General practitioners' role in preventive medicine: scenario analysis using alcohol as a case study

The purpose of this analysis is threefold: first, to extract from the literature, current levels of GP detection of at-risk drinking by their patients, rates at which general practitioners (GPs) offer an intervention; and the effectiveness of these interventions; secondly, to develop a model based on this literature to be used in conjunction with scenario analysis; and thirdly, to consider the cost implications of current efforts and various scenarios. This study deals specifically with Australian general practice. A two-step procedure is used in the scenario analysis, which involves identifying opportunities for detection, intervention, effectiveness and assigning probabilities to outcomes. The results suggest that increasing rates of GP intervention achieves greatest benefit and return on resource use. For every 5% point increase in the rate of GP intervention, an additional 26 754 at-risk drinkers modify their drinking behaviour at a cost of $231.45 per patient. This compares with a cost per patient modifying drinking behaviour of $232.60 and $208.31 for every 5% point increase in the rates of detection and effectiveness, respectively. The knowledge, skill and attitude of practitioners toward drinking are significant, and they can be the prime motivators in persuading their patients to modify drinking behaviour.

After hours medical ward duties in a teaching hospital

In many Australian hospitals a medical officer is available for urgent review of in-patients outside normal working hours. Current practice in nurse-initiated requests for medical officer involvement out of hours may adversely affect patient outcome as well as medical and nursing resource use at these times. Of 10 523 nurse-initiated requests for out-of-hours review recorded by medical officers at our hospital in 2002-2003, the most frequent reasons for the requests were medication review, IV fluid orders, IV resite, venesection and pathology review, none of which are related to acute changes in clinical condition. Requests for routine review of medication and fluid orders were found to be rarely essential and often inappropriate. Medical officer activity was highest before midnight and least after midnight, suggesting most requests are fulfilled in the evening. Several strategies to reduce inappropriate out-of-hours requests were identified. Routine tasks could be completed by primary treating unit staff before going off-duty. IV cannulation and venesection may be performed by appropriately trained phlebotomists or skilled advanced practice nursing staff. Meticulous ordering of 'as required' analgesia and night sedation would reduce unnecessary requests. Clinical protocols for nurse-initiated adjustment of drugs with variable dosing may also decrease inefficiencies. This would leave the ward cover medical officers more available for their primary function of urgent patient review.

Cost-effectiveness analysis of a kidney and cardiovascular disease treatment program in an Australian aboriginal population

The objective of the study was to assess, from a health service perspective, whether a systematic program to modify kidney and cardiovascular disease reduced the costs of treating end-stage kidney failure. The participants in the study were 1,800 aboriginal adults with hypertension, diabetes with microalbuminuria or overt albuminuria, and overt albuminuria, living on two islands in the Northern Territory of Australia during 1995 to 2000. Perindopril was the primary treatment agent, and other medications were also used to control blood pressure. Control of glucose and lipid levels were attempted, and health education was offered. Evaluation of program resource use and costs for follow-up periods was done at 3 and 4.7 years. On an intention-to-treat basis, the number of dialysis starts and dialysis-years avoided were estimated by comparing the fate of the treatment group with that of historical control subjects, matched for disease severity, who were followed in the before the treatment program began. For the first three years, an estimated 11.6 person-years of dialysis were avoided, and over 4.7 years, 27.7 person-years of dialysis were avoided. The net cost of the program was $1,210 more per person per year than status quo care, and dialyses avoided gave net savings of $1.0 million at 3 years and $3.4 million at 4.6 years. The treatment program provided significant health benefit and impressive cost savings in dialysis avoided. (C) 2005 by the National Kidney Foundation, Inc.

Impulses towards a multifunctional transition in rural Australia: Gaps in the research agenda

The direction, complexity and pace of rural change in affluent, western societies can be conceptualized as a multifunctional transition, in which a variable mix of consumption and protection values has emerged, contesting the former dominance of production values, and leading to greater complexity and heterogeneity in rural occupance at all scales. This transition is propelled by three dominant driving forces, namely: agricultural overcapacity; the emergence of market-driven amenity values; and growing societal awareness of sustainability and preservation issues. Australia's generous supply of land and sparse investment in agriculture has facilitated local transitions towards enhanced consumption and protection values, enabling a clearer delineation of emerging differentiated modes of rural occupance than in more contested locales. In Australia seven distinctive modes of occupance can be identified, according to the relative precedence given to production, consumption or protection values. These modes are described as: productivist agricultural; rural amenity; small farm (or pluriactive); peri-metropolitan; marginalized agricultural; conservation; and indigenous. Within these seven modes, alternative trajectories are identified, indicating variability in the intensity and type of resource use. Articulation of the transition concept may provide synergy between discrete discourses in rural research. (c) 2005 Elsevier Ltd. All rights reserved.

Adaptations of strangler figs to life in the rainforest canopy

Figs are rainforest keystone species. Non-strangler figs establish on the forest floor; strangler figs establish epiphytically, followed by a dramatic transition from epiphyte to free-standing tree that kills its hosts. Free-standing figs display vigorous growth and resource demand suggesting that epiphytic strangler figs require special adaptations to deal with resource limitations imposed by the epiphytic environment. We studied epiphytic and free-standing strangler figs, and non-strangler figs in tropical rainforest and in cultivation, as well as strangler figs in controlled conditions. We investigated whether the transition from epiphyte to free-standing tree is characterised by morphological and physiological plasticity. Epiphyte substrate had higher levels of plant-available ammonium and phosphate, and similar levels of nitrate compared with rainforest soil, suggesting that N and P are initially not limiting resources. A relationship was found between taxonomic groups and plant N physiology; strangler figs, all members of subgenus Urostigma, had mostly low foliar nitrate assimilation rates whereas non-strangler figs, in subgenera Pharmacocycea, Sycidium, Sycomorus or Synoecia, had moderate to high rates. Nitrate is an energetically expensive N source, and low nitrate use may be an adaptation of strangler figs for conserving energy during epiphytic growth. Interestingly, significant amounts of nitrate were stored in fleshy taproot tubers of epiphytic stranglers. Supporting the concept of plasticity, leaves of epiphytic Ficus benjamina L. had lower N and C content per unit leaf area, lower stomatal density and 80% greater specific leaf area than leaves of conspecific free-standing trees. Similarly, glasshouse-grown stranglers strongly increased biomass allocation to roots under water limitation. Epiphytic and free-standing F. benjamina had similar average foliar delta C-13, but epiphytes had more extreme values; this indicates that both groups of plants use the C-3 pathway of CO2 fixation but that water availability is highly variable for epiphytes. We hypothesise that epiphytic figs use fleshy stem tubers to avoid water stress, and that nitrate acts as an osmotic compound in tubers. We conclude that strangler figs are a unique experimental system for studying the transition from rainforest epiphyte to tree, and the genetic and environmental triggers involved.

Cost-effectiveness of cholesterol-lowering therapy with pravastatin in patients with previous acute coronary syndromes aged 65 to 74 years compared with younger patients: Results from the LIPID study

Background We compared cost-effectiveness of pravastatin in a placebo-controlled trial in 5500 younger (31-64 years) and 3514 older patients (65-74 years) with previous acute coronary syndromes. Methods Hospitalizations and long-term medication within the 6 years of the trial were estimated in all patients. Drug dosage, nursing home, and ambulatory care costs were estimated from substudies. Incremental costs per life saved of pravastatin relative to placebo were estimated from treatment effects and resource use. Results Over 6 years, pravastatin reduced all-cause mortality by 4.3% in the older patients and by 2.3% in the younger patients. Older patients assigned pravastatin had marginally lower cost of pravastatin and other medication over 6 years (A$4442 vs A$4637), but greater cost offsets (A$2061 vs. A$897) from lower rates of hospitalizations. The incremental cost per life saved with pravastatin was A$55500 in the old and A$167200 in the young. Assuming no treatment effect beyond the study period, the life expectancy to age 82 years of additional survivors was 9.1 years in the older and. 17.3 years in the younger. Estimated additional life-years saved from pravastatin therapy were 0.39 years for older and 0.40 years for younger patients. Incremental costs per life-year saved were A$7581 in the older and A$1.4944 in the younger, if discounted at 5% per annum. Conclusions Pravastatin therapy was more cost-effective among older than younger patients, because of their higher baseline risk and greater cost offsets, despite their shorter life expectancy.

Repurchase of renewal rights: A policy option for the National Water Initiative

Management of the Murray-Darling river system involves a large number of users with imprecisely defined rights, and an aggregate rate of resource use that is environmentally unsustainable. One possible policy response is to make formal or informal contracts with users, under which users receive current benefits in return for a commitment to forgo usage rights in future. In this paper, this issue is explored with specific reference to the possibility of repurchasing the renewal rights for irrigation licenses.

Use and non-use values of wild Asian elephants: A total economic valuation approach

The contingent valuation method is often used for valuing environmental goods possessing use as well as non-use values. This paper investigates the relative importance of these values in relation to the existence of the wild Asian elephant. It does so by analysing results from a contingent valuation survey of a sample of urban residents living in three selected housing schemes in Colombo. We find that the major proportion of the respondents’ willingness to pay (WTP) for conservation of wild elephants is attributable to the non-use values of the elephant. However, differences in the relative importance of these values exist between those who visit national parks and those who do not. Differences in respondents’ WTP for conservation of elephants are found to be largely influenced by attitudinal and behavioural factors rather than socio-economic ones. We conclude that policymakers must recognise and take account of the importance of non-use values of the Asian elephant, if this endangered species is to survive in the long run. Nevertheless, the non-consumptive use value of elephants in Sri Lanka is also found to be substantial.

Nature-based tourism and the valuation of its environmental resources: Economic and other aspects

Nature-based tourism has grown in importance in recent decades, and strong links have been established between it and ecotourism. This reflects rising incomes, greater levels of educational attainment and changing values, especially in the Western world. Nature-based tourism is quite varied. Different types of such tourism are identified and their consequences for sustainability of their resource-base are briefly considered. The development and management of nature-based tourism involves many economic aspects, several of which are discussed. For example, one must consider the economics of reserving or protecting land for this type of tourism. What economic factors should be taken into account? Economists stress the importance of taking into account the opportunity costs involved in such a decision. This concept is explained. However, determining the net economic value of an area used for tourism is not straightforward. Techniques for doing this, such as the travel cost method and stated value methods, are introduced. Natural areas reserved for tourism may have economic value not only for tourism but also jointly for other purposes, such as conserving wildlife, maintaining hydrological cycles and so on. These other purposes, should be taken into account when considering the use of land for nature-based tourism. According to one economic point of view, land should be used in a way that maximises its total economic value. While this approach has its merits, it does not take into account the distribution of benefits from land use and its local impacts on income and employment. These can be quite important politically and for nature conservation, and are discussed. Finally, there is some discussion of whether fees charged to tourists for access to environmental resources should discriminate between domestic tourists and foreigners.