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To authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1467-8462.2009.00533.x Byline: Kees van Gool ([dagger]), Elizabeth Savage ([dagger]), Rosalie Viney ([dagger]), Marion Haas ([dagger]), Rob Anderson ([double dagger]) Abstract: Abstract The Medicare Safety Net (MSN) was introduced in March 2004 to provide financial relief for those who incur high out-of-pocket costs from medical services. The policy has the potential to improve equity. This study examines: (i) how the health and income profiles of small areas influence MSN expenditure; and (ii) the distribution of expenditure by medical service type. The results indicate that MSN expenditure is positively related to income and that patients who use private obstetricians and assisted reproductive services are the greatest beneficiaries. The MSN has possibly created greater inequities in Australia's health-care financing arrangements. Author Affiliation: ([dagger])Centre for Health Economics Research and Evaluation, University of Technology ([double dagger])Peninsula Technology Assessment Group (PENTAG), Institute of Health Service Research, Peninsula Medical School, Universities of Exeter & Plymouth Article History: First version received May 2006;final version accepted October 2008 (Eds).

Objective: To evaluate the cost effectiveness of interventions designed to prevent falls and fall-related injuries among older people living in residential aged care facilities (RACFs) from an Australian health care perspective.Methods: A decision analytic Markov model was developed that stratified individuals according to their risk of falling and accounted for the risk of injury following a fall. The effectiveness of the interventions was derived from two Cochrane reviews of randomized controlled trials for falls/fall-related injury prevention in RACFs. Interventions were considered effective if they reduced the risk of falling or reduced the risk of injury following a fall. The interventions that were modelled included vitamin D supplementation, annual medication review, multifactorial intervention (a combination of risk assessment, medication review, vision assessment and exercise) and hip protectors. The cost effectiveness was calculated as the incremental cost relative to the incremental benefit, in which the benefit was estimated using quality-adjusted life-years (QALYs). Uncertainty was explored using univariate and probabilistic sensitivity analysis.Results: Vitamin D supplementation and medication review both dominated 'no intervention', as these interventions were both more effective and cost saving (because of healthcare costs avoided). Hip protectors are dominated (less effective and more costly) by vitamin D and medication review. The incremental cost-effectiveness ratio (ICER) for medication review relative to vitamin D supplementation is AU$2442 per QALY gained, and the ICER for multifactorial intervention relative to medication review is AU$1,112,500 per QALY gained. The model is most sensitive to the fear of falling and the cost of the interventions.Conclusion: The model suggests that vitamin D supplementation and medication review are cost-effective interventions that reduce falls, provide health benefits and reduce health care costs in older adults living in RACFs. [ABSTRACT FROM AUTHOR]

Objective: This review explores the evidence from the literature regarding how meta-health effects (effects other than health resulting from the consumption of health care) are valued for use in economic evaluations.Methods: A systematic review of the published literature (the EMBASE, MEDLINE, PsycINFO, CINAHL, EconLit and SocINDEX databases were searched for publications in March 2016, plus manual searching) investigated the associations between study methods and the resulting values for meta-health effects estimated for use in economic evaluations. The review considered which meta-health effects were being valued and how this differed by evaluation approach, intervention investigated, source of funds and year of publication. Detailed reasons for differences observed between values for comparable meta-health effects were explored, accounting for the method of valuation.Results: The search of the literature revealed 71 studies of interest; 35% involved drug interventions, with convenience, information and process of care the three meta-health effects most often investigated. Key associations with the meta-health effects were the evaluation method, the intervention, and the source of funds. Relative values for meta-health effects ranged from 0.9% to 68% of the overall value reported in a study. For a given meta-health effect, the magnitude of the effect evaluated and how the meta-health effect was described and framed relative to overall health explained the differences in relative values.Conclusions: Evidence from the literature shows variability in how meta-health effects are being measured for use in economic evaluations. Understanding the sources of that variability is important if decision makers are to have confidence in how meta-health effects are valued. [ABSTRACT FROM AUTHOR]

Introduction: Estimating the real-world cost-effectiveness of a new drug relies on understanding the differences between clinical trial data (pre-reimbursement) and clinical practice (post-reimbursement). This is important for decision makers when reviewing reimbursement decisions, prices, and considering other drugs for the same condition. Differences can arise from differences in patient characteristics, but also from the availability of new evidence and evolving treatment practices. This paper examines these issues using a case study.Methods: In 2001, the Australian Government funded trastuzumab for the treatment of HER2+ metastatic breast cancer through the Herceptin Program. The administrative arrangements of the Program resulted in rich observational data that captured information about patients treated with trastuzumab between 2001 and 2010 (n = 3830). The dataset included patient characteristics, dispensed medicines, medical service use and date of death.Results: Compared to participants in the clinical trials, patients were older, received more prior chemotherapies and a broader range of co-administered chemotherapies. Treatment practices differed from the clinical trials, but also changed over time. For example, in situ hybridization testing, rather than immunohistochemistry testing, and a three weekly administration schedule, rather than one weekly, were increasingly used. Compared to the clinical trials, patients administered trastuzumab with a concomitant chemotherapy generally experienced longer overall survival (151.3 weeks, 95 % CI: 142.6, 163.4), while those who received trastuzumab as a monotherapy experienced shorter overall survival (94.4 weeks, 95%CI: 86.4, 102.9). These findings may be due to a differing relative treatment effect in clinical practice, but may also be due to a range of other factors.Conclusion: This analysis demonstrates the challenges for decision makers that arise because new evidence and evolving treatment practices create a gap between clinical trial data and real-world clinical practice and outcomes. [ABSTRACT FROM AUTHOR]

Background: There is growing interest in end-of-life care in cancer patients. We aim to characterise health service use and costs in decedents with cancer history and examine factors associated with resource use and costs at life's end.Methods: We used routinely collected claims data to quantify health service use and associated costs in two cohorts of elderly Australians diagnosed with cancer: one cohort died from cancer (n=4271) and the other from non-cancer causes (n=3072). We used negative binomial regression to examine the factors associated with these outcomes.Results: Those who died from cancer had significantly higher rates of hospitalisations and medicine use but lower rates of emergency department use than those who died from non-cancer causes. Overall health care costs were significantly higher in those who died from cancer than those dying from other causes; and 40% of costs were expended in the last month of life.Conclusions: We analysed health services use and costs from a payer perspective, and highlight important differences in patterns of care by cause of death in patients with a cancer history. In particular, there are growing numbers of highly complex patients approaching the end of life and the heterogeneity of these populations may present challenges for effective health service delivery. [ABSTRACT FROM AUTHOR]

Background: Given evidence shows physical activity, a healthful diet and weight management can improve cancer outcomes and reduce chronic disease risk, the major cancer organisations and health authorities have endorsed related guidelines for cancer survivors. Despite these, and a growing evidence base on effective lifestyle interventions, there is limited uptake into survivorship care.Methods/design: Healthy Living after Cancer (HLaC) is a national dissemination and implementation study that will evaluate the integration of an evidence-based lifestyle intervention for cancer survivors into an existing telephone cancer information and support service delivered by Australian state-based Cancer Councils. Eligible participants (adults having completed cancer treatment with curative intent) will receive 12 health coaching calls over 6 months from Cancer Council nurses/allied health professionals targeting national guidelines for physical activity, healthy eating and weight control. Using the RE-AIM evaluation framework, primary outcomes are service-level indicators of program reach, adoption, implementation/costs and maintenance, with secondary (effectiveness) outcomes of patient-reported anthropometric, behavioural and psychosocial variables collected at pre- and post-program completion. The total participant accrual target across four participating Cancer Councils is 900 over 3 years.Discussion: The national scope of the project and broad inclusion of cancer survivors, alongside evaluation of service-level indicators, associated costs and patient-reported outcomes, will provide the necessary practice-based evidence needed to inform future allocation of resources to support healthy living among cancer survivors.Trial Registration: Australian and New Zealand Clinical Trials Registry (ANZCTR)--ACTRN12615000882527 (registered on 24/08/2015). [ABSTRACT FROM AUTHOR]

Importance: The benefits of rehabilitation after immobilization for ankle fracture are unclear.Objectives: To determine the effectiveness of a supervised exercise program and advice (rehabilitation) compared with advice alone and to determine if effects are moderated by fracture severity or age and sex.Design, Setting, and Participants: The EXACT trial was a pragmatic, randomized clinical trial conducted from December 2010 to June 2014. Patients with isolated ankle fracture presenting to fracture clinics in 7 Australian hospitals were randomized on the day of removal of immobilization. Of 571 eligible patients, 357 chose not to participate and 214 were allocated to rehabilitation (n = 106) or advice alone (n = 108), with 194 (91%) followed up at 1 month, 173 (81%) at 3 months, and 170 (79%) at 6 months. There were no withdrawals attributed to adverse effects. Recruitment terminated early on December 31, 2013 (planned enrollment, 342; actual, 214), because funding was exhausted.Interventions: Supervised exercise program and advice about self-management (rehabilitation) (individually tailored, prescribed, monitored, and progressed) or advice alone, both delivered by a physical therapist.Main Outcomes and Measures: Primary outcomes were activity limitation assessed using the Lower Extremity Functional Scale (score range, 0-80; higher scores indicate better activity), and quality of life assessed using the Assessment of Quality of Life (score range, 0-1; higher scores indicate better quality of life), measured at baseline and at 1, 3 (primary time point), and 6 months.Results: Mean activity limitation and quality of life at baseline were 30.1 (SD, 12.5) and 0.51 (SD, 0.24), respectively, for advice and 30.2 (SD, 13.2) and 0.54 (SD, 0.24) for rehabilitation, increasing to 64.3 (SD, 13.5) and 0.85 (SD, 0.17) for advice vs 64.3 (SD, 15.1) and 0.85 (SD, 0.20) for rehabilitation at 3 months. Rehabilitation was not more effective than advice for activity limitation (mean effect at 3 months, 0.4 [95% CI, -3.3 to 4.1]) or quality of life (-0.01 [95% CI, -0.06 to 0.04]). Treatment effects were not moderated by fracture severity or age and sex.Conclusions and Relevance: A supervised exercise program and advice did not confer additional benefits in activity limitation or quality of life compared with advice alone for patients with isolated and uncomplicated ankle fracture. These findings do not support the routine use of supervised exercise programs after removal of immobilization for patients with isolated and uncomplicated ankle fracture.Trial Registration: anzctr.org.au Identifier: ACTRN12610000979055. [ABSTRACT FROM AUTHOR]

Aim To determine the monthly treatment costs for each element of cancer care in patients receiving chemotherapy and to apportion the burden of cost by financing agent ( Commonwealth, State government, private health insurer, patient). Methods A cohort of 478 patients (54% breast, 33% colorectal and 13% non-small-cell lung cancer) were recruited from 12 centers representing metropolitan and regional settings in public and private sectors. Primary data were linked to secondary data held in New South Wales state ( Admitted Patients and Emergency Department Data) and Commonwealth ( Medicare and Pharmaceutical Benefits) databases. The monthly treatment costs of each element of care and the funding agent were calculated from secondary health data. Results Across all tumor types, the mean monthly treatment cost was $4162 (10%-90% quantiles $1018-$8098; range $2853 [adjuvant colorectal] to $5622 [metastatic lung]), with 54% of this cost borne by Commonwealth government, 26% by private health insurers, 14% by State government and 6% by patients. The mean monthly costs of treating metastatic disease were $1415 greater than those for adjuvant therapy. The mean monthly costs were contributed to by inpatient care ($1657, 40%), chemotherapy prescriptions ($1502, 36%), outpatient care ($452, 11%) and administration of chemotherapy ($364, 9%). Conclusion All four funders have a shared incentive to reduce absolute monthly treatment costs since their proportional contribution is relatively constant for most tumor types and stages. There are opportunities to reduce cancer care costs by minimizing the risk of inpatient hospital admissions that arise from chemotherapy administration and by recognizing incentives for cost-shifting. [ABSTRACT FROM AUTHOR]

OBJECTIVE. The goal was to investigate the cost-effectiveness of tandem mass spectrometry screening for the detection of inborn metabolic errors in an Australian setting. METHODS. Cost-effectiveness analysis from the health service perspective was under- taken on the basis of registry data for affected individuals. The intervention group was contrasted with both a contemporaneous group in nonscreening states and a historical cohort. The registry covers all individuals identified in Australia between 1994 and 2002. Main outcome measures were the total net cost of screening, the cost of treatment, life-years saved, and deaths averted. RESULTS. The total net cost of testing was estimated to be A$218 000 per 100 000 infants. Medical costs incurred by the intervention group exceeded those for the control group by A$ 131 000 per 100 000 infants. The number of life-years saved per 100 000 infants screened was 32.378 life-years per 100 000 infants through an expected mortality rate reduction of 0.738 deaths per 100 000 infants. The cost per death averted was estimated to be A$472 913 and the cost per life-year saved was estimated to be A$10 779, which compare favorably with existing cost-effectiveness standards. This conclusion is particularly robust because conservative assumptions were made throughout, because of data limitations. Sensitivity analyses suggested that this result was relatively robust to adjustment of model parameters. CONCLUSIONS. Tandem mass spectrometry screening for conditions caused by rare errors of metabolism is likely to be a cost-effective intervention in Australia. [ABSTRACT FROM AUTHOR]

Background. To save costs, the Australian Government recently deferred approval of seven new medicines recommended by the Pharmaceutical Benefits Advisory Committee (PBAC) for up to 7 months. Objectives. The aim of this research is to examine the timelines of PBAC applications following approval by the Therapeutic Goods Administration (TGA), allowing the recent Cabinet delays to be considered in the context of the overall medicines approval process. Methods. All new chemical entities and products for new indications approved in 2004 by the Australian Drug Evaluation Committee (ADEC) were identified. Outcomes of PBAC meetings from 2004 to 2010 were then searched to identify if and when these products were reviewed by PBAC. Results. ADEC recommended 63 eligible products for registration in 2004. Of the 113 submissions made to PBAC for these products, 66 were successful. Only 43% of the products were submitted to PBAC within 2 years, with an average 17-month delay from TGA approval of a product to consideration by the PBAC. Conclusions. Cabinet decisions to defer listing of new medicines delays access to new treatments. This occurred in addition to other longer delays, earlier in the approval process for medicines, resulting in a significant impact on the overall timeliness of listing. [ABSTRACT FROM AUTHOR]

Healthcare technology is a two-edged sword - it offers new and better treatment to a wider range of people and, at the same time, is a major driver of increasing costs in health systems. Many countries have developed sophisticated systems of health technology assessment (HTA) to inform decisions about new investments in new healthcare interventions. In this paper, we question whether HTA is also the appropriate framework for guiding or informing disinvestment decisions. In exploring the issues related to disinvestment, we first discuss the various HTA frameworks which have been suggested as a means of encouraging or facilitating disinvestment. We then describe available means of identifying candidates for disinvestment (comparative effectiveness research, clinical practice variations, clinical practice guidelines) and for implementing the disinvestment process (program budgeting and marginal analysis (PBMA) and related techniques). In considering the possible reasons for the lack of progress in active disinvestment, we suggest that HTA is not the right framework as disinvestment involves a different decision making context. The key to disinvestment is not just what to stop doing but how to make it happen - that is, decision makers need to be aware of funding disincentives. What is known about this topic? Disinvestment is an increasingly popular topic amongst academics and policy makers. Most discussions focus on the need to increase disinvestment as a corollary of investment, the lack of overt disinvestment decisions and the use of a framework based on health technology assessment (HTA) to implement disinvestment. What does this paper add? This paper focusses on the difficulties associated with deciding which technologies to disinvest in, and the problems in using an HTA framework to make such decisions, when disinvestment involves a different decision making context from that of investment. What are the implications for practitioners? The key to disinvestment is not just what to stop doing but how to implement such decisions. Making it happen means being aware of funding disincentives. [ABSTRACT FROM AUTHOR]

New medicines and therapeutic combinations are tested and marketed every year. Healthcare decision makers have to make explicit choices about adopting new treatments and deal with the resource consequences of their choices. The aim of this article is to examine the nursing workload of administering alternative chemotherapy protocols as a driver of costs. Data collection (focus groups with chemotherapy nurses and a survey of nurse unit managers) was conducted to ascertain the time required to undertake chemotherapy-related tasks and the sources of variability in six chemotherapy centers in New South Wales, Australia. Four task types (patient education, patient assessment, administration, and patient communication) were identified as being associated with administering chemotherapy. On average, patient education required 48 minutes during the first visit and 18.5 minutes thereafter, patient assessment took 20.3 minutes, administration averaged 23 minutes, and patient communication required 24.2 minutes. Each center treated an average of 14 patients per day. Each patient received 3.3 hours of staff time (1.7 hours of direct contact time and 1.6 hours of noncontact time). The result of this research will allow healthcare decision makers and evaluators to predict the amount of nursing time required to administer chemotherapy based on the characteristics of a wide range of chemotherapy protocols. [ABSTRACT FROM AUTHOR]