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Objective Out-of-pocket costs strongly affect patient adherence with medicines. For asthma, guidelines recommend that most patients should be prescribed regular low-dose inhaled corticosteroids (ICS) alone, but in Australia most are prescribed combination ICS-long-acting β2-agonists (LABA), which cost more to patients and government. The present qualitative study among general practitioners (GPs) explored the acceptability, and likely effect on prescribing, of lower patient copayments for ICS alone. Methods Semistructured telephone interviews were conducted with 15 GPs from the greater Sydney area; the interviews were transcribed and thematically analysed. Results GPs reported that their main criteria for selecting medicines were appropriateness and effectiveness. They did not usually discuss costs with patients, had low awareness of out-of-pocket costs and considered that these were seldom prohibitive for asthma patients. GPs strongly believed that patient care should not be compromised to reduce cost to government. They favoured ICS-LABA combinations over ICS alone because they perceived that ICS-LABA combinations enhanced adherence and reduced costs for patients. GPs did not consider that lower patient copayments for ICS alone would affect their prescribing. Conclusion The results suggest that financial incentives, such as lower patient copayments, would be unlikely to encourage GPs to preferentially prescribe ICS alone, unless accompanied by other strategies, including evidence for clinical effectiveness. GPs should be encouraged to discuss cost barriers to treatment with patients when considering treatment choices. What is known about the topic? Australian guidelines recommend that most patients with asthma should be treated with low-dose ICS alone to minimise symptom burden and risk of flare ups. However, most patients in Australian general practice are instead prescribed combination ICS-LABA preventers, which are indicated if asthma remains uncontrolled despite treatment with ICS alone. It is not known whether GPs are aware that the combination preventers have a higher patient copayment and a higher cost to government. What does this paper add? This qualitative study found that GPs favoured combination ICS-LABA inhalers over ICS alone because they perceived ICS-LABA combinations to have greater effectiveness and promote patient adherence. This aligned with GPs' views that their primary responsibility was patient care rather than generating cost savings for government. However, it emerged that GPs rarely discussed medicine costs with patients, had low knowledge of medicine costs to patients and the health system and reported that patients rarely volunteered cost concerns. GPs believed that lower patient copayments for asthma preventer medicines would have little effect on their prescribing practices. What are the implications for practitioners? This study suggests that, when considering asthma treatment choices, GPs should empathically explore with the patient whether cost-related medication underuse is an issue, and should be aware of the option of lower out-of-pocket costs with guideline-recommended ICS alone treatment. Policy makers must be aware that differential patient copayments for ICS preventer medicines are unlikely to act as an incentive for GPs to preferentially prescribe ICS alone preventers, unless the position of these preventers in guidelines and evidence for their clinical effectiveness are also reiterated.

It is difficult to define the true cost of a burns injury, however there has always been a consensus that the costs associated with burns care are high. This study aims to achieve an accurate calculation of the cost of acute burns care in an Australian context. A retrospective review of 20 adult burn patients treated at our Centre was performed. An itemized price list was prepared based on items, services and equipment actually utilized in the care of burns patients. Case records were reviewed for a count of quantities to calculate costs for each item. Regression analysis was performed to produce a cost vs %TBSA curve for cost prediction. A cost breakdown was also performed for analysis of the most significant areas of expenditure and their trends with %TBSA. The cost calculated for an average adult burns patient was AU$71,056 (US$73,532). The total cost of all 20 patients was AU$2,449,112 (US$2,534,464). %TBSA injured was confirmed as the primary determinant of cost. Hospital length of stay, operative costs, dressings and staffing were found to be the most significant components of cost and increased most prominently with %TBSA. Compared to our findings, expenditure for prevention and education programs is minimal. There is limited conclusive evidence that changes in management protocols have had successful impact on the cost of burns treatment. Future progress in burns management may effect factors such as hospital length of stay, however until such changes, resource allocation should recognize the importance of prevention and its success at reduction of injury severity for real reductions in cost of burns care., (Crown Copyright © 2012. Published by Elsevier Ltd. All rights reserved.)

Objective: To determine the within-trial cost-efficacy of surgical therapy relative to conventional therapy for achieving remission of recently diagnosed type 2 diabetes in class I and II obese patients., Research Design and Methods: Efficacy results were derived from a 2-year randomized controlled trial. A health sector perspective was adopted, and within-trial intervention costs included gastric banding surgery, mitigation of complications, outpatient medical consultations, medical investigations, pathology, weight loss therapies, and medication. Resource use was measured based on data drawn from a trial database and patient medical records and valued based on private hospital costs and government schedules in 2006 Australian dollars (AUD). An incremental cost-effectiveness analysis was undertaken., Results: Mean 2-year intervention costs per patient were 13,400 AUD for surgical therapy and 3,400 AUD for conventional therapy, with laparoscopic adjustable gastric band (LAGB) surgery accounting for 85% of the difference. Outpatient medical consultation costs were three times higher for surgical patients, whereas medication costs were 1.5 times higher for conventional patients. The cost differences were primarily in the first 6 months of the trial. Relative to conventional therapy, the incremental cost-effectiveness ratio for surgical therapy was 16,600 AUD per case of diabetes remitted (currency exchange: 1 AUD = 0.74 USD)., Conclusions: Surgical therapy appears to be a cost-effective option for managing type 2 diabetes in class I and II obese patients.

Aim of Study: This study sought to determine whether multidisciplinary case conference reviews improved outcomes for nursing home residents, and the effects of this team approach to resident care on carers, including the hands-on carers employed by the nursing home, and health professionals., Method: 245 residents of three Canberra nursing homes were enrolled in this non-randomised controlled trial. The intervention consisted of sessions of three case conference reviews held between 10/4/96 and 4/12/96. These sessions were attended by the General Practitioners (GPs) of the residents discussed, the GP project officer from the ACT Division of General Practice, a clinical pharmacist, senior nursing staff, other health professionals e.g. physiotherapist, and occasionally the resident concerned or their representative. At each review, a case presentation by the resident's GP was followed by a multidisciplinary discussion of all aspects, medical and non-medical, of the resident's care. The review concluded with a management plan for the resident. In total 75 residents were reviewed., Main Outcome Measures: Medication use and cost, and mortality., Results: One month after the reviews were completed comparisons between those who were reviewed and those who were not showed non-significant reductions in medication orders, medication cost, and mortality in the reviewed group. Many of the 92 recommendations in the management plans that were carried out benefited the residents (n = 37) and/or carers (n = 24). The responses of the GPs and the Directors of Nursing to the reviews were overwhelmingly positive., Conclusion: Recommendations arising from multidisciplinary case conferences were carried out to the benefit of patients and carers. Given the support shown by key stakeholders, multidisciplinary conferences should be used more.

The increasing need to consider rationing strategies within the healthcare environment is being driven by pressures such as the development of new medical technologies, the aging population, patient awareness and expectations, healthcare professionals' appetite for new treatments, and government restrictions on healthcare costs. Solutions to these pressures will need to be sought urgently to avoid a situation in which quality of healthcare is affordable only for the wealthy. The fundamental principles of equity and fairness will need to be applied universally if the solutions are to be accepted by the community, patients and practitioners. There are several measures that a hospital must have in place before the concept of drug rationing can be contemplated. The approach essentially involves ensuring rational drug approval processes based on critical review of the available data, coupled with ongoing education and audit. Thus, accurate information and clinical budgeting systems, processes which encourage and ensure structural and technical efficiencies within the drug use sequence and an effective Drug and Therapeutics committee are required to facilitate this approach. To assist with its overriding goals of the quality use of medicines and optimal patient care, the Drug and Therapeutics committee needs to implement an effective formulary system, obtain detailed guidelines governing drug use within the institution, conduct an ongoing drug utilisation review programme, and provide education and training. The move to consider allocative decision making (rationing) will become increasingly necessary as limits on structural and technical efficiency measures are reached. An institution will then need to decide whether to treat a particular group of patients, or provide a certain form of treatment. Improved methods for community consultation need to be explored and there must be a partnership between the health provider and the consumer in enunciating the existence of scarcity, determining priorities and ensuring that ethics and equity are not abandoned through this process.

The aim of the study was to determine if there is a relationship between the stage of breast cancer at the time of detection and the costs of treatment and to assess whether any such relationship would have an influence on the cost of a mammographic screening programme. A retrospective analysis of the stage at presentation for primary breast cancer and the treatment costs over the duration of treatment was made. Multiple regression analysis was employed, with treatment cost as the dependent variable and categorical variables to represent stage at detection. A total of 301 women whose treatment for breast cancer commenced at the Royal Brisbane Hospital participated in the study. A statistically significant relationship was found between the stage of disease at the time of detection and subsequent treatment costs; more advanced stages of disease incurred higher treatment costs. This relationship was robust even after taking into account the age of patients, their discharge status, and differences between patients in the duration of treatment. When the effect of earlier detection on treatment cost was assessed in relation to a breast screening programme, cost savings were estimated to be in the range of 8-36% of total screening costs. There are treatment cost savings to be gained from breast cancer screening as a result of the detection of earlier stages of disease. These treatment cost savings should be offset against the cost of a mammographic screening programme.

The treatment of mild-to-moderate hypertension is used to illustrate the role of cost-effectiveness analysis in assessing the economic efficiency of pharmacological interventions. The reasons why it is important to consider economic efficiency are discussed, after which the major issues involved in conducting a cost-effectiveness analysis are outlined. Attention is focused on the relative merits of measuring benefits in terms of intermediate and final outcome indicators, and the concept of marginal cost-effectiveness analysis is introduced. Although some difficulties arise, cost-effectiveness analysis is a potentially powerful guide for decisions about the allocation of scarce resources.

Medications were checked by a trained nurse during the course of her duties in a controlled study of 150 elderly people with cerebrovascular disease. The cost of medications was marginally reduced in a group of people receiving the additional supervision, while it rose by 12.0% in a control group. In the group visited by the nurse, containers were labelled correctly for significantly more people than was the case with the control group.

In the provision of cancer therapy, usage of expensive cancer facilities and deployment of cancer services to the full, the aims and performance of a comprehensive cancer centre have been discussed. Increasing utilization of cancer chemotherapy and its cost have been contrasted with that of radiotherapy. With the current expansion in oncology there is a limit to what the cancer centre can make available within the specific tumour clinic role and for general cancer treatment purposes at other hospitals. It is timely to attempt rationalization of the cancer arrangements peripheral to the centre.