Around the world government agencies responsible for the selection and reimbursement of prescribed medicines and other health technologies are considering how best to bring community preferences into ...their decision making. In particular, community views about the distribution or equity of funding across the population. These official committees and agencies often have access to the best available and latest evidence on clinical effectiveness, safety and cost from large clinical trials and population-based studies. All too often they do not have access to high quality evidence about community views. We therefore, conducted a large and representative population-based survey in Australia to determine what community members think about the factors that do and should influence government spending on prescribed medicines.
A choice-based survey was designed to elicit the importance of individual criteria when considering the equity of government spending on prescribed medicines. A representative sample of 3080 adult Australians completed the survey by allocating a hypothetical budget to different combinations of money spent on two patient populations. Societal preferences were inferred from absolute majority responses i.e. populations with more than 50% of respondents' allocation for a particular allocation criterion.
This study shows that, all else being equal, severity of disease, diseases for which there is no alternative treatment available on the government formulary, diseases that affect patients who are not financially well off, and life-style unrelated diseases are supported by the public as resource allocation criteria. Where 'all else is not equal', participants allocated more resources to the patient population that gained considerable improvement in health and fewer resources to those that gained little improvement in health. This result held under all scenarios except for 'end-of-life treatments'. Responses to cost (and corresponding number of patients treated) trade-off scenarios indicated a significant reduction in the proportion of respondents choosing to divide resources equally and a shift in preference towards devoting resources to the population that were more costly to treat for all criteria with the exception of severity of disease.
The general public have clear views on what's fair in terms of government spending on prescribed medicines. In addition to supporting the application of the 'rule of rescue', important considerations for government spending included the severity of disease being treated, diseases for which there is no alternative treatment available on the government formulary, diseases that affect patients who are not financially well off and life-style unrelated diseases. This study shows that the general public are willing to share their views on what constitutes an equitable allocation of the government's drug budget. The challenge remains to how best to consider those views alongside clinical and economic considerations.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
BACKGROUND Internationally, most atrial fibrillation (AF) management guidelines recommend opportunistic screening for AF in people ≥65 years of age and oral anticoagulant treatment for those at high ...stroke risk (CHA₂DS₂-VA≥2). However, gaps remain in screening and treatment. METHODS AND RESULTS General practitioners/nurses at practices in rural Australia (n=8) screened eligible patients (≥65 years of age without AF) using a smartphone ECG during practice visits. eHealth tools included electronic prompts, guideline-based electronic decision support, and regular data reports. Clinical audit tools extracted de-identified data. Results were compared with an earlier study in metropolitan practices (n=8) and nonrandomized control practices (n=69). Cost-effectiveness analysis compared population-based screening with no screening and included screening, treatment, and hospitalization costs for stroke and serious bleeding events. Patients (n=3103, 34%) were screened (mean age, 75.1±6.8 years; 47% men) and 36 (1.2%) new AF cases were confirmed (mean age, 77.0 years; 64% men; mean CHA₂DS₂-VA, 3.2). Oral anticoagulant treatment rates for patients with CHA₂DS₂-VA≥2 were 82% (screen detected) versus 74% (preexisting AF)(
=NS), similar to metropolitan and nonrandomized control practices. The incremental cost-effectiveness ratio for population-based screening was AU$16 578 per quality-adjusted life year gained and AU$84 383 per stroke prevented compared with no screening. National implementation would prevent 147 strokes per year. Increasing the proportion screened to 75% would prevent 177 additional strokes per year. CONCLUSIONS An AF screening program in rural practices, supported by eHealth tools, screened 34% of eligible patients and was cost-effective. Oral anticoagulant treatment rates were relatively high at baseline, trending upward during the study. Increasing the proportion screened would prevent many more strokes with minimal incremental cost-effectiveness ratio change. eHealth tools, including data reports, may be a valuable addition to future programs. REGISTRATION URL: https://www.anzctr.org.au. Unique identifier: ACTRN12618000004268.
Objectives
To determine whether an enhanced occupational therapy discharge planning intervention that involved pre‐ and postdischarge home visits, goal setting, and follow‐up (the HOME program) would ...be superior to a usual care intervention in which an occupational therapy in‐hospital consultation for planning and supporting discharge to home is provided to individuals receiving acute care.
Design
Randomized controlled trial.
Setting
Acute and medical wards.
Participants
Individuals aged 70 and older (N = 400).
Measurements
Primary outcomes: activities daily living (ADLs; Nottingham Extended Activities of Daily Living) and participation in life roles and activities (Late Life Disability Index (LLDI)).
Results
Occupational therapist recommendations differed significantly between groups (P < .001) (HOME n = 892 recommendations; control n = 329 recommendations). There was no difference between groups in ADLs (Nottingham Extended Activities of Daily Living scale (NEADL): β = −0.17, 95% confidence interval (CI) = −0.99–0.66) or participation (LLDI—Frequency: β = −0.23, 95% CI = −2.05–1.59; LLDI—Limitation: β = −0.14, 95% CI = −2.86–2.58). Both groups maintained prehospital functional status at 90 days, and there was no difference between groups in the number of people with unplanned readmissions (HOME 23.5%, n = 43; control 21.9%, n = 37). When groups were combined, being male (P = .03) or having lower perceived participation because of physical problems (P = .04) resulted in higher risk of unplanned readmissions.
Conclusion
HOME discharge planning, which had a strong emphasis on task modification, well‐being, and prevention strategies, implemented twice as many occupational therapy recommendations as the in‐hospital only consultation, which had a greater emphasis on equipment provision, but HOME did not demonstrate greater benefit in global measures of ADLs or participation in life tasks than in‐hospital consultation alone. It is not recommended that home visits be conducted routinely as part of discharge planning for acutely hospitalized medical patients. Further work should develop guidelines for quality in‐hospital consultation.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Objectives
Prostate cancer screening using prostate‐specific antigen (PSA) remains controversial. In deciding about screening, men must weigh the benefits and harms: little is known about benefit: ...harm trade‐offs men are willing to accept. The objective of this study was to assess men's preferences for PSA screening, and the trade‐offs between benefits and harms men are willing to accept when deciding about screening.
Methods
Preferences of 662 men aged 40–69 were assessed using a discrete choice experiment. PSA screening was described by six attributes: prostate cancer deaths, prostate cancer diagnoses, unnecessary biopsies from false‐positive PSA tests, impotence, urinary incontinence/bowel problems and cost. A mixed logit model was used to examine the influence of attributes on men's preferences for PSA testing; benefit: harm trade‐offs were also calculated.
Results
Men's preferences were significantly influenced by test characteristics, particularly potential mortality benefit, unnecessary biopsies and likelihood of urinary incontinence or bowel problems; preferences were also influenced by age, prior PSA testing experience and perceived risk of prostate cancer. Men were willing to accept between 65 and 233 of 10 000 extra men with unnecessary biopsies, and between 31 and 72 of 10 000 extra men with incontinence/bowel problems to avoid one prostate cancer death.
Conclusions
Differences in valuations of attributes and trade‐offs acceptable to men of different ages suggest a one size fits all approach to PSA testing, regardless of age, may not reflect men's preferences. Our results can be used by policymakers to ensure screening programmes are in line with men's preferences and by clinicians and patients to facilitate informed discussions of the most relevant benefits and downsides of PSA screening for an individual man.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Background
There are a range of treatment options for osteoarthritis (OA) of the knee and hip, each with a unique profile of risks and benefits. Patient decision aids can help incorporate patient ...preferences in treatment decision‐making. The aim of this study was to develop and test the utility of a patient decision aid for OA that was developed using a multicriteria decision analytic framework.
Methods
People contemplating treatment for OA who had accessed the website myjointpain.org.au were invited to participate in the study by using the online patient decision aid. Two forms of the patient decision aid were created: A shorter form and a longer form, which allowed greater customization that was offered to respondents after they had completed the shorter form. Respondents also completed questions asking about their experience using the patient decision aid.
Results
A total of 625 self‐selected respondents completed the short‐form and 180 completed the long‐form. Across both forms, serious side effects, pain and function were rated as the most important treatment outcomes. Most respondents (64%) who completed the longer form reported that using the tool was a positive experience, 38% reported that using the tool had changed their mind and 48% said that using the tool would improve the quality of their decision‐making.
Conclusions
Overall, the findings suggest that this patient decision aid may be of use to a substantial number of people in facilitating appropriate treatment decision‐making.
Patient or Public Contribution
Service users of myjointpain.org.au were involved through their participation in the study, and their feedback will guide the development of future iterations of the tool.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Decision support tools can assist people to apply population-based evidence on benefits and harms to individual health decisions. A key question is whether "personalising" choice within decisions ...aids leads to better decision quality.
To assess the effect of personalising the content of a decision aid for prostate cancer screening using the Prostate Specific Antigen (PSA) test.
Randomized controlled trial.
Australia.
1,970 men aged 40-69 years were approached to participate in the trial.
1,447 men were randomly allocated to either a standard decision aid with a fixed set of five attributes or a personalised decision aid with choice over the inclusion of up to 10 attributes.
To determine whether there was a difference between the two groups in terms of: 1) the emergent opinion (generated by the decision aid) to have a PSA test or not; 2) self-rated decision quality after completing the online decision aid; 3) their intention to undergo screening in the next 12 months. We also wanted to determine whether men in the personalised choice group made use of the extra decision attributes.
5% of men in the fixed attribute group scored 'Have a PSA test' as the opinion generated by the aid, as compared to 62% of men in the personalised choice group (χ2 = 569.38, 2df, p< 0001). Those men who used the personalised decision aid had slightly higher decision quality (t = 2.157, df = 1444, p = 0.031). The men in the personalised choice group made extensive use of the additional decision attributes. There was no difference between the two groups in terms of their stated intention to undergo screening in the next 12 months.
Together, these findings suggest that personalised decision support systems could be an important development in shared decision-making and patient-centered care.
Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12612000723886.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Objective: To examine the costs and cost‐effectiveness of full implementation of biennial bowel cancer screening for Australian residents aged 50–74 years.
Design and setting: Identification of ...existing economic models from 1993 to 2010 through searches of PubMed and economic analysis databases, and by seeking expert advice; and additional modelling to determine the costs and cost‐effectiveness of full implementation of biennial faecal occult blood test screening for the five million adults in Australia aged 50–74 years.
Main outcome measures: Estimated number of deaths from bowel cancer prevented, costs, and cost‐effectiveness (cost per life‐year gained LYG) of biennial bowel cancer screening.
Results: We identified six relevant economic analyses, all of which found colorectal cancer (CRC) screening to be very cost‐effective, with costs per LYG under $55 000 per year in 2010 Australian dollars. Based on our additional modelling, we conservatively estimate that full implementation of biennial screening for people aged 50–74 years would have gross costs of $150 million, reduce CRC mortality by 15%–25%, prevent 300–500 deaths from bowel cancer, and save 3600–6000 life‐years annually, for an undiscounted cost per LYG of $25 000–$41 667, compared with no screening, and not taking cost savings as a result of treatment into consideration. The additional expenditure required, after accounting for reductions in CRC incidence, savings in CRC treatment costs, and existing ad‐hoc colonoscopy use, is likely to be less than $50 million annually.
Conclusions: Full implementation of biennial faecal occult blood test screening in Australia can reduce bowel cancer mortality, and is an efficient use of health resources that would require modest additional government investment.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
SUMMARY
Background: Renal replacement therapy (RRT) consumes sizable proportions of health budgets internationally, but there is considerable variability in choice of RRT modality among and within ...countries with major implications for health outcomes and costs. We aimed to quantify these implications for increasing kidney transplantation and improving the rate of home‐based dialysis.
Methods: A multiple cohort Markov model was used to assess costs and health outcomes of RRT for new end‐stage kidney disease (ESKD) patients in Australia for 2005–2010, using a health‐care funder perspective. Patient characteristics and current practice patterns were based on the ANZDATA Registry. Two proposed changes were modelled: (i) increasing kidney transplants by between 10% and 50% by 2010; and (ii) increasing home haemodialysis (HD) and peritoneal dialysis (PD) to the highest rates observed among Australian centres. We assessed costs (Australian dollars), survival and quality‐adjusted survival, and cost‐effectiveness.
Results: The number of new ESKD patients in 2010 was estimated to be 2700, with annual RRT costs of about $A700 million; cumulative costs (2005–2010) were $A5 billion. Increasing transplants by 10–50% saves between $A5.8 and $A26.2 million, and increases quality‐adjusted life years (QALYs) by 130–658 QALYs. Switching new patients from hospital HD to (i) home HD saves $A46.6 million by 2010; or (ii) PD saves $A122.1 million.
Conclusions: These clinical practice changes reduce costs, improve patient quality of life and, in the case of transplantation, increase survival. Planning for RRT services should incorporate efforts to maximize rates of transplantation and to encourage home‐based over hospital‐based dialysis to optimize cost‐effectiveness in RRT service delivery.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
9.
Population Health Science Salkeld, Glenn
International journal of epidemiology,
08/2017, Volume:
46, Issue:
4
Journal Article
ABSTRACT Objectives Chronic kidney disease is, increasingly, both a contributor to premature deaths and a financial burden to the health system, and is estimated to affect between 10% and 15% of the ...adult population in Western countries. Hypertension and, in particular diabetes, are significant contributors to the global burden of chronic kidney disease. Although it might increase costs, screening for, and improved management of, persons at increased risk of progressive kidney disease could improve health outcomes. We therefore sought to estimate the costs and health outcomes of alternative strategies to prevent end-stage kidney disease, compared with usual care. Methods A Markov model comparing: 1) intensive management versus usual care for patients with suboptimally managed diabetes and hypertension; and 2) screening for and intensive treatment of diabetes, hypertension, and proteinuria versus usual care was developed. Intervention effectiveness was based on published meta-analyses and randomized controlled trial data; costs were measured from a central health-care funder perspective in 2008 Australian dollars ($A), and outcomes were reported in quality-adjusted life-years (QALYs). Results Intensive treatment of inadequately controlled diabetes was both less costly (an average lifetime saving of $A133) and more effective (with an additional 0.075 QALYs per patients) than conventional management. Intensive management of hypertension had an incremental cost-effectiveness ratio (ICER) $A2588 per QALY gained. Treating all known diabetics with angiotensin-converting enzyme (ACE) inhibitors was both less costly (an average lifetime saving of $A825 per patient) and more effective than current treatment (resulting in 0.124 additional QALYs per patient). Primary care screening for 50- to 69-year-olds plus intensive treatment of diabetes had an ICER of $A13,781 per QALY gained. Primary care screening for hypertension (between ages 50 and 69 years) plus intensive blood pressure management had an ICER of $A491 per QALY gained. Primary care screening for proteinuria (between ages 50 and 69 years) combined with prescription of an ACE inhibitor for all persons showing proteinuria and all known diabetics had an ICER of $A4793 per QALY gained. Conclusions Strategies combining primary care screening of 50- to 69-year-olds for proteinuria, diabetes, and hypertension followed by the routine use of ACE inhibitors, and optimal treatment of diabetes and hypertension, respectively, have the potential to reduce death and end-stage kidney disease and are likely to represent good value for money.
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BFBNIB, DOBA, FZAB, GEOZS, GIS, IJS, IMTLJ, IZUM, KILJ, KISLJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBJE, SBMB, UILJ, UKNU, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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