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.

Trial application of a model of resource utiliztion, costs, and outcomes for stroke (MORUCOS) to assist priority setting in stroke.

Background and Purpose— Cost-effectiveness data for stroke interventions are limited, and comparisons between studies are confounded by methodological inconsistencies. The aim of this study was to trial the use of the intervention module of the economic model, a Model of Resource Utilization, Costs, and Outcomes for Stroke (MORUCOS) to facilitate evaluation and ranking of the options.

Methods— The approach involves using an economic model together with added secondary considerations. A consistent approach was taken using standard economic evaluation methods. Data from the North East Melbourne Stroke Incidence Study (NEMESIS) were used to model "current practice" (base case), against which 2 interventions were compared. A 2-stage process was used to measure benefit: health gains (expressed in disability-adjusted life years [DALYs]) and filter analysis. Incremental cost-effectiveness ratios (ICERs) were calculated, and probabilistic uncertainty analysis was undertaken.

Results— Aspirin, a low-cost intervention applicable to a large number of stroke patients (9153 first-ever cases), resulted in modest health benefits (946 DALYs saved) and a mean ICER (based on incidence costs) of US $1421 per DALY saved. Although the health gains from recombinant tissue-type plasminogen activator (rtPA) were less (155 DALYs saved), these results were impressive given the small number of persons (256) eligible for treatment. rtPA dominates current practice because it is more effective and cost-saving.

Conclusions— If used to assess interventions across the stroke care continuum, MORUCOS offers enormous capacity to support decision-making in the prioritising of stroke services.

Space and place

This article suggests an exploration of space and place as both an actual and metaphorical construct. The thematic intent and approach to my own artistic making is also addressed as a way of reflecting on the processes of art making.

During 2004 I travelled around the United Kingdom and Ireland, finishing up in Paris. Amongst many things, I pursued two particular interests, one, how place is a location of constant accretions of human intervention and presence and, two, the structure of bridges and the built environment formally, conceptually and historically. These two interests are an ongoing focus for my art making.

Teaching and learning online with wikis

Wikis are fully editable websites; any user can read or add content to a wiki site. This functionality means that wikis are an excellent tool for collaboration in an online environment. This paper presents wikis as a useful tool for facilitating online education. Basic wiki functionality is outlined and different wikis are reviewed to highlight the features that make them a valuable technology for teaching and learning online. Finally, the paper discuses a wiki project underway at Deakin University. This project uses a wiki to host an icebreaker exercise which aims to facilitate ongoing interaction between members of online learning groups. Wiki projects undertaken in America are outlined and future wiki research plans are also discussed. These wiki projects illustrate how e-learning practitioners can and are moving beyond their comfort zone by using wikis to enhance the process of teaching and learning online.

Exploration of a first year university multimedia module on field geology

As part of the teaching programme within a first year university unit on the earth’s physical systems, a ‘virtual reality’ field trip has been developed to support field studies relating to geological materials and landscape history. This module aims to increase student understanding of the use of geological features in the evaluation of geological / landscape history. The module has various applications in the curriculum. For students attending a weekend excursion, the module is available as an adjunct to actual field studies and can be used by students as either a digital pre-lab or as an excursion review tutorial. For students not attending a weekend excursion (i.e. off campus students), it is used as a digital ‘virtual reality’ substitute for field site inspection. The module has simple linked interactive and dynamic image base digital media that provide a framework in which the geology and landscape history of excursion sites can be explored. This module is delivered as a website via CD, but can also be integrated with the 'online interface' for this unit via a QuickTime reference movie loaded inside a relevant 'Deakin (University) Studies Online’ web page. The latter strategy enables assimilation of large multimedia files into online teaching formats

Freedom and slavery: constructions of ideologies in illicit drugs treatment

Freedom, autonomy, enslavement and coercion have a multitude of meanings which are determined by the writer’s discipline background and intent, even more so in the area of illicit drugs’ policy and treatment. This paper proposes to begin to untangle the multiplicity of meanings which are attached to two contrasting forms of illicit drugs treatment, harm minimisation and abstinence-based treatments. Both treatment regimes lay claim to the high moral ground in this regard - freedom and autonomy are explicit terms used in the rhetoric of both. How this can best be understood and what sociologists can contribute to the debates about illicit drug treatments is the terrain this paper traverses. It does this by laying out the different meanings of the terms in social theory and then by trying to understand the ‘truth’ claims of treatment proponents and using a Foucauldian perspective to critique these claims.

Urban sociology and the stranger

The paper investigates the extent to which urban sociology has neglected the analytical potential of the stranger and puts forward an interpretative model that can broaden and deepen our understanding of the relationship between urbanity and difference. The interpretative model adopts a typology of the stranger consisting of three types of strangers: pre-modern, modern and post-modern. These three types of strangers are abstract descriptions constructed by accentuating certain features of real individuals. They are ‘ideal types’ and not intended as a reflection of urban realities but as a way of interpreting them. In addition, they are not mutually exclusive and may in some cases overlap, interconnect and complement each other. Finally, this typology is neither comprehensive nor definitive; rather, through an analysis of the modern city, the post-modern city I and post-modern city II, the paper demonstrates its exploratory power.

Program assessment and reporting: linking people, processes and data

As part of a larger Simplification Project for program quality assurance processes conducted at RMIT University, this paper chronicles the refinement of one aspect: program assessment and reporting. This involved the realignment of criteria used in program quality assurance with those developed in higher-level strategic and business planning processes. In addition, the project attempted to address the lack of alignment between annual program processes and subsequent decisions made about the future of programs, particularly in profile planning processes.
A revised Program Annual Report process was developed that aimed to achieve simplicity and alignment while re-engaging program leaders and heads of schools with the quality agenda. A concerted effort was made to develop a process that improved on previously poor vertical communication inherent in program quality assurance. This paper explores the ways in which this was achieved by a) linking people to data through the use of agreed and contextualised performance indicators, and b) linking people to process through more meaningful input into planning and opportunity for dialogue.

A new approach to assessing the health benefit from obesity interventions in children and adolescents: the assessing cost-effectiveness in obesity project

OBJECTIVE: To report on a new modelling approach developed for the assessing cost-effectiveness in obesity (ACE-Obesity) project and the likely population health benefit and strength of evidence for 13 potential obesity prevention interventions in children and adolescents in Australia. METHODS: We used the best available evidence, including evidence from non-traditional epidemiological study designs, to determine the health benefits as body mass index (BMI) units saved and disability-adjusted life years (DALYs) saved. We developed new methods to model the impact of behaviours on BMI post-intervention where this was not measured and the impacts on DALYs over the child's lifetime (on the assumption that changes in BMI were maintained into adulthood). A working group of stakeholders provided input into decisions on the selection of interventions, the assumptions for modelling and the strength of the evidence. RESULTS: The likely health benefit varied considerably, as did the strength of the evidence from which that health benefit was calculated. The greatest health benefit is likely to be achieved by the 'Reduction of TV advertising of high fat and/or high sugar foods and drinks to children', 'Laparoscopic adjustable gastric banding' and the 'multi-faceted school-based programme with an active physical education component' interventions. CONCLUSIONS: The use of consistent methods and common health outcome measures enables valid comparison of the potential impact of interventions, but comparisons must take into account the strength of the evidence used. Other considerations, including cost-effectiveness and acceptability to stakeholders, will be presented in future ACE-Obesity papers. Information gaps identified include the need for new and more effective initiatives for the prevention of overweight and obesity and for better evaluations of public health interventions.

Lifetime cost of stroke subtypes in Australia: findings from the North East Melbourne stroke incidence study (NEMESIS)

Background and Purpose-: Little is known about any variations in resource use and costs of care between stroke subtypes, especially nonhospital costs. The purpose of this study was to describe the patterns of resource use and to estimate the first-year and lifetime costs for stroke subtypes.

Methods-: A cost-of-illness model was used to estimate the total first-year costs and lifetime costs of stroke subtypes for all strokes (subarachnoid hemorrhages excluded) that occurred in Australia during 1997. For each subtype, average cost per case during the first year and the present value of average cost per case over a lifetime were calculated. Resource use data obtained in the North East Melbourne Stroke Incidence Study (NEMESIS) were used.

Results-: The present value of total lifetime costs for all strokes was Aus $1.3 billion (US $985 million). Total lifetime costs were greatest for ischemic stroke (72%; Aus $936.8 million; US $709.7 million), followed by intracerebral hemorrhage (26%; Aus $334.5 million; US $253.4 million) and unclassified stroke (2%; Aus $30 million; US $22.7 million). The average cost per case during the first year was greatest for total anterior circulation infarction (Aus $28 266). Over a lifetime, the present value of average costs was greatest for intracerebral hemorrhage (Aus $73 542), followed by total anterior circulation infarction (Aus $53 020), partial anterior circulation infarction (Aus $50 692), posterior circulation infarction (Aus $37 270), lacunar infarction (Aus $34 470), and unclassified stroke (Aus $12 031).

Conclusions-: First-year and lifetime costs vary considerably between stroke subtypes. Variation in average length of total hospital stay is the main explanation for differences in first-year costs.

Informal care for stroke survivors. Results from the North East Melbourne stroke incidence study (NEMESIS)

Background and Purpose-: Informal caregivers play an important role in the lives of stroke patients, but the cost of providing this care has not been estimated. The purpose of this study was to determine the nature and amount of informal care provided to stroke patients and to estimate the economic cost of that care.

Methods-: The primary caregivers of stroke patients registered in the North East Melbourne Stroke Incidence Study (NEMESIS) were interviewed at 3, 6, and 12 months after stroke, and the nature and amount of informal care provided were documented. The opportunity and replacement costs of informal care for all first-ever-in-a-lifetime strokes (excluding subarachnoid hemorrhages) that occurred in 1997 in Australia were estimated.

Results-: Among 3-month stroke survivors, 74% required assistance with activities of daily living and received informal care from family or friends. Two thirds of primary caregivers were women, and most primary caregivers (>90%) provided care during family or leisure time. Total first-year caregiver time costs for all first-ever-in-a-lifetime strokes were estimated to be A$21.7 million (opportunity cost approach) or A$42.5 million (replacement cost approach), and the present values of lifetime caregiver time costs were estimated to be A$171.4 million (opportunity cost approach) or A$331.8 million (replacement cost approach).

Conclusions-: Informal care for stroke survivors represents a significant hidden cost to Australian society. Because our community is rapidly aging, this informal care burden may increase significantly in the future.