Impact of cystic fibrosis multidisciplinary virtual clinics on patient experience, time commitments and costs

BACKGROUND AND AIMS

The experience of outpatient care may differ for select patient groups. This prospective study evaluates the adult patient experience of multidisciplinary outpatient cystic fibrosis (CF) care with videoconferencing through telehealth compared with face-to-face care the year prior.

METHODS

People with CF without a lung transplant were recruited. Patient-reported outcomes were obtained at commencement and 12 months into the study, reflecting both their face-to-face and telehealth through videoconferencing experience, respectively. Three patient cohorts were analysed: (i) participants with a regional residence, (ii) participants with a nonregional including metropolitan residence and (iii) participants with colonised multiresistant microbiota.

RESULTS

Seventy-four patients were enrolled in the study (mean age, 37 ± 11 years; 50% male; mean forced expiratory volume in the first second of expiration, 60% [standard deviation, 23]) between February 2020 and May 2021. No differences between models were observed in the participants' rating of the health care team, general and mental health rating, and their confidence in handling treatment plans at home. No between-group differences in the Cystic Fibrosis Questionnaire - Revised (CFQ-R) were observed. Travel duration and the cost of attending a clinic was significantly reduced, particularly for the regional group (4 h, AU$108 per clinic; P < 0.05). A total of 93% respondents preferred to continue with a hybrid approach.

CONCLUSION

In this pilot study, participants' experience of care and quality of life were no different with face-to-face and virtual care between the groups. Time and cost-savings, particularly for patients living in regional areas, were observed. Most participants preferred to continue with a hybrid model for outpatient care.

A feasibility, randomised controlled trial of Club Connect: a group-based healthy brain ageing cognitive training program for older adults with major depression within an older people's mental health service

BACKGROUND

Using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework, we outline steps taken to implement an evidence-based cognitive training program, Club Connect, in older adults with major depressive disorder in an Older People's Mental Health Service in Sydney, Australia. The primary aim was to explore feasibility (or 'reach'), tolerability (or 'implementation'), and acceptability (or 'adoption'). The secondary aim was to explore the most sensitive clinical outcomes and measurement tools (i.e. 'effectiveness') to inform a formal randomised controlled trial, and to explore the healthcare resources used (i.e. costs) to assist decision-making by health care managers and policy-makers in relation to future resource allocation.

METHODS

Using a single blinded feasibility design, 40 participants (mean age: 76.13 years, SD: 7.45, range: 65-95 years) were randomised to either (a) Club Connect, a 10-week group-based multifaceted program, comprising psychoeducation and computer-based cognitive training, or (b) a waitlist control group.

RESULTS

Implementing group-based cognitive training within a clinical setting was feasible, well tolerated and accepted by participants. Further, cognitive training, in comparison to the waiting list control, was associated with moderate to very large effect size improvements in depression, stress and inhibition (ηp2 = 0.115-0.209). We also found moderate effect size improvements on measures of daily functioning, wellbeing and cognitive flexibility. Small effect size improvements for other cognitive and psychosocial outcomes were also observed. The average cost per person participating in in the intervention was AU$607.50.

CONCLUSIONS

Our findings support the feasibility of implementing group-based cognitive training into a specialised clinical (public health) setting. This trial was registered on the Australian and New Zealand Clinical Trial Registry (ACTRN12619000195156, 12/02/2019).

Prospective cohort study investigating quality of life outcomes following multi-speciality robotic-assisted surgery

INTRODUCTION

Despite recent evidence on the surgical outcomes of robotic-assisted surgery (RAS), other patient centre outcomes, including quality of life (QOL), are lacking. This study aims to examine changes in QoL trajectories following RAS across different surgical specialities.

PATIENTS AND METHODS

A prospective cohort study was conducted for patients undergoing urologic, cardiothoracic, colorectal or benign gynaecological RAS, between June 2016 and January 2020 at a tertiary referral hospital in Australia. QoL was measured using the 36-item Short-Form Health Survey at pre-operative, 6 weeks and 6 months postoperatively. Physical and mental summary scores and utility index were primary outcomes, and sub-domains were secondary outcomes.

STATISTICAL ANALYSIS USED

Mixed-effects linear regressions were used to determine changes in QoL trajectories.

RESULTS

Of the 254 patients undergoing RAS, 154 underwent urologic, 36 cardiothoracic, 24 colorectal and 40 benign gynaecological surgery. Overall, the average age was 58.8 years and most patients were male (75.1%). Physical summary scores significantly decreased from pre-operative to 6 weeks' post-operative in urologic and colorectal RAS; with all surgical specialities at least returning to pre-operative levels within 6 months postoperatively. Mental summary scores consistently increased from pre-operative to 6 months postoperatively for colorectal and gynaecological RAS.

CONCLUSIONS

RAS contributed to positive changes in QoL, with physical health returning to the pre-operative level and mental health improvements across specialities, in the short term. While degrees of post-operative changes varied amongst specialities, significant improvements demonstrate benefits in RAS.

Stakeholders' preferences for the design and delivery of virtual care services: A systematic review of discrete choice experiments

This systematic review aimed to synthesise evidence from discrete choice experiments (DCEs) eliciting preferences for virtual models of care, as well as to assess the quality of those DCEs and compare the relative preferences for different stakeholder groups. Articles were included if published between January 2010 and December 2022. Data were synthesised narratively, and attributes were assessed for frequency, significance, and relative importance using a semi-quantitative approach. Overall, 21 studies were included encompassing a wide range of virtual care modalities, with the most common setting being virtual consultations for outpatient management of chronic conditions. A total of 135 attributes were identified and thematically classified into six categories: service delivery, service quality, technical aspects, monetary aspects, health provider characteristics and health consumer characteristics. Attributes related to service delivery were most frequently reported but less highly ranked. Service costs were consistently significant across all studies where they appeared, indicating their importance to the respondents. All studies examining health providers' preferences reported either system performance or professional endorsement attributes to be the most important. Substantial heterogeneity in attribute selection and preference outcomes were observed across studies reporting on health consumers' preferences, suggesting that the consideration of local context is important in the design and delivery of person-centred virtual care services. In general, the experimental design and analysis methods of included studies were clearly reported and justified. An improvement was observed in the quality of DCE design and analysis in recent years, particularly in the attribute development process. Given the continued growth in the use of DCEs within healthcare settings, further research is needed to develop a standardised approach for quantitatively synthesising DCE findings. There is also a need for further research on preferences for virtual care in post-pandemic contexts, where emerging evidence suggests that preferences may differ to those observed in pre-pandemic times.

A randomised controlled trial of clinician supported vs self-help delivery of online cognitive behaviour therapy for Bulimia Nervosa

High dropout rates and poor adherence associated with digital interventions have prompted research into modifications of these treatments to improve engagement and completion rates. This trial aimed to investigate the added benefit of clinician support when paired alongside a ten-session, online cognitive behaviour therapy (CBT) self-help intervention for bulimia nervosa (BN). As part of a three-arm, phase II randomised controlled trial, 114 participants (16 years or over) with full or subthreshold BN were randomly assigned to complete the intervention in a self-help mode (with administrative researcher contact; n = 38), with adjunct clinician support (weekly 30-minute videoconferencing sessions; n = 37), or a no-treatment waitlist control (WLC; n = 39). Baseline to post-treatment (12-weeks) decreases in objective binge episode frequency were significantly greater for clinician-supported participants as compared to WLC, but not for self-help when compared to WLC. However, due to continued improvements for self-help across follow-up (24-weeks), both arms outperformed WLC when analysed as an overall rate of change across three timepoints. Clinician-supported participants outperformed self-help in regards to laxative use and dietary restraint. Our results demonstrate that good clinical outcomes can be achieved with a relatively brief online CBT-based program even in the absence of structured clinical support, indicating a possible overreliance upon clinician support as a primary adherence-facilitating mechanism.

The impact of targeted interventions aimed to improve quality of life in patients receiving home parenteral nutrition: A systematic literature review

BACKGROUND

Home parenteral nutrition (HPN) is a specialised therapy offered to people suffering from intestinal failure. Underlying disease, HPN complications and limitations of HPN can significantly impact a person's quality-of-life (QOL). The aim of this review was to evaluate the evidence on existing non-surgical/non-pharmacological interventions aimed at improving QOL, clinical, patient-reported and economic outcomes for patients receiving parenteral nutrition therapy at home across adult and paediatric settings.

METHODS

Online databases Medline (Ovid), Embase and Cinahl were searched to identify studies published between 1937 and 31 March 2022. Identified studies were appraised using the Cochrane Collaboration risk of bias tool and Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment.

RESULTS

Nine studies were included in this review. Interventions were focused on education (n = 4), telemedicine (n = 2), preparation of infusion mixtures (n = 1), mindfulness-based cognitive therapy (n = 1) and a multi-modal approach (n = 1). Only one study measured QOL before and after the intervention using a validated QOL tool. All studies were assessed at either some, high or critical risk of bias, resulting in low or very low-quality evidence for the interventions evaluated.

CONCLUSIONS

The findings from this review highlight the lack of high-quality non-surgical/non-pharmacological studies seeking to improve QOL for people on HPN. Because the majority of people receiving HPN are not eligible for surgical or pharmaceutical treatments, higher quality research using clinical trial design, and research focused on improving QOL is needed to inform healthcare managers about the effectiveness (and value) of alternative service delivery models for this vulnerable patient group.

The experience of hospital care for older surgical patients and their carers: A mixed-methods study

OBJECTIVE

A growing proportion of older adults are undergoing surgery, but there is a paucity of patient and carer experience research in this group. This study investigated the experience of hospital care in an older vascular surgery population for patients and their carers.

METHODS

This was a mixed-methods convergent design, including simultaneous collection of quantitative and qualitative research strands by combining open-ended questions with rating scales in a questionnaire. Recently hospitalised vascular surgery patients aged ≥65 years at a major teaching hospital were recruited. Carers were also approached to participate.

RESULTS

Forty-seven patients (mean age 77 years, 77% male, 20% with a Clinical Frailty Scale score >4) and nine carers participated. The majority of patients reported that their views were listened to (n = 42, 89%), they were kept informed (n = 39, 83%), and were asked about their pain (n = 37, 79%). Among carers, seven reported their views were listened to and that they were kept informed. Thematic analysis of patients' and carers' responses to open-ended questions about their experience of hospital care revealed four themes in terms of what mattered to them: fundamental care including hygiene and nutrition, comfort of the hospital environment such as sleep and meals, being informed and involved in health-care decision-making, and treating pain and deconditioning to help recovery.

CONCLUSIONS

Older adults admitted to hospital for vascular surgery and their carers, valued highly the care that met both their fundamental needs and facilitated shared decisions for care and recovery. These priorities can be addressed through Age-Friendly Health System initiatives.

Appraisal of the costs, health effects, and cost-effectiveness of screening, prevention, treatment and policy-indicated evidence-based interventions for eating disorders: a systematic review protocol

BACKGROUND

Having reliable information to make decisions about the allocation of healthcare resources is needed to improve well-being and quality-of-life of individuals with eating disorders (EDs). EDs are a main concern for healthcare administrators globally, particularly due to the severity of health effects, urgent and complex healthcare needs, and relatively high and long-term healthcare costs. A rigorous assessment of up-to-date health economic evidence on interventions for EDs is essential for informing decision-making in this area. To date, health economic reviews on this topic lack a comprehensive assessment of the underlying clinical utility, type and amount of resources used, and methodological quality of included economic evaluations. The current review aims to (1) detail the type of costs (direct and indirect), costing approaches, health effects, and cost-effectiveness of interventions for EDs; (2) assess the nature and quality of available evidence to provide meaningful insights into the health economics associated with EDs.

METHODS

All interventions for screening, prevention, treatment, and policy-based approaches for all Diagnostic and Statistics Manual (DSM-IV and DSM-5) listed EDs among children, adolescents, and adults will be included. A range of study designs will be considered, including randomised controlled trials, panel studies, cohort studies, and quasi-experimental trials. Economic evaluations will consider key outcomes, including type of resources used (time and valued in a currency), costs (direct and indirect), costing approach, health effects (clinical and quality-of-life), cost-effectiveness, economic summaries used, and reporting and quality assessments. Fifteen general academic and field-specific (psychology and economics) databases will be searched using subject headings and keywords that consolidate costs, health effects, cost-effectiveness and EDs. Quality of included clinical studies will be assessed using risk-of-bias tools. Reporting and quality of the economic studies will be assessed using the widely accepted Consolidated Health Economic Evaluation Reporting Standards and Quality of Health Economic Studies frameworks, with findings of the review presented in tables and narratively.

DISCUSSION

Results emanating from this systematic review are expected to highlight gaps in healthcare interventions/policy-focused approaches, under-estimates of the economic costs and disease-burden, potential under-utilisation of ED-related resources, and a pressing need for more complete health economic evaluations.

Mobile Health Pulmonary Rehabilitation Compared to a Center-Based Program for Cost-Effectiveness and Effects on Exercise Capacity, Health Status, and Quality of Life in People with Chronic Obstructive Pulmonary Disease: A Protocol for a Randomized Controlled Trial

OBJECTIVE

A comprehensive digitalized program is a novel way to improve access to pulmonary rehabilitation for people with chronic obstructive pulmonary disease (COPD). This study aims to determine if a home-based pulmonary rehabilitation program supported by mobile health (mHealth) technology is equivalent to center-based pulmonary rehabilitation in terms of improvements in exercise capacity and health status in people with COPD.

METHODS

This study is a prospective, multicenter, equivalence randomized controlled trial (RCT) with intention-to-treat analysis. A hundred participants with COPD will be recruited from 5 pulmonary rehabilitation programs. Following randomization, participants will be assigned in a concealed manner to receive either home-based pulmonary rehabilitation supported by mHealth or center-based pulmonary rehabilitation. Both programs will be 8 weeks and will include progressive exercise training, disease management education, self-management support, and supervision by a physical therapist. Co-primary outcome measures will be the 6-Minute Walk Test and the COPD Assessment Test. Secondary outcome measures will include the St George's Respiratory Questionnaire, the EuroQol 5 Dimension 5 Level, the modified Medical Research Council dyspnea scale, the 1-minute sit-to-stand test, the 5 times sit-to-stand test, the Hospital Anxiety and Depression Scale, daily physical activity levels, health care utilization, and costs. Outcomes will be measured at baseline and at the end of the intervention. Participant experience will be assessed through semistructured interviews at the end of the intervention. Utilization of health care and costs will also be measured again after 12 months.

IMPACT

This study will be the first rigorous RCT to examine the effects of a home-based pulmonary rehabilitation program supported by mHealth technology that includes comprehensive clinical outcome evaluation, assessment of daily physical activity, a health economic analysis, and qualitative analysis. If findings demonstrate that there is equivalence in clinical outcomes, that the mHealth program costs the least amount (and is thus cost-effective), and that the mHealth program is acceptable to participants, such programs should be widely implemented to improve access to pulmonary rehabilitation.

Systematic review of service improvements for home enteral tube feeding in adults

BACKGROUND

Patients receiving home enteral tube feeding (HETF) have a high risk of complications and readmission to hospital. This study aims to evaluate effectiveness of staff- and/or patient-focused service-improvement strategies on clinical, patient-reported, and economic outcomes for patients receiving HETF across adult settings.

METHODS

The search was conducted using MEDLINE, EMBASE, and CINAHL databases. Quality of studies were appraised using the Cochrane Collaboration Risk of Bias tool and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessment.

RESULTS

Eleven studies met the inclusion criteria. Pooled data found targeted HETF education with patients, carers, and staff significantly improved knowledge immediately after education and was sustained at 3-6 months. Multimodal interventions, including the formation of specialist HETF teams, significantly reduced complications such as infection, gastrostomy blockage, tube displacement, and feed intolerance but do not significantly reduce unplanned hospital encounters (outpatient clinic visits, hospitalizations, and emergency presentations). Owing to the high risk of bias in the included studies, there is low-quality evidence to support staff training, patient education, and dedicated HETF teams.

CONCLUSION

This review highlights the need for further quality research to allow higher-level evidence for determining the usefulness of interventions aimed at improving outcomes for patients receiving HETF. Future research needs to include greater assessment of quality of life, quantification of the value of interventions in economic terms, and use of translational research frameworks. However, effective staff and patient education programs, along with comprehensive multidisciplinary care, should be considered standard care until a larger research base is developed.

WHAT MATTERS TO OLDER SURGICAL PATIENTS AND THEIR CARERS DURING THEIR HOSPITALIZATION?

Older adults account for a growing proportion of the surgical population. We investigated patient- and carer-reported experiences of hospitalization in this group. A mixed-methods study using telephone and postal surveys of recently hospitalized vascular surgical patients aged ≥ 65 years at an acute care academic hospital. Qualitative data were thematically analyzed using a framework approach. In total 46 patients (mean age 77 years, 78% male) and nine carers were surveyed. Nine (20%) patients were frail (Clinical Frailty Scale score >4). The majority of patients reported overall they felt their views were listened to (n=42, 89%), were kept informed (n=39, 83%) and were asked about their pain level (n=37, 79%). Among the nine carers, seven reported overall they felt their views were listened to (n=42, 89%) and were kept informed (n=39, 83%). Thematic analysis of responses to open-ended survey questions about their experience of hospitalization revealed four key themes: receiving fundamental care including hygiene and nutrition, importance of the hospital environment such as sleep and meals, being informed and involved in health care decision-making, and treating pain and deconditioning to help recovery. Findings from this study identified that older adults admitted to hospital for surgical care, and their carers, highly value care that meets fundamental needs and involves them in decision-making and recovery. These priorities can be addressed through Age-Friendly Health System initiatives such as the implementation of the “4Ms” of geriatrics care: what matters, medication, mobility and mentation.

Adolescent Depression from a Developmental Perspective: The Importance of Recognizing Developmental Distress in Depressed Adolescents

OBJECTIVE

To make the case that developmental distress needs to be assessed when evaluating adolescent depression.

METHODS

Reviews of relevant papers relating to adolescent depression.

RESULTS

Adolescent depression is a common and costly health condition, confounded by a lack of consensus among health professionals regarding evidence-based approaches regarding treatments. Little attention has been paid to the contribution of developmental distress.

CONCLUSION

The current adult-like model of adolescent depression fails to advance the understanding of adolescent depression. A systematic evidence-based approach to identifying developmental self-perception distress in depressed adolescents could provide important advances in treatment to improve short-term and longer-term mental health outcomes. This paper proposes the creation of a psychometric tool to systematically measure developmental self-perception distress in adolescents with depression.

The costs, health outcomes and cost-effectiveness of interventions for the prevention and treatment of incontinence-associated dermatitis: A systematic review

BACKGROUND

Incontinence-associated dermatitis is a common, under-recognized painful skin condition associated with poorer quality of life, increased nurse workloads, and costs.

OBJECTIVE

To systematically review economic evidence for the prevention and treatment of incontinence-associated dermatitis.

DESIGN

Systematic review of quantitative research.

DATA SOURCES

PubMed, MEDLINE, EMBASE, Cochrane Library, York Centre for Reviews and Dissemination database, Econlit, Tufts' Cost-Effectiveness Analysis Registry, and Web of Science.

REVIEW METHODS

A comprehensive search for studies on resource use (costs), health outcomes, and cost-effectiveness of interventions for incontinence-associated dermatitis was conducted. Screening, data extraction, and initial quality assessment were conducted independently by two reviewers, with disagreements/queries regarding quality settled through consensus with the larger team. Quality evaluated using the Consolidated Health Economic Evaluation Reporting Standards checklist and results narratively arranged.

FINDINGS

Seventeen studies (10 for prevention, one for treatment and six for both prevention and treatment) included. All studies measured resource use from a healthcare provider perspective; 14 quantified resources in monetary terms. Considerable variation existed in the resource use data primarily due to differences in the type of resources counted, selected time horizons, valuation methods, and reporting approaches. Ten studies provided evidence of their intervention to be cost saving (or at least cost avoiding). Five studies on barrier products provided evidence to be cost saving: three for prevention, one for treatment, and one for both prevention and treatment. Two studies of cleanser and barrier products provided evidence to be cost saving for the prevention and treatment of incontinence-associated dermatitis. One study found a cleanser to be a cost saving preventative intervention. One bowel management system was found to be cost saving over time only, and one nurse education intervention was found to be cost saving for preventing and treating incontinence-associated dermatitis. One barrier product was found to be cost-effective for preventing and treating the condition. Finally, one study found a cleanser and barrier product was time saving for prevention. None of the studies incorporated a multi-attribute quality of life measure; however, two studies included person-reported outcome measures for pain. A narrow range of resources (mainly products) were considered, and there was limited information on how they were counted and valued. Analyses relating to heterogeneity among patients/hospital wards or health facilities and uncertainty were lacking.

CONCLUSIONS

Barrier products are possibly a more cost-effective treatment than others; however, this evidence lacks certainty. Structured health economic evaluations are required for a reliable evidence-base on the interventions for incontinence-associated dermatitis.

TWEETABLE ABSTRACT

Most incontinence-associated dermatitis studies lack person-reported outcomes, costs beyond product/staff time, and economic evaluation.

Clinician Knowledge of Incontinence-Associated Dermatitis: A Multisite Survey of Healthcare Professionals in Acute and Subacute Settings

PURPOSE

This study examined clinicians' knowledge of incontinence-associated dermatitis (IAD) using the Barakat-Johnson Incontinence-Associated Dermatitis Knowledge Tool (Know-IAD).

DESIGN

A cross-sectional multicenter survey.

SUBJECTS AND SETTING

The setting was 6 hospitals across 5 health districts in New South Wales, Australia. The participants were nurses (registered nurses and enrolled nurses), physicians, allied health (occupational therapists, dietitians, and physiotherapists), and students (nursing and allied health).

METHODS

Data about IAD knowledge were collected from November 2019 to January 2020. The Know-IAD, an 18-item validated instrument that measures knowledge of IAD in 3 domains (etiology and risk, classification and diagnosis, and prevention and management), was administered to a cross section of eligible clinicians. The participants anonymously completed hard copy surveys. Descriptive and exploratory analyses were conducted to quantify clinicians' knowledge about the etiology and risk, classification and diagnosis, and prevention and management of IAD. A mean knowledge score of 70% was considered to be satisfactory.

RESULTS

Four hundred twelve respondents completed the survey. One hundred twenty nine respondents (31.3%) achieved 70% correct responses and greater for the entire set of items. For the etiology and risk domain, 348 respondents (84.5%) obtained a score of 70% correct responses and greater, 67 respondents (16.3%) achieved 70% correct responses and greater for the classification and diagnosis domain, and 84 respondents (20.4%) achieved 70% correct responses and greater for the prevention and management domain.

CONCLUSION

Clinicians tend to have low knowledge and recognition of IAD, particularly in the areas of classification and diagnosis along with prevention and management. They tend to have higher knowledge of how IAD is caused and the risk factors. This study has identified knowledge gaps for further education that can improve assessment, prevention, and management of IAD.

Health, social and economic implications of adolescent risk behaviours/states: protocol for Raine Study Gen2 cohort data linkage study

BACKGROUND

Risk-taking behaviours are a major contributor to youth morbidity and mortality. Vulnerability to these negative outcomes is constructed from individual behaviour including risk-taking, and from social context, ecological determinants, early life experience, developmental capacity and mental health, contributing to a state of higher risk. However, although risk-taking is part of normal adolescent development, there is no systematic way to distinguish young people with a high probability of serious adverse outcomes, hindering the capacity to screen and intervene. This study aims to explore the association between risk behaviours/states in adolescence and negative health, social and economic outcomes through young adulthood.

METHODS

The Raine Study is a prospective cohort study which recruited pregnant women in 1989-91, in Perth, Western Australia. The offspring cohort (N = 2,868) was followed up at regular intervals from 1 to 27 years of age. These data will be linked to State government health and welfare administrative data. We will empirically examine relationships across multiple domains of risk (for example, substance use, sexual behaviour, driving) with health and social outcomes (for instance, road-crash injury, educational underachievement). Microsimulation models will measure the impact of risk-taking on educational attainment and labour force outcomes.

DISCUSSION

Comprehensive preventive child health programmes and policy prioritise a healthy start to life. This is the first linkage study focusing on adolescence to adopt a multi-domain approach, and to integrate health economic modelling. This approach captures a more complete picture of health and social impacts of risk behaviour/​states in adolescence and young adulthood.

Mental health and behavioural factors involved in road traffic crashes by young adults: analysis of the Raine Study

BACKGROUND

Road traffic crashes (RTC) are a leading cause of mortality and morbidity in young people. Severe mental health and behavioural conditions increase the likelihood of RTC, as do a range of driving-risk activities.

METHOD

We used data from the Raine Study, a prebirth cohort from Perth, Australia, to assess the relationship between measures of common mental health or behavioural conditions (Child Behavior Checklist Internalising and Externalising scores) at age 17 and subsequent RTC by 27 years, controlling for substance use and driving-risk activities.

RESULTS

By 27 years of age, of 937 participants, 386 (41.2%) reported zero crashes and 551 (58.8%) reported ≥1 crashes. In the baseline Poisson model, increased Externalising scores (eg, aggression and delinquency) were associated with increased RTC (incidence rate ratio (IRR)=1.02, 95% CI 1.01 to 1.02): increased Internalising scores (eg, anxiety and depression) were associated with fewer RTC (IRR=0.99, 95% CI 0.98 to 1.00). In the fully adjusted model, the mental health measures were not significant (Externalising IRR=1.01, 95% CI 0.99 to 1.02: Internalising IRR=0.99, 95% CI 0.99 to 1.00). Risky driver activities, such as falling asleep while driving (IRR=1.34), more frequent use of a hands-free telephone (IRR=1.35) and more frequent hostility towards other drivers (IRR=1.30) increased the rate of RTC.

CONCLUSION

Measures of mental health scores at age 17 were not predictive of subsequent RTC, after adjusting for measures of driving-risk activities. We need to better understand the determinants of externalising and risky driving behaviours if we are to address the increased risk of RTC.

Cost-effectiveness of Multidisciplinary Interventions for Chronic Low Back Pain: A Narrative Review

OBJECTIVE

Chronic musculoskeletal pain in adults is a global health and economic problem. The aim of this paper was to systematically review and determine what proportion of multidisciplinary approaches to managing chronic musculoskeletal pain are cost-effective.

MATERIALS AND METHODS

The EconLit, Embase, and PubMed electronic databases were searched for randomized and nonrandomized economic evaluation studies of nonpharmaceutical multidisciplinary chronic pain management interventions published from inception through to August 2019.

RESULTS

Seven studies comprising 2095 patients were included. All studies involved diverse multidisciplinary teams in one or more of the study arms. All studies involved chronic (both chronic and subacute) low back pain and were economic evaluations from either a societal or health care perspective. Two of the 3 studies that reported on a multidisciplinary pain intervention compared with nonmultidisciplinary intervention concluded favorable cost-effectiveness based on cost per quality adjusted life years gained, 1 study was not found to be cost-effective. Cost-effectiveness of the multidisciplinary intervention of interest was also not established by another 3-arm study. Two studies compared 2 multidisciplinary interventions; neither of these could definitively declare cost-effectiveness. The remaining study indicated the intervention by a multidisciplinary team was more effective but at a higher cost. None of the included studies used decision models to estimate long-term health outcomes and cost-effectiveness of multidisciplinary programs.

DISCUSSION

There are few studies on the cost-effectiveness of multidisciplinary chronic pain management interventions. This study encourages additional rigorous economic evaluations of multidisciplinary models for chronic pain management. Economic evaluations that enable extrapolating costs and effects of multidisciplinary programs beyond the time horizon of clinical trials may be more informative for clinicians and health administrators.

Supported online cognitive behavioural therapy for bulimia nervosa: a study protocol of a randomised controlled trial

BACKGROUND

Despite the availability of effective treatments for bulimia nervosa (BN), a number of barriers to accessibility exist. Examples include access to trained clinicians, the expense of treatment, geographical limitations, and personal limitations such as stigma regarding help seeking. Self-help interventions, delivered via a digital platform, have the potential to overcome treatment gaps by providing patients with standardised, evidence-based treatments that are easily accessible, cost-effective, and require minimal clinician support. Equally, it is important to examine the shortcomings of digital interventions when compared to traditional to face-to-face delivery (e.g., high dropout rates) in order to maximise the therapeutic effectiveness of online, self-help interventions.

METHODS

A three-arm, multisite randomised controlled trial will be conducted in Australia examining the effectiveness and cost-effectiveness of a newly developed online self-help intervention, Binge Eating eTherapy (BEeT), in a sample of patients with full or sub-threshold BN. The BEeT program consists of 10, multimedia sessions delivering the core components of cognitive behaviour therapy. Eligible participants will be randomised to one of three groups: independent completion of BEeT as a purely self-help program, completion of BEeT alongside clinician support (in the form of weekly telemedicine sessions), or waitlist control. Assessments will take place at baseline, weekly, post-intervention, and three-month follow up. The primary outcome is frequency of objective binge episodes. Secondary outcomes include frequency of other core eating disorder behavioural symptoms and beliefs, psychological distress, and quality of life. Statistical analyses will examine treatment effectiveness, feasibility, acceptability and cost effectiveness.

DISCUSSION

There is limited capacity within the mental health workforce in Australia to meet the demand of people seeking treatment for eating disorders. This imbalance has only worsened following outbreak of the COVID-19 pandemic. Further research is required into innovative digital modes of treatment delivery with the capacity to service mental health needs in an accessible and affordable manner. Self-help programs may also appeal to individuals who are more reluctant to engage in traditional face-to-face treatment formats. This study will provide rigorous evidence on how to diversify treatment options for individuals with BN, ensuring more people with the illness can access evidence-based treatment. The study has been registered with the Australia New Zealand Clinical Trials Registry (ANZCTR Registration Number: ACTRN12619000123145p). Registered 22 January 2019, https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12619000123145 .

Development and implementation of venous thromboembolism stewardship across a hospital network

BACKGROUND

Venous thromboembolism (VTE) is a leading cause of preventable death in hospital. Ensuring all hospitalized patients are assessed for VTE risk and given appropriate prophylaxis can reduce the burden of VTE on patients and the healthcare system. This is the first study to explore the effectiveness of a VTE stewardship program using electronic clinical decision support (eCDS) to provide oversight of hospital initiatives to prevent VTE.

AIM

To determine if a VTE stewardship program can increase risk-appropriate VTE prophylaxis, VTE risk assessment using eCDS, any documented risk assessment and risk assessment within 24 h of admission, plus reduce the incidence of hospital acquired VTE (HA-VTE).

METHODS

Education, daily medication chart auditing, weekly clinician performance feedback, health promotion and gamification were deployed over 6 months by two multidisciplinary VTE stewardship teams across four hospitals. Service impact was assessed through cross-sectional audits of electronic medical records every 3 months and review of HA-VTE events pre- and post-intervention. Implementation costs were calculated.

RESULTS

A total of 1622 patients were audited in separate cohorts at baseline, 3, 6 and 9 months. There was significant improvement in the prescription of appropriate prophylaxis (78%, 83%, 84%, and 88%, p = 0.004), VTE risk assessment using the eCDS tool (20%, 50%, 81% and 87%, p < 0.001), any documented risk assessment (71%, 82%, 95% and 93%, p < 0.001) and any documented risk assessment within 24 h of admission (54%, 56%, 65% and 63%, p = 0.001). Use of eCDS was associated with prescription of risk-appropriate VTE prophylaxis (p < 0.001). Annual incidence of HA-VTE decreased from 7.88 to 6.99 events per 10,000 discharges pre- to post-intervention (Odds Ratio (OR) 0.89, 95 %CI 0.66-1.18, p = 0.43). The cost of implementing the program across 133,078 episodes of care during the study period was AUD$108,167 (mean cost of $0.82 per patient).

Effect of a smartphone application (Perx) on medication adherence and clinical outcomes: a 12-month randomised controlled trial

OBJECTIVE

To determine whether the Perx app improves medication adherence and clinical outcomes over 12 months compared with standard care in patients requiring polypharmacy.

DESIGN

Randomised controlled trial with 12-month follow-up.

SETTING

Outpatient clinics in three tertiary hospitals in Sydney, Australia.

PARTICIPANTS

Eligible participants were aged 18-75 years, with at least one chronic condition, taking ≥3 different medications (oral medications or injections), with smartphone accessibility. Participants were randomised in a 1:1 ratio.

INTERVENTIONS

The intervention group used the Perx app that contained customised reminders and gamified interactions to reward verified medication adherence.

MAIN OUTCOME MEASURES

The primary outcome was medication adherence over 12 months measured using pill counts. Secondary outcomes included clinical outcomes (haemoglobin A1c (HbA1c), cholesterol, blood glucose, triglycerides, creatinine, thyroid function, blood pressure and weight).

RESULTS

Of 1412 participants screened for eligibility, 124 participants were randomised; 45 in the Perx arm and 40 in the control arm completed the study. The average age was 59.5, 58.9% were women, chronic conditions were cardiovascular disease (78%), type 2 diabetes (75%), obesity (65%) or other endocrine disorders (18%). On average, participants were taking six medications daily. The Perx group had greater improvements in adherence at month 2 (Coef. 8%; 95% CI 0.01 to 0.15), month 3 (Coef. 7%; 95% CI 0.00 to 0.14) and month 12 (Coef. 7%; 95% CI 0.00 to 0.13). The probability of HbA1c ≤6.5% was greater in the Perx group at months 9 and 12 and cholesterol (total and low-density lipoprotein cholesterol) was lower in the Perx group at month 3. The intervention was particularly effective for those with obesity, taking medications for diabetes and taking ≤4 medications.

CONCLUSIONS

This study provides evidence that app-based behavioural change interventions can increase medication adherence and produce longer-term improvements in some clinical outcomes in adults managing multimorbidity. More trials are needed to build the evidence base.

TRIAL REGISTRATION NUMBER

ACTRN12617001285347.

Factors related to length of stay, referral on discharge and hospital readmission for children and adolescents with anorexia nervosa

OBJECTIVE

This study examined factors related to hospital length of stay (LOS), reported referral on discharge, and hospital readmission, for children and adolescents (C&A) admitted to public hospitals for anorexia nervosa (AN), in a large health jurisdiction in Australia.

METHOD

Sociodemographic, illness, treatment, and hospital factors associated with LOS, reported referral to post-hospital treatment, and readmission within 28 days were analyzed for C&A with AN admitted to all New South Wales public hospitals in 2017, using median, multinomial logit and logit models. The sample comprised 289 admissions by 200 C&A aged 9-18 years with a primary or secondary diagnosis of AN.

RESULTS

AN as a primary diagnosis and the presence of some physical and mental co-occurring conditions (e.g., malnutrition and obsessive-compulsive disorders) conferred a longer LOS. The majority of admissions were recorded being referred to primary care physicians (59.86%) and relatively small numbers to outpatient mental health services (5.54%) or outpatient eating disorder services (8.30%), with age, area socioeconomic status, and illness factors related to referral type. Male, low socioeconomic status, the presence of some co-occurring illnesses (e.g., adjustment disorder and viral infection), and rural or remote locations increased the likelihood of readmission.

DISCUSSION

The findings have implications for service design, in particular the pathway to care from hospital into community for AN. Targeted interventions should consider recognizing and treating physical co-occurring illnesses at presentation to the health system, ensuring appropriate referral to community services, and providing services in socioeconomically disadvantaged and rural or remote areas.

Implementing best available evidence into practice for incontinence-associated dermatitis in Australia: A multisite multimethod study protocol

AIMS

Incontinence-associated dermatitis (IAD) is an insidious and under-reported hospital-acquired complication which substantially impacts on patients' quality of life. A published international guideline and the Ghent Global IAD Categorisation Tool (GLOBIAD) outline the best available evidence for the optimal management of IAD. This study aims to implement theguideline and the GLOBIAD tool and evaluate the effect on IAD occurrences and sacral pressure injuries as well as patient, clinician and cost-effectiveness outcomes.

MATERIALS AND METHODS

The study will employ a multi-method design across six hospitals in five health districts in Australia, and will be conducted in three phases (pre-implementation, implementation and post-implementation) over 19 months. Data collection will involve IAD and pressure injury prevalence audits for patient hospital admissions, focus groups with, and surveys of, clinicians, patient interviews, and collection of the cost of IAD hospital care and patient-related outcomes including quality of life. Eligible participants will be hospitalised adults over 18 years of age experiencing incontinence, and clinicians working in the study wards will be invited to participate in focus groups and surveys.

CONCLUSION

The implementation of health district-wide evidence-based practices for IAD using a translational research approach that engages key stakeholders will allow the standardisation of IAD care that can potentially be applicable to a range of settings. Knowledge gained will inform future practice change in patient care and health service delivery and improve the quality of care for patients with IAD. Support at the hospital, state and national levels, coupled with a refined stakeholder-inclusive strategy, will enhance this project's success, sustainability and scalability beyond this existing project.

Translating evidence-based treatment for digital health delivery: a protocol for family-based treatment for anorexia nervosa using telemedicine

BACKGROUND

Family-based treatment (FBT) is an efficacious outpatient intervention for young people diagnosed with Anorexia Nervosa (AN). To date, treatment to protocol has relied on standard face-to-face delivery. Face-to-face therapy is subject to geographic, temporal and human factors, rendering it particularly susceptible to inequities and disruption. This has resulted in poorer service provision for rural and regional families, and recently a significant challenge to providing face-to-face services during the COVID-19 global pandemic. The present study examines whether FBT for AN can be successfully translated to a digital delivery platform to address these access issues.

METHOD

Forty young people aged 12 to 18 years who meet DSM-5 diagnostic criteria for AN, and live in a rural or regional setting, will along with their family be recruited to the study. Trained therapists will provide 18 sessions of FBT over 9 months via telemedicine to the home of the young person and their family. The analysis will examine treatment effectiveness, feasibility, acceptability, and cost-effectiveness.

DISCUSSION

The study addresses the treatment needs of families not able to attend face-to-face clinical services for evidence-based treatment for eating disorders. This might be due to several barriers, including a lack of local services or long travel distances to services. There has been a recent and unprecedented demand for telemedicine to facilitate the continuity of care during COVID-19 despite geographical circumstances. If delivering treatment in this modality is clinically and economically effective and feasible, it will facilitate access to potentially lifesaving, evidence-based treatments for families formerly unable to access such care and provide evidence for the continuity of services when and where face-to-face treatment is not feasible.

Improving Adherence to Weight-Loss Medication (Liraglutide 3.0 mg) Using Mobile Phone Text Messaging and Healthcare Professional Support

BACKGROUND

Adherence to weight-loss medication is suboptimal, leading to poor health outcomes. Short message service (SMS) can potentially improve adherence.

METHODS

A total of 3,994 participants with overweight or obesity in Australia receiving Saxenda® (liraglutide 3.0 mg) were enrolled from September 1, 2017, to February 28, 2018, through doctors, pharmacists, or websites and were randomly assigned to receive none, three, or five SMS per week. Participants were additionally offered a face-to-face consultation with a diabetes educator or a call from a dietitian. Medication adherence was measured as whether the total scripts claimed were at least as many as the total claims expected by March 31, 2018, and was modeled adjusting for age, sex, baseline BMI, residential region, enrolment channel, the total number of SMS, and additional patient support.

RESULTS

Participants receiving five SMS (OR, 6.25; 95% CI: 4.28-9.12) had greater adherence than those receiving three SMS (OR, 3.67; 95% CI: 2.67-5.03) or zero SMS per week. The effectiveness of SMS on adherence decreased as participants received more SMS over time. Moreover, the odds of adhering to liraglutide were higher for participants enrolled with pharmacists compared with those enrolled with doctors (OR, 2.28; 95% CI: 1.82-2.86) and for participants who received a face-to-face consultation (OR, 3.10; 95% CI: 1.82-5.29) or a call (OR, 1.31; 95% CI: 1.02-1.68) compared with those who received no extra support.

CONCLUSIONS

Integration of SMS into routine clinical practice should consider not only the frequency and content of reminders but also additional patient support to achieve higher and more sustained adherence to medication and health behavior changes.

An evaluation of health workforce models addressing oral health in residential aged care facilities: A systematic review of the literature

BACKGROUND

In Australia and globally, there is an increasing problem of unmet oral health needs of older people above 65 residing in aged care facilities. Various workforce models have been trialled to implement oral health care programmes in aged care facilities, but the evidence behind these programmes and their underlying workforce models is not known.

OBJECTIVE

To systematically review the literature on the effectiveness, and economic feasibility of the current workforce models addressing oral care in aged care facilities.

METHODS

CINAHL, Cochrane CENTRAL, MEDLINE, EMBASE, EMB Reviews, NHS Economic Evaluation Database and grey literature were searched. Studies were included if they described an oral health workforce model with a clinical intervention and defined oral health outcome measures. Analysis was conducted using the NHMRC guidelines for scientific and economic evaluations.

RESULTS

Twenty-eight studies were included. Four distinct workforce models of care were identified. 60% of the studies demonstrated short-term effectiveness in clinical measures. Workforce models were similar in their effectiveness, with varying levels of quality within each model. Although three studies considered individual components of economic feasibility, only one provided a comprehensive economic analysis of both the costs and health outcomes.

CONCLUSIONS IMPLICATIONS OF FINDINGS

All workforce models of care had some positive impact on oral health for residents of aged care. Oral health should be included as a health focus in age care facilities. Future studies should include longer-term health outcomes with rigorous economic analysis to ensure sustainably delivered workforce models of care for oral health management within aged care.

The indirect costs of ischemic heart disease through lost productive life years for Australia from 2015 to 2030: results from a microsimulation model

Background

Most studies measure the impact of ischemic heart disease (IHD) on individuals using quality of life metrics such as disability-adjusted life-years (DALYs); however, IHD also has an enormous impact on productive life years (PLYs). The objective of this study was to project the indirect costs of IHD resulting from lost PLYs to older Australian workers (45–64 years), government, and society 2015–2030.

Methods

Nationally representative data from the Surveys of Disability, Ageing and Carers (2003, 2009) were used to develop the base population in the microsimulation model (Health&WealthMOD2030), which integrated data from established microsimulation models (STINMOD, APPSIM), Treasury’s population and workforce projections, and chronic conditions trends.

Results

We projected that 6700 people aged 45–64 were out of the labour force due to IHD in 2015, increasing to 8100 in 2030 (21 increase). National costs consisted of a loss of AU$273 (US$263) million in income for people with IHD in 2015, increasing to AU$443 ($US426) million (62% increase). For the government, extra welfare payments increased from AU$106 (US$102) million in 2015 to AU$143 (US$138) million in 2030 (35% increase); and lost income tax revenue increased from AU$74 (US$71) million in 2015 to AU$117 (US$113) million in 2030 (58% increase). A loss of AU$785 (US$755) million in GDP was projected for 2015, increasing to AU$1125 (US$1082) million in 2030.

Conclusions

Significant costs of IHD through lost productivity are incurred by individuals, the government, and society. The benefits of IHD interventions include not only improved health but also potentially economic benefits as workforce capacity.

Indirect costs of depression and other mental and behavioural disorders for Australia from 2015 to 2030

BACKGROUND

The impact of mental disorders has been assessed in relation to longevity and quality of life; however, mental disorders also have an impact on productive life-years (PLYs).

AIMS

To quantify the long-term costs of Australians aged 45-64 having lost PLYs because of mental disorders.

METHOD

The Survey of Disability, Ageing and Carers 2003, 2009 formed the base population of Health&WealthMOD2030 - a microsimulation model integrating output from the Static Incomes Model, the Australian Population and Policy Simulation Model, the Treasury and the Australian Burden of Disease Study.

RESULTS

For depression, individuals incurred a loss of AU$1062 million in income in 2015, projected to increase to AU$1539 million in 2030 (45% increase). The government is projected to incur costs comprising a 22% increase in social security payments and a 45% increase in lost taxes as a result of depression through its impact on PLYs.

CONCLUSIONS

Effectiveness of mental health programmes should be judged not only in terms of healthcare use but also quality of life and economic well-being.

DECLARATION OF INTEREST

None.

Evaluating the effectiveness of an evidence-based online training program for health professionals in eating disorders

BACKGROUND

Early detection and treatment are essential to ensuring the best possible health outcomes for people with eating disorders (EDs). However, low diagnostic accuracy and a lack of specific ED training are common workforce challenges in Australia and internationally. Online learning provides a potential solution in facilitating the access to evidence-based training programs. The InsideOut Institute has developed the first online clinical training program in EDs to assist with educating health professionals in the identification, assessment, and management of EDs. The aim of the study is to evaluate the effectiveness of the online training program, The Essentials, in mitigating barriers to health professionals treating patients with EDs.

METHODS

Pre and post training questionnaires assessed participants' attitudes, knowledge, and skills in relation to treating people with EDs. Demographic and work-related information (gender, discipline, work setting, practice length and remoteness) and participants' ratings of the online learning experience and satisfaction on completion were collected. The Wilcoxon signed rank test was applied to test for changes in learning outcomes before and after completion of the program. A multivariate linear regression model was estimated for each of the learning outcomes with personal and work-related characteristics as covariates.

RESULTS

Among 1813 health professionals who registered for The Essentials program between 1 October 2013 and 31 July 2018, 1160 completed at least 80% of the five learning modules. There were significant improvements in confidence, knowledge, skills to treat EDs and a reduction in stigmatised beliefs among the 480 participants who completed both pre and post assessments. Results from the regression models suggest that psychologists, dieticians, and those working in rural areas were more willing to treat EDs after completing the program. Additionally, those working in hospitals and regional or rural areas experienced the largest improvement in confidence for treating patients with EDs.

CONCLUSIONS

The Essentials program represents a new and effective way of meeting the educational needs of partaking health professionals working with ED patients. Greater investment in the development and testing of evidence-based online training programs for EDs may help to address some of the considerable workforce development challenges in EDs.

The Population Cost-Effectiveness of Weight Watchers with General Practitioner Referral Compared with Standard Care

OBJECTIVE

This study aimed to assess population-level cost-effectiveness of the Weight Watchers (WW) program with doctor referral compared with standard care (SC) for Australian adults with overweight and obesity.

METHODS

The target population was Australian adults ≥ 20 years old with BMI ≥ 27 kg/m² , whose obesity status was subsequently modeled for 2015 to 2025. A microsimulation model (noncommunicable disease model [NCDMod]) was used to assess the incremental cost-effectiveness of WW compared with SC. A health system perspective was taken, and outcomes were measured by obesity cases averted in 2025, BMI units averted for 2015 to 2025, and quality-adjusted life years for 2015 to 2025. Univariate sensitivity testing was used to measure variations in the model parameters.

RESULTS

The WW intervention resulted in 60,445 averted cases of obesity in 2025 (2,311 more cases than for SC), extra intervention costs of A$219 million, and cost savings within the health system of A$17,248 million (A$82 million more than for SC) for 2015 to 2025 compared with doing nothing. The modeled WW had an incremental cost-effectiveness ratio of A$35,195 in savings per case of obesity averted in 2025. WW remained dominant over SC for the different scenarios in the sensitivity analysis.

CONCLUSIONS

The WW intervention represents good value for money. The WW intervention needs serious consideration in a national package of obesity health services.

The long-term economic impacts of arthritis through lost productive life years: results from an Australian microsimulation model

Background

While the direct (medical) costs of arthritis are regularly reported in cost of illness studies, the 'true' cost to indivdiuals and goverment requires the calculation of the indirect costs as well including lost productivity due to ill-health.

Methods

Respondents aged 45-64 in the ABS Survey of Disability, Ageing and Carers 2003, 2009 formed the base population. We projected the indirect costs of arthritis using Health&WealthMOD2030 – Australia’s first microsimulation model on the long-term impacts of ill-health in older workers – which incorporated outputs from established microsimulation models (STINMOD and APPSIM), population and labour force projections from Treasury, and chronic conditions trends for Australia. All costs of arthritis were expressed in real 2013 Australian dollars, adjusted for inflation over time.

Results

We estimated there are 54,000 people aged 45-64 with lost PLYs due to arthritis in 2015, increasing to 61,000 in 2030 (13% increase). In 2015, people with lost PLYs are estimated to receive AU$706.12 less in total income and AU$311.67 more in welfare payments per week than full-time workers without arthritis, and pay no income tax on average. National costs include an estimated loss of AU$1.5 billion in annual income in 2015, increasing to AU$2.4 billion in 2030 (59% increase). Lost annual taxation revenue was projected to increase from AU$0.4 billion in 2015 to $0.5 billion in 2030 (56% increase). We projected a loss in GDP of AU$6.2 billion in 2015, increasing to AU$8.2 billion in 2030.

Conclusions

Significant costs of arthritis through lost PLYs are incurred by individuals and government. The effectiveness of arthritis interventions should be judged not only on healthcare use but quality of life and economic wellbeing.

The economic impacts of using adalimumab (Humira® ) for reducing pain in people with ankylosing spondylitis: A microsimulation study for Australia

AIM

The onset and progression of ankylosing spondylitis (AS) usually occurs during the life stage when individuals are more likely to be working and receiving an income, but little is known about the effects of interventions that reduce pain and improve the economic circumstances of patients out of the labour force due to AS. This study evaluates the economic benefits of pain reduction among people aged 19-64 with AS using adalimumab (Humira^® ) from the patient and governmental perspectives.

METHODS

We estimated the benefits of adalimumab for reducing pain in people aged 19-64 with AS in terms of labor force participation and earnings, and to the Australian Government in terms of income tax revenue and welfare payments using economic simulation. The simulation model integrated data from the Adalimumab Trial Evaluating Long-Term Safety and Efficacy for Ankylosing Spondylitis (ATLAS), the Household Income and Labour Dynamics in Australia (HILDA) Survey - Wave 10, and Static Incomes Model (STINMOD). All benefits are expressed in 2014 real Australian dollars.

RESULTS

We estimated an additional 131 people aged 19-64 with AS (111 males, 20 females) would be in the labour force after using adalimumab for 24 weeks. National benefits consisted of an increase in annual earnings of AU$7.4 million for patients through increased labour force participation, savings of $2 million in annual welfare payments, and an increase of $1.3 million in income tax revenue in 2014 (after 24 weeks).

CONCLUSION

Adalimumab therapy generates substantial economic benefits in addition to health benefits for individuals, and savings for government.

A six-year trend of the healthcare cost of arthritis in a population-based cohort of older women

ABSTRACT ObjectivesTo examine the trend of the healthcare cost of arthritis in a population-based cohort of older women and to estimate the mean adjusted incremental healthcare costs, and selected percentiles. ApproachThis is a healthcare cost study based on individual-level data. Data included health survey and linked administrative data, from 2003 to 2009, from the Australian Longitudinal Study on Women’s Health. The Medicare Australia datasets include the Pharmaceutical Benefits Scheme (unit record data on claims for government-subsidized prescription medicines) and the Medicare Benefits Schedule (listing of health services subsidized by the Australian Government) datasets; they were the source for all healthcare utilization and cost data in this study. The main outcome measure was the incremental healthcare cost of arthritis (estimated from the Australian Government’s cost perspective) expressed as dollars per person per year. All costs were expressed in 2012 Australian dollars. Regression models were used to estimate the adjusted incremental costs of arthritis. The mean adjusted incremental healthcare cost of arthritis was computed using GLMs with a logarithmic-link function and a gamma distribution for costs. The adjusted incremental costs at the 25th, 50th, 75th, 90th and 95th percentiles were computed using Quantile Regression. These percentiles were chosen because cost data are skewed to the right and it was expected that there would be smaller differences between the lower percentiles but bigger differences between upper adjacent percentiles. ResultsData from 4287 women were included in the analysis. Adjusted incremental healthcare cost of arthritis did not increase significantly from 2003 to 2009. However, there were indications that costs at the lower percentiles decreased slightly over the study period while costs at higher (above 50th) percentiles increased. The estimated median cost was $480 (95% CI: $498 - $759) per person per year in 2009. However, ten percent of women had more than 300% higher cost than the “average person” with arthritis. ConclusionHealthcare cost of arthritis represents a substantial burden. However, considering only overall cost does not provide a detailed picture of expenditure. Our results suggest that higher cost patients had different experiences in arthritis cost over time, compared to patients with lower costs, although overall cost has not increased over time. As healthcare spending is concentrated in the high-cost patients, characterising these patients and formulating initiatives that target them could have a considerable impact on improving care and lowering health expenditure due to arthritis.

The impact on productivity of a hypothetical tax on sugar-sweetened beverages

OBJECTIVES

To quantify the potential impact of an additional 20% tax on sugar-sweetened beverages (SSBs) on productivity in Australia.

METHODS

We used a multi-state lifetable Markov model to examine the potential impact of an additional 20% tax on SSBs on total lifetime productivity in the paid and unpaid sectors of the economy. The study population consisted of Australians aged 20 years or older in 2010, whose health and other relevant outcomes were modelled over their remaining lifetime.

RESULTS

The SSBs tax was estimated to reduce the number of people with obesity by 1.96% of the entire population (437,000 fewer persons with obesity), and reduce the number of employees with obesity by 317,000 persons. These effects translated into productivity gains in the paid sector of AU$751 million for the working-age population (95% confidence interval: AU$565 million to AU$954 million), using the human capital approach. In the unpaid sector, the potential productivity gains amounted to AU$1172 million (AU$929 million to AU$1435 million) using the replacement cost method. These productivity benefits are in addition to the health benefits of 35,000 life years gained and a reduction in healthcare costs of AU$425 million.

CONCLUSIONS

An additional 20% tax on SSBs not only improves health outcomes and reduces healthcare costs, but provides productivity gains in both the paid and unpaid sectors of the economy.

Discordance between self-reported arthritis and musculoskeletal signs and symptoms in older women

BACKGROUND

Arthritis is a gendered disease where women have a higher prevalence and more disability than men with arthritis of the same age. Health survey data is a major source of information for monitoring of the burden of arthritis. The validity of self-reported arthritis and the determinants of its accuracy among women have not been thoroughly studied. The objectives of this study were to: 1) examine the agreement between self-report diagnosed arthritis and musculoskeletal signs and symptoms in community-living older women; 2) estimate the sensitivity, specificity, and predictive values of self-reported arthritis; and 3) assess the factors associated with the disagreement.

METHODS

A cross-sectional survey of women was undertaken in 2012-13. The health survey asked women about diagnosed arthritis and musculoskeletal signs and symptoms. Agreement between self-reported arthritis and musculoskeletal signs symptoms was measured by Cohen's kappa. Sensitivity, specificity, and predictive values of self-reported arthritis were estimated using musculoskeletal signs and symptoms as the reference standard. Factors associated with disagreement between self-reported arthritis and the reference standard were examined using multiple logistic regression.

RESULTS

There were 223 participants self-reported arthritis and 347 did not. A greater number of participants who self-reported arthritis were obese compared to those who did not report arthritis. Those who reported arthritis had worse health, physical functioning, and arthritis symptom measures. Among the 570 participants, 198 had musculoskeletal signs and symptoms suggesting arthritis (the reference standard). Agreement between self-reported arthritis and the reference standard was moderate (kappa = 0.41). Sensitivity, specificity, and positive and negative predictive values of self-reported arthritis in older women were 66.7, 75.5, 59.2, and 81.0% respectively. Regression analysis results indicated that false-positive is associated with better health measured by the Short Form 36 physical summary score, the Health Assessment Questionnaire disability index, or the Western Ontario and McMaster University Osteoarthritis Index total score; whereas false-negative is negatively associated with these variables.

CONCLUSION

While some women who reported diagnosed arthritis did not have recent musculoskeletal signs or symptoms, others with the signs and symptoms did not report diagnosed arthritis. Researchers should use caution when employing self-reported arthritis as the case-definition in epidemiological studies.

The Role of Personalised Choice in Decision Support: A Randomized Controlled Trial of an Online Decision Aid for Prostate Cancer Screening

Importance

Decision support tools can assist people to apply population-based evidence on benefits and harms to individual health decisions. A key question is whether “personalising” choice within decisions aids leads to better decision quality.

Objective

To assess the effect of personalising the content of a decision aid for prostate cancer screening using the Prostate Specific Antigen (PSA) test.

Design

Randomized controlled trial.

Setting

Australia.

Participants

1,970 men aged 40–69 years were approached to participate in the trial.

Intervention

1,447 men were randomly allocated to either a standard decision aid with a fixed set of five attributes or a personalised decision aid with choice over the inclusion of up to 10 attributes.

Outcome Measures

To determine whether there was a difference between the two groups in terms of: 1) the emergent opinion (generated by the decision aid) to have a PSA test or not; 2) self-rated decision quality after completing the online decision aid; 3) their intention to undergo screening in the next 12 months. We also wanted to determine whether men in the personalised choice group made use of the extra decision attributes.

Results

5% of men in the fixed attribute group scored ‘Have a PSA test’ as the opinion generated by the aid, as compared to 62% of men in the personalised choice group (χ² = 569.38, 2df, p< 0001). Those men who used the personalised decision aid had slightly higher decision quality (t = 2.157, df = 1444, p = 0.031). The men in the personalised choice group made extensive use of the additional decision attributes. There was no difference between the two groups in terms of their stated intention to undergo screening in the next 12 months.

Conclusions

Together, these findings suggest that personalised decision support systems could be an important development in shared decision-making and patient-centered care.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12612000723886

Clarifying Clinical Nurse Consultant work in Australia: A phenomenological study

The Clinical Nurse Consultant role in Australia is an Advanced Practice Registered Nurse Role (APRN). This role has been conceptualized from the discrete pillars of research, education, practice, system support and leadership, articulated in the Strong Model of Advanced Practice. This conceptualization has been manifested in job descriptions, workforce. planning and course design. This paper explored whether there was a more refined way of conceptualizing the unique 'value add' of the role. A hermeneutic phenomenological approach was employed to explore the lived experience of the role. It was identified that the pillars of education, practice, leadership and research are interconnected and expressed in the system work of the Clinical Nurse Consultant. The findings have implications for education and workforce planning.

Factors associated with the health care cost in older Australian women with arthritis: an application of the Andersen's Behavioural Model of Health Services Use

OBJECTIVE

Factors associated with the utilisation of health care have not been rigorously examined in people with arthritis. The objective of this study was to examine the determinants of health care utilisation and costs in older women with arthritis using the Andersen's behavioural model as a framework.

STUDY DESIGN

Longitudinal cohort study.

METHODS

Participants of Surveys 3 to 5 of the Australian Longitudinal Study on Women's Health who reported arthritis were included in the study. Information about health care utilisation and unit prices were based on linked Medicare Australia data, which included prescription medicines and health services. Total health care costs of participants with arthritis were measured for the years 2002 to 2003, 2005 to 2006, and 2008 to 2009, which corresponded to the survey years. Potential explanatory variables of the health care cost and other characteristics of the participants were collected from the health surveys. Explanatory variables were grouped into predisposing characteristics, enabling factors and need variables conforming to the Andersen's Behavioural Model of Health Services Use. Longitudinal data analysis was conducted using generalized estimating equations.

RESULTS

A total of 5834 observations were included for the three periods. Regression analysis results show that higher health care cost in older Australian women with arthritis was significantly associated with residing in an urban area, having supplementary health insurance coverage, more comorbid conditions, using complementary and alternative medicine, and worse physical functioning. It was also found that predisposing characteristics (such as the area of residence) and enabling factors (such as health insurance coverage) accounted for more variance in the health care cost than need variables (such as comorbid conditions).

CONCLUSION

These results may indicate an inefficient and unfair allocation of subsidised health care among older Australian women with arthritis, where individuals with less enabling resources and more socio-economic disadvantages have a lower level of health care utilisation. Future research may focus on evaluating the effectiveness of policies designed to reduce excessive out-of-pocket costs and to improve equity in health care access in the older population.

Cost of arthritis: a systematic review of methodologies used for direct costs

A substantial amount of healthcare and costs are attributable to arthritis, which is a very common chronic disease. This paper presents the results of a systematic review of arthritis cost studies published from 2008 to 2013. MEDLINE, Embase, EconLit databases were searched, as well as governmental and nongovernmental organization websites. Seventy-one reports met the inclusion/exclusion criteria, and 24 studies were included in the review. Among these studies, common methods included the use of individual-level data, bottom-up costing approach, use of both an arthritis group and a control group to enable incremental cost computation of the disease, and use of regression methods such as generalized linear models and ordinary least squares regression to control for confounding variables. Estimates of the healthcare cost of arthritis varied considerably across the studies depending on the study methods, the form of arthritis and the population studied. In the USA, for example, the estimated healthcare cost of arthritis ranged from $1862 to $14,021 per person, per year. The reviewed study methods have strengths, weaknesses and potential improvements in relation to estimating the cost of disease, which are outlined in this paper. Caution must be exercised when these methods are applied to cost estimation and monitoring of the economic burden of arthritis.

A 6-year trend of the healthcare costs of arthritis in a population-based cohort of older women

OBJECTIVE

To provide an accurate representation of the economic burden of arthritis by estimating the adjusted incremental healthcare cost of arthritis at multiple percentiles and reporting the cost trends across time.

METHODS

A healthcare cost study based on health survey and linked administrative data, where costs were estimated from the government's perspective in dollars per person per year. Quantile regression was used to estimate the adjusted incremental cost at the 25th, 50th, 75th, 90th, and 95th percentiles.

RESULTS

Data from 4287 older Australian women were included. The median incremental healthcare cost of arthritis was, in 2012 Australian dollars, $480 (95% CI: $498-759) in 2009; however, 5% of individuals had 5-times higher costs than the 'average individual' with arthritis. Healthcare cost of arthritis did not increase significantly from 2003 to 2009.

CONCLUSION

Healthcare cost of arthritis represents a substantial burden for the governments. Future research should continue to monitor the economic burden of arthritis.

Towards generic online multicriteria decision support in patient-centred health care

OBJECTIVE

To introduce a new online generic decision support system based on multicriteria decision analysis (MCDA), implemented in practical and user-friendly software (Annalisa©).

BACKGROUND

All parties in health care lack a simple and generic way to picture and process the decisions to be made in pursuit of improved decision making and more informed choice within an overall philosophy of person- and patient-centred care.

METHODS

The MCDA-based system generates patient-specific clinical guidance in the form of an opinion as to the merits of the alternative options in a decision, which are all scored and ranked. The scores for each option combine, in a simple expected value calculation, the best estimates available now for the performance of those options on patient-determined criteria, with the individual patient's preferences, expressed as importance weightings for those criteria. The survey software within which the Annalisa file is embedded (Elicia©) customizes and personalizes the presentation and inputs. Principles relevant to the development of such decision-specific MCDA-based aids are noted and comparisons with alternative implementations presented. The necessity to trade-off practicality (including resource constraints) with normative rigour and empirical complexity, in both their development and delivery, is emphasized.

CONCLUSION

The MCDA-/Annalisa-based decision support system represents a prescriptive addition to the portfolio of decision-aiding tools available online to individuals and clinicians interested in pursuing shared decision making and informed choice within a commitment to transparency in relation to both the evidence and preference bases of decisions. Some empirical data establishing its usability are provided.

Addressing preference heterogeneity in public health policy by combining Cluster Analysis and Multi-Criteria Decision Analysis: Proof of Method

The use of subgroups based on biological-clinical and socio-demographic variables to deal with population heterogeneity is well-established in public policy. The use of subgroups based on preferences is rare, except when religion based, and controversial. If it were decided to treat subgroup preferences as valid determinants of public policy, a transparent analytical procedure is needed. In this proof of method study we show how public preferences could be incorporated into policy decisions in a way that respects both the multi-criterial nature of those decisions, and the heterogeneity of the population in relation to the importance assigned to relevant criteria. It involves combining Cluster Analysis (CA), to generate the subgroup sets of preferences, with Multi-Criteria Decision Analysis (MCDA), to provide the policy framework into which the clustered preferences are entered. We employ three techniques of CA to demonstrate that not only do different techniques produce different clusters, but that choosing among techniques (as well as developing the MCDA structure) is an important task to be undertaken in implementing the approach outlined in any specific policy context. Data for the illustrative, not substantive, application are from a Randomized Controlled Trial of online decision aids for Australian men aged 40-69 years considering Prostate-specific Antigen testing for prostate cancer. We show that such analyses can provide policy-makers with insights into the criterion-specific needs of different subgroups. Implementing CA and MCDA in combination to assist in the development of policies on important health and community issues such as drug coverage, reimbursement, and screening programs, poses major challenges -conceptual, methodological, ethical-political, and practical - but most are exposed by the techniques, not created by them.

Factors associated with higher healthcare costs in individuals living with arthritis: evidence from the quantile regression approach

OBJECTIVE

To examine the factors associated with higher healthcare cost in women with arthritis, using generalized linear models (GLMs) and quantile regression (QR).

METHODS

This is a cross-sectional healthcare cost study of individuals with arthritis that focused on older Australian women. Cost data were drawn from the Medicare Australia datasets.

RESULTS

GLM results show that healthcare cost was significantly associated with various socio-demographic and health factors. Although QR analysis results show the same direction of association between these factors and healthcare cost as in the GLMs, they indicate progressively increased effect sizes at the 50th, 75th, 90th and 95th percentiles.

CONCLUSION

Findings suggest traditional regression models such as GLMs that assume a single rate of change to accurately describe the relationships between explanatory variables and healthcare costs across the entire distribution of cost can produce biased results. QR should be considered in future healthcare cost research.

The impact of diabetes on the labour force participation, savings and retirement income of workers aged 45-64 years in Australia

Background

Diabetes is a debilitating and costly condition. The costs of reduced labour force participation due to diabetes can have severe economic impacts on individuals by reducing their living standards during working and retirement years.

Methods

A purpose-built microsimulation model of Australians aged 45-64 years in 2010, Health&WealthMOD2030, was used to estimate the lost savings at age 65 due to premature exit from the labour force because of diabetes. Regression models were used to examine the differences between the projected savings and retirement incomes of people at age 65 for those currently working full or part time with no chronic health condition, full or part time with diabetes, and people not in the labour force due to diabetes.

Results

All Australians aged 45-65 years who are employed full time in 2010 will have accumulated some savings at age 65; whereas only 90.5% of those who are out of the labour force due to diabetes will have done so. By the time they reach age 65, those who retire from the labour force early due to diabetes have a median projected savings of less than $35,000. This is far lower than the median value of total savings for those who remained in the labour force full time with no chronic condition, projected to have $638,000 at age 65.

Conclusions

Not only does premature retirement due to diabetes limit the immediate income available to individuals with this condition, but it also reduces their long-term financial capacity by reducing their accumulated savings and the income these savings could generate in retirement. Policies designed to support the labour force participation of those with diabetes, or interventions to prevent the onset of the disease itself, should be a priority to preserve living standards comparable with others who do not suffer from this condition.