Cost-effectiveness of active transport for primary school children - Walking School Bus Program

Background : To assess from a societal perspective the incremental cost-effectiveness of the Walking School Bus (WSB) program for Australian primary school children as an obesity prevention measure. The intervention was modelled as part of the ACE-Obesity study, which evaluated, using consistent methods, thirteen interventions targeting unhealthy weight gain in Australian children and adolescents.

Methods : A logic pathway was used to model the effects on body mass index [BMI] and disability-adjusted life years [DALYs] of the Victorian WSB program if applied throughout Australia. Cost offsets and DALY benefits were modelled until the eligible cohort reached 100 years of age or death. The reference year was 2001. Second stage filter criteria ('equity', 'strength of evidence', 'acceptability', feasibility', sustainability' and 'side-effects') were assessed to incorporate additional factors that impact on resource allocation decisions.

Results : The modelled intervention reached 7,840 children aged 5 to 7 years and cost $AUD22.8M ($16.6M;$30.9M). This resulted in an incremental saving of 30 DALYs (7:104) and a net cost per DALY saved of $AUD0.76M ($0.23M; $3.32M). The evidence base was judged as 'weak' as there are no data available documenting the increase in the number of children walking due to the intervention. The high costs of the current approach may limit sustainability.

Conclusions : Under current modelling assumptions, the WSB program is not an effective or cost-effective measure to reduce childhood obesity. The attribution of some costs to non-obesity objectives (reduced traffic congestion and air pollution etc.) is justified to emphasise the other possible benefits. The program's cost-effectiveness would be improved by more comprehensive implementation within current infrastructure arrangements. The importance of active transport to school suggests that improvements in WSB or its variants need to be developed and fully evaluated.

The validation of an Australian sign language instrument for outcome measurement of adults in mental health settings

Objective: There are currently no adult mental health outcome measures that have been translated into Australian sign language (Auslan). Without a valid and reliable Auslan outcome measure, empirical research into the efficacy of mental health interventions for sign language users is unattainable. To address this research problem the Outcome Rating Scale (ORS), a measure of general functioning, was translated into Auslan and recorded on to digital video disk for use in clinical settings. The purpose of the present study was therefore to examine the reliability, validity and acceptability of an Auslan version of the ORS (ORS-Auslan).
Method: The ORS-Auslan was administered to 44 deaf people who use Auslan as their first language and who identify as members of a deaf community (termed ‘Deaf’ people) on their first presentation to a mental health or counselling facility and to 55 Deaf people in the general community. The community sample also completed an Auslan version of the Depression Anxiety Stress Scale-21 (DASS-21).
Results: t-Tests indicated significant differences between the mean scores for the clinical and community sample. Internal consistency was acceptable given the low number of items in the ORS-Auslan. Construct validity was established by significant correlations between total scores on the DASS-21-Auslan and ORS-Auslan. Acceptability of ORS-Auslan was evident in the completion rate of 93% compared with 63% for DASS-21-Auslan.
Conclusions: This is the only Auslan outcome measure available that can be used across a wide variety of mental health and clinical settings. The ORS-Auslan provides mental health clinicians with a reliable and valid, brief measure of general functioning that can significantly distinguish between clinical and non-clinical presentations for members of the Deaf community.

Assessing cost-effectiveness in obesity (ACE-Obesity) : an overview of the ACE approach, economic methods and cost results

Background : The aim of the ACE-Obesity study was to determine the economic credentials of interventions which aim to prevent unhealthy weight gain in children and adolescents. We have reported elsewhere on the modelled effectiveness of 13 obesity prevention interventions in children. In this paper, we report on the cost results and associated methods together with the innovative approach to priority setting that underpins the ACE-Obesity study.

Methods : The Assessing Cost-Effectiveness (ACE) approach combines technical rigour with 'due process' to facilitate evidence-based policy analysis. Technical rigour was achieved through use of standardised evaluation methods, a research team that assembles best available evidence and extensive uncertainty analysis. Cost estimates were based on pathway analysis, with resource usage estimated for the interventions and their 'current practice' comparator, as well as associated cost offsets. Due process was achieved through involvement of stakeholders, consensus decisions informed by briefing papers and 2nd stage filter analysis that captures broader factors that influence policy judgements in addition to cost-effectiveness results. The 2nd stage filters agreed by stakeholders were 'equity', 'strength of the evidence', 'feasibility of implementation', 'acceptability to stakeholders', 'sustainability' and 'potential for side-effects'.

Results : The intervention costs varied considerably, both in absolute terms (from cost saving [6 interventions] to in excess of AUD50m per annum) and when expressed as a 'cost per child' estimate (from <AUD1.0 [reduction of TV advertising of high fat foods/high sugar drinks] to >AUD31,000 [laparoscopic adjustable gastric banding for morbidly obese adolescents]). High costs per child reflected cost structure, target population and/or under-utilisation.

Conclusions : The use of consistent methods enables valid comparison of potential intervention costs and cost-offsets for each of the interventions. ACE-Obesity informs policy-makers about cost-effectiveness, health impact, affordability and 2nd stage filters for important options for preventing unhealthy weight gain in children. In related articles cost-effectiveness results and second stage filter considerations for each intervention assessed will be presented and analysed.

The cost-effectiveness of Australia's active after-school communities program

The objective of this study was to assess from a societal perspective the cost-effectiveness of the Active After-school Communities (AASC) program, a key plank of the former Australian Government's obesity prevention program. The intervention was modeled for a 1-year time horizon for Australian primary school children as part of the Assessing Cost-Effectiveness in Obesity (ACE-Obesity) project. Disability-adjusted life year (DALY) benefits (based on calculated effects on BMI post-intervention) and cost-offsets (consequent savings from reductions in obesity-related diseases) were tracked until the cohort reached the age of 100 years or death. The reference year was 2001, and a 3% discount rate was applied. Simulation-modeling techniques were used to present a 95% uncertainty interval around the cost-effectiveness ratio. An assessment of second-stage filter criteria ("equity," "strength of evidence," "acceptability to stakeholders," "feasibility of implementation," "sustainability," and "side-effects") was undertaken by a stakeholder Working Group to incorporate additional factors that impact on resource allocation decisions. The estimated number of children new to physical activity after-school and therefore receiving the intervention benefit was 69,300. For 1 year, the intervention cost is Australian dollars (AUD) 40.3 million (95% uncertainty interval AUD 28.6 million; AUD 56.2 million), and resulted in an incremental saving of 450 (250; 770) DALYs. The resultant cost-offsets were AUD 3.7 million, producing a net cost per DALY saved of AUD 82,000 (95% uncertainty interval AUD 40,000; AUD 165,000). Although the program has intuitive appeal, it was not cost-effective under base-case modeling assumptions. To improve its cost-effectiveness credentials as an obesity prevention measure, a reduction in costs needs to be coupled with increases in the number of participating children and the amount of physical activity undertaken.

The cost-effectiveness of removing television advertising of high-fat and/or high-sugar food and beverages to Australian children

Objective: To model the health benefits and cost-effectiveness of banning television (TV) advertisements in Australia for energy-dense, nutrient-poor food and beverages during children's peak viewing times.

Methods: Benefits were modelled as changes in body mass index (BMI) and disability-adjusted life years (DALYs) saved. Intervention costs (AUD$) were compared with future health-care cost offsets from reduced prevalence of obesity-related health conditions. Changes in BMI were assumed to be maintained through to adulthood. The comparator was current practice, the reference year was 2001, and the discount rate for costs and benefits was 3%. The impact of the withdrawal of non-core food and beverage advertisements on children's actual food consumption was drawn from the best available evidence (a randomized controlled trial of advertisement exposure and food consumption). Supporting evidence was found in ecological relationships between TV advertising and childhood obesity, and from the effects of marketing bans on other products. A Working Group of stakeholders provided input into decisions surrounding the modelling assumptions and second-stage filters of 'strength of evidence', 'equity', 'acceptability to stakeholders', 'feasibility of implementation', 'sustainability' and 'side-effects'.

Results: The intervention had a gross incremental cost-effectiveness ratio of AUD$ 3.70 (95% uncertainty interval (UI) $2.40, $7.70) per DALY. Total DALYs saved were 37 000 (95% UI 16 000, 59 000). When the present value of potential savings in future health-care costs was considered (AUD$ 300m (95% UI $130m, $480m), the intervention was 'dominant', because it resulted in both a health gain and a cost offset compared with current practice.

Conclusions: Although recognizing the limitations of the available evidence, restricting TV food advertising to children would be one of the most cost-effective population-based interventions available to governments today. Despite its economic credentials from a public health perspective, the initiative is strongly opposed by food and advertising industries and is under review by the current Australian government.

Towering over all : the Italianate villa in the colonial landscape

The Picturesque aesthetic emerged in the later 18th century, uniting the Sublime and the Beautiful and had its roots in the paintings of Claude Lorrain. In Britain, and in Australia, it came to link art, literature and landscape with architecture. The Picturesque aesthetic informed much of colonial culture which was achieved, in part, through the production and dissemination of architectural pattern books catering for the aspirations of the rising middle classes. This was against a background of political change including democratic reform. The Italianate villa, codified and promoted in such pattern books, was a particularly successful synthesis of style, form and function. The first Italianate villa in England, Cronkhill (1803) by John Nash contains all the ingredients which were essential to the model and had a deeper meaning. Deepdene (from 1807) by Thomas Hope gave the model further impetus. The works of Charles Barry and others in a second generation confirmed the model's acceptability. In Britain, its public status peaked with Osborne House (from 1845), Queen Victoria's Italianate villa on the Isle of Wight, Robert Kerr used a vignette of Osborne House on the title page of his sophisticated and influential pattern book, The Gentleman's House (1864,1871). It was one of many books, including those of J.C, Loudon and AJ. Downing, current in colonial Victoria. The latter authors and horticulturists were themselves villa dwellers with libraries and orchards, two criteria for the true villa lifestyle. Situation and a sense of retreat were the two further criteria for the villa lifestyle. As the new colony of Victoria blossomed between 1851 and 1891, the Italianate villa, its garden setting and its landscape siting captured the tenor of the times. Melbourne, the capital was a rich manufacturing metropolis with a productive hinterland and international markets. The people enjoyed a prosperity and lifestyle which they wished to display. Those who had a position in society were keen to demonstrate and protect it. Those with aspirations attempted to provide the evidence necessary for such acceptance, The model matured and became ubiquitous. Its evolution can be traced through a series of increasingly complicated rural and suburban examples, a process which modernist historians have dismissed as a decadent decline. These villas, in fact, demonstrate an increasingly sophisticated retreat by merchants from ‘the Town’ and by graziers from ‘the Country’. In both town and country, the towers of villas mark territory newly acquired. The same claim was often made in humbler situations. Government House, Melbourne (from 1871), a splendid Italianate villa and arguably finer than Osborne House, was set in a cultivated landscape and towered above all It incorporated the four criteria and, in addition, claimed its domain, focused authority and established the colony's social status. It symbolised ancient notions of democracy and idealism but with a modem appreciation for the informal and domestic. Government House in Melbourne is the epitome of the Italianate villa in the colonial landscape and is the climax of the Picturesque aesthetic in Victoria.

Assessing cost-effectiveness in mental health: helping policy-makers prioritize and plan health services

Objective: We assessed, from a health sector perspective, options for change that could improve the efficiency of Australia's current mental health services by directing available resources toward 'best practice' cost-effective services.

Method: We summarize cost-effectiveness results of a range of interventions for depression, schizophrenia, attention deficit hyperactivity disorder and anxiety disorders that have been presented in previous papers in this journal. Recommendations for change are formulated after taking into account 'second-filter criteria' of equity, feasibility of implementing change, acceptability to stakeholders and the strength of the evidence. In addition, we estimate the impact on total expenditure if the recommended mental health interventions for depression and schizophrenia are to be implemented in Australia.

Results: There are cost-effective treatment options for mental disorders that are currently underutilized (e.g. cognitive–behavioural therapy (CBT) for depression and anxiety, bibliotherapy for depression, family interventions for schizophrenia and clozapine for the worst course of schizophrenia). There are also less cost-effective treatments in current practice (e.g. widespread use of olanzapine and risperidone in the treatment of established schizophrenia and, within those atypicals, a preference for olanzapine over risperidone). Feasibility of funding mechanisms and training of staff are the main second-filter issues for CBT and family interventions. Acceptability to various stakeholders is the main barrier to implementation of more cost-effective drug treatment regimens. More efficient drug intervention options identified for schizophrenia would cost A$68 million less than current practice. These savings would more than cover the estimated A$36M annual cost of delivering family interventions to the 51% of people with schizophrenia whom we estimated to be eligible and this would lead to an estimated 12% improvement in their health status. Implementing recommended strategies for depression would cost A$121M annually for the 24% of people with depression who seek care currently, but do not receive an evidence-based treatment.

Conclusions: Despite considerable methodological problems, a range of cost-effective and less cost-effective interventions for major mental disorders can be discerned. The biggest hurdle to implementation of more efficient mental health services is that this change would require reallocation of funds between interventions, between disorders and between service providers with different funding mechanisms.

Sperm immobilizing properties of lemon juice

The aim of this study was to evaluate the sperm-immobilizing properties of lemon juice to determine if they are consistent with its traditional contraceptive use. It was found that lemon juice supernatant (LJS) has high osmolality (550–60 mOsm) and low pH (2.2–2.6) and that addition of LJS to semen to give a final concentration of 20% v/v reduced the pH from around 8.4 to 4.1. This acidification was associated with irreversible cessation of all sperm movements within 1 minute. In conclusion, lemon juice should be further evaluated for acceptability, safety, and efficacy as a topical vaginal contraceptive agent.

ACE-Obesity : priority setting for obesity prevention

The ACE-Obesity study uses an evidence-based approach to evaluate interventions aimed at reducing the prevalence of obesity in Australian youth. It informs decision-makers about the benefits of individual interventions and the packaging of a coherent strategy for obesity prevention and management. To avoid methodological confounding, the approach employs standardised methods including a two stage concept of benefit; a common comparator, setting and decision context; Australian data; and extensive probabilistic uncertainty testing. The technical cost-effectiveness results (cost per DALY) for each of the selected interventions will be reported. Modelling is undertaken to convert changes in behaviour to BMI outcomes and then to DALYs, and issues of the attribution of costs across multiple objectives arise. Due process is achieved by involving stakeholders on a Working Group, and by consideration of second stage filters (such as equity, acceptability and feasibility). The results are brought together in a 'league table' in which all the interventions are ranked in order of economic merit without the usual methodological concerns about results drawn from studies lacking in comparability. In packaging interventions to meet particular budget allocations, the divisibility, mutual exclusivity and returns to scale of individual interventions are considered, as well as issues of program logic, target group coverage and a range of settings.

Fall risk management intervention : a feasibility and validation study

A fall risk management intervention was undertaken by staff caring for older people in nursing homes. Its acceptability and usefulness was tested. 'High risk times' and 'at risk' individuals were found, thereby identfying times when staff should be vigilant, and specific residents to be targeted with fall prevention strategies.

Mixed transfer function neural networks for generalization and knowledge extraction

This thesis develops a novel framework of nonlinear modelling to adaptively fit the complexity of the model to the problem domain resulting in a better modelling capability and a straightforward knowledge acquisition. The developed framework also permits increased comprehensibility and user acceptability of modelling results.

A nurse-assisted screening and referral program for depression among survivors of colorectal cancer : feasibility study

Objective: To test the feasibility and acceptability of a telephone-based program to screen survivors of colorectal cancer (CRC) for distress, and to refer distressed patients to their treating health service.

Design, setting and participants: A prospective, multicentre study involving 59 patients with CRC recruited from six public and private health services in Melbourne, Victoria, from 15 June 2008 to 22 September 2009. Patients who had completed adjuvant chemotherapy for CRC were contacted (7–10 days after recruitment [outcall one] and again 4 weeks later [outcall two]) by the Cancer Council Victoria’s helpline nurse, and screened for distress with the Distress and Impact Thermometer (DIT); participants were given tailored information and support and those with distress scores of ≥5, and impact scores of ≥4, were referred for follow-up. Telephone interviews were conducted 4 weeks after outcall two. Participating helpline and health service staff were surveyed on the feasibility and acceptability of the service. Main outcome measure: Anxiety and depression, measured by the Hospital Anxiety and Depression Scale (HADS).

Results: Of the 59 patients (87%) who agreed to participate, 63% were men; their mean age was 59 years (SD, 9.5 years). HADS depression decreased significantly from baseline (mean score, 4.93; SD, 4.22) to follow-up (mean score, 3.84; SD, 4.10; Z = −2.375; P= 0.02). However, there was no significant difference in HADS anxiety between baseline (mean score, 5.29; SD, 4.11) and follow-up (mean score, 4.78; SD, 3.65). Outcall one generated two referrals (4% of participants) and outcall two generated four referrals
(8%); five of these six participants took up the referrals. Satisfaction with the program among participants was high; 82% found outcall one “quite or very helpful” and 79% found outcall two “quite or very helpful”. Helpline and health service staff reported a straightforward process that did not adversely affect workloads.

Conclusion: This model of care carries the potential to meet ongoing psychosocial needs of survivors of CRC.

A family-based intervention to increase fruit and vegetable consumption in adolescents : a pilot study

Objective: To evaluate the feasibility and effectiveness of a pilot family-based newsletter intervention to increase fruit and vegetable (FV) consumption among adolescents.
Design: Family-based, two-group randomised control trial with baseline, postintervention and follow-up measures. The intervention group received two FV newsletter packs over a 1 month period by postal mail. Social cognitive and behavioural choice theories provide the theoretical framework for the design and development of intervention materials. Control families were provided with all intervention materials at the end of the study. Adolescent FV consumption was assessed by an FFQ. Adolescent-reported barriers to eating FV, FV habits and preferences were the secondary outcomes, along with parent FV consumption, and parents reported knowledge, encouragement, home availability and accessibility of FV. Repeated-measures ANOVA was used to detect differences in behavioural and psychosocial outcomes between groups, time and group-by-time.
Setting: East Midlands, UK.
Subjects: Forty-nine parents and adolescents aged 12–14 years.
Results: Process evaluation indicated high reach, dose acceptability and fidelity of the intervention. At post-intervention and 6 weeks later at follow-up, adolescents in the intervention group had significantly higher fruit: (P0<·01) and vegetable (P<0·05) consumption and higher preferences for vegetables (P<0·01), compared with the control group. At post-intervention and follow-up, parents in the intervention group had significantly higher fruit (P<0·001) and vegetable (P<0·01) consumption and reported higher accessibility of fruit and vegetables (P<0·001), compared with those in the control group.
Conclusions: Family-based, newsletter interventions promoting FV consumption to adolescents appear to be feasible and effective at increasing FV consumption.

Do indicated preventive interventions for depression represent good value for money?

The prevention of depression is of growing interest to researchers and policy makers. However, the question of whether interventions designed to prevent depression provide value for money at a population level remains largely unanswered. The current study assesses the cost-effectiveness of two indicated interventions designed to prevent depression: a brief psychological intervention based on bibliotherapy and a more comprehensive group-based psychological intervention following opportunistic screening for sub-syndromal depression in general practice. Method: Economic modelling using a cost utility framework was used to assess the incremental cost effectiveness ratios (ICERs) of the two interventions within the Australian population context, modelled as add-ons to current practice. The perspective was the health sector and outcomes were measured using disability-adjusted life years (DALYs). Uncertainty was measured using probabilistic uncertainty testing and important model assumptions were tested using univariate sensitivity testing. Results: The brief bibliotherapy intervention had an ICER of AU$8600 per DALY and the group-based psychological intervention had an ICER of AU$20 000 per DALY. The majority of the uncertainty simulations for both interventions fell below the cost-effectiveness threshold value of $50 000 per DALY. Extensive sensitivity testing showed that the results were robust to the assumptions made in the analyses. Conclusions: Following screening in general practice, both psychological interventions, particularly brief bibliotherapy, appear to be good value for money and worthy of further evaluation under routine care circumstances. Acceptability issues associated with such interventions, particularly to primary care practitioners as providers of the interventions and health system administrators, also need to be considered before wide-scale adoption is contemplated.

An exploratory cluster randomised controlled trial of knowledge translation strategies to support evidence-informed decision-making in local governments (The KT4LG study)

Background: Childhood overweight and obesity is the most prevalent and, arguably, politically complex child health problem internationally. Governments, communities and industry have important roles to play, and are increasingly expected to deliver an evidence-informed system-wide prevention program. However, efforts are impeded by a lack of organisational access to and use of research evidence. This study aims to identify feasible, acceptable and ideally, effective knowledge translation (KT) strategies to increase evidence-informed decision making in local governments, within the context of childhood obesity prevention as a national policy priority.
Methods/Design: This paper describes the methods for KT4LG, a cluster randomised controlled trial which is exploratory in nature, given the limited evidence base and methodological advances. KT4LG aims to examine a program of KT strategies to increase the use of research evidence in informing public health decisions in local governments. KT4LG will also assess the feasibility and acceptability of the intervention. The intervention program comprises a facilitated program of evidence awareness, access to tailored research evidence, critical appraisal skills development, networking and evidence summaries and will be compared to provision of evidence summaries alone in the control program. 28 local governments were randomised to intervention or control, using computer generated numbers, stratified by budget tertile (high, medium or low). Questionnaires will be used to measure impact, costs, and outcomes, and key informant interviews will be used to examine processes, feasibility, and experiences. Policy tracer studies will be included to examine impact of intervention on policies within relevant government policy documents.
Discussion: Knowledge translation intervention studies with a focus on public health and prevention are very few in number. Thus, this study will provide essential data on the experience of program implementation and evaluation of a system-integrated intervention program employed within the local government public health context. Standardised programs of system, organisational and individual KT strategies have not been described or rigorously evaluated. As such, the findings will make a significant contribution to understanding whether a facilitated program of KT strategies hold promise for facilitating evidence-informed public health decision making within complex multisectoral government organisations.