To quantify the current national burden of opioids for osteoarthritis (OA) pain in Australia in terms of number of dispensed opioid prescriptions and associated costs, and to forecast the likely ...burden to the year 2030/31.
Epidemiological modelling.
Published data were obtained on rates of opioid prescribing for people with OA and national OA prevalence projections. Trends in opioid dispensing from 2006 to 2016, and average costs for common opioid subtypes were obtained from the Pharmaceutical Benefits Scheme and Medicare Australia Statistics. Using these inputs, a model was developed to estimate the likely number of dispensed opioid prescriptions and costs to the public healthcare system by 2030/31.
In 2015/16, an estimated 1.1 million opioid prescriptions were dispensed in Australia for 403,954 people with OA (of a total 2.2 million Australians with OA). Based on recent dispensing trends and OA prevalence projections, the number of dispensed opioid prescriptions is expected to nearly triple to 3,032,332 by 2030/31, for an estimated 562,610 people with OA. The estimated cost to the Australian healthcare system was $AUD25.2 million in 2015/16, rising to $AUD72.4 million by 2030/31.
OA-related opioid dispensing and associated costs are set to increase substantially in Australia from 2015/16 to 2030/31. Use of opioids for OA pain is concerning given joint disease chronicity and the risk of adverse events, particularly among older people. These projections represent a conservative estimate of the full financial burden given additional costs associated with opioid-related harms and out-of-pocket costs borne by patients.
Summary
Background
Crohn's disease recurs in the majority of patients after intestinal resection.
Aim
To compare the relative efficacy of thiopurines and anti‐TNF therapy in patients at high risk of ...disease recurrence.
Methods
As part of a larger study comparing post‐operative management strategies, patients at high risk of recurrence (smoker, perforating disease, ≥2nd operation) were treated after resection of all macroscopic disease with 3 months metronidazole together with either azathioprine 2 mg/kg/day or mercaptopurine 1.5 mg/kg/day. Thiopurine‐intolerant patients received adalimumab induction then 40 mg fortnightly. Patients underwent colonoscopy at 6 months with endoscopic recurrence assessed blind to treatment.
Results
A total of 101 patients 50% male; median (IQR) age 36 (25–46) years were included. There were no differences in disease history between thiopurine‐ and adalimumab‐treated patients. Fifteen patients withdrew prior to 6 months, five due to symptom recurrence (of whom four were colonoscoped). Endoscopic recurrence (Rutgeerts score i2–i4) occurred in 33 of 73 (45%) thiopurine vs. 6 of 28 (21%) adalimumab‐treated patients intention‐to‐treat (ITT); P = 0.028 or 24 of 62 (39%) vs. 3 of 24 (13%) respectively per‐protocol analysis (PPA); P = 0.020. Complete mucosal endoscopic normality (Rutgeerts i0) occurred in 17/73 (23%) vs. 15/28 (54%) (ITT; P = 0.003) and in 27% vs. 63% (PPA; P = 0.002). The most advanced disease (Rutgeerts i3 and i4) occurred in 8% vs. 4% (thiopurine vs. adalimumab).
Conclusions
In Crohn's disease patients at high risk of post‐operative recurrence adalimumab is superior to thiopurines in preventing early disease recurrence.
Enterococci are a major cause of nosocomial bacteraemia. The impacts of vanB vancomycin resistance and antibiotic therapy on outcomes in enterococcal bacteraemia are unclear. Factors that affect ...length of stay (LOS) and costs of managing patients with enterococcal bacteraemia are also unknown. This study aimed to identify factors associated with mortality, LOS and hospitalization costs in patients with enterococcal bacteraemia and the impact of vancomycin resistance and antibiotic therapy on these outcomes. Data from 116 patients with vancomycin-resistant Enterococci (VRE), matched 1:1 with patients with vancomycin-susceptible Enterococcus (VSE), from two Australian hospitals were reviewed for clinical and economic outcomes. Univariable and multivariable logistic and quantile regression analyses identified factors associated with mortality, LOS and costs. Intensive care unit admission (OR, 8.57; 95% CI, 3.99–18.38), a higher burden of co-morbidities (OR, 4.55; 95% CI, 1.83–11.33) and longer time to appropriate antibiotics (OR, 1.02; 95% CI, 1.01–1.03) were significantly associated with mortality in enterococcal bacteraemia. VanB vancomycin resistance increased LOS (4.89 days; 95% CI, 0.56–11.52) and hospitalization costs (AU$ 28 872; 95% CI, 734–70 667), after adjustment for confounders. Notably, linezolid definitive therapy was associated with lower mortality (OR, 0.13; 95% CI, 0.03–0.58) in vanB VRE bacteraemia patients. In patients with VSE bacteraemia, time to appropriate antibiotics independently influenced mortality, LOS and hospitalization costs, and underlying co-morbidities were associated with mortality. The study findings highlight the importance of preventing VRE bacteraemia and the significance of time to appropriate antibiotics in the management of enterococcal bacteraemia.
Summary
In March 2016, the Australian government offered unrestricted access to direct‐acting antiviral (DAA) therapy for chronic hepatitis C virus (HCV) to the entire population. This included ...prescription by any medical practitioner in consultation with specialists until sufficient experience was attained. We sought to determine the outcomes and experience over the first twelve months for the entire state of South Australia. We performed a prospective, observational study following outcomes of all treatments associated with the state's four main tertiary centres. A total of 1909 subjects initiating DAA therapy were included, representing an estimated 90% of all treatments in the state. Overall, SVR12 was 80.4% in all subjects intended for treatment and 95.7% in those completing treatment and follow‐up. 14.2% were lost to follow‐up (LTFU) and did not complete SVR12 testing. LTFU was independently associated with community treatment via remote consultation (OR 1.50, 95% CI 1.04‐2.18, P = .03), prison‐based treatment (OR 2.02, 95% CI 1.08‐3.79, P = .03) and younger age (OR 0.98, 95% CI 0.97‐0.99, P = .05). Of the 1534 subjects completing treatment and follow‐up, decreased likelihood of SVR12 was associated with genotype 2 (OR 0.23, 95% CI 0.07‐0.74, P = .01) and genotype 3 (OR 0.23, 95% CI 0.12‐0.43, P ≤ .01). A significant decrease in treatment initiation was observed over the twelve‐month period in conjunction with a shift from hospital to community‐based treatment. Our findings support the high responses observed in clinical trials; however, a significant gap exists in SVR12 in our real‐world cohort due to LTFU. A declining treatment initiation rate and shift to community‐based treatment highlight the need to explore additional strategies to identify, treat and follow‐up remaining patients in order to achieve elimination targets.
Accidental injury is a major public health problem in developed countries with 20 years elapsed since a national overview of venomous bites undertaken in Australia.
Provide the first contemporary ...epidemiological insight into venomous injuries based on demographics and geography nationally in Australia in the period 2000-2013.
An analysis of national hospitalisation and mortality data was undertaken to examine the incidence of injury and death due to envenoming in Australia. Rates were calculated using the intercensal population for all Australian age groups.
Over the study period, deaths occurred due to an anaphylactic event (0.16 per 100 000), snake envenoming (0.13 per 100 000) or box jellyfish envenoming (0.01 per 100 000). Only 44% of cases involving anaphylaxis reached medical care prior to death, compared to 74% of those envenomed by snakes. Over half of all deaths (52%) occurred at home, and 64% of these occurred within a major city or inner regional area, with 48% of work-related anaphylaxis deaths. Hospital admission rates of 199 per 100 000 persons over the 11 years were caused by contact with wasps or bees (31%), spiders (30%) and snakes (15%), with a predominant age range of 30-44 years.
The greatest burden of injury due to envenoming was caused by arthropods and snakes. Causes of death were led by anaphylaxis subsequent to an arthropod bite or sting, followed by death from snake envenoming. Over half the incidents resulting in death occurred at home, in areas where healthcare is accessible. Operational data routinely collected are informative, with variations of injury incidence between the States and Territories, indicating a need for a more localised approach to the management of this injury.
Prosthetic joint infection remains one of the most devastating complications of arthroplasty. Debridement and retention of the prosthesis is an attractive management option in carefully selected ...patients. Despite this, there are no data investigating the cost of this management modality for prosthetic joint infections. The aim of this case–control study was to calculate the cost associated with debridement and retention for management of prosthetic joint infection compared with primary joint replacement surgery without prosthetic joint infection. From 1 January 2008 to 30 June 2010, there were 21 prosthetic joint infections matched to 42 control patients. Controls were matched to cases according to the arthroplasty site, age and sex. Cases had a greater number of unplanned readmissions (100% vs. 7.1%; p <0.001), more additional surgery (3.3 vs. 0.07; p <0.001) and longer total bed days (31.6 vs. 7.9 days; p <0.001). In addition they had more inpatient, outpatient and emergency department visits (p <0.001, respectively). For patients with prosthetic joint infection the total cost, including index operation and costs of management of the prosthetic joint infection, was 3.1 times the cost of primary arthoplasty; the mean cost for cases was Australian dollars (AUD) $69 414 (±29 869) compared with $22 085 (±8147) (p <0.001). The demand for arthroplasty continues to grow and with that, the number of prosthetic joint infections will also increase, placing significant burden on the health system. Our study adds significantly to the growing body of evidence highlighting the substantial costs associated with prosthetic joint infection.
The choice of antiplatelet therapy among Asian populations for the treatment of acute coronary syndrome (ACS) is complicated owing to the high prevalence of cytochrome P450 2C19 (CYP2C19) genetic ...polymorphism that has been associated with reduced efficacy of clopidogrel. Ticagrelor is a potent but more expensive alternative antiplatelet agent that is not affected by CYP2C19 polymorphism. This study aimed to evaluate the cost-effectiveness, from the Hong Kong health-care provider's perspective, of CYP2C19*2 genotype-guided selection of antiplatelet therapy compared with the universal use of clopidogrel or ticagrelor among ACS patients who undergo percutaneous coronary intervention (PCI). In the present study, a two-part model consisting of a 1-year decision tree and a lifetime Markov model was built to simulate the progress of a typical cohort of 60-year-old Chinese patients until age 85 years and compare three treatment strategies: (i) generic clopidogrel or ticagrelor based on CYP2C19*2 genotype, (ii) universal use of generic clopidogrel or (iii) universal use of ticagrelor for all patients. Incremental cost-effectiveness ratios (ICERs) of <1 gross domestic product per capita locally (US dollar (USD)42 423/quality-adjusted life year (QALY)) were considered cost-effective. Base-case results showed universal ticagrelor use was cost-effective compared with universal clopidogrel, but was dominated by genotype-guided treatment. Genotype-guided treatment was cost-effective compared with universal clopidogrel use (ICER of USD2560/QALY). Sensitivity analysis demonstrated that with the cost of genotype testing up to USD400, CYP2C19*2 genotype-guided antiplatelet treatment remained a cost-effective strategy compared with either universal use of generic clopidogrel or ticagrelor in post-PCI ACS patients in Hong Kong.
Objective
Total joint arthroplasty (TJA) places a significant economic burden on health care resources. This cohort study examines the costs associated with arthroplasty in 827 patients undergoing ...hip and knee TJA from January 2011 to June 2012 at a single center in Melbourne, Australia.
Methods
Data included total inpatient, outpatient, and readmissions costs in the 30 days following TJA. Factors associated with cost were modeled using negative binomial regression and extrapolated to the Australian population.
Results
The base cost (i.e., the cost for a patient with no modifying factors) over the first 30 days following TJA was $13,060 Australian (AU) (interquartile range $12,126–14,067 AU). The median length of stay was 4 days (range 2–33 days) and 35 patients (4%) were readmitted in the first 30 days following index TJA, the majority of whom had a surgical site infection (SSI) (74%). The following factors were independently associated with increased costs: SSI, preoperative warfarin therapy, American Society of Anesthesiologists score of 3 or 4, hip TJA, increasing operation time, increasing postoperative blood transfusion requirements, other nosocomial infections, postoperative venous thromboembolism (VTE), pressure ulcers, postoperative confusion, and acute urinary retention. Based on data from the present study, the cost of TJA in Australia is estimated to exceed $1 billion AU per year. Preventable postoperative complications were major cost drivers: SSI and VTE added a further $97 million AU and $66 million AU, respectively, to arthroplasty costs in the first 30 days following surgery.
Conclusion
This unique study has identified important factors influencing TJA costs and providing guidance for future research and resource allocation.
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