Testing for selection bias and moral hazard in private health insurance: Evidence from a mixed public-private health system.

Separating selection bias from moral hazard in private health insurance (PHI) markets has been a challenging task. We estimate selection bias and moral hazard in Australia's mixed public-private health system, where PHI premiums are community-rated rather than risk-rated. Using longitudinal cohort data, with fine-grained measures for medical services predominantly funded by PHI providers, we find consistent and robust estimates of advantageous selection among hospitalized cardiovascular disease (CVD) patients. Specifically, we show that in addition to their risk-averse attributes, CVD patients who purchase PHI use fewer services that are not covered by PHI providers (e.g., general practitioners and emergency departments) and have fewer comorbidities. Finally, unlike previous studies, we show that ex-post moral hazard exists in the use of specific "in-hospital" medical services such as specialist and physician services, miscellaneous diagnostic procedures, and therapeutic treatments. From the perspective of PHI providers, the annual cost of moral hazard translates to a lower bound estimate of $707 per patient, equivalent to a 3.03% reduction in their annual profits.

A baseline profile of the Queensland Cardiac Record Linkage Cohort (QCard) study.

BACKGROUND: Cardiovascular disease (CVD) is one of the leading causes of death in Australia. Longitudinal record linkage studies have the potency to influence clinical decision making to improve cardiac health. This paper describes the baseline characteristics of the Queensland Cardiac Record Linkage Cohort study (QCard). METHODS: International Classification of Disease, 10th Revision Australian Modification (ICD-10-AM) diagnosis codes were used to identify CVD and comorbidities. Cost and adverse health outcomes (e.g., comorbidities, hospital-acquired complications) were compared between first-time and recurrent admissions. Descriptive statistics and standard tests were used to analyse the baseline data. RESULTS: There were 132,343 patients with hospitalisations in 2010, of which 47% were recurrent admissions, and 53% were males. There were systematic differences between characteristics of recurrent and first-time hospitalisations. Patients with recurrent episodes were nine years older (70 vs. 61; p < 0.001) and experienced a twice higher risk of multiple comorbidities (3.17 vs. 1.59; p < 0.001). CVD index hospitalisations were concentrated in large metropolitan hospitals. CONCLUSIONS: Our study demonstrates that linked administrative health data provide an effective tool to investigate factors determining the progress of heart disease. Our main finding suggests that recurrent admissions were associated with higher hospital costs and a higher risk of having adverse outcomes.

Hospital frailty risk score and adverse health outcomes: evidence from longitudinal record linkage cardiac data.

BACKGROUND: Despite recent evidence on the effect of frailty on health outcomes among those with heart failure, there is a dearth of knowledge on measuring frailty using administrative health data on a wide range of cardiovascular diseases (CVD). METHODS: We conducted a retrospective record-linkage cohort study of patients with diverse CVD in Queensland, Australia. We investigated the relationship between the risk of frailty, defined using the hospital frailty risk score (HFRS), and 30-day mortality, 30-day unplanned readmission, non-home discharge, length of hospital stay (LOS) at an emergency department and inpatient units and costs of hospitalisation. Descriptive analysis, bivariate logistic regression and generalised linear models were used to estimate the association between HFRS and CVD outcomes. Smear adjustment was applied to hospital costs and the LOS for each frailty risk groups. RESULTS: The proportion of low, medium and high risk of frailty was 24.6%, 34.5% and 40.9%, respectively. The odds of frail patients dying or being readmitted within 30 days of discharge was 1.73 and 1.18, respectively. Frail patients also faced higher odds of LOS, and non-home discharge at 3.1 and 2.25, respectively. Frail patients incurred higher hospital costs (by 42.7-55.3%) and stayed in the hospital longer (by 49%). CONCLUSION: Using the HFRS on a large CVD cohort, this study confirms that frailty was associated with worse health outcomes and higher healthcare costs. Administrative data should be more accessible to research such that the HFRS can be applied to healthcare planning and patient care.

Excess mortality at Christmas due to cardiovascular disease in the HUNT study prospective population-based cohort in Norway.

BACKGROUND: Although it is known that winter inclusive of the Christmas holiday period is associated with an increased risk of dying compared to other times of the year, very few studies have specifically examined this phenomenon within a population cohort subject to baseline profiling and prospective follow-up. In such a cohort, we sought to determine the specific characteristics of mortality occuring during the Christmas holidays. METHODS: Baseline profiling and outcome data were derived from a prospective population-based cohort with longitudinal follow-up in Central Norway - the Trøndelag Health (HUNT) Study. From 1984 to 1986, 88% of the target population comprising 39,273 men and 40,353 women aged 48 ± 18 and 50 ± 18 years, respectively, were profiled. We examined the long-term pattern of mortality to determine the number of excess (all-cause and cause-specific) deaths that occurred during winter overall and, more specifically, the Christmas holidays. RESULTS: During 33.5 (IQR 17.1-34.4) years follow-up, 19,879 (50.7%) men and 19,316 (49.3%) women died at age-adjusted rate of 5.3 and 4.6 deaths per 1000/annum, respectively. Overall, 1540 (95% CI 43-45 deaths/season) more all-cause deaths occurred in winter (December to February) versus summer (June to August), with 735 (95% CI 20-22 deaths per season) of these cardiovascular-related. December 25th-27th was the deadliest 3-day period of the year; being associated with 138 (95% CI 96-147) and 102 (95% CI 72-132) excess all-cause and cardiovascular-related deaths, respectively. Accordingly, compared to 1st-21st December (equivalent winter conditions), the incidence rate ratio of all-cause mortality increased to 1.22 (95% CI 1.16-1.27) and 1.17 (95% 1.11-1.22) in men and women, respectively, during the next 21 days (Christmas/New Year holidays). All observed differences were highly significant (P < 0.001). A less pronounced pattern of mortality due to respiratory illnesses (but not cancer) was also observed. CONCLUSION: Beyond a broader pattern of seasonally-linked mortality characterised by excess winter deaths, the deadliest time of year in Central Norway coincides with the Christmas holidays. During this time, the pattern and frequency of cardiovascular-related mortality changes markedly; contrasting with a more stable pattern of cancer-related mortality. Pending confirmation in other populations and climates, further research to determine if these excess deaths are preventable is warranted.

"It Takes a Whole Day, Even Though It's a One-Hour Appointment!" Factors Impacting Access to Pediatric Feeding Services.

Feeding disorders can have a significant impact on children and their families. Access to supportive multidisciplinary care is central to improving outcomes; however, there are numerous factors that can impact service access. Using a mixed methods design, the current study examined parents' experiences and satisfaction with accessing a state-wide government-funded tertiary pediatric feeding clinic in Australia. Parents of 37 children (aged 7 weeks to 17 years) participated in the study, residing 6-1435 km from the service. Each completed questionnaires regarding satisfaction (Client Satisfaction Questionnaire-8 Child Services) and costs, and participated in a semi-structured interview. Costs were measured as both direct (e.g., accommodation) and indirect (measured as lost productivity) associated with accessing their feeding appointment. Results revealed parents were highly satisfied with their child's feeding services, but considerable impacts were reported in accessing the service with 85% of the group noting that attending their child's appointment took at least half a day. The total cost per appointment ranged between $53 and $508 Australian dollars. Interviews identified three main barrier themes: distance and travel, impact on daily activities (e.g., work, school), and parent perception of inaccurate representation of their child's feeding skills within the clinic environment. The issues raised were also tempered by an overarching theme of parental willingness to do "whatever was needed" to meet their child's needs, regardless of these barriers. Service providers should be cognizant of the factors that impact access for families and consider alternative service-delivery models where appropriate to help reduce family burden associated with accessing necessary care.

Lifetime Costs of Hospitalised Cardiovascular Disease in Australia: An Incidence-Based Estimate.

OBJECTIVES: To estimate the incidence-based, lifetime costs of health care and productivity losses associated with cardiovascular disease (CVD) using hospital admission data from Queensland, Australia. METHODS: Retrospective analysis of data on CVD health care use sourced from Queensland Hospital Admitted Patient Data Collection (QHAPDC), Emergency Department Data Collection (EDDC), Medicare Benefits Schedule (MBS) and the Pharmaceutical Benefits Scheme (PBS). Costs were estimated from the societal perspective. Study participants included patients who were first admitted to any Queensland hospital in 2010 for a CVD-related treatment. Subsequent admissions of these patients were followed until December 2015. The present value of incidence-based lifetime costs per patient were used to estimate the total costs for Australia. All costs were presented in Australian dollars at 2019 prices. RESULTS: The estimated lifetime health care cost of CVD was AUD$65,700 per person. Productivity loss cost was higher at AUD$75,200 per person, and total indirect lifetime costs were $140,900 per person. Scaling these costs up for the Australian population, the estimated incidence-based lifetime CVD costs for Australia were $60.5 billion ($28.2 billion in direct costs and $32.3 billion in indirect costs). CONCLUSIONS: Incidence-based lifetime indirect costs of CVD were higher than the direct costs. The life-time cost structure suggests that economic benefits of health care interventions for cardiovascular diseases from a societal perspective should be at least twice as large than that from a health service perspective.

Global mapping of interventions to improve the quality of life of patients with cardiovascular diseases during 1990-2018.

BACKGROUND: Cardiovascular diseases (CVDs) have been the global health problems that cause a substantial burden for the patients and the society. Assessing the Quality of Life (QOL) of CVD patients is critical in the effectiveness evaluation of CVD treatments as well as in determining potential areas for enhancing health outcomes. Through the adoption of a combination of bibliometric approach and content analysis, publications trend and the common topics regarding interventions to improve QOL of CVD patients were searched and characterized to inform priority setting and policy development. METHODS: Bibliographic data of publications published from 1990 to 2018 on interventions to improve QOL of CVD patients were retrieved from Web of Science. Network graphs illustrating the terms co-occurrence clusters were created by VOSviewer software. Latent Dirichlet Allocation approach was adopted to classify papers into major research topics. RESULTS: A total of 6457 papers was analyzed. We found a substantial increase in the number of publications, citations, and the number of download times of papers in the last 5 years. There has been a rise in the number of papers related to intervention to increase quality of life among patients with CVD during 1990-2018. Conventional therapies (surgery and medication), and psychological, behavioral interventions were common research topics. Meanwhile, the number of papers evaluating economic effectiveness has not been as high as that of other topics. CONCLUSIONS: The research areas among the scientific studies emphasized the importance of interdisciplinary and inter-sectoral approaches in both evaluation and intervention. Future research should be a focus on economic evaluation of intervention as well as interventions to reduce mental issues among people with CVD.

Malaria infection among children under-five: the use of large-scale interventions in Ghana.

BACKGROUND: Despite the significant investments to control malaria infection rates over the past years, infection rates remain significant in sub-Saharan Africa. This study investigates the association with use of large-scale malaria interventions such as: Indoor Residual Spraying (IRS), Insecticide Treated bed-Nets (ITN), and Behaviour Change Communication (BCC) strategies, and the prevalence of malaria among children under-five in Ghana. METHODS: Cross-sectional data on 2, 449 children aged 6 to 59 months who were tested for malaria, through Rapid Diagnostic Test (RDT), are drawn from the recent wave of the Ghana Demographic and Health Surveys (GDHS 2014). We use a logit model to analyse the heterogeneous association between control measures and malaria infection among under five children of different age cohorts and household poverty statuses. RESULTS: Our estimates suggest that IRS offers much more protection than ITN use. The odds of malaria infection among children who sleep in IRS is significantly lower (odds ratio [OR] = 0.312; 95% CI -1.47 -0.81; p = 0.00) compared to those who are not protected. This association is even high (odds ratio [OR] = 0.372; 95% CI -1.76 -1.02; p = 0.00) among children in poor households protected by IRS compared to those who have no IRS protection. ITN use did not have a significant association with malaria infection among children, except among children whose mothers have at least secondary education. For such children, the odds of malaria infection are significantly lower ([OR] =0.545; 95% CI = - 0.84 -0.11; p = 0.011) compared to those who are not protected. Regarding BCC strategies, we found that malaria education through television is the best strategy to covey malaria education as it significantly reduces the odds of malaria infection ([OR] =0.715; 95% CI = - 0.55 -0.10; p = 0.005) compared to those who do not received malaria education via television. BCC strategy via print media has a significant but limited protection for children of educated mothers. CONCLUSION: Policy makers should direct more resources to IRS, especially in communities where the use of ITN is less likely to be effective, such as poor and rural households. The distribution of ITNs needs to be accompanied with education programs to ensure its best protection.

Effect of insecticide-treated bed net usage on under-five mortality in northern Ghana.

BACKGROUND: Although under-five mortality rate seems to be declining in Ghana, the northern part of the country has higher levels of under-five mortality vis-à-vis the national rates. This research examines the correlates of the high under-five mortality among children in the northern part of Ghana, with emphasis on the usage of insecticide-treated bed net (ITN), as recommended by the World Health Organization. METHODS: A total of 3,839 under-five children sourced from the Ghana Demographic and Health Survey--was used for this study. Univariate descriptive statistics was employed to describe the variables used for the empirical estimation. The maximum likelihood estimation technique was used to estimate a logit model in other to determine the effect of insecticide treated bed net usage on under-five mortality. RESULTS: Insecticide-treated bed net usage among children enhances their survival rates. Thus, under-five mortality among children who sleep under treated bed nets is about 18.8% lower than among children who do not sleep under treated bed nets. While health facility delivery was found to reduce to reduce under-five mortality, child bearing among older women is detrimental to the survival of the child. CONCLUSIONS: The study, therefore, recommends that policies targeting reduction in under-five mortality in northern Ghana should consider not mere availability of ITNs in the household, but advocate the usage of these treated nets. The study recommends to the Ministry of Health to extend their services to unreached rural communities to encourage health facility delivery to reduce under-five mortality.

Informal care and financial stress: Longitudinal evidence from Australia.

The number of people providing informal care has increased considerably in the last years while, at the same time, about one in four Australians have financial stress problems. This study uses rich longitudinal data from the Household, Income and Labour Dynamics in Australia (HILDA) survey to estimate the effect of informal care on financial stress. To establish causality, we exploit a fixed effect-instrumental variable approach to address omitted variable bias and reverse causality problems. Our findings show that informal caregiving increases financial stress between 9.9 and 14.5 percentage points. This finding is robust across a battery of quasi-experimental methods. The effect of informal caregiving on financial stress is more pronounced among males, rural residents and those living in low socioeconomic areas. Our analyses further show that financial fragility and social isolation are important channels through which informal caregiving affects financial stress.

Long guidewire peripheral intravenous catheters in emergency departments for management of difficult intravenous access: A multicenter, pragmatic, randomized controlled trial.

BACKGROUND: A quarter of patients who present to emergency departments (EDs) have difficult intravenous access (DIVA), making it challenging for clinicians to successfully place a peripheral intravenous catheter (PIVC). Some literature suggests that guidewire PIVC improves first-insertion success rate. AIM: The aim was to determine the clinical and cost-effectiveness of a novel long PIVC (5.8 cm) with a retractable coiled guidewire (GW-PIVC) for patients with DIVA, compared with standard care PIVCs. METHODS: A pragmatic randomized controlled trial was conducted in two Australian EDs. Eligible participants were adults assessed as meeting DIVA criteria. Participants were randomized (1:1 ratio; stratified by hospital) to either GW-PIVC (long) or standard care group (short or long PIVC). The use of ultrasound was discretionary in the standard care group and was recommended in the GW-PIVC group due to the pragmatic design that was primarily testing the GW-PIVC rather than the ultrasound use. Primary outcome was first-insertion success and secondary outcomes included all-cause device failure, patient and staff satisfaction, and cost-effectiveness. The analysis was intention to treat. RESULTS: A total of 446 participants were randomized and 409 received PIVCs. The use of GW-PIVC, compared with standard PIVC, had a lower first-insertion success rate (68% vs. 77%, odds ratio [OR] 0.65, 95% confidence interval [CI] 0.43-0.99, p < 0.05). There was no difference in PIVC failure (134.0 per 1000 catheter days [GW-PIVC] vs. 111.8 [standard PIVC] per 1000 catheter days, hazard ratio 1.18, 95% CI 0.72-1.95). Both participant (8/10 vs. 9/10, median difference [MD] -1.00, 95% CI -1.37 to -0.63) and clinician (8/10 vs. 10/10, MD -2.00, 95% CI -2.37 to -1.63) satisfaction was lower with GW-PIVCs compared with standard PIVCs. More nurses inserted standard PIVCs than GW-PIVCs (56.9% vs. 36.5%) and had less confidence in their ultrasound skills (28.0% vs. 46.6% self-claimed as advanced/expert users). The cost per participant of GW-PIVC insertions was 2.46 times greater than standard PIVC insertions ($AU80.24 vs. $AU32.57). CONCLUSIONS: GW-PIVCs had significantly lower first-insertion success and non-significantly higher all-cause catheter failure. Additional training and device design familiar to clinicians are vital factors to enhance the likelihood of successful future implementation of GW-PIVCs.

Saving children's lives through interventions: a quasi-experimental analysis of GAVI.

This study evaluates the impact of the Global Alliance for Vaccines and Immunization (GAVI) on children's health outcomes in developing countries. Using a difference-in-differences identification strategy, we find that GAVI has reduced neonatal, infant and under-five mortality rates. The impact of GAVI on children's health outcomes is larger in countries with lower per capita income. Our findings underscore the relevance of health interventions in improving children's health outcomes in developing economies.

Cost Effectiveness of Strategies to Manage Atrial Fibrillation in Middle- and High-Income Countries: A Systematic Review.

BACKGROUND: Atrial fibrillation (AF) remains the most common form of cardiac arrhythmia. Management of AF aims to reduce the risk of stroke, heart failure and premature mortality via rate or rhythm control. This study aimed to review the literature on the cost effectiveness of treatment strategies to manage AF among adults living in low-, middle- and high-income countries. METHODS: We searched MEDLINE (OvidSp), Embase, Web of Science, Cochrane Library, EconLit and Google Scholar for relevant studies between September 2022 and November 2022. The search strategy involved medical subject headings or related text words. Data management and selection was performed using EndNote library. The titles and abstracts were screened followed by eligibility assessment of full texts. Selection, assessment of the risk of bias within the studies, and data extraction were conducted by two independent reviewers. The cost-effectiveness results were synthesised narratively. The analysis was performed using Microsoft Excel 365. The incremental cost effectiveness ratio for each study was adjusted to 2021 USD values. RESULTS: Fifty studies were included in the analysis after selection and risk of bias assessment. In high-income countries, apixaban was predominantly cost effective for stroke prevention in patients at low and moderate risk of stroke, while left atrial appendage closure (LAAC) was cost effective in patients at high risk of stroke. Propranolol was the cost-effective choice for rate control, while catheter ablation and the convergent procedure were cost-effective strategies in patients with paroxysmal and persistent AF, respectively. Among the anti-arrhythmic drugs, sotalol was the cost-effective strategy for rhythm control. In middle-income countries, apixaban was the cost-effective choice for stroke prevention in patients at low and moderate risk of stroke while high-dose edoxaban was cost effective in patients at high risk of stroke. Radiofrequency catheter ablation was the cost-effective option in rhythm control. No data were available for low-income countries. CONCLUSION: This systematic review has shown that there are several cost-effective strategies to manage AF in different resource settings. However, the decision to use any strategy should be guided by objective clinical and economic evidence supported by sound clinical judgement. REGISTRATION: CRD42022360590.

A time and cost analysis of speech pathology paediatric feeding services delivered in-person versus via telepractice.

INTRODUCTION: Telepractice models of care have the potential to reduce the time and financial burdens that consumers may experience accessing healthcare services. The current study aimed to conduct a time and financial cost analysis of paediatric feeding appointments accessed via telepractice (using videoconferencing) compared to an in-person model. METHODS: Parents of 44 children with paediatric feeding disorders (PFDs) residing in a metropolitan area completed three questionnaires relating to (a) demographics, (b) time and cost for in-person care and (c) time and cost for telepractice. Both cost questionnaires collected data required for direct and indirect costs comparisons (e.g. out-of-pocket costs associated with the appointment (direct), time away from usual duties (indirect)). Average number of services accessed by each participant, and PFD appointments conducted annually by the service, were collected from service statistics. Analysis involved cost minimisation and cost modelling from a societal perspective. RESULTS: The telepractice appointment resulted in significant time (p = 0.007) and cost (AUD$95.09 per appointment, SD = AUD$64.47, p = < 0.0001) savings per family. The health service cost was equivalent for both models (AUD$58.25). Cost modelling identified cost savings of up to AUD$475.45 per family if 50% of appointments in a 10-session block were converted to telepractice. Potential cost savings of AUD$68,750.07 per annum to society could be realised if 50% of feeding appointments within the service were provided via telepractice. DISCUSSION: The telepractice model offered both time and cost benefits. Future service re-design incorporating hybrid services (in-person and telepractice) will help optimise benefits and minimise burden for families accessing services for PFDs.

Benchmarking hospital safety and identifying determinants of hospital-acquired complication: the case of Queensland cardiac linkage longitudinal cohort.

BACKGROUND: Hospital-acquired complications (HACs) are costly and associated with adverse health outcomes, although they can be avoided. Administrative linkage health data have become more accessible and can be used to monitor and reduce HAC. AIMS: This study aims to use linkage administrative data to benchmark the safety performance of hospitals and estimate the feasible magnitude that HAC can be reduced. We also identify risk factors associated with HACs, and estimate the effects of HACs on adverse health outcomes and hospital costs. METHODS: This is a retrospective linkage cohort study. The cohort includes 371,040 inpatient multiple-day admissions of 83,025 cardiovascular disease patients admitted to public hospitals in 2010 with follow-ups until 2015.Data envelopment analysis was applied to benchmark the patient safety performance of hospitals. Logistic regression was used to examine the odds of HAC and its effects on in-hospital mortality and 30-day readmission. Generalised linear models were used to identify the impacts of HACs on hospital costs and the length of hospital stay. FINDINGS: On average, 9.3% of multiple-day hospital admissions were associated with HACs. The average HAC rate can be reduced by two percentage points if all hospitals achieve the safety record of best-practice hospitals. Old age and multiple comorbidities were major driving factors of HACs. CONCLUSIONS: Cardiovascular disease patients with HAC have a higher risk of death, stay longer in hospitals and incur higher health care costs. The average HAC rates can be reduced by two percentage points by learning from best-practice hospitals operating in the same region.

Counting the cost of premature mortality with progressively worse aortic stenosis in Australia: a clinical cohort study.

BACKGROUND: Aortic stenosis is the most common cardiac valve disorder requiring clinical management. However, there is little evidence on the societal cost of progressive aortic stenosis. We sought to quantify the societal burden of premature mortality associated with progressively worse aortic stenosis. METHODS: In this observational clinical cohort study, we examined echocardiograms on native aortic valves of 98 565 men and 99 357 women aged 65 years or older across 23 sites in Australia, from Jan 1, 2003, to Dec 31, 2017. Individuals were grouped according to their peak aortic valve velocity in 0·50 m/s increments up to 4·00 m/s or more (severe aortic stenosis), using 1·00-1·99 m/s (no aortic stenosis) as the reference group. Sex-specific premature mortality and years of life lost during a 5-year follow-up were calculated, along with willingness-to-pay to regain quality-adjusted life years (QALYs). FINDINGS: Overall, 20 701 (21·0%) men and 18 576 (18·7%) women had evidence of mild-to-severe aortic stenosis. The actual 5-year mortality in men with normal aortic valves was 32·1% and in women was 26·1%, increasing to 40·9% (mild aortic stenosis) and 52·2% (severe aortic stenosis) in men and to 35·9% (mild aortic stenosis) and 55·3% (severe aortic stenosis) in women. Overall, the estimated societal cost of premature mortality associated with aortic stenosis was AU$629 million in men and $735 million in women. Per 1000 men and women investigated, aortic stenosis was associated with eight more premature deaths in men resulting in 32·5 more QALYs lost (societal cost of $1·40 million) and 12 more premature deaths in women resulting in 57·5 more QALYs lost (societal cost of $2·48 million) when compared with those without aortic stenosis. INTERPRETATION: Any degree of aortic stenosis in older individuals is associated with premature mortality and QALYs. In this context, there is a crucial need for cost-effective strategies to promptly detect and optimally manage this common condition within our ageing populations. FUNDING: Edwards LifeSciences, National Health and Medical Research Council of Australia, and the National Heart, Lung, and Blood Institute.

Rising unemployment reduces the demand for healthcare services among people with cardiovascular disease: an Australian cohort study.

Cardiovascular diseases (CVDs) remain a global health challenge due to number of deaths and use of healthcare services related to the condition. Although a plethora of studies have shown the impact of unemployment on health outcomes, evidence on the unemployment effects on the demand for expensive cardiac healthcare services is rare. This study exploits longitudinal cohort dataset to examine the impact of variations in local level unemployment rate on the demand for healthcare services among working aged people with CVD in Australia. Our findings show an inverse relationship between unemployment and the demand for healthcare services. Specifically, we find that a rising unemployment reduces the demand for primary and secondary healthcare services, with the largest effect observed for hospital admissions and hospitalisation days. We further show that rising unemployment at the local level has a greater impact on CVD patients with comorbidities and those who live in nonremote areas. Finally, our estimates suggest that increasing local level unemployment averts a substantial number of healthcare services use, leading to an unintended cost savings of $1.2 million to the health sector.

Weather Trumps Festivity? More Cardiovascular Disease Events Occur in Winter than in December Holidays in Queensland, Australia.

Objective: Cardiovascular disease (CVD) is the leading cause of hospitalisations and deaths in Australia. This study estimates the excess CVD hospitalisations and deaths across seasons and during the December holidays in Queensland, Australia. Methods: The study uses retrospective, longitudinal, population-based cohort data from Queensland, Australia from January 2010 to December 2015. The outcomes were hospitalisations and deaths categorised as CVD-related. CVD events were grouped according to when they occurred in the calendar year. Excess hospitalisations and deaths were estimated using the multivariate ordinary least squares method after adjusting for confounding effects. Results: More CVD hospitalisations and deaths occurred in winter than in summer, with 7811 (CI: 1353, 14,270; p < 0.01) excess hospitalisations and 774 (CI: 35, 1513; p < 0.01) deaths compared to summer. During the coldest month (July), there was an excess of 42 hospitalisations and 7 deaths per 1000 patients. Fewer CVD hospitalisations (-20 (CI: -29, -9; p < 0.01)) occurred during the December holidays than any other period during the calendar year. Non-CVD events were mostly not statistically significant different between periods. Conclusion: Most CVD events in Queensland occurred in winter rather than during the December holidays. Potentially cost-effective initiatives should be explored such as encouraging patients with CVD conditions to wear warmer clothes during cold temperatures and/or insulating the homes of CVD patients who cannot otherwise afford to.

Can Administrative Health Data Improve the Gold Standard? Evidence from a Model of the Progression of Myocardial Infarction.

Background: Myocardial infarction (MI), remains one of the leading causes of death and disability globally but publications on the progression of MI using data from the real world are limited. Multistate models have been widely used to estimate transition rates between disease states to evaluate the cost-effectiveness of healthcare interventions. We apply a Bayesian multistate hidden Markov model to investigate the progression of MI using a longitudinal dataset from Queensland, Australia. Objective: To apply a new model to investigate the progression of myocardial infarction (MI) and to show the potential to use administrative data for economic evaluation and modeling disease progression. Methods: The cohort includes 135,399 patients admitted to public hospitals in Queensland, Australia, in 2010 treatment of cardiovascular diseases. Any subsequent hospitalizations of these patients were followed until 2015. This study focused on the sub-cohort of 8705 patients hospitalized for MI. We apply a Bayesian multistate hidden Markov model to estimate transition rates between health states of MI patients and adjust for delayed enrolment biases and misclassification errors. We also estimate the association between age, sex, and ethnicity with the progression of MI. Results: On average, the risk of developing Non-ST segment elevation myocardial infarction (NSTEMI) was 8.7%, and ST-segment elevation myocardial infarction (STEMI) was 4.3%. The risk varied with age, sex, and ethnicity. The progression rates to STEMI or NSTEMI were higher among males, Indigenous, or elderly patients. For example, the risk of STEMI among males was 4.35%, while the corresponding figure for females was 3.71%. After adjustment for misclassification, the probability of STEMI increased by 1.2%, while NSTEMI increased by 1.4%. Conclusions: This study shows that administrative health data were useful to estimate factors determining the risk of MI and the progression of this health condition. It also shows that misclassification may cause the incidence of MI to be under-estimated.

Investigation of current models of care for genetic heart disease in Australia: A national clinical audit.

BACKGROUND: This sub-study of the Australian Genomics Cardiovascular Genetic Disorders Flagship sought to conduct the first nation-wide audit in Australia to establish the current practices across cardiac genetics clinics. METHOD: An audit of records of patients with a suspected genetic heart disease (cardiomyopathy, primary arrhythmia, autosomal dominant congenital heart disease) who had a cardiac genetics consultation between 1st January 2016 and 31 July 2018 and were offered a diagnostic genetic test. RESULTS: This audit included 536 records at multidisciplinary cardiac genetics clinics from 11 public tertiary hospitals across five Australian states. Most genetic consultations occurred in a clinic setting (90%), followed by inpatient (6%) and Telehealth (4%). Queensland had the highest proportion of Telehealth consultations (9% of state total). Sixty-six percent of patients had a clinical diagnosis of a cardiomyopathy, 28% a primary arrhythmia, and 0.7% congenital heart disease. The reason for diagnosis was most commonly as a result of investigations of symptoms (73%). Most patients were referred by a cardiologist (85%), followed by a general practitioner (9%) and most genetic tests were funded by the state Genetic Health Service (73%). Nationally, 29% of genetic tests identified a pathogenic or likely pathogenic gene variant; 32% of cardiomyopathies, 26% of primary arrhythmia syndromes, and 25% of congenital heart disease. CONCLUSION: We provide important information describing the current models of care for genetic heart diseases throughout Australia. These baseline data will inform the implementation and impact of whole genome sequencing in the Australian healthcare landscape.