Costs and advance directives at the end of life: a case of the ‘Coaching Older Adults and Carers to have their preferences Heard (COACH)’ trial

BACKGROUND: Total costs associated with care for older people nearing the end of life and the cost variations related with end of life care decisions are not well documented in the literature. Healthcare utilisation and associated health care costs for a group of older Australians who entered Transition Care following an acute hospital admission were calculated. Costs were differentiated according to a number of health care decisions and outcomes including advance directives (ADs).

METHODS: Study participants were drawn from the Coaching Older Adults and Carers to have their preferences Heard (COACH) trial funded by the Australian National Health and Medical Research Council. Data collected included total health care costs, the type of (and when) ADs were completed and the place of death. Two-step endogenous treatment-regression models were employed to test the relationship between costs and a number of variables including completion of ADs.

RESULTS: The trial recruited 230 older adults with mean age 84 years. At the end of the trial, 53 had died and 80 had completed ADs. Total healthcare costs were higher for younger participants and those who had died. No statistically significant association was found between costs and completion of ADs.

CONCLUSION: For our frail study population, the completion of ADs did not have an effect on health care utilisation and costs. Further research is needed to substantiate these findings in larger and more diverse clinical cohorts of older people.

Tightening eligibility for bail for persons on supervision orders in Victoria: repairing a broken system?

Victoria Nourse has observed that political debates about crime legislation are predictable and invariably one-sided because ‘no-one is “for” crime.’1 This certainly appears to be the case with regard to recent proposed changes to the Bail Act 1977 (‘the Act’) by the government of Victoria. The reforms were triggered by the case of Sean Price, an offender with a history of mental disorder, serious offending and lengthy incarceration who was on bail and subject to a supervision order when he murdered Masa Vukotic, raped another woman and assaulted a third person in March 2015. The Premier of Victoria, Daniel Andrews, stated that a bail system that allowed Price to be free and unmonitored was failing the community and pledged to repair ‘a system that is broken.’

Stress triangle: do introduced predators exert indirect costs on native predators and prey?

Non-consumptive effects of predators on each other and on prey populations often exceed the effects of direct predation. These effects can arise from fear responses elevating glucocorticoid (GC) hormone levels (predator stress hypothesis) or from increased vigilance that reduces foraging efficiency and body condition (predator sensitive foraging hypothesis); both responses can lead to immunosuppression and increased parasite loads. Non-consumptive effects of invasive predators have been little studied, even though their direct impacts on local species are usually greater than those of their native counterparts. To address this issue, we explored the non-consumptive effects of the invasive red fox Vulpes vulpes on two native species in eastern Australia: a reptilian predator, the lace monitor Varanus varius and a marsupial, the ringtail possum Pseudocheirus peregrinus. In particular, we tested predictions derived from the above two hypotheses by comparing the basal glucocorticoid levels, foraging behaviour, body condition and haemoparasite loads of both native species in areas with and without fox suppression. Lace monitors showed no GC response or differences in haemoparasite loads but were more likely to trade safety for higher food rewards, and had higher body condition, in areas of fox suppression than in areas where foxes remained abundant. In contrast, ringtails showed no physiological or behavioural differences between fox-suppressed and control areas. Predator sensitive foraging is a non-consumptive cost for lace monitors in the presence of the fox and most likely represents a response to competition. The ringtail's lack of response to the fox potentially represents complete naiveté or strong and rapid selection to the invasive predator. We suggest evolutionary responses are often overlooked in interactions between native and introduced species, but must be incorporated if we are to understand the suite of forces that shape community assembly and function in the wake of biological invasions.

Effectiveness, costs, and cost-effectiveness of recruitment strategies for a mammographic screening program to detect breast cancer

BACKGROUND AND PURPOSE: Since effective and affordable recruitment methods are essential for the widespread implementation of mammographic screening for detection of breast cancer, we studied the effectiveness, the costs, and the cost-effectiveness of various recruitment strategies in the population targeted by a pilot Australian program that offered free mammography screening between 1988 and 1990. METHODS: We evaluated three public recruitment strategies--local newspaper articles, community promotion, and promotion to physicians--and five personal strategies--invitation letters with or without specified appointment times, either alone or with a follow-up letter, or telephone call to nonattenders. The effectiveness of public recruitment strategies was estimated from monthly attendance rates by Poisson regression analysis, while the probability of attendance in response to personal strategies was calculated using logistic regression analysis. Costs were determined by resource usage studies. The cost-effectiveness ratios for personal strategies were determined using decision analysis. RESULTS: The costs in 1988-1989 Australian dollars per woman recruited were $22 for local newspaper articles and $106 for community promotion. No detectable increase in attendance resulted from promotion to physicians. When the cost of reserving an appointment was considered, the most cost-effective personal recruitment strategy was an invitation letter without a specified appointment time, followed by a second letter to nonattenders. This strategy recruited 35.6% of women in the sample targeted and cost $10.52 per attendee. In comparison, the most effective personal recruitment strategy was a letter with a specified appointment time followed by a second letter to nonattenders, which recruited 44.1% of women at an average cost of $19.99 and a marginal cost of $59.71 per additional attendee. CONCLUSIONS: Personal recruitment strategies were more cost-effective than public strategies. The most cost-effective personal strategy was an invitation letter without a specified appointment time, followed by a second letter to nonattenders.

Construction and aggregation of preference relations based on fuzzy partial orders

In group decision-making problems it is common to elicit preferences from human experts in the form of pairwise preference relations. When this is extended to a fuzzy setting, entries in the pairwise preference matrix are interpreted to denote strength of preference, however once logical properties such as consistency and transitivity are enforced, the resulting preference relation requires almost as much information as providing raw scores or a complete order over the alternatives. Here we instead interpret fuzzy degrees of preference to only apply where the preference over two alternatives is genuinely fuzzy and then suggest an aggregation procedure that minimizes a generalized Kemeny distance to the nearest complete or partial order. By focusing on the fuzzy partial order, the method is less affected by differences in the natural scale over which an expert expresses their preference, and can also limit the influence of extreme scores.

Win at all costs or lose gracefully in high-stakes competition? Gender differences in professional tennis

This article examines line-call challenges by male and female professional tennis players in major tournaments around the world. In terms of utilization rates, we find that the genders behave similarly. Nevertheless, we do detect some intriguing gender differences in these challenges. First, male players’ challenges are more likely to be provoked by those of their opponents. More importantly, at tiebreaks, females are more likely to reverse an umpire’s unfavorable call, while males make relatively more unsuccessful challenges. Furthermore, we find that men are a lot more likely to make “embarrassing” line-call challenges at tiebreaks and offenses (i.e., when the shot lands at the opponent’s side of the tennis court) than women. These significant gender differences suggest that women particularly diverge from men at crucial junctures of the match such as tiebreaks. Differences in factors such as risk aversion, overconfidence, pride, shame, and strategic signalling behavior might help us to explain these gender-difference findings in line call challenges.

Influence of body mass index on prescribing costs and potential cost savings of a weight management programme in primary care

Objectives Prescribed medications represent a high and increasing proportion of UK health care funds. Our aim was to quantify the influence of body mass index (BMI) on prescribing costs, and then the potential savings attached to implementing a weight management intervention.

Methods Paper and computer-based medical records were reviewed for all drug prescriptions over an 18-month period for 3400 randomly selected adult patients (18–75 years) stratified by BMI, from 23 primary care practices in seven UK regions. Drug costs from the British National Formulary at the time of the review were used. Multivariate regression analysis was applied to estimate the cost for all drugs and the ‘top ten’ drugs at each BMI point. This allowed the total and attributable prescribing costs to be estimated at any BMI. Weight loss outcomes achieved in a weight management programme (Counterweight) were used to model potential effects of weight change on drug costs. Anticipated savings were then compared with the cost programme delivery. Analysis was carried out on patients with follow-up data at 12 and 24 months as well as on an intention-to-treat basis. Outcomes from Counterweight were based on the observed lost to follow-up rate of 50%, and the assumption that those patients would continue a generally observed weight gain of 1 kg per year from baseline.

Results The minimum annual cost of all drug prescriptions at BMI 20 kg/m2 was £50.71 for men and £62.59 for women. Costs were greater by £5.27 (men) and £4.20 (women) for each unit increase in BMI, to a BMI of 25 (men £77.04, women £78.91), then by £7.78 and £5.53, respectively, to BMI 30 (men £115.93 women £111.23), then by £8.27 and £4.95 to BMI 40 (men £198.66, women £160.73). The relationship between increasing BMI and costs for the top ten drugs was more pronounced. Minimum costs were at a BMI of 20 (men £8.45, women £7.80), substantially greater at BMI 30 (men £23.98, women £16.72) and highest at BMI 40 (men £63.59, women £27.16). Attributable cost of overweight and obesity accounted for 23% of spending on all drugs with 16% attributable to obesity. The cost of the programme was estimated to be approximately £60 per patient entered. Modelling weight reductions achieved by the Counterweight weight management programme would potentially reduce prescribing costs by £6.35 (men) and £3.75 (women) or around 8% of programme costs at one year, and by £12.58 and £8.70, respectively, or 18% of programme costs after two years of intervention. Potential savings would be increased to around 22% of the cost of the programme at year one with full patient retention and follow-up.

Conclusion Drug prescriptions rise from a minimum at BMI of 20 kg/m2 and steeply above BMI 30 kg/m2. An effective weight management programme in primary care could potentially reduce prescription costs and lead to substantial cost avoidance, such that at least 8% of the programme delivery cost would be recouped from prescribing savings alone in the first year.