Costs of bronchoalveolar lavage-directed therapy in the first 5 years of life for children with cystic fibrosis.

To determine whether bronchoalveolar lavage (BAL)-directed therapy for infants and young children with cystic fibrosis (CF), rather than standard therapy, was justified on the grounds of a decrease in average costs and whether the use of BAL reduced treatment costs associated with hospital admissions.

Modeling the cost effectiveness of child care policy changes in the U.S.

INTRODUCTION: Child care facilities influence diet and physical activity, making them ideal obesity prevention settings. The purpose of this study is to quantify the health and economic impacts of a multi-component regulatory obesity policy intervention in licensed U.S. child care facilities. METHODS: Two-year costs and BMI changes resulting from changes in beverage, physical activity, and screen time regulations affecting a cohort of up to 6.5 million preschool-aged children attending child care facilities were estimated in 2014 using published data. A Markov cohort model simulated the intervention's impact on changes in the U.S. population from 2015 to 2025, including short-term BMI effects and 10-year healthcare expenditures. Future outcomes were discounted at 3% annually. Probabilistic sensitivity analyses simulated 95% uncertainty intervals (UIs) around outcomes. RESULTS: Regulatory changes would lead children to watch less TV, get more minutes of moderate and vigorous physical activity, and consume fewer sugar-sweetened beverages. Within the 6.5 million eligible population, national implementation could reach 3.69 million children, cost $4.82 million in the first year, and result in 0.0186 fewer BMI units (95% UI=0.00592 kg/m(2), 0.0434 kg/m(2)) per eligible child at a cost of $57.80 per BMI unit avoided. Over 10 years, these effects would result in net healthcare cost savings of $51.6 (95% UI=$14.2, $134) million. The intervention is 94.7% likely to be cost saving by 2025. CONCLUSIONS: Changing child care regulations could have a small but meaningful impact on short-term BMI at low cost. If effects are maintained for 10 years, obesity-related healthcare cost savings are likely.

A telephone support program to reduce costs and hospital admissions for patients at risk of readmissions: lessons from an evaluation of a complex health intervention

This study aimed to evaluate the effectiveness of a telephone health coaching and support service provided to members of an Australian private health insurance fund-Telephonic Complex Care Program (TCCP)-on hospital use and associated costs. A case-control pre-post study design was employed using propensity score matching. Private health insurance members (n=273) who participated in TCCP between April and December 2012 (cases) were matched (1:1) to members who had not previously been enrolled in the program or any other disease management programs offered by the insurer (n=232). Eligible members were community dwelling, aged ≥65 years, and had 2 or more hospital admissions in the 12 months prior to program enrollment. Preprogram variables that estimated the propensity score included: participant demographics, diagnoses, and hospital use in the 12 months prior to program enrollment. TCCP participants received one-to-one telephone support, personalized care plan, and referral to community-based services. Control participants continued to access usual health care services. Primary outcomes were number of hospital admission claims and total benefits paid for all health care utilizations in the 12 months following program enrollment. Secondary outcomes included change in total benefits paid, hospital benefits paid, ancillary benefits paid, and total hospital bed days over the 12 months post enrollment. Compared with matched controls, TCCP did not appear to reduce health care utilization or benefits paid in the 12 months following program enrollment. However, program characteristics and implementation may have impacted its effectiveness. In addition, challenges related to evaluating complex health interventions such as TCCP are discussed.

Using smartphones for accountable care and evidence-based decision making in managing gestational diabetes : an Australian case study

Better managing diabetes has become a global priority, especially given the exponential increase in the number of diabetes patients and the financial implications of treating this silent epidemic. In this paper, we focus on how it might be possible to use a mobile technology solution to support and enable superior diabetes monitoring and management. To test this solution, we examined the context of gestational diabetes and adopted a non-blinded randomized control trial with two-arm cross over applied to a private hospital in Victoria, Australia. Further, we use an accountable care system as the theoretical lens and, from this, develop a conceptual framework to bridge evidence-based management with technologies. Theoretically, we unpack McCleallan, McKethan, Lewis, Roski, and Fisher’s (2010) study with our conceptual framework that comprises providers for information (evidence-based management) and technology (smartphone). We enhance Muhlestein, Croshaw, Merrill, Pena, and James’ (2013) accountable care paradigm with three concepts: 1) quality of life, 2) evidence-based management, and 3) affordable care. From the perspective of practice, far-reaching implications have arisen particularly for hospital management pertaining to the cost and quality of care issues. In particular, it appears that adapting mobile technology solutions such as smartphones to support various aspects of care and patient-clinician interactions is a prudent choice to minimize costs and yet provide highquality care.

Building the capacity of family day care educators to promote children’s social and emotional wellbeing: Results of an exploratory cluster randomised-controlled trial

© 2015 Early Childhood Australia Inc. All rights reserved. THIS PAPER PRESENTS THE results of an exploratory cluster randomised-controlled trial that was used to pilot Thrive, a capacity-building program for family day care (FDC) educators. Participants were educators and coordinators from one FDC service in Melbourne, Australia. Data collection consisted of a survey including information on costs, an in-home quality of care observation and process evaluation. Data was collected over 12 months (2011–2012), at baseline and one, six and 12 months post-intervention. Positive caregiver interaction scores increased over time for the intervention group: F (3, 51.69) = 3.08, p < 0.05, and detached interaction scores decreased over time: F (3, 51.19) = 2.78, p < 0.05. Educators’ knowledge and confidence in children’s social and emotional wellbeing showed no significant change. Thrive gives important information about the challenges FDC educators face and is relevant to implementing changes in their education and support. For a program like Thrive to be successful in engaging educators, a stronger framework for supporting additional learning activities at both the FDC organisational and scheme level is warranted.

A discrete choice experiment to examine the preferences of patients with cancer and their willingness to pay for different types of health care appointments

BACKGROUND: This study sought to understand the preferences of patients with cancer and the trade-offs between appointment attributes using discrete choice experiment (DCE). METHODS AND STUDY DESIGN: Patients with cancer at 3 hospitals completed a self-administered DCE. Each scenario described 6 attributes: expertise of health care professionals (HCPs), familiarity of doctors with patients' medical history, waiting time, accompaniment by family/friends, travel time, and out-of-pocket costs. Patient preferences were estimated using logistic regression. Willingness to pay (WTP) estimates were derived from regression coefficients. RESULTS: Of 512 patients contacted, 185 returned the questionnaire. The mean age was 61 years, and 60% of respondents were female. The mean time since cancer diagnosis was 34 months, 90% had received treatment; and 61% had early-stage disease. The most important attributes were expertise and familiarity of doctors with patients' medical history; distance traveled was least likely to influence patient preferences. The WTP analysis estimated that patients were willing to pay $680 (95% CI, 470-891) for an appointment with a specialist, $571 (95% CI, 388-754) for doctors familiar with their history, $422 (95% CI, 262-582) for shorter waiting times, $399 (95% CI, 249-549) to be accompanied by family/friends, and $301 (95% CI, 162-441) for shorter traveling times. Male patients had a stronger preference for accompaniment by family/friends. The expertise of HCP was the most important attribute for patients regardless of geographic remoteness. CONCLUSIONS: Our study can assist the development of patient-centered health care models that improve patient access to experienced HCPs, support the role of primary care providers during the cancer journey, and educate patients about the roles of non-oncology HCPs to cope with increasing demand for cancer care.

The impact of obesity on drug prescribing in primary care

Background

Healthcare costs attributable to obesity have previously involved estimations based on costs of diseases commonly considered as having obesity as an underlying factor.

Aim

To quantify the impact of obesity on total primary care drug prescribing.

Design of study

Review of computer generated and handwritten prescriptions to determine total prescribing volume for all drug classes.

Setting

Twenty-three general practice surgeries in the UK.

Method

Stratified random selection of 1150 patients who were obese (body mass index [BMI]>30 kg/m2) and 1150 age- and sex-matched controls of normal weight (BMI 18.5–<25 kg/m2). Retrospective review of medical records over an 18-month period.

Results

A higher percentage of patients who were obese, compared with those of normal weight, were prescribed at least one drug in the following disease categories: cardiovascular (36% versus 20%), central nervous system (46% versus 35%), endocrine (26% versus 18%), and musculoskeletal and joint disease (30% versus 22%). All of these categories had a P-value of <0.001. Other categories, such as gastrointestinal (24% versus 18%), infections (42% versus 35%), skin (24% versus 19%) had a P-value of <0.01, while respiratory diseases (18% versus 21%) had a P-value of <0.05. Total prescribing volume was significantly higher for the group with obesity and was increased in the region of two- to fourfold in a wide range of prescribing categories: ulcer healing drugs, lipid regulators, β-adrenoreceptor drugs, drugs affecting the rennin angiotensin system, calcium channel blockers, antibacterial drugs, sulphonylureas, biguanides, non-steroidal anti-inflammatories (NSAIDs) (P<0.001) and fibrates, angiotensin II antagonists, and thyroid drugs (P<0.05). The main impact on prescribing volumes is from numbers of patients treated, although in some areas there is an effect from greater dosage or longer treatment in those who are obese including calcium channel blockers, antihistamines, hypnotics, drugs used in the treatment of nausea and vertigo, biguanides, and NSAIDs (P<0.05) reflected in significantly increased defined daily dose prescribing.

Burden of epilepsy: a prevalence-based cost of illness study of direct, indirect and intangible costs for epilepsy

OBJECTIVES: We aimed to gauge the burden of epilepsy in China from a societal perspective by estimating the direct, indirect and intangible costs. METHODS: Patients with epilepsy and controls were enrolled from two tertiary hospitals in China. Patients were asked to complete a Cost-of-Illness (COI), Willingness-to-Pay (WTP) questionnaires, two utility elicitation instruments and Mini Mental State Examination (MMSE). Healthy controls only completed WTP questionnaire, and utility instruments. Univariate analyses were performed to investigate the differences in cost on the basis of different variables, while multivariate analysis was undertaken to explore the predictors of cost/cost component. RESULTS: In total, 141 epilepsy patients and 323 healthy controls were recruited. The median total cost, direct cost and indirect cost due to epilepsy were US$949.29, 501.34 and 276.72, respectively. Particularly, cost of anti-epileptic drugs (AEDs) (US$394.53) followed by cost of investigations (US$59.34), cost of inpatient and outpatient care (US$9.62) accounted for the majority of the direct medical costs. While patients' (US$103.77) and caregivers' productivity costs (US$103.77) constituted the major component of indirect cost. The intangible costs in terms of WTP value (US$266.07 vs. 88.22) and utility (EQ-5D, 0.828 vs. 0.923; QWB-SA, 0.657 vs. 0.802) were both substantially higher compared to the healthy subjects. CONCLUSIONS: Epilepsy is a cost intensive disease in China. According to the prognostic groups, drug-resistant epilepsy generated the highest total cost whereas patients in seizure remission had the lowest cost. AED is the most costly component of direct medical cost probably due to 83% of patients being treated by new generation of AEDs.

Cost-analysis of teledentistry in residential aged care facilities

INTRODUCTION: The purpose of this research was to conduct a cost-analysis, from a public healthcare perspective, comparing the cost and benefits of face-to-face patient examination assessments conducted by a dentist at a residential aged care facility (RACF) situated in rural areas of the Australian state of Victoria, with two teledentistry approaches utilizing virtual oral examination.

METHODS: The costs associated with implementing and operating the teledentistry approach were identified and measured using 2014 prices in Australian dollars. Costs were measured as direct intervention costs and programme costs. A population of 100 RACF residents was used as a basis to estimate the cost of oral examination and treatment plan development for the traditional face-to-face model vs. two teledentistry models: an asynchronous review and treatment plan preparation; and real-time communication with a remotely located oral health professional.

RESULTS: It was estimated that if 100 residents received an asynchronous oral health assessment and treatment plan, the net cost from a healthcare perspective would be AU$32.35 (AU$27.19-AU$38.49) per resident. The total cost of the conventional face-to-face examinations by a dentist would be AU$36.59 ($30.67-AU$42.98) per resident using realistic assumptions. Meanwhile, the total cost of real-time remote oral examination would be AU$41.28 (AU$34.30-AU$48.87) per resident.

DISCUSSION: Teledental asynchronous patient assessments were the lowest cost service model. Access to oral health professionals is generally low in RACFs; however, the real-time consultation could potentially achieve better outcomes due to two-way communication between the nurse and a remote oral health professional via health promotion/disease prevention delivered in conjunction with the oral examination.

Personal perspectives on enablers and barriers to accessing care for hip and knee osteoarthritis

BACKGROUND: Despite increasing demand for joint replacement surgery and other health services for hip and knee osteoarthritis (OA), barriers and enablers to individual access to care are not well understood. A comprehensive understanding of drivers at all levels is needed to inform efforts for improving access. OBJECTIVE: The aim of this study was to explore perceived barriers and enablers to receiving conservative (nonsurgical) and surgical treatment for hip and knee OA. DESIGN: This was a qualitative study using directed content analysis. METHODS: Semistructured telephone interviews were conducted, with 33 participants randomly sampled from an Australian population-based survey of hip and knee OA. Each interview covered factors contributing to receiving treatment for OA and perceived barriers to accessing care. Interview transcripts were coded and organized into themes. RESULTS: Key barriers to accessing care for OA included medical opinions about saving surgery for later and the appropriate age for joint replacement. Other common barriers included difficulty obtaining referrals or appointments, long waiting times, work-related issues, and limited availability of primary and specialist care in some areas. Several participants perceived a lack of effective treatment for OA. Private health insurance was the most frequently cited enabler and was perceived to support the costs of surgical and conservative treatments, including physical therapy, while facilitating faster access to surgery. Close proximity to services and assistance from medical professionals in arranging care also were considered enablers. CONCLUSIONS: People with hip or knee OA experience substantial challenges in accessing treatment, and these challenges relate predominantly to health professionals, health systems, and financial factors. Private health insurance was the strongest perceived enabler to accessing care for OA.

SA HealthPlus : a controlled trial of a statewide application of a generic model of chronic illness care

SA HealthPlus, one of nine national Australian coordinated care trials, addressed chronic illness care by testing whether coordinated care would improve health outcomes at the cost of usual care. SA HealthPlus compared a generic model of coordinated care for 3,115 intervention patients with the usual care for 1,488 controls. Service coordinators and the behavioral and care-planning approach were new. The health status (SF-36) in six of eight projects improved, and those patients who had been hospitalized in the year immediately preceding the trial were the most likely to save on costs. A mid-trial review found that health benefits from coordinated care depended more on patients' self-management than the severity of their illness, a factor leading to the Flinders Model of Self-Management Support.

The science of the COAG coordinated care trials

Objectives: To explicate the organisational change agenda of the COAG coordinated care trials within the Australian health system and to illuminate the role of science in this process. Methods and Results: This article briefly outlines the COAG coordinated care trial aims and the effect of the trial as a change initiative in rural South Australia. It is proposed that although the formal trial outcomes are still not clear, the trial had significant impact upon health service delivery in some sites. The trial involved standard research methods with control and intervention groups and with key hypotheses being tested to compare the costs and service utilization profile of intervention and control groups. Formal results indicate that costs were not significantly different between intervention and control groups across all sites, but that the trial, nonetheless, had a powerful impact on the attitude and behaviours of service providers in the rural trial on Eyre Peninsula in particular. Some of the key structural changes now in place are outlined. Conclusions: The COAG trial has had many and varied impacts upon those organisations and individual providers involved with it. It is argued here that since successive initiatives had been implemented before final evaluation results were published, other agendas were served by the trial apart from those of standard scientific research and hypothesis testing. That is, the main impact of the coordinated care trial in Eyre Region at least has been change by stealth, and not through scientific research and demonstration. Implications: The COAG trials have set in train a series of structural and procedural changes in the methods of delivery and management of primary health care systems; changes that are embodied in the Enhanced Primary Care packages (EPC) and other initiatives recently introduced by the Commonwealth Government. These changes have occurred and are occurring across the system without formal evidence as to their efficacy, suggesting that other financial motives are driving these new approaches apart from the goal of improving health outcomes for consumers. Also, if science is to be used in this way to drive policy and procedural change ahead of actual outcome evidence, it is important that we examine the more subtle agendas of such research projects in future if the integrity of the scientific method is to be maintained. The occurrence of such phenomena questions the very foundation of scientific endeavour and weakens the application of scientific principles in the arena of social and political science.

Economic evaluation plan (EEP) for a very early rehabilitation trial (AVERT): an international trial to compare the costs and cost-effectiveness of commencing out of bed standing and walking training (very early mobilization) within 24 h of stroke onset

RATIONALE: A key objective of A Very Early Rehabilitation Trial is to determine if the intervention, very early mobilisation following stroke, is cost-effective. Resource use data were collected to enable an economic evaluation to be undertaken and a plan for the main economic analyses was written prior to the completion of follow up data collection. AIM AND HYPOTHESIS: To report methods used to collect resource use data, pre-specify the main economic evaluation analyses and report other intended exploratory analyses of resource use data. SAMPLE SIZE ESTIMATES: Recruitment to the trial has been completed. A total of 2,104 participants from 56 stroke units across three geographic regions participated in the trial. METHODS AND DESIGN: Resource use data were collected prospectively alongside the trial using standardised tools. The primary economic evaluation method is a cost-effectiveness analysis to compare resource use over 12 months with health outcomes of the intervention measured against a usual care comparator. A cost-utility analysis is also intended. STUDY OUTCOME: The primary outcome in the cost-effectiveness analysis will be favourable outcome (modified Rankin Scale score 0-2) at 12 months. Cost-utility analysis will use health-related quality of life, reported as quality-adjusted life years gained over a 12 month period, as measured by the modified Rankin Scale and the Assessment of Quality of Life. DISCUSSION: Outcomes of the economic evaluation analysis will inform the cost-effectiveness of very early mobilisation following stroke when compared to usual care. The exploratory analysis will report patterns of resource use in the first year following stroke.

An integrated model of care for inflammatory bowel disease sufferers in Australia: development and the effects of its implementation.

BACKGROUND: Psychological comorbidities are associated with poor outcome and increased healthcare utilization in patients with inflammatory bowel disease (IBD). However, a model of care addressing the biopsychosocial dimension of disease is not routinely applied in IBD. This review describes the development of such a model and the effects of its implementation in a hospital-based cohort of patients with IBD. METHODS: Three different approaches were used: 1) collecting baseline epidemiological data on mental health comorbidities; 2) raising awareness of and targeting mental health problems; 3) examining the effects of the model implementation. RESULTS: High rates of anxiety and depressive symptoms (36% and 13%, respectively) that are maintained over time were identified in IBD patients presenting at a metropolitan teaching hospital. Patients with documented psychological comorbidities were more likely to be hospitalized than those without (odds ratio [OR] = 4.13, 95% confidence interval [CI]: 1.25, 13.61). Improvements in disease activity, anxiety, depression, quality of life, and coping have been noted when cognitive-behavioral therapy (CBT) was provided to patients. A drop in the use of opiates (P = 0.037) and hospitalization rates (from 48% to 30%) in IBD patients has been noted as a result of introduction of the changed model of care. In addition, the mean total cost of inpatient care was lower for IBD patients than controls (US$12,857.48 [US$15,236.79] vs. US$ 30,467.78 [US$ 53,760.20], P = 0.005). CONCLUSION: Our data to date suggest that an integrated model of care for patients with IBD may yield superior long-term outcomes in terms of medication use and hospitalization rates and reduce healthcare costs.