Health-Related Quality of Life Scores and Values as Predictors of Mortality: A Scoping Review.

Health-related quality of life (HRQoL) can be assessed through measures that can be generic or disease specific, encompass several independent scales, or employ holistic assessment (i.e., the derivation of composite scores). HRQoL measures may identify patients with differential risk profiles. However, the usefulness of generic and holistic HRQoL measures in identifying patients at higher risk of death is unclear. The aim of the present study was to undertake a scoping review of generic, holistic assessments of HRQoL as predictors of mortality in general non-patient populations and clinical sub-populations with specified conditions or risk factors in persons 18 years or older. Five databases were searched from 18 June to 29 June 2020 to identify peer-reviewed published articles. The searches were updated in August 2022. Reference lists of included and cited articles were also searched. Of 2552 articles screened, 110 met criteria for inclusion. Over one-third of studies were from North America. Most studies pertained to sub-populations with specified conditions and/or risk factors, almost a quarter for people with cardiovascular diseases. There were no studies pertaining to people with mental health conditions. Nearly three-quarters of the studies used a RAND Corporation QoL instrument, predominantly the SF-36, and nearly a quarter, a utility instrument, predominantly the EQ-5D. HRQoL was associated with mortality in 67 of 72 univariate analyses (92%) and 100 of 109 multivariate analyses (92%). HRQoL was found to be associated with mortality in the general population and clinical sub-populations with physical health conditions. Whether this relationship holds in people with mental health conditions is not known. HRQoL assessment may be useful for screening and/or monitoring purposes to understand how people perceive their health and well-being and as an indicator of mortality risk, encouraging better-quality and timely patient care to support and maximize what may be a patient's only modifiable outcome.

The cost-effectiveness of coronary calcium score-guided statin therapy initiation for Australians with family histories of premature coronary artery disease.

OBJECTIVES: To compare the cost-effectiveness of coronary artery calcium (CAC) score-guided statin therapy criteria and American College of Cardiology/American Heart Association (ACC/AHA) guidelines (10-year pooled cohort equation [PCE] risk ≥ 7.5%) with selection according to Australian guidelines (5-year absolute cardiovascular disease risk [ACVDR] ≥ 10%), for people with family histories of premature coronary artery disease. STUDY DESIGN, SETTING: Markov microsimulation state transition model based on data from the Coronary Artery calcium score: Use to Guide management of Hereditary Coronary Artery Disease (CAUGHT-CAD) trial and transition probabilities derived from published statin prescribing and adherence outcomes and clinical data. PARTICIPANTS: 1083 people with family histories of premature coronary artery disease but no symptomatic cardiovascular disease. MAIN OUTCOME MEASURES: Relative cost-effectiveness over fifteen years, from the perspective of the Australian health care system, compared with usual care (Australian guidelines), assessed as incremental cost-effectiveness ratios (ICERs), with a notional willingness-to-pay threshold of $50 000 per quality-adjusted life-year (QALY) gained. RESULTS: Applying the Australian guidelines, 77 people were eligible for statin therapy (7.1%); with ACVDR 5-year risk ≥ 2% and CAC score > 0, 496 people (46%); with ACVDR 5-year risk ≥ 2% and CAC score ≥ 100, 155 people (14%); and with the ACC/AHA guidelines, 256 people (24%). The ICERs for CAC-guided selection were $33 108 (CAC ≥ 100) and $53 028 per QALY gained (CAC > 0); the ACC/AHA guidelines approach (ICER, $909 241 per QALY gained) was not cost-effective. CAC score-guided selection (CAC ≥ 100) was cost-effective for people with 5-year ACVDR of at least 5%. CONCLUSION: Expanding the number of people at low to intermediate CVD risk eligible for statin therapy should selectively target people with subclinical atherosclerosis identified by CAC screening. This approach can be more cost-effective than simply lowering treatment eligibility thresholds.

Outdoor mental healthcare: What, who, why and where to?

Objective: Outdoor mental healthcare can increase the breadth of multidisciplinary interventions available to people with a therapeutic need. The aim of this article is to educate readers about the field of outdoor mental healthcare through the exploration of a series of basic questions.Conclusions: Outdoor mental healthcare spans a range of therapies that apply a variety of theoretical approaches and treatments across a multiplicity of settings, patient groups and desired outcomes unified by key evidence-informed practice elements. Through use of a predominantly non-mainstream workforce working in non-conventional clinical settings outdoor mental healthcare may contribute to treatment accessibility and acceptability.

Health-related quality of life in people with psychotic disorders: The role of loneliness and its contributors.

BACKGROUND: Perception of loneliness has been identified as the strongest predictor of health-related quality of life assessed with the Assessment of Quality of Life-4D in people with psychotic disorders. We aimed to establish contributors to perceived loneliness, and ascertain the mediating role of loneliness in the relationship between identified contributors to loneliness and other known predictors of health-related quality of life with health-related quality of life. METHODS: Data for 1642 people collected as part of the 2010 Australian National Survey of Psychosis were analysed. Health-related quality of life was assessed using the Assessment of Quality of Life-4D, and loneliness through a single-item five-level categorical variable. To identify independent contributors to loneliness, a statistical model was constructed with reference to a theoretical model comprising 23 variables. A predictive model with health-related quality of life as the dependent variable was then developed and tested to assess the mediating role of loneliness. RESULTS: Nine contributors to loneliness were found (social dysfunction, experienced stigma, contact with friends, diagnosis, depressive symptoms, anxiety, mental health service utilisation, arthritis and traumatic events in childhood), with social dysfunction the strongest. In the prediction of health-related quality of life, all contributors to loneliness were partially mediated through loneliness (except service utilisation) as were negative symptoms and use of psychotropic/anticholinergic medications. CONCLUSION: Assuming a plausible causal model of mediation, loneliness was found to have direct and indirect effects on health-related quality of life in people with psychotic disorders. Findings add impetus to efforts to develop and trial strategies aimed at reducing loneliness in this population, and, in turn, improving their health-related quality of life.

Maternal smoking during pregnancy: Trends and determinants in the conception to community study.

BACKGROUND: Despite earlier declines, maternal smoking during pregnancy continues to be a public health problem. We examined trends and factors associated with maternal smoking during and between pregnancy over six years. METHODS: Participants were 27 532 pregnant women in Tasmanian public hospitals whose smoking status was gathered by midwives during perinatal care between July 2008 and June 2014. Generalized linear modeling was used to examine the trends in prevalence of maternal smoking over time and factors associated with change in smoking status both within and between pregnancies. RESULTS: Smoking during pregnancy decreased from 25.9% in 2008 to 16.4% in 2014 (57.9% decline). Multivariable regression analysis suggested that maternal alcohol consumption during pregnancy, living in a highly socioeconomically disadvantaged area, and being an Aboriginal or Torres Strait Islander significantly increased the risk of maternal smoking during pregnancy. Being older, married, or in a de facto relationship, and intending to breastfeed were associated with reduced risk of smoking during pregnancy. Between index (first birth recorded in data set) and last pregnancy, 35.1% of smokers quit, but 5.1% of nonsmokers started smoking. Only 8.1% of mothers who smoked during the first half of pregnancy quit by the second half. CONCLUSIONS: Maternal smoking during pregnancy is decreasing. To sustain the decline, preventive efforts must address the role of social determinants of health (eg, mothers who drink alcohol, live in highly disadvantaged areas, are younger and single) among women who smoke during pregnancy.

Mental disorders in children known to child protection services during early childhood.

OBJECTIVES: To examine associations between being the subject of child protection reports in early childhood and diagnoses of mental disorders during middle childhood, by level of service response. DESIGN, SETTING, PARTICIPANTS: Retrospective analysis of linked New South Wales administrative data, 2001-2016, for a population cohort of children (mean age in 2016, 13.2 years; SD, 0.37 years) enrolled in the longitudinal NSW Child Development Study (NSW-CDS), wave 2 linkage. MAIN OUTCOME MEASURES: Associations between being the subject of a child protection report (any, and by level of child protection response) during early childhood (birth to 6 years of age) and diagnoses of mental disorders during middle childhood (6-14 years). RESULTS: 13 796 of 74 462 children in the NSW-CDS (18.5%) had been the subjects of reports to child protection services during early childhood: 1148 children had been placed in out-of-home care at least once, and 1680 had been the subjects of substantiated risk-of-significant-harm reports but were not placed in care, while 9161 had non-substantiated reports, and 1807 had reports of facts that did not reach the threshold for significant harm. After adjusting for sex, socio-economic disadvantage, perinatal complications, and parental mental illness, early childhood contact with protection services was associated with increased frequency of being diagnosed with a mental disorder during middle childhood (adjusted odds ratio [aOR], 2.72; 95% CI, 2.51-2.95). The frequency was highest for children who had been placed in out-of-home care (aOR, 5.25; 95% CI, 4.46-6.18). CONCLUSION: Childhood-onset mental disorders are more frequently diagnosed in children who come to the attention of child protection services during early childhood, particularly in children placed in out-of-home care.

Cardiovascular and other competing causes of death among patients with cancer from 2006 to 2015: An Australian population-based study.

BACKGROUND: With improved cancer survivorship, cardiovascular disease (CVD) and other noncancer events compete with cancer as the underlying cause of death, but the risks of mortality in competing-risk settings have not been well characterized. METHODS: The authors identified 21,637 individuals who had a first cancer registered between 2006 and 2013, with follow-up to 2015, in the Australian population-based Tasmanian Cancer Registry. The cumulative incidence of deaths from specific competing events was assessed in competing-risk analyses. Standardized mortality ratios (SMRs) and absolute excess risks (AERs) for deaths from noncancer causes were calculated for comparison with the general population. RESULTS: Overall, 8844 deaths were observed, with 1946 (22%) from competing events. The cumulative incidence of deaths from CVD increased significantly with age at first cancer diagnosis and exceeded other competing events at age ≥65 years. The risk of death from CVD was more common than expected in the first year of follow-up (SMR, 1.44 [95% confidence interval, 1.26-1.64]; AER, 36.8 per 10,000 person-years). The SMR and AER for CVD deaths varied by first cancer site, indicating increased risks after a first diagnosis of lung cancer, hematologic malignancy, and urinary tract cancer. For other noncancer events, the SMRs increased significantly for deaths from infectious disease and respiratory disease and were highest in the first year of follow-up. CONCLUSIONS: CVD was the leading cause of competing mortality among Tasmanian patients with cancer who were diagnosed from 2006 to 2013. The higher than expected occurrence of death from CVD and other noncancer events during the first year after a cancer diagnosis highlights the importance of early preventive interventions.

Psychological distress and self-rated health status in reproductive aged women with pain: findings from a national, cross-sectional survey.

BACKGROUND: Pain impacts upon psychological wellbeing. In pregnant and postpartum women psychological distress may negatively affect the mother-infant relationship and lead to adverse infant development. Yet, co-occurrence of pain with psychological distress in women of reproductive age has not been investigated. Therefore, this study aimed to: 1) assess prevalence of psychological distress in reproductive aged women by pain severity; and 2) examine the self-rated health status of reproductive aged women with and without pain. METHOD: Data for women aged 18-49 years were obtained from the 2011-12 Australian Bureau of Statistics National Health Survey. Sample data were weighted to give population estimates. Recent pain severity, self-rated health and psychological distress were analysed for pregnant, breastfeeding and non-pregnant/non-breastfeeding women. RESULTS: Moderate-to-very severe pain was reported by 17.6% of pregnant (sample n = 165, weighted N = 191,856), 25.9% of breastfeeding (sample n = 210, weighted N = 234,601) and 23.9% of non-pregnant/non-breastfeeding women (sample n = 4005, weighted N = 4,607,140). Psychological distress was associated with pain in non-pregnant/non-breastfeeding women (p < 0.001). High-to-very high distress was seen in 26.4% (95% CI, 23.2-29.6) of NP/NBF, 8.1% (95% CI, 0-17.2) of breastfeeding and 7.3% (95% CI, 0-18.0) of pregnant women with moderate-to-very severe pain. Self-rated health status was associated with pain severity in pregnant (p = 0.001) and non-pregnant/non-breastfeeding (p < 0.001) women. CONCLUSION: Given the strong association between psychological distress and pain in non-pregnant/non-breastfeeding women, and the relatively common occurrence of moderate-to-very severe pain in both pregnant and breastfeeding women, assessment of psychological distress levels in all women of reproductive age who report experiencing moderate-to-very severe levels of pain may be of benefit.

Temporal trends in the risk of second primary cancers among survivors of adult-onset cancers, 1980 through 2013: An Australian population-based study.

BACKGROUND: The authors' systematic review indicated an increasing trend in the risk of second primary cancers (SPCs) from the 1980s to 2000 when considering studies from the United States and Australia. It is uncertain whether this trend has continued to increase since 2000. METHODS: The current study was a population-based study of 51,802 individuals with adult-onset cancers identified in the Tasmanian Cancer Registry. Patients with a first cancer diagnosis made between 1980 and 2009 were followed up to December 2013. SPC risks were quantified using standardized incidence ratios (SIRs) and absolute excess risks (AERs). Trends in SPC risk were assessed using multivariable Poisson models. RESULTS: With a median follow-up of 4.8 years (mean, 6.9 years), a total of 5339 SPCs were observed. The SIRs for any SPC increased from 0.98 (95% confidence interval, 0.90-1.07) after a first cancer diagnosis in 1980 through 1984 to 1.12 (95% confidence interval, 1.05-1.20) in 2005 through 2009. In multivariable Poisson models accounting for patient sex, age at the time of the first cancer diagnosis, follow-up interval, and first cancer type, the trend in SIRs increased significantly from 1980 through 2009 for all SPCs (P for trend <.001) and for specific SPCs of the head and neck, lung, digestive tract, and prostate (all P for trend <.05). From 2000 onward, the AER for specific SPCs after specific first cancers was highest for prostate cancer after first cancers of the urinary tract (AER, 54.3 per 10,000 person-years). CONCLUSIONS: In Tasmania, the risk of SPCs among survivors of adult-onset cancers has increased with periods of first cancer diagnosis from 1980 through 2009. Increased cancer screening and improved medical imaging may have contributed to the greater risk in recent years. Cancer 2018;124:1808-18. © 2018 American Cancer Society.

Health-Related Quality of Life in People Living with Psychotic Illness and Factors Associated with Its Variation.

OBJECTIVES: To establish whether the four-dimensional Assessment of Quality of Life (AQoL-4D) produces robust utility values in adults with psychotic illness, and identify health inequalities compared with the general population. METHODS: The AQoL-4D was completed by 1613 individuals with an International Classification of Diseases, Tenth Revision, psychotic illness in the 2010 Australian National Survey of Psychosis. Utilities were assessed for this sample and 20 subgroups, and were compared with general population norms. Modified Cohen d was used as an index of effect size. Utilities were collapsed into 10 health-related quality-of-life (HRQOL) bands or decades. RESULTS: HRQOL in people with psychotic illness was half of the maximum achievable utility (half-"full health") with a mean utility of 0.49 (95% confidence interval [CI] 0.48-0.51), and showing substantial variability across subgroups. Participants with essentially normal functioning had the highest mean utility (0.72; 95% CI 0.68-0.77), and those with very poor perceived mental health had the lowest (0.22; 95% CI 0.18-0.26). These subgroups showed the most variability. Negative symptoms also gave rise to substantial variation. Among diagnostic categories, only depressive psychosis had a large effect relative to delusional disorders. The distribution of utilities in people with psychotic illness differed markedly from that in the general population, with 6.8% versus 47.2% having values in the highest decade (>0.90-1.00). Utilities were lower in every age group in people with psychosis. CONCLUSIONS: Profound HRQOL impacts are revealed by the AQoL-4D in people with psychotic illness, and marked variations in utilities were observed for key subjective and objective measures. We provide a suite of utility values for economic modeling studies and recommend the AQoL-4D for assessing HRQOL in people with psychotic illness.

The prevalence of pain and analgesia use in the Australian population: Findings from the 2011 to 2012 Australian National Health Survey.

BACKGROUND: Opioid analgesic use and associated adverse events have increased over the last 15 years, including in Australia. Whether this is associated with increased chronic pain prevalence in the Australian population is unknown. This study aimed to estimate (1) the prevalence of chronic pain and analgesia use in the Australian population by age and sex; (2) the severity of pain in the population with chronic pain by sex; and (3) the distribution of recent pain severity in those using analgesia by age and sex. METHODS: This study used cross-sectional, nationally representative data collected by the Australian Bureau of Statistics 2011 to 2012 National Health Survey. A total of n = 20 426 participants were included with an overall response rate of 84.8%. Weighting procedures were applied to obtain population estimates, confidence intervals, and when testing for statistical significance. RESULTS: The prevalence of chronic and reoccurring pain (over a 6-month period) was 15.4% (2.75 million) for Australians aged ≥15 years. Prevalence increased with age for both sexes. Significantly more females reported moderate-to-very severe pain overall (P < 0.001), and within most age groups. Recent use of opioid analgesia was reported by 12.0% of males and 13.4% of females with chronic pain. CONCLUSION: Chronic pain and opioid analgesic use are important public health issues in Australia. Study estimates of chronic pain and recent pain were no greater than earlier estimates. The acknowledged increase of opioid use in the literature thus appears consistent with changing treatment and/or prescribing patterns over time. Sex differences regarding pain prevalence, severity, and opioid use were apparent.

Responding to challenges for people with psychotic illness: Updated evidence from the Survey of High Impact Psychosis.

OBJECTIVE: The objective is to summarise recent findings from the 2010 Australian Survey of High Impact Psychosis (SHIP) and examine their implications for future policy and planning to improve mental health, physical health and other circumstances of people with a psychotic disorder. METHODS: Survey of High Impact Psychosis collected nationally representative data on 1825 people with psychotic illness. Over 60 papers have been published covering key challenges reported by participants: financial problems, loneliness and social isolation, unemployment, poor physical health, uncontrolled symptoms of mental illness, and lack of stable, suitable housing. Findings are summarised under the rubric of participant-ranked top challenges. RESULTS: The main income source for the majority (85%) of participants was a government benefit. Only one-third was employed, and the most appropriate employment services for this group were under-utilised. High rates of loneliness and social isolation impacted mental and physical health. The rate of cardiometabolic disease was well above the general population rate, and associated risk factors were present from a very young age. Childhood abuse (30.6%), adult violent victimisation (16.4%) and alcohol and substance abuse/dependence (lifetime rates of 50.5% and 54.5%, respectively) complicated the clinical profile. Treatment with medication was suboptimal, with physical health conditions undertreated, a high rate of psychotropic polypharmacy and underutilisation of clozapine in chronic persistent psychotic illness. Only 38.6% received evidence-based psychosocial therapies. In the previous year, 27.4% had changed housing and 12.8% had been homeless, on average for 155 days. CONCLUSION: Money, social engagement and employment are the most important challenges for people with psychotic illness, as well as good physical and mental health. An integrated approach to recovery is needed to optimise service delivery and augment evidence-based clinical practice with measures to improve physical health and social circumstances. Meeting these challenges has the potential to reduce costs to government and society, as well as promote recovery.

Temporal trends in the risk of developing multiple primary cancers: a systematic review.

BACKGROUND: Cancer survivors are at risk of developing second and subsequent primary cancers, referred to as multiple primary cancers (MPCs). It is not clear whether the risk of MPCs has increased over recent decades, but increasing use of radiological imaging and potentially harmful effects of certain cancer treatments raise this possibility. A systematic review was undertaken to assess whether there has been a temporal change in the risk of developing MPCs. METHODS: A systematic search to identify population-based studies of MPCs was performed in Medline/PubMed and Embase databases from inception to August 2016. Included studies were those reporting risk of MPCs for all sites combined following a first cancer at any site or a specific site, using standard incidence ratios (SIRs) or equivalent, and with analysis stratified by calendar years. RESULTS: We identified 28 articles eligible for inclusion, comprising 26 population-based studies and two monographs. MPC incidence was reported in nearly 6.5 million cancer survivors. For all first cancer sites combined, a higher rate of MPCs was reported in more recent than earlier calendar periods in four of the six relevant studies. The SIRs ranged from 1.14 for a first cancer diagnosis in the early 1980s to 1.21-1.46 in the late 1990s in the USA and Australia. Two studies from Italy and France showed no significant difference in SIRs across time periods 1978-2010 and 1989-2004. The remaining 22 studies reported various temporal trends in the risk of developing MPCs after a first cancer at a specific site, but most showed little change. CONCLUSION: Overall, the risk of developing MPCs appears to have increased since the 1980s when considering studies of all primary cancer sites combined from the USA and Australia but not from Europe. With the introduction of more routine nuclear medical imaging over the last 15 years, more studies are needed to confirm recent trends of MPC risk in adult cancer survivors.

General practice after-hours incentive funding: a rationale for change.

After-hours incentive funding for general practice was introduced in 1998 through the introduction of the Practice Incentives Program (PIP). In 2010, a national audit of the PIP identified after-hours incentive funding as having the greatest levels of non-compliance across 12 PIP components. The audit specified the need for secondary data sources to ensure practice compliance. In this article, we examine the drivers of the 1998-2013 PIP mechanism to inform development of a fair, transparent and auditable after-hours incentive funding scheme for Tasmania. The PIP after-hours incentive funding mechanism paid, at diminishing levels, for anticipated burden of care (practice size), claimed method of providing care (stream) and remoteness of practice. Increasing remoteness rather than practice size or stream is the primary determinant of urgent after-hours attendances per practice in Tasmania; after-hours attendances to residential aged care facilities are unrelated to individual practice location or stream but concentrated in urban areas. The PIP after-hours incentive funding mechanism does not preferentially support practices that provide after-hours care and arguably led to perverse incentives. A new after-hours incentive funding mechanism embodying pre-specified objectives - such as support for (unavoidable) burden and/or provision of care to residential aged care facilities - is required. Claimed provision is considered an inappropriate funding determinant.

What difference a decade? The costs of psychosis in Australia in 2000 and 2010: comparative results from the first and second Australian national surveys of psychosis.

OBJECTIVES: To assess differences in costs of psychosis between the first and second Australian national surveys of psychosis and examine them in light of policy developments. METHOD: Cost differences due to changes in resource use and/or real price rises were assessed by minimizing differences in recruitment and costing methodologies between the two surveys. For each survey, average annual societal costs of persons recruited through public specialized mental health services in the census month were assessed through prevalence-based, bottom-up cost-of-illness analyses. The first survey costing methodology was employed as the reference approach. Unit costs were specific to each time period (2000, 2010) and expressed in 2010 Australian dollars. RESULTS: There was minimal change in the average annual costs of psychosis between the surveys, although newly included resources in the second survey's analysis cost AUD$3183 per person. Among resources common to each analysis were significant increases in the average annual cost per person for ambulatory care of AUD$7380, non-government services AUD$2488 and pharmaceuticals AUD$1892, and an upward trend in supported accommodation costs. These increases were offset by over a halving of mental health inpatient costs of AUD$11,790 per person and a 84.6% (AUD$604) decrease in crisis accommodation costs. Productivity losses, the greatest component cost, changed minimally, reflecting the magnitude and constancy of reduced employment levels of individuals with psychosis across the surveys. CONCLUSIONS: Between 2000 and 2010 there was little change in total average annual costs of psychosis for individuals receiving treatment at public specialized mental health services. However, there was a significant redistribution of costs within and away from the health sector in line with government initiatives arising from the Second and Third National Mental Health Plans. Non-health sector costs are now a critical component of cost-of-illness analyses of mental illnesses reflecting, at least in part, a whole-of-government approach to care.

Costs of psychosis in 2010: findings from the second Australian National Survey of Psychosis.

OBJECTIVES: To estimate the annual costs of psychosis in Australia from societal and government perspectives and assess whether average costs per person differ by principal service provider at time of census. METHODS: Costs of psychosis encompassing health sector costs, other sector costs, and productivity losses were assessed for 2010 using a prevalence-based, bottom-up approach. Resource use data were obtained from the second Australian National Survey of Psychosis and unit costs were from government and non-government organization (NGO) sources. Costs to society were assessed by principal service provider at census: public specialized mental health services (PSMHS) and NGOs during the census month (current clients), and PSMHS in the 11 months preceding census (recent clients), and any differences were ascertained. RESULTS: The average annual costs of psychosis to society are estimated at $77,297 per affected individual, comprising $40,941 in lost productivity, $21,714 in health sector costs, and $14,642 in other sector costs. Health sector costs are 3.9-times higher than those for the average Australian. Psychosis costs Australian society $4.91 billion per annum, and the Australian government almost $3.52 billion per annum. There are significant differences between principal service providers for each cost category. Current PSMHS clients had the highest health sector costs overall, and the highest mental health ambulatory, inpatient, and antipsychotic medication costs specifically. NGO clients had the highest other sector costs overall and the highest NGO assistance, supported employment, and supported accommodation costs. Recent PSMHS clients had the lowest productivity losses for reduced participation and the highest costs for absenteeism and presenteeism. CONCLUSIONS: The costs of psychosis are broad ranging and very high. Development and implementation of cost-effective prevention, treatment, and support strategies is critical to maximizing the efficiency of service delivery. A needs-based framework based on principal service provider and recency of contact may facilitate this process.

Out-of-pocket payments: impacts on healthcare decision-making and system and individual level measures to minimise the burden.

Out-of-pocket healthcare payments are a concern for all, particularly those least able to afford them, a situation only being exacerbated by the current cost-of-living crisis. This article aims to provide an overview of out-of-pocket payments and their impacts on decision-making: whether, or not to delay care or seek care at all. The impact of average out-of-pocket payments on demand for mental healthcare services is provided as a specific example. The available data indicate a positive linear relationship between the average out-of-pocket payments for Medicare services by type of provider, and the proportion of patients who decide not to obtain care from a given type provider. This article also poses that current safety net processes are not consumer centric, the Pharmaceutical Benefits Scheme (PBS) Safety Net particularly so, and that change is required. It is recommended that a consumer-centric approach should be adopted with everyone listed on a Medicare card automatically included in the assessment of the Medicare and PBS Safety Nets and for the PBS Safety Net to be automatically assessed through Services Australia. Links to websites are provided to support individual decision-making and registering for available safety nets. Finally, supply side considerations and their implications for market equilibrium and the economy are briefly overviewed.