Utilising survey data to inform public policy: Comparison of the cost-effectiveness of treatment of ten mental disorders

Background Mental health survey data are now being used proactively to decide how the burden of disease might best be reduced. Aims To study the cost-effectiveness of current and optimal treatments for mental disorders and the proportion of burden avertable by each. Method Data for three affective, four anxiety and two alcohol use disorders and for schizophrenia were compared in terms of cost, burden averted and efficiency of current and optimal treatment. We then calculated the burden unavertable given current knowledge. The unit of health gain was a reduction in the years lived with disability (YLDs). Results Summing across all disorders, current treatment averted 13% of the burden, at an average cost of AUS$30 000 per YLD gained. Optimal treatment at current coverage could avert 20% of the burden, at an average cost of AUS$18 000 per YLD gained. Optimal treatment at optimal coverage could avert 28% of the burden, at AUS$16 000 per YLD gained. Sixty per cent of the burden of mental disorders was deemed to be unavertable. Conclusions The efficiency of treatment varied more than tenfold across disorders. Although coverage of some of the more efficient treatments should be extended, other factors justify continued use of less-efficient treatments for some disorders. Declaration of interest None. Funding detailed in Acknowledgements.

Developments in National Physical Activity Policy: An international review and recommendations towards better practice

Physical activity (PA) is increasingly considered an important public health issue and as such requires the development of good public health policy. This paper provides a summary of the literature on policy development and defines what a policy on PA may usefully comprise. The results of an international review of national level PA policies, using a defined set of criteria, are reported. Considerable similarities were found in the methods and approaches to policy development on PA across countries, with most adopting an intersectoral approach, with consultation and partnership between sectors occurring at a high level of government. The need for action across the lifespan is recognised, as is the need for multiple strategies across a variety of settings. A review of Australian PA policy found that, after promising strategic developments through Active Australia in the late 1990s, PA policy and the role of the federal health sector has become less clear, with PA policy existing now only as a component part integrated into other chronic disease prevention policy initiatives. Recommendations towards better practice in policy making are made with particular reference to developing a clearly defined integrated national PA policy in the Australian context.

Equity weights in the allocation of health care: the rank-dependent QALY model

This paper introduces the rank-dependent quality-adjusted life-years (QALY) model, a new method to aggregate QALYs in economic evaluations of health care. The rank-dependent QALY model permits the formalization of influential concepts of equity in the allocation of health care, such as the fair innings approach, and it includes as special cases many of the social welfare functions that have been proposed in the literature. An important advantage of the rank-dependent QALY model is that it offers a straightforward procedure to estimate equity weights for QALYs. We characterize the rank-dependent QALY model and argue that its central condition has normative appeal. (C) 2003 Elsevier B.V. All rights reserved.

A perspective on Australia's national medicines policy

There is international interest in Australia's health care system for prescription medicines. The issue is particularly topical in Canada with the debate following publication of the Romanow Report into the future of health care in Canada. This Report recommended a new National Drug Agency. Australia has a National Medicines Policy with four arms-quality, safety and efficacy of medicines; equity of access; a viable and responsible pharmaceutical industry; quality use of medicines. The four arms of the Policy are interlinked and interdependent for optimal functioning. In this paper, an overview of how the prescription drug system in Australia works is presented. The manuscript focuses upon specific aspects of the Policy, describing how it functions and some of the processes integral to success, from the viewpoint of the author. The discussion includes some of the advantages of Australia's system for pharmaceuticals as well as some of the problems, as these present opportunities for development and change

The contribution of research to Australian policy responses to heroin dependence 1990-2001: a personal retrospection

Periodic public concern about heroin use has been a major driver of Australian drug policy in the four decades since heroin use was first reported. The number of heroin-dependent people in Australia has increased from several hundreds in the late 1960s to around 100000 by the end of the 1990s. In this paper I do the following: (1) describe collaborative research on heroin dependence that was undertaken between 1991 and 2001 by researchers at the National Drug and Alcohol Research Centre: (2) discuss the contribution that this research may have made to the formulation of policies towards the treatment of heroin dependence during a period when the policy debate crystallized around the issue of whether or not Australia should conduct a controlled trial of heroin prescription; and (3) reflect on the relationships between research and policy-making in the addictions field, specifically on the roles of investigator-initiated and commissioned research, the interface between researchers, funders and policymakers: and the need to be realistic about the likely impact of research on policy and practice.

The policy and ethical implications of genetic research on attention deficit hyperactivity disorder

Objective: To review the policy and ethical implications of recent research on the molecular genetics of attention deficit hyperactivity disorder (ADHD). Method: MEDLINE and psycINFO database searches were used to identify studies on the genetics of ADHD. The implications of replicated candidate genes are discussed. Results: The findings for most genes have been inconsistent but several studies have implicated the genes in the dopaminergic pathway in the aetiology of ADHD. Conclusions: The current evidence on the genetics of ADHD is insufficient to justify genetic screening tests but it will provide important clues as to the aetiology of ADHD. Genetic information on susceptibility to ADHD has the potential to be abused and to stigmatize individuals. Researchers and clinicians need to be mindful of these issues in interpreting and disseminating the results of genetic studies of ADHD.

The mental health country profile: Background, design and use of a systematic method of appraisal

This article describes the construction and use of a systematic structured method of mental health country situation appraisal, in order to help meet the need for conceptual tools to assist planners and policy makers develop and audit policy and implementation strategies. The tool encompasses the key domains of context, needs, resources, provisions and outcomes, and provides a framework for synthesizing key qualitative and quantitative information, flagging up gaps in knowledge, and for reviewing existing policies. It serves as an enabling tool to alert and inform policy makers, professionals and other key stakeholders about important issues which need to be considered in mental health policy development. It provides detailed country specific information in a systematic format, to facilitate global sharing of experiences of mental health reform and strategies between policy makers and other stakeholders. Lastly, it is designed to be a capacity building tool for local stakeholders to enhance situation appraisal, and multisectorial policy development and implementation.

The appropriateness and use of focus group methodology across international mental health communities

The ability to interpret collected data across international mental health communities often proves to be difficult. The following paper reports on the use and appropriateness of focus group methodology in helping to Clarify issues that could help substantiate data collection and comparison across different cultures and regions. Field tests of the focus group methodology were undertaken in different regions and this paper describes an overview of the final field test in Sofia, Bulgaria. The findings and experiences with utilizing this methodology were incorporated in subsequent data collections.

Do nations' mental health policies, programs and legislation influence their suicide rates? An ecological study of 100 countries

Objective: To test the hypothesis that the presence of national mental health policies, programs and legislation would be associated with lower national suicide rates. Method: Suicide rates from 100 countries were regressed on mental health policy, program and legislation indicators. Results: Contrary to the hypothesized relationship, the study found that after introducing mental health initiatives (with the exception of substance abuse policies), countries' suicide rates rose. Conclusion: It is of concern that most mental health initiatives are associated with an increase in suicide rates. However, there may be acceptable reasons for the observed findings, for example initiatives may have been introduced in areas of increasing need, or a case-finding effect may be operating. Data limitations must also be considered.

Economics and health promotion

Health promotion activities consume a growing proportion of health sector spending in most developed countries. Yet, there is still considerable debate in the non-economic literature about exactly what health promotion constitutes and precisely how its role is to be conceived. This paper provides one economic answer to such questions. It sets out an argument that health promotion may be viewed, through the lens of traditional welfare economics, as a response to problems of market failure. A Grossman-type health investment model is invoked to analyse individual deviations from equilibrium and the possible instruments and targets of health promotion policy. The paper concludes by suggesting some of the alternative conceptual approaches that might be brought to bear, as well as some ideas for empirical research.

Does pharmacogenomics provide an ethical challenge to the utilisation of cost-effectiveness analysis by public health systems?

Pharmacogenomics promotes an understanding of the genetic basis for differences in efficacy or toxicity of drugs in different individuals. Implementation of the outcomes of pharmacogenomic research into clinical practice presents a number of difficulties for healthcare. This paper aims to highlight one of the Unique ethical challenges which pharmacogenomics presents for the utilisation of cost-effectiveness analysis by public health systems. This paper contends that pharmacogenomics provides a challenge to fundamental principles which underlie most systems for deciding which drugs should be publicly subsidised. Pharmacogenomics brings into focus the conflict between equality and utility in the context of using cost-effectiveness analysis to aid distribution of a limited national drug budget.

Attaching unit costs to Australia's National Survey of Mental Health and Wellbeing

Background: In mental health, policy-makers and planners are increasingly being asked to set priorities. This means that health economists, health services researchers and clinical investigators are being called upon to work together to define and measure costs. Typically, these researchers take available service utilisation data and convert them to costs, using a range of assumptions. There are inefficiencies, as individual groups of researchers frequently repeat essentially similar exercises in achieving this end. There are clearly areas where shared or common investment in the development of statistical software syntax, analytical frameworks and other resources could maximise the use of data. Aims of the Study: This paper reports on an Australian project in which we calculated unit costs for mental health admissions and community encounters. In reporting on these calculations, our purpose is to make the data and the resources associated with them publicly available to researchers interested in conducting economic analyses, and allow them to copy, distribute and modify them, providing that all copies and modifications are available under the same terms and conditions (i.e., in accordance with the 'Copyleft' principle), Within this context, the objectives of the paper are to: (i) introduce the 'Copyleft' principle; (ii) provide an overview of the methodology we employed to derive the unit costs; (iii) present the unit costs themselves; and (iv) examine the total and mean costs for a range of single and comorbid conditions, as an example of the kind of question that the unit cost data can be used to address. Method: We took relevant data from the Australian National Survey of Mental Health and Wellbeing (NSMHWB), and developed a set of unit costs for inpatient and community encounters. We then examined total and mean costs for a range of single and comorbid conditions. Results: We present the unit costs for mental health admissions and mental health community contacts. Our example, which explored the association between comorbidity and total and mean costs, suggested that comorbidly occurring conditions cost more than conditions which occur on their own. Discussion: Our unit costs, and the materials associated with them, have been published in a freely available form governed by a provision termed 'Copyleft'. They provide a valuable resource for researchers wanting to explore economic questions in mental health. Implications for Health Policies: Our unit costs provide an important resource to inform economic debate in mental health in Australia, particularly in the area of priority-setting. In the past, such debate has largely, been based on opinion. Our unit costs provide the underpinning to strengthen the evidence-base of this debate. Implications for Further Research: We would encourage other Australian researchers to make use of our unit costs in order to foster comparability across studies. We would also encourage Australian and international researchers to adopt the 'Copyleft' principle in equivalent circumstances. Furthermore, we suggest that the provision of 'Copyleft'-contingent funding to support the development of enabling resources for researchers should be considered in the planning of future large-scale collaborative survey work, both in Australia and overseas.

A process for the systematic review of community-based rehabilitation evaluation reports: formulating evidence for policy and practice

A methodological framework for conducting a systematic, mostly qualitative, meta-synthesis of community-based rehabilitation (CBR) project evaluation reports is described. Developed in the course of an international pilot study, the framework proposes a systematic review process in phases which are strongly collaborative, methodologically rigorous and detailed. Through this suggested process, valuable descriptive data about CBR practice, strategies and outcomes may be synthesized. It is anticipated that future application of this methodology will contribute to an improved evidence base for CBR, which will facilitate the development of more appropriate policy and practice guidelines for disability service delivery in developing countries. The methodology will also have potential applications in areas beyond CBR, which are similarly. evidence poor' (lacking empirical research) but 'data rich' (with plentiful descriptive and evaluative reports).

Challenges in implementing evidence-based practice into mental health services

This paper highlights challenges in implementing mental health policy at a service delivery level. It describes an attempt to foster greater application of recovery-orientated principles and practices within mental health services. Notwithstanding a highly supportive policy environment, strong support from service administrators, and an enthusiastic staff response to training, application of the training and support tools was weaker than anticipated. This paper evaluates the dissemination trial against key elements to promote sustained adoption of innovations. Organisational and procedural changes are required before mental health policies are systematically implemented in practice.