Assessing cost-effectiveness in mental health : family interventions for schizophrenia and related conditions

Objective: Existing evidence suggests that family interventions can be effective in reducing relapse rates in schizophrenia and related conditions. Despite this, such interventions are not routinely delivered in Australian mental health services. The objective of the current study is to investigate the incremental cost-effectiveness ratios (ICERs) of introducing three types of family interventions, namely: behavioural family management (BFM); behavioural intervention for families (BIF); and multiple family groups (MFG) into current mental health services in Australia.

Method: The ICER of each of the family interventions is assessed from a health sector perspective, including the government, persons with schizophrenia and their families/carers using a standardized methodology. A two-stage approach is taken to the assessment of benefit. The first stage involves a quantitative analysis based on disability-adjusted life years (DALYs) averted. The second stage involves application of 'second filter' criteria (including equity, strength of evidence, feasibility and acceptability to stakeholders) to results. The robustness of results is tested using multivariate probabilistic sensitivity analysis.

Results: The most cost-effective intervention, in order of magnitude, is BIF (A$8000 per DALY averted), followed by MFG (A$21 000 per DALY averted) and lastly BFM (A$28 000 per DALY averted). The inclusion of time costs makes BFM more cost-effective than MFG. Variation of discount rate has no effect on conclusions.

Conclusions: All three interventions are considered 'value-for-money' within an Australian context. This conclusion needs to be tempered against the methodological challenge of converting clinical outcomes into a generic economic outcome measure (DALY). Issues surrounding the feasibility of routinely implementing such interventions need to be addressed.

Health-related quality of life and metabolic control in children with type 1 diabetes : a prospective cohort study

OBJECTIVE—To assess change in health-related quality of life (HRQOL) in children with diabetes over 2 years and determine its relationship to change in metabolic control.

RESEARCH DESIGN AND METHODS—In 1998, parents of children aged 5–18 years attending a tertiary diabetes clinic reported their child’s HRQOL using the Child Health Questionnaire PF-50. Those aged 12–18 years also self-reported their HRQOL using the analogous Child Health Questionnaire CF-80. HbA_1c levels were recorded. In 2000, identical measures were collected for those who were aged ≤18 years and still attending the clinic.

RESULTS—Of 117 eligible subjects, 83 (71%) participated. Parents reported no significant difference in children’s HRQOL at baseline and follow-up. However, adolescents reported significant improvements on the Family Activities (P < 0.001), Bodily Pain (P = 0.04), and General Health Perceptions (P = 0.001) scales and worsening on the Behavior (P = 0.04) scale. HbA1c at baseline and follow-up were strongly correlated (r = 0.57). HbA_1c increased significantly (mean 7.8% in 1998 vs. 8.5% in 2000; P < 0.001), with lower baseline HbA_1c strongly predicting an increase in HbA_1c over the 2 years (r² = 0.25, P < 0.001). Lower parent-reported Physical Summary and adolescent-reported Physical Functioning scores at baseline also predicted increasing HbA_1c. Poorer parent-reported Psychosocial Summary scores were related to higher HbA_1c at both times but did not predict change in HbA_1c.

CONCLUSIONS—Changes in parent and adolescent reports of HRQOL differ. Better physical functioning may protect against deteriorating HbA_1c, at least in the medium term. While the HRQOL of children with diabetes does not appear to deteriorate over time, we should not be complacent, as it is consistently poorer than that of their healthy peers.

The health equity dimensions of urban food systems

There is increasing recognition that the nutrition transition sweeping the world’s cities is multifaceted. Urban food and nutrition systems are beginning to share similar features, including an increase in dietary diversity, a convergence toward “Western-style” diets rich in fat and refined carbohydrate and within-country bifurcation of food supplies and dietary conventions. Unequal access to the available dietary diversity, calories, and gastronomically satisfying eating experience leads to nutritional inequalities and diet-related health inequities in rich and poor cities alike. Understanding the determinants of inequalities in food security and nutritional quality is a precondition for developing preventive policy responses. Finding common solutions to under- and overnutrition is required, the first step of which is poverty eradication through creating livelihood strategies. In many cities, thousands of positions of paid employment could be created through the establishment of sustainable and self-sufficient local food systems, including urban agriculture and food processing initiatives, food distribution centers, healthy food market services, and urban planning that provides for multiple modes of transport to food outlets. Greater engagement with the food supply may dispel many of the food anxieties affluent consumers are experiencing.

Assessing cost-effectiveness in mental health : vocational rehabilitation for schizophrenia and related conditions

Objective: Existing evidence suggests that vocational rehabilitation services, in particular individual placement and support (IPS), are effective in assisting people with schizophrenia and related conditions gain open employment. Despite this, such services are not available to all unemployed people with schizophrenia who wish to work. Existing evidence suggests that while IPS confers no clinical advantages over routine care, it does improve the proportion of people returning to employment. The objective of the current study is to investigate the net benefit of introducing IPS services into current mental health services in Australia.

Method: The net benefit of IPS is assessed from a health sector perspective using cost–benefit analysis. A two-stage approach is taken to the assessment of benefit. The first stage involves a quantitative analysis of the net benefit, defined as the benefits of IPS (comprising transfer payments averted, income tax accrued and individual income earned) minus the costs. The second stage involves application of 'second-filter' criteria (including equity, strength of evidence, feasibility and acceptability to stakeholders) to results. The robustness of results is tested using the multivariate probabilistic sensitivity analysis.

Results: The costs of IPS are $A10.3M (95% uncertainty interval $A7.4M–$A13.6M), the benefits are $A4.7M ($A3.1M–$A6.5M), resulting in a negative net benefit of $A5.6M ($A8.4M–$A3.4M).

Conclusions: The current analysis suggests that IPS costs are greater than the monetary benefits. However, the evidence-base of the current analysis is weak. Structural conditions surrounding welfare payments in Australia create disincentives to full-time employment for people with disabilities.

Global change and health - the good, the bad, and the evidence

Debates over the merits and demerits of globalisation for health are increasingly polarised. Conclusions range from globalisation being essentially positive for health, albeit with a need to smooth out some rough edges, to one of utter condemnation, with adverse effects on the majority of the world's population. Anyone wading into this debate is immediately confronted by seemingly irreconcilable differences in ideology, opinion and interests. Both camps agree that global changes are occurring, and with them many of the determinants of population health status. While some skepticism persists about whether “globalisation” has value beyond being a fashionable buzzword, most agree that we need better understanding of these changes. Two difficult questions arise: (i) What are the health impacts of these changes; and (ii) how can we respond more effectively to them? To move beyond the stand-offs that have already formed within the health community, this paper reviews the main empirical evidence that currently exists, summarises key points of debate that remain, and suggests some ways forward for the research and policy communities. In particular, there is need for an informed and inclusive debate about the positive and negative health consequences of globalisation.

The primary health professional education : current models and barriers to participation

Introduction
Continuing Education (CE) for health professionals is a life-long process which endeavours to update or enhance knowledge, refine skills, reinforce professional values and support the delivery of professional practice. It plays a pivotal role in the maintenance of professional competence and in the past decade participation in CE has become an expectation of, rather than an option for, practising health professionals. The time and resources required from organisers and participants in
CE and the need to ensure practical outcomes justifies a review of current models being used for its delivery. This entails an understanding of the purpose of CE, a consideration of how it should be delivered, and the role played by assessment in achieving the goals of CE.
Aim of Report
The overall aim of this study is to identify important considerations and subsequently make recommendations for the development of an ideal model(s) of CE for community pharmacy.
Goals of Report
1. Define CE and its role.
2. Identify and assess current CE delivery models.
3. Examine the current status of continuing education and registration requirements for pharmacists.
4. Identify barriers to participation in CE.
5. Identify components and considerations for developing a model of CE delivery.
Methods
The following methods were employed for this project:
1. Literature review
A number of electronic databases were systematically searched in order to profile current trends and concepts in CE. CE structures currently in use were investigated by directly accessing the websites of appropriate associations.
2. Stakeholder interviews
A series of semi-structured interviews were completed with stakeholders from CE delivery organisations across a range of professions including pharmacy.
3. Community pharmacy focus groups
A series of focus group teleconferences were held with groups of pharmacists thought to have distinct CE needs: experienced pharmacists (qualified more than 5 years), recently-qualified pharmacists (5 years or less), rural/remote pharmacists, and pharmacists with specialist training
needs (such as Home Medication Reviews). These focus groups asked about participants’ experiences and opinions in relation to many aspects of CE including its delivery and its assessment.

Traffic safety education and health promoting school : a metropolitan and rural pilot study

Traffic Safety Education (TSE) is an important part of a school's program; however, it competes with many other components of schooling such as literacy, numeracy and a number of health areas. Hence TSE provision in Victorian schools has been somewhat fragmented and haphazard in its delivery. This small pilot study involved two metropolitan and two rural schools which attempted to link TSE into mainstream school activities through the new Victorian Essential Learning Standards (VELS) utilising the internationally accepted Health Promoting Schools (HPS) framework.
The findings of the pilot study showed that though schools face many demands, understanding and ownership of TSE is possible when administrative support, professional development and adequate planning time are made available. The report outlines several key recommendations to improve the delivery of Traffic Safety Education in Victorian schools.

Influencing health through intestinal microbiota modulation and probiotics

Science has progressed fast in providing answers to probiotic health benefits to the consumers. This symposium also proves that progress is fast. However, several challenges still need to be solved and more effective strains and strain combinations discovered. This will pave the way from good probiotics to specific products for clearly identified target populations. The intestinal microbiota and its interaction(s) with probiotics challenges researchers to turn to the next new page to discover new approaches and treatment modalities that utilize probiotics as means of providing good nutrition with clear health benefits to all consumers.

Quality of occupational health provision: two rating scales and their determinants

Background To develop quality scales for occupational health services (OHSs) and describe and explain variation in quality across the UK university sector.

Methods Analysis of data from a national survey, to which 93 of 117 (79%) UK universities responded, and from the Higher Education Statistics Agency. Two quality scales were generated, one from the 1985 International Labour Organization recommendations on OHSs and one from clinicians’ perceptions (good, adequate, poor) about their OHS. The determinants examined were number of university staff, type of OHS (in-house, contracted, none/other), number of full-time equivalent occupational health doctors and nurses and OHS leadership (doctor, nurse, other).

Results There was wide variation in quality and a correlation (r = 0.65) between scales. In-house service, increasing service size and leadership by a doctor or nurse were determinants of higher quality; size of the university was not statistically significant after taking account of these factors.

Conclusions Some university OHSs may not be structured or operated to promote the highest quality of service. Inspection of individual quality scale items may be informative. These scales may be applicable in other employment sectors.

The impact of the work conditions of allied health professionals on satisfaction, commitment and psychological distress

BACKGROUND: Allied health professionals are integral to the effective delivery of hospital-based health care, yet little is known about the working conditions associated with the attitudinal and health outcomes of these employees.

PURPOSE: The purpose of this study was to investigate the extent to which the demand-control-support model, in combination with organizational justice variables, predicts the employee-level outcomes of allied health professionals.

METHODOLOGY/APPROACH: Allied health professionals from an Australian health care organization were surveyed, with 113 (52.6%) participating. The survey included measures of job demands, job control, social support, organizational justice, satisfaction, commitment and psychological distress.

FINDINGS: Multiple regression analyses reveal that the additive demand-control-support model predicts the outcome variables of job satisfaction, organizational commitment and psychological distress, whereas the organizational justice variables predicted organizational commitment and psychological distress. Further, both work and nonwork sources of support, in addition to specific justice dimensions, were closely associated with employee-level outcomes.

PRACTICAL IMPLICATIONS: When coupled with previous research involving social support and organizational justice, the findings from this study suggest that initiatives aimed at strengthening supervisor and nonwork support, while enhancing perceptions of organizational fairness, may offer useful avenues for increasing the levels of satisfaction, commitment and well-being experienced by allied health professionals.