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.

Cost factors affecting the design of ground-supported floors

The cost of concrete ground-supported floor slabs represents a significant proportion of the total capital cost of industrial projects. There are many structural design issues that impact on the concrete contractors’ method of construction. This is becoming more apparent with the use of new high-technology levelling and trowelling equipment, which has significantly increased the pour and finishing rates, resulting in much faster slab construction times compared with the traditional methods of construction. Selection of both the design and the construction methods exerts a large influence on the initial cost. According to the results of the research reported in this paper, it may be possible to save between 2-4 per cent of the building cost if high technology solutions are incorporated into the design and construction process. This paper investigates cost issues that impact on the design and construction of ground-supported floors for industrial buildings.

The role of socio-cultural factors in the obesity epidemic

Obesity is socio-culturally distributed; that is the prevalence of obesity is known to vary according to socio-cultural factors, including socio-economic position, social roles and circumstance, and cultural factors. Further, these socio-cultural patterns are complex and specific to sex, age, and sometimes racial groups, as well as type of society, with patterns of relationships observed in developed countries sometimes reversed in developing countries. As described in Chapter 4, there is little doubt of the importance of the changing physical environment to the increases in obesity observed over the past several decades. However, far less attention has been paid to investigating the potential contribution of socio-cultural factors and to changes in the socio-cultural environment over time to the current obesity pandemic. The mechanisms through which socio-cultural factors may influence body weight and risk for obesity are also not well understood. In discussing socio-cultural influences we refer to systems of social relations (roles and relationships that define class, gender, ethnicity, and other social factors) and the meanings attached to these (1). For the purposes of this chapter, we focus on the impact of social, economic, and value systems on individuals' obesity-related behaviors (particularly, certain eating patterns and physical inactivity). In particular, we examine socio-cultural categories (socio-economic status, ethnicity, marital/family roles) for which evidence exists that rates of obesity are differentially distributed. We have not focused on the role of physical environmental factors, which is covered in Chapter 4, and we have largely restricted our focus to developed countries, from where the majority of the evidence for socio-cultural influences on obesity is derived. Issues relating to influences on obesity in developing countries are covered in detail in Chapter 5. This chapter provides an overview of the impact of socio-cultural influences on obesity in developed countries, and considers the potential pathways through which these influences may operate. The chapter concludes by speculating about the potential impact of societal trends on future rates and patterns of obesity in developed countries.

Organizational factors in the diffusion of an industry standard: implementing an online documentation system for Australian exporters

At present, governments in many countries are actively engaged in the development of electronic trading and certification standards to enable the smooth operation of export markets. Standards and their usability underpin confidence in the operations of markets and their effective functioning. In institutional markets, an important role for government agencies lies in developing the initial specifications for standards for interoperable systems. Once these specifications are accepted, governments can then facilitate the eventual diffusion of a standard to the B2B marketplace. Acceptance of an industry standard can determine demand, which defines the viability of that market. In this paper, we describe an initiative by a government agency, the Australian Quarantine and Inspection Service (AQIS), in developing EXDOC, a standard for export documentation and the role that AQIS played in its implementation and diffusion. Our case study illustrates a successfully facilitated B2G implementation. It demonstrates how a standard can be supported and promulgated for the effective functioning of markets in the transition from manual to online export documentation. Once the overarching specifications for related industries have been established and diffused by government, opportunities arise for private sector markets to develop across these industries. Government agencies can promote the effective operation of standards for electronic markets. The EXDOC implementation and its iterations provide an exemplar of active engagement in the development of electronic trading and certification standards for an institutional market. Its successful diffusion provides a model of the implementation process for other export sectors and agencies.

Key success factors in bidding for hallmark sporting events

Hallmark sporting events often are commercially driven entertainment entities which represent an economically important part of the overall sport industry. Because of the high popularity of international sporting contests, hallmark sporting events attract significant commercial, media, and consumer attention. Cities around the world are beginning to understand the potential of using these events to draw attention to the host city, which is why the market for hallmark sporting events is becoming increasingly competitive. In order to award the hosting of the event to the most suitable organizer, event owners often require potential hosts to bid. The most important elements in this process have been largely based on logical assumptions rather than empirical data. This study focused on the bid process in order to ascertain the important elements essential in achieving a successful bid.

A longitudinal analysis of the role of biopsychosocial factors in predicting body change strategies among adolescent boys.

In this study we examined the role of biopsychosocial factors on adolescent boys' body modification strategies over an 8-month period. Participants were 434 adolescent boys aged between 11 and 16 years. The majority of respondents were from Anglo-Australian backgrounds (83%); the others were from Asian and European non-English-speaking backgrounds. The results indicated a consistent relationship between perceived encouragement to engage in body change strategies and increases in adolescents' body modification strategies, including muscle gain, weight gain, and weight loss. In addition, poor parent relations, being younger, and higher scores on the pubertal development scale predicted increased use of food supplements. However, the stability of the body modification strategies and the examined variables over the 8-month period were low. Further studies are needed to examine the stability of adolescent self-perceptions over both longer and shorter periods. Moreover, researchers need to include other factors that may be more relevant for adolescent boys (e.g., involvement in sports).

Critical success factors in mobile communictions: a comparative roadmap for Germany and India

The world of telecommunications, especially mobile communications, continues to evolve with innovative technologies and high-speed data services. In many economies, mobile phones have overtaken fixed lines. In this dynamic context, we have envisaged to study mobile communication diffusion in Germany and India, from a historical comparative perspective. The basic standard for comparison has been Global Systems for Mobile Communications (GSM) and its data services, which was adopted by both economies. Subsequently, critical success factors in each economy is drawn and compared with the other, to elicit future directions.

Role of personal factors in women's self-reported weight management behaviour.

The aim of this study was to investigate the role of motivation, anxiety and self-efficacy in self-reported behaviour that may be important for weight loss and weight maintenance. One hundred and twenty-nine females aged 18–81 years were recruited from a variety of social, sporting venues and work places within a local community. Participants completed questionnaires assessing their levels of participation and perseverance in weight management activities, their motivation levels, their anxiety levels (State Anxiety Inventory) and their levels of self-efficacy for weight management behaviours. Motivation was found to play a major role in participation in weight management activities. Anxiety and self-efficacy played no significant role. The findings are discussed in relation to previous studies, and directions for future studies are indicated. It is argued that the level of motivation is a key factor that should be taken into account for each individual engaging in women's weight management programmes, and that further research should be undertaken to identify other relevant factors.

Socio-economic factors in obesity: a case of slim chance in a fat world?

The global obesity pandemic has been well-documented and widely discussed by the public, the media, health officials, the food industry and academic researchers. While the problem is widely recognised, the potential solutions are far less clear. There is only limited evidence to guide decisions as to how best to manage obesity in individuals and in populations. While widely viewed as a clinical and public health problem in developed countries, it is now clear that many developing countries also have to grapple with this problem or face the crippling healthcare costs resulting from obesity-related morbidity. There is also abundant evidence that obesity is socio-economically distributed. In developed countries persons of lower socio-economic position are more likely to be affected, while in developing countries, it is often those of higher socio-economic position who are overweight or obese. The aim of this paper is to briefly review the evidence that links socio-economic position and obesity, to discuss what is known about underlying mechanisms, and to consider the role of social, physical, policy and cultural environments in explaining the relationships between socio-economic position and obesity. We introduce the concept of ‘resilience’ as a potential theoretical construct to guide research efforts aimed at understanding how some socio-economically disadvantaged individuals manage to avoid obesity. We conclude by considering an agenda to guide future research and programs focused on understanding and reducing obesity among those of low socio-economic position.

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.

Role of dietary factors in the development of basal cell cancer and squamous cell cancer of the skin

The role of dietary factors in the development of skin cancer has been investigated for many years; however, the results of epidemiologic studies have not been systematically reviewed. This article reviews human studies of basal cell cancer (BCC) and squamous cell cancer (SCC) and includes all studies identified in the published scientific literature investigating dietary exposure to fats, retinol, carotenoids, vitamin E, vitamin C, and selenium. A total of 26 studies were critically reviewed according to study design and quality of the epidemiologic evidence. Overall, the evidence suggests a positive relationship between fat intake and BCC and SCC, an inconsistent association for retinol, and little relation between ß-carotene and BCC or SCC development. There is insufficient evidence on which to make a judgment about an association of other carotenoids with skin cancer. The evidence for associations between vitamin E, vitamin C, and selenium and both BCC and SCC is weak. Many of the existing studies contain limitations, however, and further well-designed and implemented studies are required to clarify the role of diet in skin cancer. Additionally, the role of other dietary factors, such as flavonoids and other polyphenols, which have been implicated in skin cancer development in animal models, needs to be investigated.

Randomised controlled trial evaluating the effectiveness of behavioural interventions to modify cardiovascular risk factors in men and women with imparied glucose tolerance: outcomes at 6 months

Aims: To evaluate the efficacy of interventions to promote a healthy diet and physical activity in people with impaired glucose tolerance (IGT). Methods: A randomised controlled trial in Newcastle upon Tyne, UK, 1995–98. Participants included 67 adults (38 men; 29 women) aged 24–75 years with IGT. The intervention consisted of regular diet and physical activity counselling based on the stages of change model. Main outcome measures were changes between baseline and 6 months in nutrient intake; physical activity; anthropometric and physiological measurements including serum lipids; glucose tolerance; insulin sensitivity. Results: The difference in change in total fat consumption was significant between intervention and control groups (difference &minus;21.8 (95% confidence interval (CI) &minus;37.8 to &minus;5.8) g/day, P=0.008). A significantly larger proportion of intervention participants reported taking up vigorous activity than controls (difference 30.1, (95% CI 4.3–52.7)%, P=0.021). The change in body mass index was significantly different between groups (difference &minus;0.95 (95% CI &minus;1.5 to &minus;0.4) kg/m2, P=0.001). There was no significant difference in change in mean 2-h plasma glucose between groups (difference &minus;0.19 (95% CI &minus;1.1 to 0.71) mmol/l, NS) or in serum cholesterol (difference 0.02 (95% CI &minus;0.26 to 0.31) mmol/l, NS). The difference in change in fasting serum insulin between groups was significant (difference &minus;3.4 (95% CI &minus;5.8 to &minus;1.1) mU/l, P=0.005). Conclusions: After 6 months of intensive lifestyle intervention in participants with IGT, there were changes in diet and physical activity, some cardiovascular risk factors and insulin sensitivity, but not glucose tolerance. Further follow-up is in progress to investigate whether these changes are sustained or augmented over 2 years.

Differences between differentiators and cost leaders in market research and internal CRM usage

The Porter strategy types of Differentiation and Cost Leadership are put forward as strategies leading to competitive advantage (Porter 1980). These types have quite contrasting implementation guidelines in terms of human resources, organisational structure, job design decision-making process, control systems, and information systems. These internal contrasts suggest Differentiators and Cost Leaders require contrasting roles for market research and internal CRM systems. Very few studies have explored the contingent role business strategy may have in explaining contrasting roles in marketing information systems or market research.

This study involved a cross-industry postal survey of 240 Australian marketing managers. One contribution of this study was to find market research having quite different roles in supporting Marketing (i.e. brand) Differentiators compared to Product (i.e. innovative feature) Differentiators. Surprisingly only one market research role differed when comparing Cost Leaders with Marketing Differentiator strategies. A final contribution was to find that no one strategy having a greater reliance on internal CRM systems in supporting decisionmaking.