers of SES and BMI categories (underweight, normal weight, overweight, obese) and central adiposity in Ghanaian adults.

METHODS

Data from 4,464 adults (2,610 women) who participated in the World Health Organization's Study on global AGEing and adult health (SAGE) Wave 2 were examined. Multilevel multinomial and binomial logistic regression models were used to examine associations. SES markers included parental education, individual education, intergenerational educational mobility and household wealth. Intergenerational educational mobility was classified: stable-low (low parental and low individual education), stable-high (high parental and high individual education), upwardly (low parental and high individual education), or downwardly mobile (high parental and low individual education).

RESULTS

The prevalence of obesity (12.9%) exceeded the prevalence of underweight (7.2%) in the population. High parental and individual education were significantly associated with higher odds of obesity and central adiposity in women. Compared to the stable low pattern, stable high (obesity: OR = 3.15; 95% CI: 1.96, 5.05; central adiposity: OR = 1.75; 95% CI: 1.03, 2.98) and upwardly (obesity: OR = 1.71; 95% CI: 11.13, 2.60; central adiposity: OR = 1.60; 95% CI: 1.08, 2.37) mobile education patterns were associated with higher odds of obesity and central adiposity in women, while stable high pattern was associated with higher odds of overweight (OR = 1.88; 95% CI: 1.11, 3.19) in men. Additionally, high compared to the lowest household wealth was associated with high odds of obesity and central adiposity in both sexes.

CONCLUSION

Stable high and upwardly mobile education patterns are associated with higher odds of obesity and central adiposity in women while the stable high pattern was associated with higher odds of overweight in men.