Specialist Palliative Care and Health Care Costs at the End of Life

BACKGROUND/AIMS

The use and costs of health care rise substantially in the months prior to death, and although the use of palliative care services may be expected to lead to less costly care, the evidence is mixed. We analysed the costs of care over the last year of life and the extent to which these are associated with the use and duration of specialist palliative care (SPC) for decedents who died from cancer or another life-limiting illness.

METHODS

The decedents were participants in a cohort study of older residents of the state of New South Wales, Australia. Using linked survey and administrative health data from 2007 to 2016, two cohorts were identified: n = 10,535 where the cause of death was cancer; and n = 11,179 where the cause of death was another life-limiting illness. Costs of various types were analysed with separate risk-adjusted linear regression models for the last 1, 3, 6, 9 and 12 months before death and for both cohorts. SPC was categorised according to time to death from first contact with the service as 1-7 days, 7-30 days, 30-180 days and more than 180 days.

RESULTS

SPC use was higher among the cancer cohort (30.0%) relative to the non-cancer cohort (4.8%). The mean costs over the final year of life were AU$55,037 (SD 45,059) for the cancer cohort and AU$35,318 (SD 41,948) for the non-cancer cohort. Earlier use of SPC was associated with higher costs over the last year of life but lower costs in the last 1 and 3 months for both cohorts. Initiating SPC use more than 180 days before death was associated with a mean difference relative to the no SPC group of AU$15,590 (95% CI 10,617 to 20,562) and AU$13,739 (95% CI 733 to 26,746) over the last year of life for those dying from cancer and another illness, respectively. The same differences over the last month of life were - AU$2810 (95% CI -  3945 to -  1676) and - AU$4345 (95% CI -  6625 to - 2066). Admitted hospital care was the major driver of costs, with longer SPC associated with lower rates of death in hospital for both cohorts.

CONCLUSION

Early initiation of SPC was associated with higher costs over the last year of life and lower costs over the last months of life. This was the case for both the cancer and non-cancer cohorts, and appeared to be largely attributed to reduced hospitalisation. Although further investigation is required, our results suggest that expanding the availability of SPC services to provide more equitable access could enable patients to spend more time at their usual place of residence, reduce pressure on inpatient services and facilitate death at home when that is preferred.

Use of Health Technology Assessment for the Continued Funding of Health Technologies: The Case of Immunoglobulins for the Management of Multifocal Motor Neuropathy

INTRODUCTION

Funding decisions for many health technologies occur without undergoing health technology assessment (HTA), in particular, without assessment of cost effectiveness (CE). Immunoglobulins in Australia are an interesting case study because they have been used for a long time for various rare disorders and their price is publicly available. Undertaking an HTA enables us to assess CE for an intervention for which there is limited clinical and economic evidence. This study presents a post-market review to assess the CE of immunoglobulins for the treatment of multifocal motor neuropathy (MMN) compared with best supportive care.

METHODS

A Markov model was used to estimate costs and quality-adjusted life-years (QALYs). Input sources included randomised controlled trials, single-arm studies, the Australian clinical criteria for MMN, clinical guidelines, previous Medical Services Advisory Committee (MSAC) reports and inputs from clinical experts. Sensitivity analyses were conducted to assess the uncertainty and robustness of the CE results.

RESULTS

The cost per patient of treating MMN with immunoglobulin was AU$275,853 versus AU$26,191when no treatment was provided, with accrued QALYs of 6.83 versus 6.04, respectively. The latter translated into a high incremental cost-effectiveness ratio (ICER) of AU$317,552/QALY. The ICER was most sensitive to the utility weights and the price of immunoglobulins. MSAC advised to continue funding of immunoglobulins on the grounds of efficacy, despite the high and uncertain ICER.

CONCLUSIONS

Beyond the ICER framework, other factors were acknowledged, including the high clinical need in a patient population for which there are no other active treatments available. This case study highlights the challenges of conducting HTA for already funded interventions, and the efficiency trade-offs required to fund effective high-cost therapies in rare conditions.

Provider responses to the expansion of public subsidies in healthcare: The case of oral chemotherapy treatment in Australia

We examine provider responses to the expansion of public subsidies in 2015 for innovative oral chemotherapy treatment, in a health system where providers were free to determine their own prices. The new treatment was known to have similar efficacy to its traditional intravenous alternative and was preferred by patients for its at-home administration. However, from a policymaker's perspective, the potential for misalignment between patient and provider preferences was significant given the shift to full reimbursement for the oral chemotherapy medication but no change in fee-for-service payments for associated chemotherapy services. Under this scenario, a shift away from traditional intravenous chemotherapy may entail reduced activity and revenues associated with infusions for providers, and we hypothesise that it may result in unintended policy consequences such as reduced take-up of the new therapy or higher prices. We implement a difference-in-difference model using national administrative data on services provided, and chemotherapy medications prescribed, by providers to 1850 patients in New South Wales, Australia. Our estimates indicate that the subsidies expanded access to oral chemotherapy for newly eligible patients by 15 percentage points. However, prices charged by providers for an episode of care rose by 23 percent, driven mostly by increases in service volumes. The results illustrate the importance of understanding differential provider responses to policy changes in financial incentives.

Estimating the willingness-to-pay to avoid the consequences of foodborne illnesses: a discrete choice experiment

Lost productivity is one of the largest costs associated with foodborne illness (FBI); however, the methods used to estimate lost productivity are often criticised for overestimating the actual burden of illness. A discrete choice experiment (DCE) was undertaken to elicit preferences to avoid six possible FBIs and estimate whether ability to work, availability of paid sick leave and health-related quality of life affect willingness-to-pay (WTP) to avoid FBI. Respondents (N = 1918) each completed 20 DCE tasks covering two different FBIs [gastrointestinal illness, flu-like illness, irritable bowel syndrome (IBS), Guillain-Barre syndrome (GBS), reactive arthritis (ReA), or haemolytic uraemic syndrome (HUS)]. Attributes included: ability to work, availability of sick leave, treatment costs and illness duration. Choices were modelled using mixed logit regression and WTP was estimated. The WTP to avoid a severe illness was higher than a mild illness. For chronic conditions, the marginal WTP to avoid a chronic illness for one year, ranged from $531 for mild ReA ($1412 for severe ReA) to $1025 for mild HUS ($2195 for severe HUS). There was a substantial increase in the marginal WTP to avoid all the chronic conditions when the ability to work was reduced and paid sick leave was not available, ranging from $6289 for mild IBS to $11,352 for severe ReA. Including factors that reflect productivity and compensation to workers influenced the WTP to avoid a range of FBIs for both acute and chronic conditions. These results have implications for estimating the burden and cost of FBI.

Higher fees and out-of-pocket costs in radiotherapy point to a need for funding reform

ObjectiveTo elucidate the policy implications of recent trends in the funding of radiotherapy services between 2009-10 and 2021-22.MethodWe use national aggregate claims data to determine time trends in the fees, benefits and out-of-pocket (OOP) costs of radiotherapy and nuclear therapeutic medicine claims funded through the Medicare Benefits Schedule (MBS) program. All dollar figures are expressed in constant 2021 Australian dollars.ResultsRadiotherapy and nuclear therapeutic medicine MBS claims increased by 78% whereas MBS funding increased by 137% between 2009-10 and 2021-22. The main driver of Medicare funding growth has been the Extended Medicare Safety Net, which has increased by 404%. Over the 13 year observation period, the percentage of bulk-billed claims peaked in 2017-18 at 76.1% but fell to 69.8% in 2021-22. For non-bulk billed services, average OOP costs per claim increased from $20.40 in 2009-10 to $69.78 in 2021-22.ConclusionDespite increased Medicare funding, patients face increasing financial barriers to access radiation oncology services. Policies with regard to funding radiotherapy services should be reviewed to ensure that services are easily accessible and affordable for all those needing treatment and at a reasonable cost to Government.

Geographic variation in out-of-pocket costs for radiation oncology services

OBJECTIVES

To examine out-of-pocket costs incurred by patients for radiation oncology services and their variation by geographic location.

DESIGN

Analysis of patient-level Medical Benefits Schedule (MBS) claims data linked with data from the Sax Institute 45 and Up Study.

SETTING, PARTICIPANTS

People who received Medicare-subsidised radiation oncology services in New South Wales, 2006-2017.

MAIN OUTCOME MEASURE

Mean out-of-pocket costs for an episode of radiation oncology (during 90 days from start of radiotherapy planning service), by geographic location (postcode-based), overall and after excluding episodes with no out-of-pocket costs (fully bulk-billed).

RESULTS

During 2006-2017, 12 724 people received 15 506 episodes of radiation oncology care in 25 postcode-defined geographic areas. The proportion of episodes for which the out-of-pocket cost was less than $1 increased from 39% in 2006 to 76% in 2017; the proportion for which out-of-pocket costs exceeded $500 declined from 43% in 2006 to 10% in 2014, before increasing to 17% in 2017. For care episodes with non-zero out-of-pocket costs, the mean amount rose from around $1186 to $1611 per episode of care during 2006-2017. The proportion of radiation oncology episodes bulk-billed exceeded 90% in nine areas; in seven areas, all with exclusively private care provision of radiation oncology, it was 21% or smaller. Within geographic areas, out-of-pocket costs for individual care episodes varied widely; in ten areas with lower bulk-billing rates, the interquartile range for costs ranged from $240 to $1857.

CONCLUSION

Out-of-pocket costs are an important determinant of access to care. Although radiotherapy costs for most people are moderate, some face very high costs, and these vary markedly by location. It is important to ensure that radiation oncology services remain affordable for all people who need treatment.

Evaluation of the Victorian Healthy Homes Program: protocol for a randomised controlled trial

INTRODUCTION

The evaluation of the Victorian Healthy Homes Program (VHHP) will generate evidence about the efficacy and cost-effectiveness of home upgrades to improve thermal comfort, reduce energy use and produce health and economic benefits to vulnerable households in Victoria, Australia.

METHODS AND ANALYSIS

The VHHP evaluation will use a staggered, parallel group clustered randomised controlled trial to test the home energy intervention in 1000 households. All households will receive the intervention either before (intervention group) or after (control group) winter (defined as 22 June to 21 September). The trial spans three winters with differing numbers of households in each cohort. The primary outcome is the mean difference in indoor average daily temperature between intervention and control households during the winter period. Secondary outcomes include household energy consumption and residential energy efficiency, self-reported respiratory symptoms, health-related quality of life, healthcare utilisation, absences from school/work and self-reported conditions within the home. Linear and logistic regression will be used to analyse the primary and secondary outcomes, controlling for clustering of households by area and the possible confounders of year and timing of intervention, to compare the treatment and control groups over the winter period. Economic evaluation will include a cost-effectiveness and cost-benefit analysis.

ETHICS AND DISSEMINATION

Ethical approval was received from Victorian Department of Human Services Human Research Ethics Committee (reference number: 04/17), University of Technology Sydney Human Research Ethics Committee (reference number: ETH18-2273) and Australian Government Department of Veterans Affairs. Study results will be disseminated in a final report and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12618000160235.

Differences in health care spending and utilization among older frail adults in high-income countries: ICCONIC hip fracture persona

OBJECTIVE

This study explores differences in spending and utilization of health care services for an older person with frailty before and after a hip fracture.

DATA SOURCES

We used individual-level patient data from five care settings.

STUDY DESIGN

We compared utilization and spending of an older person aged older than 65 years for 365 days before and after a hip fracture across 11 countries and five domains of care as follows: acute hospital care, primary care, outpatient specialty care, post-acute rehabilitative care, and outpatient drugs. Utilization and spending were age and sex standardized..

DATA COLLECTION/EXTRACTION METHODS

The data were compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries as follows: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States.

PRINCIPAL FINDINGS

The sample ranged from 1859 patients in Spain to 42,849 in France. Mean age ranged from 81.2 in Switzerland to 84.7 in Australia. The majority of patients across countries were female. Relative to other countries, the United States had the lowest inpatient length of stay (11.3), but the highest number of days were spent in post-acute care rehab (100.7) and, on average, had more visits to specialist providers (6.8 per year) than primary care providers (4.0 per year). Across almost all sectors, the United States spent more per person than other countries per unit ($13,622 per hospitalization, $233 per primary care visit, $386 per MD specialist visit). Patients also had high expenditures in the year prior to the hip fracture, mostly concentrated in the inpatient setting.

CONCLUSION

Across 11 high-income countries, there is substantial variation in health care spending and utilization for an older person with frailty, both before and after a hip fracture. The United States is the most expensive country due to high prices and above average utilization of post-acute rehab care.

International comparison of health spending and utilization among people with complex multimorbidity

OBJECTIVE

The objective of this study was to explore cross-country differences in spending and utilization across different domains of care for a multimorbid persona with heart failure and diabetes.

DATA SOURCES

We used individual-level administrative claims or registry data from inpatient and outpatient health care sectors compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States (US).

DATA COLLECTION/EXTRACTION METHODS

Data collected by ICCONIC partners.

STUDY DESIGN

We retrospectively analyzed age-sex standardized utilization and spending of an older person (65-90 years) hospitalized with a heart failure exacerbation and a secondary diagnosis of diabetes across five domains of care: hospital care, primary care, outpatient specialty care, post-acute rehabilitative care, and outpatient drugs.

PRINCIPAL FINDINGS

Sample sizes ranged from n = 1270 in Spain to n = 21,803 in the United States. Mean age (standard deviation [SD]) ranged from 76.2 (5.6) in the Netherlands to 80.3 (6.8) in Sweden. We observed substantial variation in spending and utilization across care settings. On average, England spent $10,956 per person in hospital care while the United States spent $30,877. The United States had a shorter length of stay over the year (18.9 days) compared to France (32.9) and Germany (33.4). The United States spent more days in facility-based rehabilitative care than other countries. Australia spent $421 per person in primary care, while Spain (Aragon) spent $1557. The United States and Canada had proportionately more visits to specialist providers than primary care providers. Across almost all sectors, the United States spent more than other countries, suggesting higher prices per unit.

CONCLUSION

Across 11 countries, there is substantial variation in health care spending and utilization for a complex multimorbid persona with heart failure and diabetes. Drivers of spending vary across countries, with the United States being the most expensive country due to high prices and higher use of facility-based rehabilitative care.

Differences in health outcomes for high-need high-cost patients across high-income countries

OBJECTIVE

This study explores variations in outcomes of care for two types of patient personas-an older frail person recovering from a hip fracture and a multimorbid older patient with congestive heart failure (CHF) and diabetes.

DATA SOURCES

We used individual-level patient data from 11 health systems.

STUDY DESIGN

We compared inpatient mortality, mortality, and readmission rates at 30, 90, and 365 days. For the hip fracture persona, we also calculated time to surgery. Outcomes were standardized by age and sex.

DATA COLLECTION/EXTRACTION METHODS

Data was compiled by the International Collaborative on Costs, Outcomes and Needs in Care across 11 countries for the years 2016-2017 (or nearest): Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States.

PRINCIPAL FINDINGS

The hip sample across ranged from 1859 patients in Aragon, Spain, to 42,849 in France. Mean age ranged from 81.2 in Switzerland to 84.7 in Australia, and the majority of hip patients across countries were female. The congestive heart failure (CHF) sample ranged from 742 patients in England to 21,803 in the United States. Mean age ranged from 77.2 in the United States to 80.3 in Sweden, and the majority of CHF patients were males. Average in-hospital mortality across countries was 4.1%. for the hip persona and 6.3% for the CHF persona. At the year mark, the mean mortality across all countries was 25.3% for the hip persona and 32.7% for CHF persona. Across both patient types, England reported the highest mortality at 1 year followed by the United States. Readmission rates for all periods were higher for the CHF persona than the hip persona. At 30 days, the average readmission rate for the hip persona was 13.8% and 27.6% for the CHF persona.

CONCLUSION

Across 11 countries, there are meaningful differences in health system outcomes for two types of patients.

A methodology for identifying high-need, high-cost patient personas for international comparisons

OBJECTIVE

To establish a methodological approach to compare two high-need, high-cost (HNHC) patient personas internationally.

DATA SOURCES

Linked individual-level administrative data from the inpatient and outpatient sectors compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States.

STUDY DESIGN

We outline a methodological approach to identify HNHC patient types for international comparisons that reflect complex, priority populations defined by the National Academy of Medicine. We define two patient profiles using accessible patient-level datasets linked across different domains of care-hospital care, primary care, outpatient specialty care, post-acute rehabilitative care, long-term care, home-health care, and outpatient drugs. The personas include a frail older adult with a hip fracture with subsequent hip replacement and an older person with complex multimorbidity, including heart failure and diabetes. We demonstrate their comparability by examining the characteristics and clinical diagnoses captured across countries.

DATA COLLECTION/EXTRACTION METHODS

Data collected by ICCONIC partners.

PRINCIPAL FINDINGS

Across 11 countries, the identification of HNHC patient personas was feasible to examine variations in healthcare utilization, spending, and patient outcomes. The ability of countries to examine linked, individual-level data varied, with the Netherlands, Canada, and Germany able to comprehensively examine care across all seven domains, whereas other countries such as England, Switzerland, and New Zealand were more limited. All countries were able to identify a hip fracture persona and a heart failure persona. Patient characteristics were reassuringly similar across countries.

CONCLUSION

Although there are cross-country differences in the availability and structure of data sources, countries had the ability to effectively identify comparable HNHC personas for international study. This work serves as the methodological paper for six accompanying papers examining differences in spending, utilization, and outcomes for these personas across countries.

Health system costs and days in hospital for colorectal cancer patients in New South Wales, Australia

Introduction

Colorectal cancer (CRC) care costs the Australian healthcare system more than any other cancer. We estimated costs and days in hospital for CRC cases, stratified by site (colon/rectal cancer) and disease stage, to inform detailed analyses of CRC-related healthcare.

Methods

Incident CRC patients were identified using the Australian 45 and Up Study cohort linked with cancer registry records. We analysed linked hospital admission records, emergency department records, and reimbursement records for government-subsidised medical services and prescription medicines. Cases’ health system costs (2020 Australian dollars) and hospital days were compared with those for cancer-free controls (matched by age, sex, geography, smoking) to estimate excess resources by phase of care, analysed by sociodemographic, health, and disease characteristics.

Results

1200 colon and 546 rectal cancer cases were diagnosed 2006–2013, and followed up to June 2016. Eighty-nine percent of cases had surgery, chemotherapy or radiotherapy, and excess costs were predominantly for hospitalisations. Initial phase (12 months post-diagnosis) mean excess health system costs were $50,434 for colon and $60,877 for rectal cancer cases, with means of 16 and 18.5 excess hospital days, respectively. The annual continuing mean excess costs were $6,779 (colon) and $8,336 (rectal), with a mean of 2 excess hospital days each. Resources utilised (costs and days) in these phases increased with more advanced disease, comorbidities, and younger age. Mean excess costs in the year before death were $74,952 (colon) and $67,733 (rectal), with means of 34 and 30 excess hospital days, respectively–resources utilised were similar across all characteristics, apart from lower costs for cases aged ≥75 at diagnosis.

Conclusions

Health system costs and hospital utilisation for CRC care are greater for people with more advanced disease. These findings provide a benchmark, and will help inform future cost-effectiveness analyses of potential approaches to CRC screening and treatment.

Paying for value: options for value-based payment reform in Australia

Value-based health care has gained increasing prominence among funders and providers in efforts to improve the outcomes important to patients relative to the resources used to deliver care. In Australia, the value-based healthcare agenda has focused on reducing the use of 'low-value' interventions, redesigning models of care to improve integration between providers and increasing the use of patient-reported measures to drive improvement; all have occurred within existing payment structures. In this paper we describe options for value-based payment reform and highlight two challenges critical for success: attributing financial risk fairly and organisational structures.What is known about the topic?'Fee for service' is the dominant payment method in Australia and creates incentives to increase service volume, rewarding inputs rather than improvements in longer-term health outcomes. There is increasing recognition that payment reform is needed to support the shift to value-based health care in Australia.What does this paper add?This paper describes the three main options for value-based payment reform: episode-based bundled payments chronic condition bundled payments and comprehensive capitation payments. Each involves some degree of funds pooling, and the shifting of risk from the funder to provider to stimulate the more efficient use of resources.What are the implications for practitioners?We conclude that local hospital authorities in the states, private health insurers and primary health networks could implement reform as payment holders, but that capacity development in coordination and risk adjustment will be required. Successful implementation of payment reform will also require investment in data collection and information technology to track patients' care and measure outcomes and costs.

Clinical assessment of chemotherapy-induced peripheral neuropathy: a discrete choice experiment of patient preferences

PURPOSE

Up to 40% of cancer patients treated with neurotoxic chemotherapies experience chemotherapy-induced peripheral neuropathy (CIPN). Currently, there is no gold standard assessment tool for CIPN and there is little information in the literature on patient preferences for such assessments. This study aims to address this gap by identifying the features of a CIPN assessment tool that cancer patients value.

METHODS

An online discrete choice experiment (DCE) survey of neurotoxic chemotherapy-treated patients was implemented. Respondents completed 8 choice questions each. In each choice question, they chose between two hypothetical CIPN assessment tools, each described by six attributes: impact on quality of life; level of nerve damage detected; questionnaire length; physical tests involved; impact on clinic time; impact on care.

RESULTS

The survey was completed by 117 respondents who had a range of cancers of which breast cancer was the most common. Respondents favoured an assessment tool that includes a physical test and that asks about impact on quality of life. Respondents were strongly opposed to clinicians, alone, deciding how the results of a CIPN assessment might influence their care especially their chemotherapy treatment. They were concerned about small changes in their CIPN, independent of clinical relevance. Respondents were willing to add half an hour to the usual clinic time to accommodate the CIPN assessment.

CONCLUSION

The findings of this DCE will assist clinicians in choosing an assessment tool for CIPN that is satisfactory to both clinician and patient.

Cost of Salmonella Infections in Australia, 2015

Gastroenteritis caused from infections with Salmonella enterica (salmonellosis) causes significant morbidity in Australia. In addition to acute gastroenteritis, approximately 8.8% of people develop irritable bowel syndrome (IBS) and 8.5% of people develop reactive arthritis (ReA). We estimated the economic cost of salmonellosis and associated sequel illnesses in Australia in a typical year circa 2015. We estimated incidence, hospitalizations, other health care usage, absenteeism, and premature mortality for four age groups using a variety of complementary data sets. We calculated direct costs (health care) and indirect costs (lost productivity and premature mortality) by using Monte Carlo simulation to estimate 90% credible intervals (CrI) around our point estimates. We estimated that 90,833 cases, 4,312 hospitalizations, and 19 deaths occurred from salmonellosis in Australia circa 2015 at a direct cost of AUD 23.8 million (90% CrI, 19.3 to 28.9 million) and a total cost of AUD 124.4 million (90% CrI, 107.4 to 143.1 million). When IBS and ReA were included, the estimated direct cost was 35.7 million (90% CrI, 29.9 to 42.7 million) and the total cost was AUD 146.8 million (90% CrI, 127.8 to 167.9 million). Foodborne infections were responsible for AUD 88.9 million (90% CrI, 63.9 to 112.4 million) from acute salmonellosis and AUD 104.8 million (90% CrI, 75.5 to 132.3 million) when IBS and ReA were included. Targeted interventions to prevent illness could considerably reduce costs and societal impact from Salmonella infections and sequel illnesses in Australia.

Cost-Effectiveness of Reclassifying Triptans in Australia: Application of an Economic Evaluation Approach to Regulatory Decisions

BACKGROUND

Migraine is a common, chronic, disabling headache disorder. Triptans, used as an acute treatment for migraine, are available via prescription in Australia. An Australian Therapeutic Goods Administration (TGA) committee rejected reclassifying sumatriptan and zolmitriptan from prescription medicine to pharmacist-only between 2005 and 2009, largely on the basis of concerns about patient risk. Nevertheless, pharmacist-only triptans may reduce migraine duration and free up healthcare resources.

OBJECTIVES

To estimate the cost-effectiveness of reclassifying triptans from prescription-only to pharmacist-only in Australia.

METHODS

The study design included decision-analytic modeling combining data from various sources. Behavior before and after reclassification was estimated using medical practitioner and patient surveys and also administrative data. Health outcomes included migraine frequency and duration as well as adverse events (AEs) discussed by the TGA committee. Efficacy and AEs were estimated using randomized controlled trials and observational studies.

RESULTS

Reclassifying triptans will reduce migraine duration but increase AEs. This will result in 337 quality-adjusted life-years gained at an increased cost of A$5.9 million over 10 years for all Australian adults older than 15 years (19.6 million). The incremental cost-effectiveness ratio was estimated to be A$17 412/quality-adjusted life-year gained.

CONCLUSIONS

The incremental cost-effectiveness ratio is likely to be considered cost-effective by Australian decision makers. Serotonin syndrome, a key concern of the TGA committee, had little impact on the results. Further research is needed regarding pharmacist-only triptan use by migraineurs currently using over-the-counter medicines and by nonmigraineurs, the efficacy of triptans, and the risk of cardiovascular and cerebrovascular AEs and chronic headaches with triptans.

The prevalence of persistence and related health status: An analysis of persistently high healthcare costs in the short term and medium term

Understanding whether high healthcare costs for individuals persist over time is critical for the development of policies that aim to reduce the prevalence of high cost patients. And while high healthcare costs will occur in any given year based on the prevalence of certain morbidities and acute conditions, a large random component of the distribution means that it is rarely the same people driving the bulk of healthcare expenditures. Using administrative data for over 250,000 Australian residents for the years between 2006 and 2011, we analyse the persistence of high annual healthcare costs. We examine the prevalence of high cost persistence in this sample, and then, we use endogenous switching models to identify the morbidity groups that are related with high cost persistence. These models also measure cases of cost amplification that are associated with a history of high cost healthcare. This analysis uses data from multiple categories of healthcare, specifically medical services, pharmaceuticals and admitted patient care. While there is a relatively low number of patients with persistent high cost (approximately 3% of the sample), this group accounted for 19% of aggregate expenditure. Pharmaceuticals were the most persistently high cost category of healthcare with 5% of the sample accounting for 32% of aggregate pharmaceutical expenditure. The morbidities associated with notable cost amplifications are morbidities that are hard to prevent or involve escalations of adverse health states that are difficult to avert. This casts doubt on whether broad policies can reduce the prevalence of individuals with persistently high healthcare costs.

Incidence and severity of self-reported chemotherapy side effects in routine care: A prospective cohort study

Aim

Chemotherapy side effects are often reported in clinical trials; however, there is little evidence about their incidence in routine clinical care. The objective of this study was to describe the frequency and severity of patient-reported chemotherapy side effects in routine care across treatment centres in Australia.

Methods

We conducted a prospective cohort study of individuals with breast, lung or colorectal cancer undergoing chemotherapy. Side effects were identified by patient self-report. The frequency, prevalence and incidence rates of side effects were calculated by cancer type and grade, and cumulative incidence curves for each side effect computed. Frequencies of side effects were compared between demographic subgroups using chi-squared statistics.

Results

Side effect data were available for 449 eligible individuals, who had a median follow-up of 5.64 months. 86% of participants reported at least one side effect during the study period and 27% reported a grade IV side effect, most commonly fatigue or dyspnoea. Fatigue was the most common side effect overall (85%), followed by diarrhoea (74%) and constipation (74%). Prevalence and incidence rates were similar across side effects and cancer types. Age was the only demographic factor associated with the incidence of side effects, with older people less likely to report side effects.

Conclusion

This research has produced the first Australian estimates of self-reported incidence of chemotherapy side effects in routine clinical care. Chemotherapy side effects in routine care are common, continue throughout chemotherapy and can be serious. This work confirms the importance of observational data in providing clinical practice-relevant information to decision-makers.

Use and outcomes of targeted therapies in early and metastatic HER2-positive breast cancer in Australia: protocol detailing observations in a whole of population cohort

BACKGROUND

The management of human epidermal growth factor receptor 2 (HER2)-positive breast cancer (BC) has changed dramatically with the introduction and widespread use of HER2-targeted therapies. However, there is relatively limited real-world information on patterns of use, effectiveness and safety in whole of population cohorts. The research programme detailed in this protocol will generate evidence on the prescribing patterns, safety monitoring and outcomes of patients with BC treated with HER2-targeted therapies in Australia.

METHODS/DESIGN

Our ongoing research programme will involve a series of retrospective cohort studies that include every patient accessing Commonwealth-funded HER2-targeted therapies for the treatment of early BC and advanced BC in Australia. At the time of writing, our cohorts consist of 11 406 patients with early BC and 5631 with advanced BC who accessed trastuzumab and lapatinib between 2001 and 2014. Pertuzumab and trastuzumab emtansine were publicly funded for metastatic BC in 2015, and future data updates will include patients accessing these medicines. We will use dispensing claims for cancer and other medicines, medical service claims and demographics data for each patient accessing HER2-targeted therapies to undertake this research.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Population Health Service Research Ethics Committee and data access approval has been granted by the Australian Department of Human Services (DHS) External Review Evaluation Committee. Our findings will be reported in peer-reviewed publications, conference presentations and policy forums. By providing detailed information on the use and outcomes associated with HER2-targeted therapies in a national cohort treated in routine clinical care, our research programme will better inform clinicians and patients about the real-world use of these treatments and will assist third-party payers to better understand the use and economic costs of these treatments.

Cost of cancer care for patients undergoing chemotherapy: The Elements of Cancer Care study

AIM

To determine the monthly treatment costs for each element of cancer care in patients receiving chemotherapy and to apportion the burden of cost by financing agent (Commonwealth, State government, private health insurer, patient).

METHODS

A cohort of 478 patients (54% breast, 33% colorectal and 13% non-small-cell lung cancer) were recruited from 12 centers representing metropolitan and regional settings in public and private sectors. Primary data were linked to secondary data held in New South Wales state (Admitted Patients and Emergency Department Data) and Commonwealth (Medicare and Pharmaceutical Benefits) databases. The monthly treatment costs of each element of care and the funding agent were calculated from secondary health data.

RESULTS

Across all tumor types, the mean monthly treatment cost was $4162 (10%-90% quantiles $1018-$8098; range $2853 [adjuvant colorectal] to $5622 [metastatic lung]), with 54% of this cost borne by Commonwealth government, 26% by private health insurers, 14% by State government and 6% by patients. The mean monthly costs of treating metastatic disease were $1415 greater than those for adjuvant therapy. The mean monthly costs were contributed to by inpatient care ($1657, 40%), chemotherapy prescriptions ($1502, 36%), outpatient care ($452, 11%) and administration of chemotherapy ($364, 9%).

CONCLUSION

All four funders have a shared incentive to reduce absolute monthly treatment costs since their proportional contribution is relatively constant for most tumor types and stages. There are opportunities to reduce cancer care costs by minimizing the risk of inpatient hospital admissions that arise from chemotherapy administration and by recognizing incentives for cost-shifting.

Can administrative data be used to measure chemotherapy side effects?

Many of the issues with using data from clinical trials and observational studies for economic evaluations are highlighted in the case of chemotherapy side effects. We present the results of an observational cohort study using linked administrative data. The chemotherapy side effects identified in the administrative data are compared with patient self-reports of such events. The results of these comparisons are then used to guide a discussion of the issues surrounding the use of administrative data to identify clinical events for the population of economic models. Although the advantages of easy access and generalizability of the results make administrative data an attractive option for populating economic models, this is not always possible because of the limitations of these data.

Delays in access to affordable medicines: putting policy into perspective

BACKGROUND

To save costs, the Australian Government recently deferred approval of seven new medicines recommended by the Pharmaceutical Benefits Advisory Committee (PBAC) for up to 7 months.

OBJECTIVES

The aim of this research is to examine the timelines of PBAC applications following approval by the Therapeutic Goods Administration (TGA), allowing the recent Cabinet delays to be considered in the context of the overall medicines approval process.

METHODS

All new chemical entities and products for new indications approved in 2004 by the Australian Drug Evaluation Committee (ADEC) were identified. Outcomes of PBAC meetings from 2004 to 2010 were then searched to identify if and when these products were reviewed by PBAC.

RESULTS

ADEC recommended 63 eligible products for registration in 2004. Of the 113 submissions made to PBAC for these products, 66 were successful. Only 43% of the products were submitted to PBAC within 2 years, with an average 17-month delay from TGA approval of a product to consideration by the PBAC.

CONCLUSIONS

Cabinet decisions to defer listing of new medicines delays access to new treatments. This occurred in addition to other longer delays, earlier in the approval process for medicines, resulting in a significant impact on the overall timeliness of listing.

Chemotherapy administration: modelling the costs of alternative protocols

BACKGROUND AND OBJECTIVE

The increasing cost of chemotherapy is placing greater pressures on limited healthcare budgets. A potentially important, but often overlooked, aspect of chemotherapy is the cost associated with administration. This study aims to develop a better understanding of these costs, and in doing so, develop a model to estimate the comparative cost of administering alternative chemotherapy protocols for economic evaluation or local decision making.

METHODS

We identified the potential tasks and choices related to administering intravenous chemotherapy, grouped tasks according to anticipated resource use, and allocated costs to each task using data from an evidence-based collection of cancer protocols or from primary data collection. The resources were costed from a healthcare system perspective using standard data sources within Australia. The model was applied to alternative protocols used in the treatment of three different cancers: locally advanced and metastatic non-small-cell lung cancer, adjuvant colorectal cancer and adjuvant breast cancer.

RESULTS

For the three cancer types examined, the cost of completed administration ranged from 1274 Australian dollars ($A) to $A3015 (year 2009 values) for 13 different protocols potentially used for the initial treatment of locally advanced and metastatic non-small-cell lung cancer; $A5175-8445 for seven protocols for adjuvant colorectal cancer treatment; and $A1494-4074 for seven protocols for adjuvant breast cancer treatment.

CONCLUSIONS

The results are of practical significance to those undertaking economic evaluations and to decision makers who use this information within the area of chemotherapy. The examples used suggest that administration costs per visit varied inversely with the number of visits. The results provide information where little has previously been available and may allow decisions about costs and resource allocation to be made with more certainty. Although our model uses costs from the public health system within an Australian state (New South Wales), it can be adapted for use in other jurisdictions.

Movement disorder emergencies in childhood

The literature on paediatric acute-onset movement disorders is scattered. In a prospective cohort of 52 children (21 male; age range 2mo-15y), the commonest were chorea, dystonia, tremor, myoclonus, and Parkinsonism in descending order of frequency. In this series of mainly previously well children with cryptogenic acute movement disorders, three groups were recognised: (1) Psychogenic disorders (n = 12), typically >10 years of age, more likely to be female and to have tremor and myoclonus (2) Inflammatory or autoimmune disorders (n = 22), including N-methyl-d-aspartate receptor encephalitis, opsoclonus-myoclonus, Sydenham chorea, systemic lupus erythematosus, acute necrotizing encephalopathy (which may be autosomal dominant), and other encephalitides and (3) Non-inflammatory disorders (n = 18), including drug-induced movement disorder, post-pump chorea, metabolic, e.g. glutaric aciduria, and vascular disease, e.g. moyamoya. Other important non-inflammatory movement disorders, typically seen in symptomatic children with underlying aetiologies such as trauma, severe cerebral palsy, epileptic encephalopathy, Down syndrome and Rett syndrome, include dystonic posturing secondary to gastro-oesophageal reflux (Sandifer syndrome) and Paroxysmal Autonomic Instability with Dystonia (PAID) or autonomic 'storming'. Status dystonicus may present in children with known extrapyramidal disorders, such as cerebral palsy or during changes in management e.g. introduction or withdrawal of neuroleptic drugs or failure of intrathecal baclofen infusion; the main risk in terms of mortality is renal failure from rhabdomyolysis. Although the evidence base is weak, as many of the inflammatory/autoimmune conditions are treatable with steroids, immunoglobulin, plasmapheresis, or cyclophosphamide, it is important to make an early diagnosis where possible. Outcome in survivors is variable. Using illustrative case histories, this review draws attention to the practical difficulties in diagnosis and management of this important group of patients.

Survivin expression in in situ and invasive breast cancer relates to COX-2 expression and DCIS recurrence

In lung cancer cyclooxygenase-2 (COX-2) expression has been reported to stabilise survivin, an inhibitor of apoptosis (IAP) which prevents cell death by blocking activated caspases. COX-2 expression limits the ubiquitination of survivin, protecting it from degradation. To determine if COX-2 expression in breast cancer showed an association with survivin expression, we assessed the levels of each protein in ductal carcinoma in situ (DCIS) and invasive breast cancer (IBC); relating expression patterns to recurrence of DCIS after surgery. Patterns of COX-2 and survivin expression were determined by intensity-graded immunohistochemistry of the primary tumours. Patients with DCIS (n=161) which had either recurred (n=47) or shown no evidence of recurrence (n=114) 5 years following primary surgery were studied. These were compared to 58 cases of IBC. Survivin was expressed in the cytoplasm of 59% of DCIS and 17% of IBC. High levels of both cytoplasmic survivin and COX-2 expression significantly correlated to DCIS recurrence. COX-2 expression was present in 72% of DCIS, and levels of expression positively correlated with cytoplasmic survivin expression in DCIS and invasive disease. The majority of DCIS that recurred expressed both proteins (69%) vs 39% nonrecurrent. Recurrence was not seen in DCIS lacking both proteins at 5 years (P=0.001). Expression of the IAP survivin is increased in DCIS and correlates closely with COX-2 expression. Increased expression of IAP, (leading to reduced apoptosis) may explain the effect of COX-2 in increasing recurrence of DCIS after surgical treatment.

Accuracy of visual estimates of joint angle and angular velocity using criterion movements

A descriptive study to document undergraduate physical education majors' (22.8 +/- 2.4 yr. old) estimates of sagittal plane elbow angle and angular velocity of elbow flexion visually was performed. 42 subjects rated videotape replays of 30 movements organized into three speeds of movement and two criterion elbow angles. Video images of the movements were analyzed with Peak Motus to measure actual values of elbow angles and peak angular velocity. Of the subjects 85.7% had speed ratings significantly correlated with true peak elbow angular velocity in all three angular velocity conditions. Few (16.7%) subjects' ratings of elbow angle correlated significantly with actual angles. Analysis of the subjects with good ratings showed the accuracy of visual ratings was significantly related to speed, with decreasing accuracy for slower speeds of movement. The use of criterion movements did not improve the small percentage of novice observers who could accurately estimate body angles during movement.

Theory verses empiricism in health economics. An analysis of the past 20 years

We report the results of a study analyzing the proportion of theoretical and empirical articles in two core health economics journals. The Journal of Health Economics published 30% theory during the period 1982-1986, but by 1997-2001 the proportion had risen to 40% theory. Health Economics published 38% theory during 1992-1996, but the proportion fell to 32% theory during 1997-2001. In both journals articles were more likely to be published by men (78%), and published women were 50% less likely to publish theory than were men. Articles were more likely to be published by United States authors (54%), but United States authors were less likely to publish theory than authors from other countries. Compared to other disciplines, health economics published a higher proportion of theory than sociology, chemistry, and physics but less than economics and political science.

Diagnosis and prognosis of Australia's health information for evidence-based policy

Without adequate information it is difficult to determine the success or failure of health policies. This paper assesses the adequacy of Australia's health information for evidence-based policy. Three policy areas are analysed: the impact of changing the public and private health financing mix; waiting lists and waiting times; and pooling of funds. In each, the issue is analysed to identify the key policy questions, the available data and existing analyses are examined, and gaps in data availability and analysis are assessed. There is variability in the extent and usefulness of current health information. In terms of the impact of changing the financing mix, there is good information on the distribution of finance, but much less available on comparative use or efficiency of public and private hospitals. There is comprehensive information available on waiting lists and waiting times but little analysis of the implications of this for equity of access or the costs and benefits of reducing waiting times. There is insufficient information for the development of the capitation based formulae required for the introduction of the pooling of funds, nor enough information to assess the extent and impact of current cost-shifting which might be addressed by pooling funds. While the concept of evidence-based medicine has been embraced with regard to specific treatment decisions, there has not been a parallel investment in the use of evidence to drive policy decisions.

Analysis of polycyclic aromatic hydrocarbons in metered dose inhaler drug formulations by isotope dilution gas chromatography/mass spectrometry

Organic compounds extracted into metered dose inhalers (MDIs) from the rubber components of the metering valve are of increasing interest in the development of these formulations. Polycyclic aromatic hydrocarbons (PAHs) are a class of extractable organic compounds whose source is the carbon black commonly used as a reinforcing agent in rubber. The analytical method for PAHs described in this report employs "cold filtration" to remove the suspended drug substance and excipients, and gas chromatography/mass spectrometry (GC/MS) for separation and detection of individual PAHs. After filtration, stable isotope labelled analogues of target PAHs are spiked into the drug product to act as internal standards, correcting for recovery (termed "isotope dilution GC/MS"). Validation of the method was accomplished with respect to linearity, precision, limit of detection/quantitation, selectivity and ruggedness. Application to a variety of MDI drug product formulations revealed that certain PAHs are present at the ng/inhaler level.

Taking local management responsibility for NHS pay

An extract from the Payfolio series published by North West Thames Regional Health Authority′s Pay Unit which guides managers of local units on decisions which will have to be made on remuneration issues that were previously taken centrally. Identifies the need for both a new management structure to reflect these new responsibilities and a strategic review as prerequisites. The constraints on change include the capacity of the personnel function, the inadequacy of information on labour costs, the assimilation costs of moving to new pay and conditions, the contractual entitlements of individual employees, the continuation of national pay determination, and the attitudes of staff and their representatives. Makes suggestions about making the transition to a local pay strategy in a way which is incremental yet strategic, so that change to new payment systems, structures, grading and staff groups are achieved gradually over time in a way which flows as smoothly as possible from the status quo.

Isolation of L-forms of Bacillus subtilis which grow in liquid medium

L-forms of Bacillus subtilis can be isolated by treatment of the parent strain sequentially with N-methyl-N'-nitro-N-nitrosoguanidine and lysozyme and selection of the surviving protoplasts on semisolid medium containing 2,000 units of penicillin per ml. Some of these clones can be adapted to grow in liquid cultures containing 1.2 m NaCl. This method will aid in the isolation of cell wall mutants which require hypertonic medium for growth.