Reducing the burden of road traffic injury: translating high-income country interventions to middle-income and low-income countries

OBJECTIVE

To increase seat belt restraint use in Guangzhou City, People's Republic of China.

DESIGN

Comparison group pre-test, post-test design.

SETTING

Guangzhou City.

INTERVENTIONS

Interventions to increase the prevalence of seat belt use in high-income countries (enhanced training and enforcement practices along with raising of public awareness) were adapted and implemented in Guangzhou. The prevalence of seat belt use was determined before and after the introduction of the 12-month intervention. Seat belt prevalence was also examined over the same time period in the neighboring city of Nanning, and an incremental cost-effectiveness analysis of the intervention was undertaken.

MAIN OUTCOME MEASURES

Prevalence rates and incremental cost effectiveness ratios.

RESULTS

A 12% increase in seat belt use was observed in Guangzhou over the study period, increasing from a prevalence of 50% before (error range 30-62%) to 62% after (error range 60-67%) (p<0.001) the intervention; an absolute change difference between the intervention and reference city of 20% was achieved. The incremental cost-effectiveness ratio of the intervention was yen 3246 (US dollars 418) per disability-adjusted life year saved.

CONCLUSIONS

This city-wide intervention demonstrates that it is possible to increase the prevalence of seat belt use using similar methods to those used in high-income countries and, importantly, that such an approach is cost-effective.

Effects of demographic variables on mental illness admission for victims of interpersonal violence

BACKGROUND

To assess the effects of demographic factors on mental illness admission for victims of interpersonal violence.

METHODS

A population-based retrospective cohort study was conducted to investigate victims of violence using the 1990-2004 linked data extracted from the Western Australia Hospital Morbidity Data System and the Mental Health Information System. Factors associated with the risk for hospitalization for mental illness were assessed by logistic regression analysis.

RESULTS

Among the 25,427 victims admitted to hospital for at least one episode of interpersonal violence during the study period, 6395 (25%) had been hospitalized with a mental illness diagnosis. Female [odds ratio (OR) 1.54, 95% CI 1.40-1.63] and Indigenous (OR 1.47, 95% CI 1.34-1.57) victims of violence were significantly more likely to be admitted for mental illness. The presence of additional co-morbidity also increased the risk (OR 1.49, 95% CI 1.44-1.54). Other variables that significantly increased the risk of mental illness admission were advancing age, other methods of assault and victims who had been separated, divorced or widowed.

CONCLUSIONS

The results are beneficial for designing and implementing intervention strategies to reduce the adverse consequences of interpersonal violence particularly for women and Indigenous victims of violence.

Effectiveness of the black spot programs in Western Australia

This study evaluates the effectiveness of the Black Spot Programs in Western Australia. Reduction in crash rate at the treated locations and the economic benefits of these treatments were assessed. The results showed that the programs have been effective overall, reducing all reported crash rate by 15%. The estimated crash cost savings were 50.8 million Australian dollars, of which 89% could be attributed to the reduction in casualty crashes. This led to net savings to the community of 40.4 million Australian dollars ($35.1 million attributable to casualty crashes) after subtracting the capital costs of treating sites, maintenance and operating costs. The benefit cost ratio across all treatment sites was 4.9. Evaluation of the treatments has identified some effective treatment types and others without any significant change in either the rate or cost of crashes. The latter could be due to insufficient number of sites that received the treatment, the post-treatment period being relatively short, or the treatments genuinely had little impact on road safety. Findings of this study provide objective information for the development of effective strategies on road safety investment.

The epidemiology and cost of falls requiring hospitalisation in children in Western Australia: a study using linked administrative data

OBJECTIVE

The aim of this study was to examine the epidemiology and health system cost of children's falls resulting in hospitalisation in 2003 in Western Australia.

METHODS

The Injury Cost Database was used to identify children who were admitted to hospital with a falls related injury. Adjusted incidence rate ratios (IRR) of hospitalisation were modelled using Poisson regression. In-patient hospital costs were assigned using the published DRG costs for Western Australia. These costs were then extrapolated to health system costs based on previously published relative proportions.

RESULTS

When adjusted for other covariates in the model males had a 53% higher incidence of falls requiring hospitalisation compared with females. Aboriginal children had a 36% higher incidence compared with their non-Aboriginal counterparts, and the incidence of falls reduced with increasing age. The total cost of in-patient hospitalisation associated with children's falls in Western Australia was A$4,554,000 with an average cost of A$1876 per case. In children aged 0-4 years and 10-14 years the highest cost resulted from falls on the flat (slips and trips). However, in children aged 5-9 years injuries resulting from falls from playground equipment resulted in both the highest cost group (A$539,000) and the highest cost per case (A$1917). The total cost to the health system of children's falls in Western Australia in 2003 were estimated to be A$21.5 million, with the total cost to the community estimated at A$108.5 million.

CONCLUSION

Children's falls impose a considerable burden and cost to both the health care system and the community. This study has provided information on where the burden of risk and the majority of costs lie, namely males, Aboriginal children and for children aged 5-9 years, unlike their younger and older peers, playground equipment.

Electronic injury surveillance in Perth emergency departments: Validity of the data

OBJECTIVE

To assess the validity of data collected by a new injury surveillance system in metropolitan public hospital ED in Western Australia.

METHODS

A reference group of four experts used text descriptions recorded in the injury surveillance system to independently assign codes for intent and cause of injury for each case in the sample. These codes were then compared with the intent and cause codes which triage nurses had assigned to these cases. The level of agreement between these codes were assessed by means of descriptive statistics. Systematic coding errors were also identified and analysed.

RESULTS

Of the 419 cases with adequate text descriptions, triage nurses agreed with the reference group of experts in 91.9% (intent) and 79.2% (cause) of cases. Falls accounted for 28.6% (n = 120) of cases and falls code agreement was 86.7%. Self-harm accounted for 5.3% (n = 22) of cases and self-harm code agreement was 77.3%. Systematic errors were detected in the coding of agent of injury, the underlying mechanism of injury and falls involving a mode of transport.

CONCLUSIONS

The new injury surveillance system can be successfully used in ED and provides a valid mechanism for monitoring injuries. Refinements to reduce systematic coding errors might improve the validity and quality of the data. A larger sample is needed to assess the validity of the self-harm code.

Employer costs of alcohol-involved injuries

BACKGROUND

This study estimates the annual cost of alcohol-related injuries to employers in 1998-2000.

METHODS

Incidence was estimated with occupational injury data, motor vehicle crash data and health care data for 1998-2000. Employer costs were estimated from federal estimates of injury costs by source of payment using data on the percentage of varied payment streams (e.g., health insurance, sick leave) paid by employers.

RESULTS

The annual employer cost of alcohol-related injuries to employees and their dependents exceed US dollars 28.6 billion. Out of this, US dollars 13.2 billion comes from job-related, alcohol-involved injuries. The annual employer cost of motor vehicle crashes in which at least one driver was alcohol-impaired is over US dollars 9.2 billion. Out of this, only US dollars 3.4 billion comes from job-related alcohol involvement.

CONCLUSION

Safety programs can reduce the fringe benefit bill without reducing the benefits offered to employees.

Effectiveness of child safety seats vs safety belts for children aged 2 to 3 years

OBJECTIVE

To compare the effectiveness of child safety seats and lap-shoulder belts in rear passenger vehicle seats for 2- to 3-year-old crash survivors.

DESIGN

Cohort study.

SETTING

The January 1, 1998, to December 31, 2004, US data on a nationally representative sample of crashes that resulted in at least 1 vehicle being towed away.

PARTICIPANTS

Toddlers who were sitting in rear vehicle seats and using lap-shoulder belts or child seats when involved in highway crashes.

INTERVENTION

Child safety seat vs safety belt.

OUTCOME MEASURE

Presence of any injury after a crash.

RESULTS

The adjusted odds of injury were 81.8% lower (95% confidence interval, 58.3%-92.1% lower) for toddlers in child seats than belted toddlers.

CONCLUSIONS

Child safety seats seem to be more effective rear seat restraints than lap-shoulder safety belts for children aged 2 to 3 years. Laws requiring that children younger than 4 years travel in child safety seats have a sound basis and should remain in force.

Retail alcohol monopolies, underage drinking, and youth impaired driving deaths

OBJECTIVE

To explore associations of state retail alcohol monopolies with underage drinking and alcohol-impaired driving deaths.

DATA

Surveys on youth who drank alcohol and binge-drank recently and their beverage choices; census of motor vehicle fatalities by driver blood alcohol level.

METHODS

Regressions estimated associations of monopolies with under-21 drinking, binge drinking, alcohol-impaired driving deaths, and odds a driver under 21 who died was alcohol-positive.

RESULTS

About 93.8% of those ages 12-20 who consumed alcohol in the past month drank some wine or spirits. In states with a retail monopoly over spirits or wine and spirits, an average of 14.5% fewer high school students reported drinking alcohol in the past 30 days and 16.7% fewer reported binge drinking in the past 30 days than high school students in non-monopoly states. Monopolies over both wine and spirits were associated with larger consumption reductions than monopolies over spirits only. Lower consumption rates in monopoly states, in turn, were associated with a 9.3% lower alcohol-impaired driving death rate under age 21 in monopoly states versus non-monopoly states. Alcohol monopolies may prevent 45 impaired driving deaths annually.

CONCLUSIONS

Continuing existing retail alcohol monopolies should help control underage drinking and associated harms.

Cost-outcome analysis of booster seats for auto occupants aged 4 to 7 years

OBJECTIVES

The purpose of this work was to analyze the societal return on investment in booster seats and in laws requiring their use in the United States. Booster seats reduce crash-related injury. Their use is mandatory for vehicle occupants aged 4 to 7 years in most of the United States. This study estimates the injury cost savings attributable to booster seat use.

METHODS

Seat cost came from pricing on the Web and at retailers. Costs of passing and enforcing a legal mandate were estimated as a percentage of the costs of seat use. Injury risk when belted absent a seat was computed from national probability samples of crashes in the last years before booster seats entered into general use (1993-1999). Published estimates were used of the percentage of reduction in injuries achieved with booster seats, the mix of diagnoses reduced, and injury cost by diagnosis. The computations used a 3% discount rate. We studied the net cost per quality-adjusted life year saved, benefit-cost ratio, and net savings per seat.

RESULTS

A booster seat costs 30 dollars plus 167 dollars for maintenance and time spent on installation and use. This investment saves 1854 dollars per seat, a return on investment of 9.4 to 1. Even lower bound estimates in sensitivity analysis indicated that society would benefit from the use of booster seats. Seat laws offer a return of 8.6 to 1.

CONCLUSIONS

Belt-positioning booster seats offer a sound return on investment. Booster seat use laws should be passed, publicized, and enforced nationwide.

Cataract surgery practice and endophthalmitis prevention by Australian and New Zealand ophthalmologists

PURPOSE

Our aim was to examine current cataract surgery practice and the methods of chemoprophylaxis used in Australia and New Zealand, and to determine if these factors were related to self-reported incidence rates of postoperative endophthalmitis.

METHODS

All Fellows and trainees of the Royal Australian and New Zealand College of Ophthalmologists were surveyed about their cataract surgery practices and methods of chemoprophylaxis for the prevention of postoperative endophthalmitis. Associations between self-reported incidence rates of endophthalmitis and clinical practice were examined using multivariate Poisson regression modelling.

RESULTS

There were 731 respondents (81.6% of 896 surveyed) to the survey. Respondents reported a total of 162,120 cataract operations and 92 cases of endophthalmitis in 2003, a cumulative incidence of 0.057%. The self-reported incidence of endophthalmitis varied from 0.034% in Victoria to 0.56% in the Northern Territory. Topical antibiotics were used preoperatively by 46.7% compared with 97.4% postoperatively; while only 44.1% used subconjunctival antibiotics. The routine use of subconjunctival antibiotic halved the self-reported incidence of postoperative endophthalmitis (incidence rate ratio 0.53, 95% confidence interval 0.30-0.92).

CONCLUSIONS

Subconjunctival antibiotics may be beneficial in the prevention of endophthalmitis after cataract surgery.

The obesity-driven rising costs of type 2 diabetes in Australia: projections from the Fremantle Diabetes Study

BACKGROUND

The cost of diabetes is high for both the individual and society. Future health-care planning requires patient-level diabetes-attributable health-care cost data that have not previously been available for Australia.

AIM

To determine Australian national direct diabetes-attributable health-care costs for known type 2 diabetes in 2000 and project these to 2051.

METHODS

A total of 1294 patients with type 2 diabetes was recruited to the Fremantle Diabetes Study between 1993 and 1996. A bottom-up, prevalence-based approach using diabetes-attributable costs provided average annual per patient health-care costs (in year 2000 A$). Costs were extrapolated to 2051 using Australian type 2 diabetes prevalence figures and Australian Bureau of Statistics population projections, assuming that prevalence rates (i) remain at current levels and (ii) rise steadily.

RESULTS

Total annual direct diabetes-attributable health-care costs in 2000 in Australia for people > or =25 years with known type 2 diabetes were estimated at A$636 million. As a result of ageing, the number of people with type 2 diabetes will double between 2000 and 2051 with a 2.5-fold increase in diabetes-attributable health-care costs. If obesity and inactivity prevalence rates continue to rise, prevalence rates of type 2 diabetes will further increase. The number of people with type 2 diabetes in 2051 may be 3.5 times higher than in 2000 with a 3.7-fold cost increase.

CONCLUSIONS

The financial burden of treating type 2 diabetes could quadruple by 2051 unless more is done to prevent type 2 diabetes and its complications. A smaller proportion of the population will have the capacity to fund these rising health-care costs.

Child and family safety device affordability by country income level: an 18 country comparison

OBJECTIVE

To compare availability, urban price, and affordability of child/family safety devices between 18 economically diverse countries.

DESIGN

Descriptive: urban price surveys by local safety organisations or shoppers.

SETTING

Retail stores and internet vendors.

MAIN OUTCOME MEASURES

Prices expressed in US dollars, and affordability measured by hours of factory work needed to buy a child safety seat, a belt-positioning booster seat, a child bicycle helmet, and a smoke alarm.

RESULTS

Prices of child and family safety devices varied widely between countries but the variation for child safety seats and bicycle helmets did not relate strongly to country income. Safety devices were expensive, often prohibitively so, in lower income countries. Far more hours of factory work were required to earn a child safety device in lower income than middle income, and middle income than higher income, countries. A bicycle helmet, for example, cost 10 hours of factory work in lower income countries but less than an hour in higher income countries. Smoke alarms and booster seats were not available in many lower income countries.

CONCLUSIONS

Bicycles and two-axle motor vehicles were numerous in lower and middle income countries, but corresponding child safety devices were often unaffordable and sometimes not readily available. The apparent market distortions and their causes merit investigation. Advocacy, social marketing, local device production, lowering of tariffs, and mandatory use legislation might stimulate market growth. Arguably, a moral obligation exists to offer subsidies that give all children a fair chance of surviving to adulthood.

Determinants of diabetes-attributable non-blood glucose-lowering medication costs in type 2 diabetes: the Fremantle Diabetes Study

OBJECTIVE

To prospectively examine the magnitude and predictors of diabetes-attributable non-blood glucose-lowering (non-BGL) medication costs in type 2 diabetes.

RESEARCH DESIGN AND METHODS

Detailed data from 593 community-dwelling patients were available over 4.3 +/- 0.4 years. Diabetes-attributable costs (in year 2000 Australian dollars [A$]) were calculated by applying a range of attributable proportions for each complication for which medication was prescribed.

RESULTS

Non-BGL medications accounted for 75% of all prescription medication costs over the study period, and one-third were attributable to diabetes. The median annual cost (in A$) of non-BGL medications per patient increased from A$220 to A$429 over 4 years (P < 0.001), whereas the diabetes-attributable contribution increased from A$31 (range 15-40) to A$159 (range 95-219) per patient (P < 0.001). Diabetes-attributable hospital costs remained stable during the study. Diabetes-attributable non-BGL costs were skewed and, therefore, square root transformed before regression analysis. Independent baseline determinants of square root cost/year were coronary heart disease, systolic blood pressure, total serum cholesterol, ln(serum triglycerides), ln(albumin-to-creatinine ratio), serum creatinine, education, and, negatively, male sex and fasting plasma glucose (P </= 0.043; R(2) = 29%). Projected to the Australian population, diabetes-attributable non-BGL medication costs for patients with type 2 diabetes totaled A$79 million/year.

CONCLUSIONS

The median annual cost of diabetes-attributable non-BGL medications increased fivefold over 4 years. This increase was predicted by vascular risk factors and complications at baseline. Better-educated patients had higher costs, probably reflecting improved health care access. Men and patients with higher fasting plasma glucose levels had lower costs, suggesting barriers to health care and/or poor self-care. The contemporaneous containment of hospital costs may be due to the beneficial effect of increased medication use.

Health system costs of falls of older adults in Western Australia

The aim of this study was to determine the health system costs associated with falls in older adults who had attended an emergency department (ED) in Western Australia. The data relating to the ED presentations and hospital admissions were obtained from population-based hospital administrative records for 2001-2002. The type of other health services (eg, outpatient, medical, community, ancillary and residential care), the quantity, and their cost were estimated from the literature. In adults aged 65 years and above, there were 18 706 ED presentations and 6222 hospital admissions for fall-related injuries. The estimated cost of falls to the health system was $86.4 million, with more than half of this attributable to hospital inpatient treatment. Assuming the current rate of falls remains constant for each age group and gender, the projected health system costs of falls in older adults will increase to $181 million in 2021 (expressed in 2001-02 Australian dollars). The economic burden to the health services imposed by falls in older adults is substantial, and a long-term strategic approach to falls prevention needs to be adopted. Policy in this area should be targeted at both reducing the current rate of falls through preventing injury in people from high-risk groups and reducing the future rate of falls through reducing population risk.

Treatment patterns for cancer in Western Australia: does being Indigenous make a difference?

OBJECTIVE

To examine whether hospital patients with cancer who were identified as Indigenous were as likely to receive surgery for the cancer as non-Indigenous patients.

DESIGN, SETTING AND PATIENTS

Epidemiological survey of all Western Australian (WA) patients who had a cancer registration in the state-based WA Record Linkage Project that mentioned cancer of the breast (1982-2000) or cancer of the lung or prostate (1982-2001).

MAIN OUTCOME MEASURES

The likelihoods of receiving breast-conserving surgery or mastectomy for breast cancer, lung surgery for lung cancer, or radical or non-radical prostatectomy for prostate cancer were compared between the Indigenous and non-Indigenous populations using adjusted logistic regression analyses.

RESULTS

Indigenous people were less likely to receive surgery for their lung cancer (odds ratio [OR], 0.64; 95% CI, 0.41-0.98). Indigenous men were as likely as non-Indigenous men to receive non-radical prostatectomy (OR, 0.69; 95% CI, 0.40-1.17); only one Indigenous man out of 64 received radical prostatectomy. Indigenous women were as likely as non-Indigenous women to undergo breast-conserving surgery (OR, 0.86; 95% CI, 0.60-1.21).

CONCLUSIONS

These results indicate a different pattern of surgical care for Indigenous patients in relation to lung and prostate, but not breast, cancer. Reasons for these disparities, such as treatment choice and barriers to care, require further investigation.

A randomized trial of interactive group sessions achieved greater improvements in nutrition and physical activity at a tiny increase in cost

OBJECTIVE

Weight gain may follow altered eating habits and decreased physical activity in couples beginning to live together. Mutual support and willingness to accept changes in lifestyle at this stage may facilitate positive responses to health promotion. We aimed to compare the effects of a diet and physical activity program in couples using a randomized controlled trial.

STUDY DESIGN AND SETTING

Couples were randomized to a control group or to one of two intervention groups in whom the program was either delivered mainly by mail or with a combination of mail-outs and interactive group sessions.

RESULTS

Diets, physical fitness, and blood cholesterol improved up to 12 months after beginning the 4-month program, mainly in the interactive group. In that group, at the end of the program, the estimated cost was 445.30 dollars (111.33 dollars/month) per participant per unit change in outcome variables, only 0.03 dollars per participant per month more than the group receiving the program mainly by mail. One year after beginning the program, costs per participant per month were 38.37 dollars in the interactive group and 38.22 dollars in the group receiving the program mainly by mail-out.

CONCLUSION

The changes observed in cardiovascular risk factors could translate to a substantial cost-savings relating to health.

Hospital services and casemix in Western Australia

The Health Department of WA currently operates as a single integrated funder and purchaser of health services for the State. Health Service Agreements defining the level of health provision are negotiated with the various health services in WA. During the latter part of the 1990s, the funding of public hospitals for acute inpatient care moved away from a historical basis to output-based funding using a casemix approach based on Diagnosis Related Groups (DRGs). Other hospital services are still mainly purchased using historical funding levels, negotiated block funding or bedday payments, with output-based funding mechanisms under investigation. WA has developed its own approach to classifying admitted patients that recognises differences in complexity of care among episodes grouped to the same DRG. WA also has a unique cost estimation model for calculating DRG cost weights, which is based on a linear estimate of the relationship between nights of stay in hospital and the cost of hospital care for each DRG. Another emerging trend in the provision of public hospital services in WA has been the greater involvement of the private sector through the contracting of private providers to operate public hospitals. While no close examination has been undertaken of the outcomes of these changes in terms of their effect on efficiency or other relevant indicators of hospital performance, current purchasing arrangements are being reviewed following recommendations made in a report by the Health Administrative Review Committee. No decision has yet been made as to future changes to the funding policy of WA public hospitals.

Shifting the balance between in-patient and out-patient care for tuberculosis results in economic savings

SETTING

Although hospitalisation is not always necessary for the treatment of tuberculosis (TB), in Australia 90% of TB patients have treatment initiated in hospital.

OBJECTIVE

To calculate and compare the costs of in-patient and out-patient tuberculosis treatment, and to measure the impact of shifting care from in-patient to out-patient settings.

METHODS

In a costing study performed in Victoria, Australia, the proportion of all notified TB cases who were hospitalised was calculated by matching coded state hospital morbidity data with the Victoria Notifiable Diseases database for the financial year 1994-1995. In-patient and out-patient costs were calculated using data obtained from a number of sources. The effect on health care costs of varying the proportion of TB cases treated as in-patients and out-patients was calculated using Excel.

RESULTS

Nearly 90% (239/269) of notified TB cases received hospitalised care in 1994-1995. The cost of treatment for hospitalised patients (mean length of stay 2 weeks) was AU$5447 per patient, with a total cost of $1,301,833. Hospitalisation comprised 60% of the total cost of treatment. The cost of out-patient treatment was $2260 per patient. If 90% of patients were treated on an out-patient basis, the total cost would be $693,670. We estimated that it would be feasible to treat at least 55% of TB patients as out-patients, reducing costs by nearly 30%.

CONCLUSIONS

Routine hospitalisation for patients with uncomplicated TB is not necessary, but is often used in industrialised countries. More cost-effective use of resources can be achieved by giving initial TB treatment on an out-patient basis rather than in hospital for a greater proportion of cases.

The cost-effectiveness of evidence-based guidelines and practice for screening and prevention of tuberculosis

INTRODUCTION

The potential cost-effectiveness of screening depends on the risk of tuberculosis (TB) in the population being screened and the rate at which the screening outcome (prevention) is achieved.

AIMS

To compare the cost-effectiveness of contact screening for TB for: (1) contact screening as it actually occurred in Victoria in 1991 (Model 1); (2) the process which should have occurred had the 1991 contact screening guidelines been followed (Model 2); (3) a hypothetical evidence-based model (Model 3).

METHODS

Three models were constructed according to the aims. The cost-effectiveness of contact screening is presented as costs to government per unit outcome (in the form of cases prevented, cases found and contacts traced) for each model. Assumptions about disease behaviour were consistent between models. A sensitivity analysis was performed to examine the effect of the assumptions made in Model 3 about rates of referral and treatment of infected contacts, and about the efficacy of isoniazid (INH) in preventing TB.

RESULTS

The total cost of Model 1 was greater than that of the other Models. Model 1 is the least cost-effective, costing $309 065 per case prevented, and Model 3 is the most cost-effective, costing $32 210 per case prevented. The cost of Model 2 was $58 742 per case prevented. The incremental cost-effectiveness of Model 3 compared to Model 2 is $107 per additional contact screened, and $3881 per additional case prevented. Case finding is not as cost-effective as best-practice case prevention, ranging from $231 799 per case found in Model 1 to $205 596 per case found in Model 2. The sensitivity analysis shows that the cost-effectiveness of Model 3 decreases with lower referral rates, lower rates of preventive therapy, and lower efficacy of INH. However, even allowing for reduced programme parameters, Model 3 is most cost-effective.

DISCUSSION

Costing policy options is an important component of programme delivery, but needs to be considered in the context of the product being purchased, e.g. the prevention of disease, or case finding. Case finding as a product of contact screening is expensive in all three models. Prevention of TB, on the other hand, can be cost-effective, as shown in Model 3. It was least cost-effective in Model 1, largely because prevention was not considered a priority, and few infected contacts actually received preventive therapy. Clear programme aims, adherence to guidelines and high rates of preventive therapy are essential in order to achieve cost-effectiveness.

Hospital inpatient costs resulting from road crashes in Western Australia

The purpose of this study was to estimate the inpatient costs of road crashes in Western Australia, and to investigate factors relating to casualties and their injuries that affect the hospital costs resulting from road crashes. All road crash casualties who were injured severely enough to be hospitalised in Western Australia in 1988 were included. A casemix classification system was used to classify patients into diagnostic related groups. Hospital costs were assigned to individual patients on the basis of their diagnostic related group and length of hospital stay. The annual cost of hospital treatment for road crash casualties was estimated as $13.9 million, and 33 per cent of this was incurred by those with lower extremity injuries and 27 per cent by those with head injuries. Hospital costs per casualty ranged from an average of $1388 for those sustaining minor (Abbreviated Injury Scale severity score of 1 or 2) spinal injuries to $16,580 and $33,424, respectively, for those sustaining severe (Abbreviated Injury Scale severity score of 4 or 5) head and spinal injuries. A multivariate analysis of variance revealed the following factors as having a significant independent effect on the hospital inpatient costs of road crash casualties: type of hospital (teaching or nonteaching), body region of injury, injury severity level and road user group. There were also significant interaction effects between different factors. Since hospital inpatient costs vary considerably across factors, using average cost data in the specific economic evaluation of road safety interventions for groups of road users is inappropriate.

Sequelae of Haemophilus influenzae type b meningitis in aboriginal and non-aboriginal children under 5 years of age

Between 1984 and 1990, 257 cases of Haemophilus influenzae type b (Hib) meningitis occurred in children under five years of age in Western Australia. We obtained information on possible sequelae in 131 cases (all non-Aboriginal) by medical record review and parental interview, and in a further 116 cases (60 non-Aboriginal, 56 Aboriginal) by medical record review only; no follow-up information was available for ten children (nine non-Aboriginal, 1 Aboriginal). The incidence of Hib meningitis in children under five years of age was 26.3 per 100,000 for non-Aboriginal and 152.2 per 100,000 for Aboriginal children. The case fatality rate was 3.5% for non-Aboriginal children and 14.0% for Aboriginal children. Sequelae were recorded for 17.1% of non-Aboriginal and 22.4% of Aboriginal children who survived Hib meningitis. Surviving Aboriginal children experienced severe sequelae following Hib meningitis almost three times more frequently than surviving non-Aboriginal children (10.5% vs 3.6%), although mild and moderate sequelae were not more common in Aboriginal children. The information on incidence and severity of sequelae in this study was obtained by chart review and parental interview, and hence may be subject to error or bias, particularly for mild and moderate disabilities. Outcomes like death and severe sequelae, such as cerebral palsy and profound intellectual and physical disability, are less subject to bias. Of Aboriginal children who contracted Hib meningitis in Western Australia over the study period, 22.8% either died or had severe sequelae, while only 7.0% of non-Aboriginal children experienced these severe outcomes.

The burden of Haemophilus influenzae type b disease in Australia and an economic appraisal of the vaccine PRP-OMP

OBJECTIVES

To estimate the incidence and sequelae of Haemophilus influenzae type b disease (Hib) in the Australian population, and to evaluate the costs and outcomes of a vaccination program using the vaccine PRP-OMP at two, four and 12 months.

DESIGN

The evaluation was based on a decision analytic model developed by Merck Sharp and Dohme (Australia) Pty Ltd, to predict the number of children who would contract Hib, and suffer mild or severe sequelae or die as a result. The state of health of a cohort of children was modelled each month over a five-year period. A survey of medical records and interviews with parents of children who contracted meningitis in Western Australia from 1984-1990 was undertaken to provide data on the extent and costs of sequelae.

RESULTS

The incidence of Hib among non-Aboriginal Australians under five years of age was estimated as 53 per 100,000, and 460 per 100,000 among Aborigines. In a single year at least 630 children may contract Hib, up to 19 may die, and a further 46 may have neurological damage, this being severe in up to 18 children. The number of deaths could be reduced by 17 per year and a further 25 cases of severe and 16 cases of mild disability could be averted. At a price of $20 per dose, and a 5% discount rate, the expected cost per year of life extended by a vaccination program is $3148. When adjusted for the increased number of years without neurological impairment, the incremental cost per quality adjusted life year (QALY) is $1965. Compared with a single vaccine at 18 months, the incremental cost per additional QALY gained is $5047. A separate analysis of the Aboriginal population showed that the proposed vaccination program would be of significant benefit, leading to a saving of resources.