Indicators of Risk for Dental Caries in Children: A Holistic Approach.

BACKGROUND: Dental caries in children is a major public health problem worldwide, with a multitude of determinants acting upon children to different degrees in different communities. The objective of this study was to determine maternal, environmental, and intraoral indicators of dental caries experience in a sample of 6- to 7-y-old children in South East Queensland, Australia. METHODS: A total of 174 mother-child dyads were recruited for this cross-sectional study from the Griffith University Environments for Healthy Living birth cohort study. Maternal education, employment status, and prepregnancy body mass index were maternal indicators, and annual household income was taken as a proxy for environmental indicators. These were collected as baseline data of the study. Clinical data on children's dental caries experience, saliva characteristics of buffering capacity, stimulated flow rate, and colony-forming units per milliliter of salivary mutans streptococci were collected for the oral health substudy. Univariate analysis was performed with 1-way analysis of variance and chi-square tests. Caries experience was the outcome, which was classified into 4 categories based on the number of carious tooth surfaces. Ordinal logistic regression was used to explore the association of risk indicators with caries experience. RESULTS: Age (P = 0.021), low salivary buffering capacity (P = 0.001), reduced levels of salivary flow rate (P = 0.011), past caries experience (P = 0.001), low annual household income; <$30,000 (P = 0.050) and <$60,000 (P = 0.033) and maternal employment status (P = 0.043) were associated with high levels of dental caries. CONCLUSION: These data support the evidence of associations between maternal, environmental, and children's intraoral characteristics and caries experience among children in a typical Western industrialized country. All of these need to be considered in preventative strategies within families and communities. KNOWLEDGE TRANSFER STATEMENT: The results of this study can be used by clinicians, epidemiologists, and policy makers to identify children who are at risk of developing dental caries. With consideration of costs for treatment for the disease, this information could be used to plan cost-effective and patient-centered preventive care.

Correction to: Recommendations from Two Citizens' Juries on the Surgical Management of Obesity.

The spelling of the name of author K. Chalkidou was incorrect in the original article. It is correct here.

Recommendations from Two Citizens' Juries on the Surgical Management of Obesity.

BACKGROUND: It is important that guidelines and criteria used to prioritise access to bariatric surgery are informed by the values of the tax-paying public in combination with the expertise of healthcare professionals. Citizens' juries are increasingly used around the world to engage the public in healthcare decision-making. This study investigated citizens' juries about prioritising patient access to bariatric surgery in two Australian cities. OBJECTIVES: The objective of this study is to examine public priorities for government expenditure on the surgical management of obesity developed through either a one or three-day citizen jury. SUBJECTS/METHODS: A three-day jury was held in Brisbane and a one-day jury in Adelaide. Jurors were selected in Brisbane (n = 18) and in Adelaide (n = 12) according to pre-specified criteria. Expert witnesses from various medical disciplines and consumers were cross-examined by jurors. RESULTS: The verdicts of the juries were similar in that both juries agreed bariatric surgery was an important option in the management of obesity and related comorbidities. Recommendations about who should receive treatment differed slightly across the juries. Both juries rejected the use of age as a rationing tool, but managed their objections in different ways. Participants' experiences of the jury process were positive, but our observations suggested that many variables may influence the nature of the final verdict. CONCLUSIONS: Citizen's juries, even when shorter in duration, can be an effective tool to guide the development of health policy and priorities. However, our study has identified a range of variables that should be considered when designing and running a jury and when interpreting the verdict.

Social and emotional wellbeing assessment instruments for use with Indigenous Australians: A critical review.

RATIONALE: There is growing recognition that in addition to universally recognised domains and indicators of wellbeing (such as population health and life expectancy), additional frameworks are required to fully explain and measure Indigenous wellbeing. In particular, Indigenous Australian wellbeing is largely determined by colonisation, historical trauma, grief, loss, and ongoing social marginalisation. Dominant mainstream indicators of wellbeing based on the biomedical model may therefore be inadequate and not entirely relevant in the Indigenous context. It is possible that "standard" wellbeing instruments fail to adequately assess indicators of health and wellbeing within societies that have a more holistic view of health. OBJECTIVE: The aim of this critical review was to identify, document, and evaluate the use of social and emotional wellbeing measures within the Australian Indigenous community. METHOD: The instruments were systematically described regarding their intrinsic properties (e.g., generic v. disease-specific, domains assessed, extent of cross-cultural adaptation and psychometric characteristics) and their purpose of utilisation in studies (e.g., study setting, intervention, clinical purpose or survey). We included 33 studies, in which 22 distinct instruments were used. RESULTS: Three major categories of social and emotional wellbeing instruments were identified: unmodified standard instruments (10), cross-culturally adapted standard instruments (6), and Indigenous developed measures (6). Recommendations are made for researchers and practitioners who assess social and emotional wellbeing in Indigenous Australians, which may also be applicable to other minority groups where a more holistic framework of wellbeing is applied. CONCLUSION: It is advised that standard instruments only be used if they have been subject to a formal cross-cultural adaptation process, and Indigenous developed measures continue to be developed, refined, and validated within a diverse range of research and clinical settings.

Standard vs. intensified management of heart failure to reduce healthcare costs: results of a multicentre, randomized controlled trial.

AIMS: To determine if an intensified form of heart failure management programme (INT-HF-MP) based on individual profiling is superior to standard management (SM) in reducing health care costs during 12-month follow-up (primary endpoint). METHODS AND RESULTS: A multicentre randomized trial involving 787 patients (full analysis set) discharged from four tertiary hospitals with chronic HF who were randomized to SM (n = 391) or INT-HF-MP (n = 396). Mean age was 74 ± 12 years, 65% had HF with a reduced ejection fraction (31.4 ± 8.9%) and 14% were remote-dwelling. Study groups were well matched. According to Green, Amber, Red Delineation of rIsk And Need in HF (GARDIAN-HF) profiling, regardless of location, patients in the INT-HF-MP received a combination of face-to-face (home visits) and structured telephone support (STS); only 9% (`low risk') were designated to receive the same level of management as the SM group. The median cost in 2017 Australian dollars (A$1 equivalent to ∼EUR €0.7) of applying INT-HF-MP was significantly greater than SM ($152 vs. $121 per patient per month; P < 0.001), However, at 12 months, there was no difference in total health care costs for the INT-HF-MP vs. SM group (median $1579, IQR $644 to $3717 vs. $1450, IQR $564 to $3615 per patient per month, respectively). This reflected minimal differences in all-cause mortality (17.7% vs. 18.4%; P = 0.848) and recurrent hospital stay (18.6 ± 26.5 vs. 16.6 ± 24.8 days; P = 0.199) between the INT-HF-MP and SM groups, respectively. CONCLUSION: During 12-months follow-up, an INT-HF-MP did not reduce healthcare costs or improve health outcomes relative to SM.

An empirical comparison of Markov cohort modeling and discrete event simulation in a capacity-constrained health care setting.

OBJECTIVES: To empirically compare Markov cohort modeling (MM) and discrete event simulation (DES) with and without dynamic queuing (DQ) for cost-effectiveness (CE) analysis of a novel method of health services delivery where capacity constraints predominate. METHODS: A common data-set comparing usual orthopedic care (UC) to an orthopedic physiotherapy screening clinic and multidisciplinary treatment service (OPSC) was used to develop a MM and a DES without (DES-no-DQ) and with DQ (DES-DQ). Model results were then compared in detail. RESULTS: The MM predicted an incremental CE ratio (ICER) of $495 per additional quality-adjusted life-year (QALY) for OPSC over UC. The DES-no-DQ showed OPSC dominating UC; the DES-DQ generated an ICER of $2342 per QALY. CONCLUSIONS: The MM and DES-no-DQ ICER estimates differed due to the MM having implicit delays built into its structure as a result of having fixed cycle lengths, which are not a feature of DES. The non-DQ models assume that queues are at a steady state. Conversely, queues in the DES-DQ develop flexibly with supply and demand for resources, in this case, leading to different estimates of resource use and CE. The choice of MM or DES (with or without DQ) would not alter the reimbursement of OPSC as it was highly cost-effective compared to UC in all analyses. However, the modeling method may influence decisions where ICERs are closer to the CE acceptability threshold, or where capacity constraints and DQ are important features of the system. In these cases, DES-DQ would be the preferred modeling technique to avoid incorrect resource allocation decisions.

Engaging the public in healthcare decision-making: results from a Citizens' Jury on emergency care services.

BACKGROUND: Policies addressing ED crowding have failed to incorporate the public's perspectives; engaging the public in such policies is needed. OBJECTIVE: This study aimed at determining the public's recommendations related to alternative models of care intended to reduce crowding, optimising access to and provision of emergency care. METHODS: A Citizens' Jury was convened in Queensland, Australia, to consider priority setting and resource allocation to address ED crowding. Twenty-two jurors were recruited from the electoral roll, who were interested and available to attend the jury from 15 to 17 June 2012. Juror feedback was collected via a survey immediately following the end of the jury. RESULTS: The jury considered that all patients attending the ED should be assessed with a minority of cases diverted for assistance elsewhere. Jurors strongly supported enabling ambulance staff to treat patients in their homes without transporting them to the ED, and allowing non-medical staff to treat some patients without seeing a doctor. Jurors supported (in principle) patient choice over aspects of their treatment (when, where and type of health professional) with some support for patients paying towards treatment but unanimous opposition for patients paying to be prioritised. Most of the jurors were satisfied with their experience of the Citizens' Jury process, but some jurors perceived the time allocated for deliberations as insufficient. CONCLUSIONS: These findings suggest that the general public may be open to flexible models of emergency care. The jury provided clear recommendations for direct public input to guide health policy to tackle ED crowding.

The Efficiency of Increasing the Capacity of Physiotherapy Screening Clinics or Traditional Medical Services to Address Unmet Demand in Orthopaedic Outpatients: A Practical Application of Discrete Event Simulation with Dynamic Queuing.

BACKGROUND: Hospital outpatient orthopaedic services traditionally rely on medical specialists to assess all new patients to determine appropriate care. This has resulted in significant delays in service provision. In response, Orthopaedic Physiotherapy Screening Clinics and Multidisciplinary Services (OPSC) have been introduced to assess and co-ordinate care for semi- and non-urgent patients. OBJECTIVES: To compare the efficiency of delivering increased semi- and non-urgent orthopaedic outpatient services through: (1) additional OPSC services; (2) additional traditional orthopaedic medical services with added surgical resources (TOMS + Surg); or (3) additional TOMS without added surgical resources (TOMS - Surg). METHODS: A cost-utility analysis using discrete event simulation (DES) with dynamic queuing (DQ) was used to predict the cost effectiveness, throughput, queuing times, and resource utilisation, associated with introducing additional OPSC or TOMS ± Surg versus usual care. RESULTS: The introduction of additional OPSC or TOMS (±surgery) would be considered cost effective in Australia. However, OPSC was the most cost-effective option. Increasing the capacity of current OPSC services is an efficient way to improve patient throughput and waiting times without exceeding current surgical resources. An OPSC capacity increase of ~100 patients per month appears cost effective (A$8546 per quality-adjusted life-year) and results in a high level of OPSC utilisation (98 %). CONCLUSION: Increasing OPSC capacity to manage semi- and non-urgent patients would be cost effective, improve throughput, and reduce waiting times without exceeding current surgical resources. Unlike Markov cohort modelling, microsimulation, or DES without DQ, employing DES-DQ in situations where capacity constraints predominate provides valuable additional information beyond cost effectiveness to guide resource allocation decisions.

The association between third trimester multivitamin/mineral supplements and gestational length in uncomplicated pregnancies.

BACKGROUND: Widespread use of maternal micronutrient supplements have been correlated to gestational length and outcome in women predisposed to pre-eclampsia and preterm birth. However, research is yet to be conducted examining the influence of micronutrient supplements on outcomes at term in uncomplicated pregnancies. AIM: To analyse the relationship between third trimester micronutrient supplementation and gestation length at birth, demographics and maternal birthing outcomes in well women at term in a South East Queensland representative population. METHODS: This research retrospectively analysed existing data pertaining to 427 uncomplicated, pregnancies birthing at the Gold Coast and Logan Hospitals using information gathered through the Environments for Healthy Living Study and Queensland perinatal data collection. Data were analysed using SPSS v20 by Chi square, ANOVA and regression analysis. FINDINGS: Women in the third trimester taking individual zinc, folic acid or iron supplements in combination with a multivitamin were twice as likely to birth beyond 41 completed weeks (AOR 2.054, 95% CI 1.310-7.383, p=0.038) then those who did not take any supplement when controlled for established confounders. Non supplement users were found to experience a lower rate of post dates labour and requirements for induction (AOR 0.483, 95% CI 0.278-0.840, p=0.01). CONCLUSION: Length of gestation demonstrates significant associations with micronutrient supplementation practices. Well women consuming third trimester individual micronutrient supplements in addition to multivitamins experienced a longer gestation at term compared to women taking no micronutrients, increasing their risk for postdates induction of labour.

Health services utilization of women following a traumatic birth.

This cohort study compared 262 women with high childbirth distress to 138 non-distressed women. At 12 months, high distress women had lower health-related quality of life compared to non-distressed women (EuroQol five-dimensional (EQ-5D) scale 0.90 vs. 0.93, p = 0.008), more visits to general practitioners (3.5 vs. 2.6, p = 0.002) and utilized more additional services (e.g. maternal health clinics), with no differences for infants. Childbirth distress has lasting adverse health effects for mothers and increases health-care utilization.

A cost-effectiveness analysis of a telephone-linked care intervention for individuals with Type 2 diabetes.

AIM: To assess the cost-effectiveness of an automated telephone-linked care intervention, Australian TLC Diabetes, delivered over 6 months to patients with established Type 2 diabetes mellitus and high glycated haemoglobin level, compared to usual care. METHODS: A Markov model was designed to synthesize data from a randomized controlled trial of TLC Diabetes (n=120) and other published evidence. The 5-year model consisted of three health states related to glycaemic control: 'sub-optimal' HbA1c ≥58mmol/mol (7.5%); 'average' ≥48-57mmol/mol (6.5-7.4%) and 'optimal' <48mmol/mol (6.5%) and a fourth state 'all-cause death'. Key outcomes of the model include discounted health system costs and quality-adjusted life years (QALYS) using SF-6D utility weights. Univariate and probabilistic sensitivity analyses were undertaken. RESULTS: Annual medication costs for the intervention group were lower than usual care [ INTERVENTION: £1076 (95%CI: £947, £1206) versus usual care £1271 (95%CI: £1115, £1428) p=0.052]. The estimated mean cost for intervention group participants over five years, including the intervention cost, was £17,152 versus £17,835 for the usual care group. The corresponding mean QALYs were 3.381 (SD 0.40) for the intervention group and 3.377 (SD 0.41) for the usual care group. Results were sensitive to the model duration, utility values and medication costs. CONCLUSION: The Australian TLC Diabetes intervention was a low-cost investment for individuals with established diabetes and may result in medication cost-savings to the health system. Although QALYs were similar between groups, other benefits arising from the intervention should also be considered when determining the overall value of this strategy.

The role of fathers in child feeding: perceived responsibility and predictors of participation.

BACKGROUND: The role of fathers in shaping their child's eating behaviour and weight status through their involvement in child feeding has rarely been studied. This study aims to describe fathers' perceived responsibility for child feeding, and to identify predictors of how frequently fathers eat meals with their child. METHODS: Four hundred and thirty-six Australian fathers (M age = 37 years, SD = 6 years; 34% university educated) of a 2-5-year-old child (M age = 3.5 years, SD = 0.9 years; 53% boys) were recruited via contact with mothers enrolled in existing research projects or a university staff and student email list. Data were collected from fathers via a self-report questionnaire. Descriptive and hierarchical linear regression analyses were conducted. RESULTS: The majority of fathers reported that the family often/mostly ate meals together (79%). Many fathers perceived that they were responsible at least half of the time for feeding their child in terms of organizing meals (42%); amount offered (50%) and deciding if their child eats the 'right kind of foods' (60%). Time spent in paid employment was inversely associated with how frequently fathers ate meals with their child (ß = -0.23, P < 0.001); however, both higher perceived responsibility for child feeding (ß = 0.16, P < 0.004) and a more involved and positive attitude toward their role as a father (ß = 0.20, P < 0.001) were positively related to how often they ate meals with their child, adjusting for a range of paternal and child covariates, including time spent in paid employment. CONCLUSIONS: Fathers from a broad range of educational backgrounds appear willing to participate in research studies on child feeding. Most fathers were engaged and involved in family meals and child feeding. This suggests that fathers, like mothers, should be viewed as potential agents for the implementation of positive feeding practices within the family.

PRIME: impact of previous mental health problems on health-related quality of life in women with childbirth trauma.

We investigated the impact of pre-existing mental ill health on postpartum maternal outcomes. Women reporting childbirth trauma received counselling (Promoting Resilience in Mothers' Emotions; n = 137) or parenting support (n = 125) at birth and 6 weeks. The EuroQol Five dimensional (EQ-5D)-measured health-related quality of life at 6 weeks, 6 and 12 months. At 12 months, EQ-5D was better for women without mental health problems receiving PRIME (mean difference (MD) 0.06; 95 % confidence interval (CI) 0.02 to 0.10) or parenting support (MD 0.08; 95 % CI 0.01 to 0.14). Pre-existing mental health conditions influence quality of life in women with childbirth trauma.

Can post-acute care programmes for older people reduce overall costs in the health system? A case study using the Australian Transition Care Programme.

There is an increasing demand for acute care services due in part to rising proportions of older people and increasing rates of chronic diseases. To reduce pressure and costs in the hospital system, community-based post-acute care discharge services for older people have evolved as one method of reducing length of stay in hospital and preventing readmissions. However, it is unclear whether they reduce overall episode cost or expenditure in the health system at a more general level. In this paper, we review the current evidence on the likely costs and benefits of these services and consider whether they are potentially cost-effective from a health services perspective, using the Australian Transition Care Programme as a case study. Evaluations of community-based post-acute services have demonstrated that they reduce length of stay, prevent some re-hospitalisations and defer nursing home placement. There is also evidence that they convey some additional health benefits to older people. An economic model was developed to identify the maximum potential benefits and the likely cost savings from reduced use of health services from earlier discharge from hospital, accelerated recovery, reduced likelihood of readmission to hospital and delayed entry into permanent institutional care for participants of the Transition Care Programme. Assuming the best case scenario, the Transition Care Programme is still unlikely to be cost saving to a healthcare system. Hence for this service to be justified, additional health benefits such as quality of life improvements need to be taken into account. If it can be demonstrated that this service also conveys additional quality of life improvements, community-based programmes such as Transition Care could be considered to be cost-effective when compared with other healthcare programmes.

A mixed treatment comparison of the short-term efficacy of biologic disease modifying anti-rheumatic drugs in established rheumatoid arthritis.

BACKGROUND: The short-term efficacy of biological disease modifying anti-rheumatic drugs (bDMARDs) for the treatment of established moderate to severe rheumatoid arthritis (RA) has been demonstrated by various randomized placebo or active treatment controlled trials. However, there is a lack of direct comparison of these agents. SCOPE: To compare the short-term efficacy of nine bDMARDs - abatacept, adalimumab, anakinra, certolizumab, etanercept, golimumab, infliximab, rituximab and tocilizumab - in patients with established RA. FINDINGS: A systematic review was conducted to obtain all available efficacy data for each included bDMARD. Medline, EMBASE, and Cochrane clinical trials were searched for trials in patients with RA. Twenty-seven trials were retrieved from a systematic literature search and included in the meta-analysis. Mixed treatment comparison (MTC) techniques were used to perform indirect comparisons. Analyses were conducted to estimate the odds ratio of an ACR20, ACR50, and ACR70 response at approximately six months if treated with a bDMARD compared with placebo or methotrexate. Between-drug comparisons were also made. The analyses were performed including recommended doses only (as per the product information). All drugs except anakinra and golimumab demonstrated a statistically significant advantage compared to control treatment for ACR20 responses. The between-drug comparisons revealed a statistically significant advantage for certolizumab compared to most bDMARDs for ACR20, ACR50 and ACR70 response and for etanercept versus adalimumab and anakinra for ACR20 and ACR50 response, as well as a statistically significant advantage for tocilizumab versus anakinra for ACR50 response. CONCLUSION: The analyses, using MTC of efficacy of nine bDMARDs suggest that treatment with anakinra is inferior to other bDMARDs and that etanercept and certolizumab may be more effective than other bDMARDs. There are some limitations of our analyses due to MTC assumptions, variations in trial design and the fact that only ACR outcomes at six months were included.

Guidelines for conducting and reporting economic evaluation of fall prevention strategies.

UNLABELLED: Falls in older people result in substantial health burden. Compelling evidence indicates that falls can be prevented. We developed comprehensive guidelines for economic evaluations of fall prevention interventions to facilitate publication of high-quality economic evaluations of the effective strategies and aid decision making. INTRODUCTION: The importance of economics applied to falls and fall prevention in older people has largely been overlooked. The use of different methodologies to assess the costs and health benefits of the interventions and their comparators and the inconsistent reporting in the studies limits the usefulness of these economic evaluations for decision making. We developed guidelines to encourage and facilitate completion of high-quality economic evaluations of effective fall prevention strategies. METHODS: We used a generic checklist for economic evaluations as a platform to develop comprehensive guidelines for conducting and reporting economic evaluations of fall prevention strategies. We considered the many challenges involved, particularly in identifying, measuring, and valuing the relevant cost items. RESULTS: We recommend researchers include cost outcomes and report incremental cost-effectiveness ratios in terms of falls prevented and quality adjusted life years in all clinical trials of fall prevention interventions. Studies should include the following cost categories: (1) implementing the intervention, (2) delivering the comparator group intervention, (3) total health care costs, (4) costs of fall-related health care resource use, and (5) personal and informal carer opportunity costs. CONCLUSIONS: This paper provides a timely benchmark to promote comparability and consistency for conducting and reporting economic evaluations of fall prevention strategies.

Using videotelephony to support paediatric oncology-related palliative care in the home: from abandoned RCT to acceptability study.

Videotelephony (real-time audio-visual communication) has been used successfully in adult palliative home care. This paper describes two attempts to complete an RCT (both of which were abandoned following difficulties with family recruitment), designed to investigate the use of videotelephony with families receiving palliative care from a tertiary paediatric oncology service in Brisbane, Australia. To investigate whether providing videotelephone-based support was acceptable to these families, a 12-month non-randomised acceptability trial was completed. Seventeen palliative care families were offered access to a videotelephone support service in addition to the 24 hours 'on-call' service already offered. A 92% participation rate in this study provided some reassurance that the use of videotelephones themselves was not a factor in poor RCT participation rates. The next phase of research is to investigate the integration of videotelephone-based support from the time of diagnosis, through outpatient care and support, and for palliative care rather than for palliative care in isolation. Trial registration ACTRN 12606000311550.

Case-control study of risk factors for fatal and non-fatal injury in crashes of rotary-wing aircraft.

INTRODUCTION: There have been few studies of the risk factors for fatal injury in air crashes of rotary-wing aircraft, and none of risk factors for all serious injury (fatal and non-fatal) in these aircraft. The aim of the study was to identify the potentially modifiable risk factors for injury in civil rotary-wing aircraft crashes in New Zealand. METHOD: We analyzed records from all reported civil rotary-wing aircraft crashes in New Zealand between 1988 and 1994. Air crash data from the official databases were merged with nationwide injury records and information obtained from Coroner's files. Crashes where the pilot-in-command was fatally injured were compared with crashes where the pilot-in-command was not fatally injured on 50 variables, covering pilot, aircraft, environmental, and operational characteristics. A second analysis compared crashes where the pilot-in-command was seriously injured (either fatally or non-fatally) with crashes where the pilot-in-command was not hospitalized with an injury. A series of multivariate logistic regression analyses were conducted to estimate the odds associated with each of the factors identified by the univariate analyses. RESULTS: The most significant risk factors for all serious injury were: (a) not obtaining a weather briefing, (b) off-airport location of the crash site, (c) flights carried out for air transport purposes, and (d) non-solo flights. Other risk factors, significant for fatal injury only, included post-crash fire and the nature of the crash terrain. Factors within the control of the pilot, environmental, and flight characteristics are the key determinants of the injury outcome of civil rotary-wing aircraft crashes.