Informing disinvestment with limited evidence: cobalamin deficiency in the fatigued.

OBJECTIVES: Health technology reassessment and disinvestment can be difficult due to uncertainties regarding available evidence. Pathology testing to investigate cobalamin (vitamin B12) deficiency is a strong case in point. We conducted a 3-month economic evaluation of five strategies for diagnosing and treating cobalamin deficiency in adult patients hypothetically presenting with new unexplained fatigue in the primary care setting. The first consultation per patient was considered. Screening tests other than serum cobalamin were not included. METHODS: A cost-effectiveness analysis was undertaken using a decision tree to represent the diagnostic / treatment pathways, with relevant cost and utility scores assigned to different stages in the evaluation process. Input parameter values were estimated from published evidence, supplemented by expert opinion, with sensitivity analysis undertaken to represent parameter uncertainty. RESULTS: Ordering serum vitamin B12 to assess cobalamin deficiency among patients with unexplained fatigue was not cost-effective in any patient population, irrespective of pretest prevalence of this deficiency. For patients with a pretest prevalence above 1 percent, treating all with oral vitamin B12 supplements without testing was most cost-effective, whereas watchful waiting with symptoms monitoring was most cost-effective for patients with lower pretest prevalence probabilities. CONCLUSIONS: Substantial evidence gaps exist for parameter estimation: questionable cobalamin deficiency levels in the fatigued; debatable treatment methods; unknown natural history of the condition. Despite this, we reveal a robust path for disinvestment decision making in the face of a paradox between the evidence required to inform disinvestment compared with its paucity in informing initial funding decisions.

Trends in hospital admissions for conditions associated with child maltreatment, Northern Territory, 1999-2010.

OBJECTIVE: To use hospital admissions data to investigate trends in maltreatment among Northern Territory Aboriginal and non-Aboriginal children. DESIGN, SETTING AND PARTICIPANTS: A historical cohort study using diagnosis and external cause codes from hospital admissions among children aged 0-17 years. MAIN OUTCOME MEASURES: Annual rates of admission with either a definitive or indicative code for child maltreatment. RESULTS: From 1 January 1999 to 31 December 2010, the average annual rates of hospital admission of NT Aboriginal and non-Aboriginal children with a definitive code of maltreatment were 8.8 (95% CI, 7.4-10.2) and 0.91 (95% CI, 0.59-1.22) per 10 000 children, respectively. There was no evidence for change over time in either population. The corresponding rates of admission with a code indicative of maltreatment were 28.4 (95% CI, 25.8-31.1) and 5.2 (95% CI, 4.4-6.0) per 10 000 children, with average annual increases of 3% (incidence rate ratio [IRR], 1.03; 95% CI, 1.00-1.07) and 4% (IRR, 1.04; 95% CI, 0.96-1.11). Physical abuse was the prominent type of maltreatment-related admission in both populations. There were increases in rates of admission for older Aboriginal children (13-17 years) and older non-Aboriginal boys. Most perpetrators in the assault of younger children were family members, while among older children most were not specified. CONCLUSION: Our study shows the utility of hospital admissions for population surveillance of child maltreatment. The relatively stable rate of maltreatment-related hospital admissions among NT Aboriginal children shown here is in contrast to substantial increases reported from child protection data. The results also highlight the overlap between violence within families and in the wider community, particularly for older children, and lends support for population-level interventions to protect vulnerable children.

Disinvestment policy and the public funding of assisted reproductive technologies: outcomes of deliberative engagements with three key stakeholder groups.

BACKGROUND: Measures to improve the quality and sustainability of healthcare practice and provision have become a policy concern. In addition, the involvement of stakeholders in health policy decision-making has been advocated, as complex questions arise around the structure of funding arrangements in a context of limited resources. Using a case study of assisted reproductive technologies (ART), deliberative engagements with a range of stakeholder groups were held on the topic of how best to structure the distribution of Australian public funding in this domain. METHODS: Deliberative engagements were carried out with groups of ART consumers, clinicians and community members. The forums were informed by a systematic review of ART treatment safety and effectiveness (focusing, in particular, on maternal age and number of treatment cycles), as well as by international policy comparisons, and ethical and cost analyses. Forum discussions were transcribed and subject to thematic analysis. RESULTS: Each forum demonstrated stakeholders' capacity to understand concepts of choice under resource scarcity and disinvestment, and to countenance options for ART funding not always aligned with their interests. Deliberations in each engagement identified concerns around 'equity' and 'patient responsibility', culminating in a broad preference for (potential) ART subsidy restrictions to be based upon individual factors rather than maternal age or number of treatment cycles. Community participants were open to restrictions based upon measures of body mass index (BMI) and smoking status, while consumers and clinicians saw support to improve these factors as part of an ART treatment program, as distinct from a funding criterion. All groups advocated continued patient co-payments, with measures in place to provide treatment access to those unable to pay (namely, equity of access). CONCLUSIONS: Deliberations yielded qualitative, socially-negotiated evidence required to inform ethical, accountable policy decisions in the specific area of ART and health care more broadly. Notably, reductionist, deterministic characterizations of stakeholder 'self-interest' proved unfounded as each group sought to prioritise universal values (in particular, 'equity' and 'responsibility') over specific, within-group concerns. Our results--from an emotive case study in ART--highlight that evidence-informed disinvestment decision-making is feasible, and potentially less controversial than often presumed.

Discounting of medicines in Australian community pharmacies.

OBJECTIVE: There are many medicines listed on the Australian Pharmaceutical Benefits Scheme (PBS) in which point of sale price is less than the level of the general patient co-payment. In these circumstances, the patient covers the total cost of the medicine from their own pocket with no government subsidy. The aim of the present study was to compare the consumer prices of under general co-payment prescription medicines between banner group pharmacies with open discounting policies and community pharmacies without; and to assess the impact of the April 2012 PBS price disclosure policies on the discounts offered. METHODS: The consumer prices of 31 under co-payment medicines were collected from banner group pharmacy websites and individual pharmacies both before and after April 2012. PBS maximum prices were obtained from the PBS website. Absolute and relative price differences between PBS and pharmacy groups were calculated. RESULTS: Before April 2012, banner group pharmacies provided discounts to patients of around 40% per prescription, whereas other pharmacies provided discounts of around 15%. Total price savings were on average $9 per prescription at banner group pharmacies and $3.50 at other pharmacies. Percentage discounts did not change greatly after April 2012, when price decreases occurred on the PBS. CONCLUSIONS: Banner group pharmacies with pricing strategies are able to provide greater discounts to patients compared with other pharmacies. Community pharmacies still have the ability to provide substantial discounts after the April 2012 price reductions. WHAT IS KNOWN ABOUT THE TOPIC?: There is currently little known about the under co-payment medicines market in Australia and the price discounts available to patients. WHAT DOES THIS PAPER ADD?: This research shows that patients who purchase under co-payment medicines are able to save money if they purchase from pharmacies with openly advertised discounting policies. Price reductions related to the implementation of the price disclosure policy had a small effect on the discounts offered by community pharmacies to patients. WHAT ARE THE IMPACTS FOR PRACTITIONERS?: The effect of discounting on under co-payment medicines to patients may increase their ability to afford essential medicines. Questions remain on whether the effect of discounting on under co-payment medicines may affect the quality of professional services provided to patients by pharmacists.

Trends in reports of child maltreatment in the Northern Territory, 1999-2010.

OBJECTIVE: To examine trends in reports of child maltreatment to the Northern Territory Department of Children and Families among Aboriginal and non-Aboriginal children. DESIGN, SETTING AND SUBJECTS: A historical cohort study using administrative data collections of notifications and substantiated cases of maltreatment among children aged from 0 to 17 years. MAIN OUTCOME MEASURES: Annual rates of notification and substantiation of different types of child maltreatment. RESULTS: From 1999 to 2010, the overall annual rates of notification for maltreatment of Aboriginal children showed an average increase of 21% (incidence rate ratio [IRR], 1.21; 95% CI, 1.19-1.24). The greatest increases were in notifications for neglect and emotional abuse. There were parallel increases in rates of substantiated cases of maltreatment. Among non-Aboriginal children, the overall annual rates of notification also increased (IRR, 1.10; 95% CI, 1.07-1.14); however, changes in annual rates of substantiated cases for all types of maltreatment were not statistically significant. CONCLUSION: There have been considerable increases in both notifications and substantiated cases of child maltreatment, most prominently among Aboriginal children. It is possible that the observed increases reflect increasing incidence of maltreatment; however, they are also consistent with a mix of increased surveillance, improved service access, changes in policy and a shift in public attitudes.

Effectiveness of interventions to promote healthy weight in general populations of children and adults: a meta-analysis.

BACKGROUND: Responding to the obesity epidemic requires robust evidence to help prioritize the allocation of scarce resources to preventive interventions. The aim of this study was to evaluate interventions that promote healthy weight [defined as reduction in body mass index (BMI) or percentage body fat] in general populations (unselected by weight) using a comprehensive meta-analysis. Interventions with both single and multiple components were considered. METHODS: Studies were first identified through well-conducted systematic reviews complemented by a search for single studies in five large medical databases up to 6 November 2008. Sixty-eight controlled studies were included. For each intervention type and age group, all relevant studies were pooled in a random effects meta-analysis. RESULTS: In children, the highest reductions in mean BMI were achieved through promoting reduced television viewing [-0.27 kg/m(2) (95% CI -0.4 to -0.13 kg/m(2))]. Programmes combining physical activity, specifically themed or general health education and nutrition achieved a lower reduction [-0.1 kg/m(2) (95% CI -0.17 to -0.04 kg/m(2))]. Other interventions had high heterogeneity or showed no statistically significant reduction in outcomes. In adults, single component interventions were found to reduce both outcome measures. Their mean percentage body fat was reduced through education by -1.22% (95% CI -1.92 to -0.52). CONCLUSION: The evidence for the effectiveness of promoting healthy weight in general populations is limited, though multi-component interventions in schools and encouraging reduced children's television viewing are promising strategies. Improving the reporting of outcomes is vital, as imputation of inadequately reported measures may have contributed to the observed heterogeneity. Longer follow-up is essential for understanding policy relevance.

1-(Thio-phen-2-yl)-N-(4-{(E)-[(thio-phen-2-yl)meth-yl]imino-meth-yl}benzyl-idene)methanamine.

The title compound C(18)H(16)N(2)S(2), crystallizes with two independent half-mol-ecules in the asymmetric unit, in one of which the thio-phene rings are disordered in a 0.67:0.33 ratio. Each independent mol-ecule lies across a crystallographic centre of symmetry. The dihedral angle between central (half) benzene ring and the thiophene ring is 11.82°.

Corrigendum to: What has driven acute public hospital expenditure growth in South Australia? An analysis of the relative importance of major expenditure drivers between 2006–07 and 2017–18.

Objective The aim of this study was to investigate whether increasing costs of delivering care have driven real growth in acute public hospital expenditure in South Australia (SA) and what has contributed to these real cost increases. Methods Using published time-series data, we decomposed inflation-adjusted growth in per capita total acute public hospital recurrent expenditure into its major utilisation and cost components to evaluate their relative contribution over the 12 years to 2017-18. Results Real per capita total acute public hospital recurrent expenditure grew by AU$667 (45.2%) over the 12-year period; of this, 86.0% was from real growth in input costs per weighted activity unit, with real growth in the average salaries of hospital staff accounting for AU$247 or 37.0%. Hospital utilisation rates contributed a minor 14.0%. Conclusion Over the 12 years to 2017-18, real growth in average clinical salaries was a more important driver of real growth in per capita total acute public hospital expenditure than rates of hospital utilisation. This would be facilitated by improvements in the scope, accuracy, quality and consistency of published national hospital data. What is known about the topic? Public hospital expenditure is one of the largest and fastest growing areas of government expenditure in Australia. Policy narratives often centre around demand pressures from an increasingly older, overweight, and chronically ill population. Comparatively little attention has been paid to the influence of increases in real input costs within the Australian context. What does this paper add? Real salary growth has been a major driver of acute public hospital recurrent expenditure growth in SA, whereas hospital utilisation rates have played a minor role. What are the implications for practitioners? A clearer understanding of the main drivers of acute public hospital expenditure growth and the resulting benefits to population health is needed to guide the efficient and sustainable use of scarce healthcare resources.

What has driven acute public hospital expenditure growth in South Australia? An analysis of the relative importance of major expenditure drivers between 2006–07 and 2017–18.

Objective The aim of this study was to investigate whether increasing costs of delivering care have driven real growth in acute public hospital expenditure in South Australia (SA) and what has contributed to these real cost increases. Methods Using published time-series data, we decomposed inflation-adjusted growth in per capita total acute public hospital recurrent expenditure into its major utilisation and cost components to evaluate their relative contribution over the 12 years to 2017-18. Results Real per capita total acute public hospital recurrent expenditure grew by AU$667 (45.2%) over the 12-year period; of this, 86.0% was from real growth in input costs per weighted activity unit, with real growth in the average salaries of hospital staff accounting for AU$247 or 37.0%. Hospital utilisation rates contributed a minor 14.0%. Conclusion Over the 12 years to 2017-18, real growth in average clinical salaries was a more important driver of real growth in per capita total acute public hospital expenditure than rates of hospital utilisation. This would be facilitated by improvements in the scope, accuracy, quality and consistency of published national hospital data. What is known about the topic? Public hospital expenditure is one of the largest and fastest growing areas of government expenditure in Australia. Policy narratives often centre around demand pressures from an increasingly older, overweight, and chronically ill population. Comparatively little attention has been paid to the influence of increases in real input costs within the Australian context. What does this paper add? Real salary growth has been a major driver of acute public hospital recurrent expenditure growth in SA, whereas hospital utilisation rates have played a minor role. What are the implications for practitioners? A clearer understanding of the main drivers of acute public hospital expenditure growth and the resulting benefits to population health is needed to guide the efficient and sustainable use of scarce healthcare resources.

Exploring health professionals' perspectives on factors affecting Iranian hospital efficiency and suggestions for improvement.

While numerous studies have been undertaken in many developed countries and in a few developing countries, there has so far been no systematic attempt to identify factors affecting efficiency in the Iranian hospitals. This study was designed to elicit the perspectives of a group of health professionals and managers so as to analyse factors affecting the efficiency of hospitals owned by the Iranian Social Security Organization (SSO), which is the second largest institutional source of hospital care in that country. This study also aimed to identify actions that would improve efficiency. Using purposive sampling (to identify key informants), interviews with seventeen health professionals and hospital managers involved in the SSO health system were conducted. The respondents identified a number of organizational factors affecting efficiency, particularly the hospital budgeting and payment system used to fund physicians, and the lack of the managerial skills needed to manage complex facilities such as hospitals. The interviewees stressed the necessity for reforms of the regulatory framework to improve efficiency. A few participants recommended the concept of a funder-provider split. The results of this exploratory study have provided meaningful insight into Iranian health professionals views of factors affecting efficiency, and of possible remedial actions. It is expected that the findings will provide guidance for health policy makers and hospital managers in the Iranian SSO to analyse factors affecting efficiency and to identify remedial actions to improve efficiency. Hospitals in other developing countries may be affected by similar factors.

1,4-Bis[(2-pyridyl-eth-yl)imino-meth-yl]benzene.

In the title compound, C(22)H(22)N(4), the centroid of the benzene ring is located on an inversion centre. The dihedral angle between the benzene and pyridine rings is 10.94 (5)°. The crystal structure displays weak inter-molecular C-H⋯N hydrogen bonding and C-H⋯π inter-actions.

Including the public in pandemic planning: a deliberative approach.

BACKGROUND: Against a background of pandemic threat posed by SARS and avian H5N1 influenza, this study used deliberative forums to elucidate informed community perspectives on aspects of pandemic planning. METHODS: Two deliberative forums were carried out with members of the South Australian community. The forums were supported by a qualitative study with adults and youths, systematic reviews of the literature and the involvement of an extended group of academic experts and policy makers. The forum discussions were recorded with simultaneous transcription and analysed thematically. RESULTS: Participants allocated scarce resources of antiviral drugs and pandemic vaccine based on a desire to preserve society function in a time of crisis. Participants were divided on the acceptability of social distancing and quarantine measures. However, should such measures be adopted, they thought that reasonable financial, household and psychological support was essential. In addition, provided such support was present, the participants, in general, were willing to impose strict sanctions on those who violated quarantine and social distancing measures. CONCLUSIONS: The recommendations from the forums suggest that the implementation of pandemic plans in a severe pandemic will be challenging, but not impossible. Implementation may be more successful if the public is engaged in pandemic planning before a pandemic, effective communication of key points is practiced before and during a pandemic and if judicious use is made of supportive measures to assist those in quarantine or affected by social isolation measures.

The cost-effectiveness of point of care testing in a general practice setting: results from a randomised controlled trial.

BACKGROUND: While point of care testing (PoCT) for general practitioners is becoming increasingly popular, few studies have investigated whether it represents value for money. This study aims to assess the relative cost-effectiveness of PoCT in general practice (GP) compared to usual testing practice through a pathology laboratory. METHODS: A cost-effectiveness analysis based on a randomized controlled trial with 4,968 patients followed up for 18 months and fifty-three general practices in urban, rural and remote locations across three states in Australia.The incremental costs and health outcomes associated with a clinical strategy of PoCT for INR, HbA1c, lipids, and ACR were compared to those from pathology laboratory testing. Costs were expressed in year 2006 Australian dollars. Non-parametric bootstrapping was used to generate 95% confidence intervals. RESULTS: The point estimate of the total direct costs per patient to the health care sector for PoCT was less for ACR than for pathology laboratory testing, but greater for INR, HbA1c and Lipids, although none of these differences was statistically significant. PoCT led to significant cost savings to patients and their families. When uncertainty around the point estimates was taken into account, the incremental cost-effectiveness ratio (ICER) for PoCT was found to be unfavourable for INR, but somewhat favourable for ACR, while substantial uncertainty still surrounds PoCT for HbA1c and Lipids. CONCLUSIONS: The decision whether to fund PoCT will depend on the price society is willing to pay for achievement of the non-standard intermediate outcome indicator. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry ACTRN12605000272695.

A conceptual framework for selecting the most appropriate variables for measuring hospital efficiency with a focus on Iranian public hospitals.

Over the past few decades, there has been an increasing interest in the measurement of hospital efficiency in developing countries and in Iran. While the choice of measurement methods in hospital efficiency assessment has been widely argued in the literature, few authors have offered a framework to specify variables that reflect different hospital functions, the quality of the process of care and the effectiveness of hospital services. However, without the knowledge of hospital objectives and all relevant functions, efficiency studies run the risk of making biased comparisons, particularly against hospitals that provide higher quality services requiring the use of more resources. Undertaking an in-depth investigation regarding the multi-product nature of hospitals, various hospital functions and the values of various stakeholders (patient, staff and community) with a focus on the Iranian public hospitals, this study has proposed a conceptual framework to select the most appropriate variables for measuring hospital efficiency using frontier-based techniques. This paper contributes to hospital efficiency studies by proposing a conceptual framework and incorporating a broader set of variables in Iran. This can enhance the validity of hospital efficiency studies using frontier-based methods in developing countries.

Relative contribution of overweight and obesity to rising public hospital in-patient expenditure in South Australia.

Objective Arguments to fund obesity prevention have often focused on the growing hospital costs of associated diseases. However, the relative contribution of overweight and obesity to public hospital expenditure growth is not well understood. This paper examines the effect of overweight and obesity on acute public hospital in-patient expenditure in South Australia over time compared with other expenditure drivers. Methods Annual inflation-adjusted acute public admitted expenditure attributable to a high body mass index was estimated for 2007-08 and 2011-12 and compared with other expenditure drivers. Results Expenditure attributable to overweight and obesity increased by A$45million, from 4.7% to 5.4% of total acute public in-patient expenditure. This increase accounted for 7.8% of the A$583million total expenditure growth, whereas the largest component of total growth (62.4%) was a real increase in the average cost per separation. Conclusions The relatively minor contribution of overweight and obesity to expenditure growth over the time period examined invites reflection on arguments to boost preventive spending that centre upon reducing hospital costs. These arguments may inadvertently detract attention from the considerable health and social burdens of overweight and obesity and from unrelated sources of expenditure growth that reduce opportunities for state governments to fund obesity prevention programs despite their comparative benefits to population health. What is known about the topic? Stand-alone estimates suggest that overweight and obesity are placing a considerable financial burden on the Australian public healthcare system. What does this paper add? Our findings challenge common perceptions about the relative importance of overweight and obesity in the context of rising public in-patient expenditure in Australia. What are the implications for practitioners? Consistent serial estimates of overweight- and obesity-attributable expenditure enable its tracking and comparison with other potentially controllable expenditure drivers that may also warrant attention. Explicit consideration of population health trade-offs in expenditure-related decisions, including in enterprise bargaining, would enhance transparency in priority setting.

Patient-Centered Educational Resources for Atrial Fibrillation.

Education has long been recognized as an important component of chronic condition management. Whereas education has been evaluated in atrial fibrillation (AF) populations as part of multifaceted interventions, it has never been tested as a single entity. The aim of this review is to describe the rationale for and role of education as part of comprehensive AF management. The development and use of educational material as part of the intervention of a randomized controlled trial, the HELP-AF (Home-Based Education and Learning Program in AF) study, will be described. This study was designed to determine the impact of a home-based structured educational program on outcomes in individuals with AF. An educational resource was developed to facilitate delivery of 4 key messages targeted at empowering individuals to self-manage their condition. The key messages focused on strategies for managing future AF episodes, the role of pharmacotherapy in the treatment of AF, the appropriate use of medicines to manage stroke risk and the role of cardiovascular risk factor management in AF. To support structured educational visiting, an educational booklet titled Living Well With Atrial Fibrillation (AF) was developed by a multidisciplinary team and was further refined following input from expert clinicians and patient interviews. Using a structured educational visiting approach, education was delivered by trained clinicians within the patient's home.

Home-Based Education and Learning Program for Atrial Fibrillation: Rationale and Design of the HELP-AF Study.

BACKGROUND: Atrial fibrillation (AF) is a growing global epidemic, with its prevalence expected to significantly rise over coming decades. AF poses a substantial burden on health care systems, largely due to hospitalizations. Home-based clinical characterization has demonstrated improved outcomes in cardiac populations, but its impact on AF remains poorly defined. To test this hypothesis in AF, we developed the Home-Based Education and Learning Program for Patients With Atrial Fibrillation (HELP-AF) study. METHODS: The HELP-AF study is a prospective multicentre randomized controlled trial that will recruit 620 patients presenting to hospital emergency departments (EDs) with symptomatic AF (ANZCTR Registration: ACTRN12611000607976). Patients will be randomized to either the HELP-AF intervention or usual care. The intervention consists of 2 home visits by a nurse or pharmacist trained in the structured educational visiting (SEV) method. Patients in the control group will receive usual discharge follow-up care. RESULTS: The primary endpoints are total unplanned hospital admissions and quality of life. Secondary endpoints include AF symptom severity and burden score; time to first hospital admission; total unplanned days in hospital; total AF-related hospital admissions (including atrial flutter); total cardiac and noncardiac hospital admissions; total AF- or atrial flutter-related; cardiac- and noncardiac-related ED presentations; and all-cause mortality. An economic evaluation will also be performed. Clinical endpoints will be adjudicated by independent blinded assessors. Follow-up will be at 24 months. CONCLUSIONS: This study will assess the efficacy of a home-based structured patient-centred educational intervention in patients with AF.

Effect of treatment of gestational diabetes mellitus on pregnancy outcomes.

BACKGROUND: We conducted a randomized clinical trial to determine whether treatment of women with gestational diabetes mellitus reduced the risk of perinatal complications. METHODS: We randomly assigned women between 24 and 34 weeks' gestation who had gestational diabetes to receive dietary advice, blood glucose monitoring, and insulin therapy as needed (the intervention group) or routine care. Primary outcomes included serious perinatal complications (defined as death, shoulder dystocia, bone fracture, and nerve palsy), admission to the neonatal nursery, jaundice requiring phototherapy, induction of labor, cesarean birth, and maternal anxiety, depression, and health status. RESULTS: The rate of serious perinatal complications was significantly lower among the infants of the 490 women in the intervention group than among the infants of the 510 women in the routine-care group (1 percent vs. 4 percent; relative risk adjusted for maternal age, race or ethnic group, and parity, 0.33; 95 percent confidence interval, 0.14 to 0.75; P=0.01). However, more infants of women in the intervention group were admitted to the neonatal nursery (71 percent vs. 61 percent; adjusted relative risk, 1.13; 95 percent confidence interval, 1.03 to 1.23; P=0.01). Women in the intervention group had a higher rate of induction of labor than the women in the routine-care group (39 percent vs. 29 percent; adjusted relative risk, 1.36; 95 percent confidence interval, 1.15 to 1.62; P<0.001), although the rates of cesarean delivery were similar (31 percent and 32 percent, respectively; adjusted relative risk, 0.97; 95 percent confidence interval, 0.81 to 1.16; P=0.73). At three months post partum, data on the women's mood and quality of life, available for 573 women, revealed lower rates of depression and higher scores, consistent with improved health status, in the intervention group. CONCLUSIONS: Treatment of gestational diabetes reduces serious perinatal morbidity and may also improve the woman's health-related quality of life.

Redefining success in airway surgery for obstructive sleep apnea: a meta analysis and synthesis of the evidence.

STUDY OBJECTIVES: The role of upper airway surgery as a treatment for adult obstructive sleep apnea (OSA) remains controversial, with perspectives on treatment efficacy varying considerably. Though debate may occur in the clinical sphere, it is necessary to appreciate the ever-increasing funding and policy focus on cost effectiveness and "efficacy" in health care. DESIGN: In this review, we examine contemporary evidence that highlights the importance of "highly effective treatment" over "sub-therapeutic treatment" as a necessity to confer improved health outcomes in OSA. We highlight that assumptions of surgical success inherent in most articles fail to assimilate contemporary, clinically significant indicators of success. We performed a literature search and present interpolated meta-analyses data from 18 surgical articles. Statistical meta-analyses highlight how surgical success decreases when new evidence-based criteria of success are applied. MEASUREMENTS AND RESULTS: Specifically, when the traditional definition is applied (50% reduction in apnea-hypopnea index [AHI] and/or < or = 20) the pooled success rate for Phase I procedures is 55% (45% fail). However, at AHI < or = 10, success reduces to 31.5% (68.5% fail) and, at AHI < or = 5, success is reduced to 13% (87% fail). According to these definitions, Phase II success (fail) rates decrease from 86% (14%) to 45% (55%) and 43% (57%), respectively. CONCLUSIONS: The evidence for clinical efficacy must define treatment "success". We propose all future surgical audits report "objective cure" rates with success based on AHI outcomes of < or = 5 and/or < or = 10. We hope this paper serves as a catalyst for debate and consensus.

Costs and consequences of treatment for mild gestational diabetes mellitus - evaluation from the ACHOIS randomised trial.

BACKGROUND: Recommended best practice is that economic evaluation of health care interventions should be integral with randomised clinical trials. We performed a cost-consequence analysis of treating women with mild gestational diabetes mellitus by dietary advice, blood glucose monitoring and insulin therapy as needed compared with routine pregnancy care, using patient-level data from a multi-centre randomised clinical trial. METHODS: Women with a singleton pregnancy who had mild gestational diabetes diagnosed by an oral glucose-tolerance test between 24 and 34 weeks' gestation and their infants were included. Clinical outcomes and outpatient costs derived from all women and infants in the trial. Inpatient costs derived from women and infants attending the hospital contributing the largest number of enrolments (26.1%), and charges to women and their families derived from a subsample of participants from that hospital (in 2002 Australian dollars). Occasions of service and health outcomes were adjusted for maternal age, ethnicity and parity. Analysis of variance was used with bootstrapping to confirm results. Primary clinical outcomes were serious perinatal complications; admission to neonatal nursery; jaundice requiring phototherapy; induction of labour and caesarean delivery. Economic outcome measures were outpatient and inpatient costs, and charges to women and their families. RESULTS: For every 100 women with a singleton pregnancy and positive oral glucose tolerance test who were offered treatment for mild gestational diabetes mellitus in addition to routine obstetric care, $53,985 additional direct costs were incurred at the obstetric hospital, $6,521 additional charges were incurred by women and their families, 9.7 additional women experienced induction of labour, and 8.6 more babies were admitted to a neonatal nursery. However, 2.2 fewer babies experienced serious perinatal complication and 1.0 fewer babies experienced perinatal death. The incremental cost per additional serious perinatal complication prevented was $27,503, per perinatal death prevented was $60,506 and per discounted life-year gained was $2,988. CONCLUSION: It is likely that the general public in high-income countries such as Australia would find reductions in perinatal mortality and in serious perinatal complications sufficient to justify additional health service and personal monetary charges. Over the whole lifespan, the incremental cost per extra life-year gained is highly favourable. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN12606000294550.