Systems integration to promote the mental health of Aboriginal and Torres Strait Islander children: protocol for a community-driven continuous quality improvement approach.

BACKGROUND: Systems integration to promote the mental health of Aboriginal and Torres Strait Islander children works towards developing a spectrum of effective, community-based services and supports. These services and supports are organised into a coordinated network, build meaningful partnerships with families and address their cultural and linguistic needs, to help children to function better at home, in school, in the community, and throughout life. This study is conducted in partnership with primary healthcare (PHC) and other services in three diverse Indigenous Australian communities. It entails conceptualising, co-designing, implementing, and evaluating the effectiveness of systems integration to promote the mental health and wellbeing of Indigenous school-aged children (4-17 years). This paper outlines a protocol for implementing such complex community-driven research. METHODS/DESIGN: Using continuous quality improvement processes, community co-designed strategies for improved systems integration will be informed by narratives from yarning circles with Indigenous children and service providers, and quantitative data from surveys of service providers and audits of PHC client records and intersectoral systems. Agreed strategies to improve the integration of community-based services and supports will be modelled using microsimulation software, with a preferred model implemented in each community. The evaluation will investigate changes in the: 1) availability of services that are community-driven, youth-informed and culturally competent; 2) extent of collaborative service networks; 3) identification by PHC services of children's social and emotional wellbeing concerns; and 4) ratio of children receiving services to identified need. Costs and benefits of improvements to systems integration will also be calculated. DISCUSSION: The study will provide evidence-informed, community-driven, and tested models that can be used for implementing systems integration to promote the mental health and wellbeing of Indigenous children. It will identify the situational enablers and barriers that impact systems integration and determine the extent to which systems integration improves service availability, systems and child outcomes. Evidence for the cost effectiveness of systems-level integration will contribute to national mental health policy reform.

A stepped wedge trial of efficacy and scalability of a virtual clinical pharmacy service (VCPS) in rural and remote NSW health facilities.

BACKGROUND: Medication errors are a leading cause of mortality and morbidity. Clinical pharmacy services provided in hospital can reduce medication errors and medication related harm. However, few rural or remote hospitals in Australia have a clinical pharmacy service. This study will evaluate a virtual clinical pharmacy service (VCPS) provided via telehealth to eight rural and remote hospitals in NSW, Australia. METHODS: A stepped wedge cluster randomised trial design will use routinely collected data from patients' electronic medical records (n = 2080) to evaluate the VCPS at eight facilities. The sequence of steps is randomised, allowing for control of potential confounding temporal trends. Primary outcomes are number of medication reconciliations completed on admission and discharge. Secondary outcomes are length of stay, falls and 28 day readmissions. A cost-effectiveness analysis (CEA) and cost-benefit analysis (CBA) will be conducted. The CEA will answer the question of whether the VCPS is more cost-effective compared to treatment as usual; the CBA will consider the rate of return on investing in the VCPS. A patient experience measure (n = 500) and medication adherence questionnaire (n = 100 pre and post) will also be used to identify patient responses to the virtual service. Focus groups will investigate implementation from hospital staff perspectives at each site. Analyses of routine data will comprise generalised linear mixed models. Descriptive statistical analysis will summarise patient experience responses. Differences in medication adherence will be compared using linear regression models. Thematic analysis of focus groups will identify barriers and facilitators to VCPS implementation. DISCUSSION: We aim to demonstrate the effectiveness of virtual pharmacy interventions for rural populations, and inform best practice for using virtual healthcare to improve access to pharmacy services. It is widely recognised that clinical pharmacists are best placed to reduce medication errors. However, pharmacy services are limited in rural and remote hospitals. This project will provide evidence about ways in which the benefits of hospital pharmacists can be maximised utilising telehealth technology. If successful, this project can provide a model for pharmacy delivery in rural and remote locations. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) -ACTRN12619001757101 Prospectively registered on 11 December 2019. Record available from: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378878&isReview=true.

Implementing health policies in Australian junior sports clubs: an RCT.

BACKGROUND: This pilot study aimed to test the potential effectiveness and acceptability of an intervention to support the implementation of 16 recommended policies and practices to improve the health promotion environment of junior sporting clubs. Reported child exposure to health promoting practices at clubs was also assessed. METHODS: A cluster randomised trial was conducted with eight football leagues. Fourty-one junior football clubs belonging to four leagues in the intervention group received support (e.g. physical resources, recognition and rewards, systems and prompts) to implement 16 policies and practices that targeted child exposure to alcohol, tobacco, healthy food and beverages, and participation in physical activity. Thirty-eight clubs belonging to the four control group leagues did not receive the implementation intervention. Study outcomes were assessed via telephone interviews with nominated club representatives and parents of junior players. Between group differences in the mean number of policies and practices implemented at the club level at follow-up were examined using a multiple linear regression model. RESULTS: While the intervention was found to be acceptable, there was no significant difference between the mean number of practices and policies reported to be implemented by intervention and control clubs at post-intervention (Estimate - 0.05; 95% CI -0.91, 0.80; p = 0.90). There was also no significant difference in the proportion of children reported to be exposed to: alcohol (OR 1.16; 95% CI 0.41, 3.28; p = 0.78); tobacco (OR 0.97; CI 0.45, 2.10; p = 0.94); healthy food purchases (OR 0.49; CI 0.11, 2.27; p = 0.35); healthy drink purchases (OR 1.48; CI 0.72, 3.05; p = 0.27); or participation in physical activity (OR 0.76; CI 0.14, 4.08; p = 0.74). CONCLUSIONS: Support strategies that better address barriers to the implementation of health promotion interventions in junior sports clubs are required. TRIAL REGISTRATION: Retrospectively registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12617001044314 ).

Optimisation: defining and exploring a concept to enhance the impact of public health initiatives.

BACKGROUND: Repeated, data-driven optimisation processes have been applied in many fields to rapidly transform the performance of products, processes and interventions. While such processes may similarly be employed to enhance the impact of public health initiatives, optimisation has not been defined in the context of public health and there has been little exploration of its key concepts. METHODS: We used a modified, three-round Delphi study with an international group of researchers, public health policy-makers and practitioners to (1) generate a consensus-based definition of optimisation in the context of public health and (2i) describe key considerations for optimisation in that context. A pre-workshop literature review and elicitation of participant views regarding optimisation in public health (round 1) were followed by a daylong workshop and facilitated face-to-face group discussions to refine the definition and generate key considerations (round 2); finally, post-workshop discussions were undertaken to refine and finalise the findings (round 3). A thematic analysis was performed at each round. Study findings reflect an iterative consultation process with study participants. RESULTS: Thirty of 33 invited individuals (91%) participated in the study. Participants reached consensus on the following definition of optimisation in public health: "A deliberate, iterative and data-driven process to improve a health intervention and/or its implementation to meet stakeholder-defined public health impacts within resource constraints". A range of optimisation considerations were explored. Optimisation was considered most suitable when existing public health initiatives are not sufficiently effective, meaningful improvements from an optimisation process are anticipated, quality data to assess impacts are routinely available, and there are stable and ongoing resources to support it. Participants believed optimisation could be applied to improve the impacts of an intervention, an implementation strategy or both, on outcomes valued by stakeholders or end users. While optimisation processes were thought to be facilitated by an understanding of the mechanisms of an intervention or implementation strategy, no agreement was reached regarding the best approach to inform decisions about modifications to improve impact. CONCLUSIONS: The study findings provide a strong basis for future research to explore the potential impact of optimisation in the field of public health.

Systematic review of economic evaluations of interventions for high risk young people.

BACKGROUND: The aim of this systematic literature review is to identify and critique full economic evaluations of interventions for high risk young people with the purpose of informing the design of future rigorous economic evaluations of such intervention programs. METHODS: A PRISMA compliant search of the literature between 2000 and April 2018 was conducted to identify full economic evaluations of youth focussed interventions for at risk young people. Duplicates were removed and two researchers independently screened the article titles and abstracts according to PICOS criteria for exclusion and inclusion. The remaining full text articles were assessed for eligibility and a quality assessment of the included articles was conducted using the Drummond checklist. RESULTS: The database, grey literature and hand searches located 488 studies of interventions for at risk young people. After preliminary screening of titles and abstracts, 104 studies remained for full text examination and 29 empirical studies containing 32 separate economic evaluations were judged eligible for inclusion in the review. These comprised 13 cost-benefit analyses (41%), 17 cost-effectiveness analyses (53%), one cost-utility analysis (3%) and a social return on investment (3%). Three main methodological challenges were identified: 1. attribution of effects; 2. measuring and valuing outcomes; and 3. identifying relevant costs and consequences. CONCLUSIONS: A cost-benefit analysis would best capture the dynamic nature of a multi-component intervention for high risk young people, incorporating broader intersectoral outcomes and enabling measurement of more domains of risk. Prospective long-term data collection and a strong study design that incorporates a control group contribute to the quality of economic evaluation. Extrapolation of impact into the future is important for this population, in order to account for the time lag in effect of many impacts and benefits arising from youth interventions.

How Much Can the USA Reduce Health Care Costs by Reducing Smoking?

In this Perspective, Wayne Hall and Chris Doran discuss Lightwood and Glantz's findings and the implications for tobacco control programs in the US, which are currently poorly funded.

Psycho-social resilience, vulnerability and suicide prevention: impact evaluation of a mentoring approach to modify suicide risk for remote Indigenous Australian students at boarding school.

BACKGROUND: The proposed study was developed in response to increased suicide risk identified in Aboriginal and Torres Strait Islander students who are compelled to attend boarding schools across Queensland when there is no secondary schooling provision in their remote home communities. It will investigate the impact of a multicomponent mentoring intervention to increase levels of psychosocial resilience. We aim to test the null hypothesis that students' resilience is not positively influenced by the intervention. The 5-year project was funded by the Australian National Health and Medical Research Council from December 2014. METHODS/DESIGN: An integrated mixed methods approach will be adopted; each component iteratively informing the other. Using an interrupted time series design, the primary research methods are quantitative: 1) assessment of change in students' resilience, educational outcomes and suicide risk; and 2) calculation of costs of the intervention. Secondary methods are qualitative: 3) a grounded theoretical model of the process of enhancing students' psychosocial resilience to protect against suicide. Additionally, there is a tertiary focus on capacity development: more experienced researchers in the team will provide research mentorship to less experienced researchers through regular meetings; while Indigenous team members provide cultural mentorship in research practices to non-Indigenous members. DISCUSSION: Australia's suicide prevention policy is progressive but a strong service delivery model is lacking, particularly for Indigenous peoples. The proposed research will potentially improve students' levels of resilience to mitigate against suicide risk. Additionally, it could reduce the economic and social costs of Indigenous youth suicide by obtaining agreement on what is good suicide prevention practice for remote Indigenous students who transition to boarding schools for education, and identifying the benefits-costs of an evidence-based multi-component mentoring intervention to improve resilience.

An approach to measuring and encouraging research translation and research impact.

BACKGROUND: Research translation, particularly in the biomedical area, is often discussed but there are few methods that are routinely used to measure it or its impact. Of the impact measurement methods that are used, most aim to provide accountability - to measure and explain what was generated as a consequence of funding research. This case study reports on the development of a novel, conceptual framework that goes beyond measurement. The Framework To Assess the Impact from Translational health research, or FAIT, is a platform designed to prospectively measure and encourage research translation and research impact. A key assumption underpinning FAIT is that research translation is a prerequisite for research impact. METHODS: The research impact literature was mined to understand the range of existing frameworks and techniques employed to measure and encourage research translation and research impact. This review provided insights for the development of a FAIT prototype. A Steering Committee oversaw the project and provided the feedback that was used to refine FAIT. RESULTS: The outcome of the case study was the conceptual framework, FAIT, which is based on a modified program logic model and a hybrid of three proven methodologies for measuring research impact, namely a modified Payback method, social return on investment, and case studies or narratives of the process by which research translates and generates impact. CONCLUSION: As funders increasingly seek to understand the return on their research investments, the routine measurement of research translation and research impact is likely to become mandatory rather than optional. Measurement of research impact on its own is insufficient. There should also be a mechanism attached to measurement that encourages research translation and impact - FAIT was designed for this task.

Priority setting in Indigenous health: assessing priority setting process and criteria that should guide the health system to improve Indigenous Australian health.

INTRODUCTION: The health of Indigenous Australians is worse than that of other Australians. Most of the determinants of health are preventable and the poor health outcomes are inequitable. The Australian Government recently pledged to close that health gap. One possible way is to improve the priority setting process to ensure transparency and the use of evidence such as epidemiology, equity and economic evaluation.The purpose of this research was to elicit the perceptions of Indigenous and non-Indigenous decision-makers on several issues related to priority setting in Indigenous-specific health care services. Specifically, we aimed to:1. identify the criteria used to set priorities in Indigenous-specific health care services;2. determine the level of uptake of economic evaluation evidence by decision-makers and how to improve its uptake; and 3. identify how the priority setting process can be improved from the perspective of decision-makers. METHODS: We used a paper survey instrument, adapted from Mitton and colleagues' work, and a face-to-face interview approach to elicit decision-makers' perceptions in Indigenous-specific health care in Victoria, Australia. We used mixed methods to analyse data from the survey. Responses were summarised using descriptive statistics and content analysis. Results were reported as numbers and percentages. RESULTS: The size of the health burden; sustainability and acceptability of interventions; historical trends/patterns; and efficiency are key criteria for making choices in Indigenous health in Victoria. There is a need for an explicit priority setting approach, which is systematic, and is able to use available data/evidence, such as economic evaluation evidence. The involvement of Indigenous Australians in the process would potentially make the process acceptable. CONCLUSIONS: An economic approach to priority setting is a potentially acceptable and useful tool for Aboriginal Community Controlled Health Services (ACCHS). It has the ability to use evidence and ensure due process at the same time. The use of evidence can ensure that health outcomes for Indigenous peoples can be maximised - hence, increase the potential for 'closing the gap' between Indigenous and other Australians.

Harm from the drinking of people you know: A range of effects from different relationships.

AIMS: To describe the range of effects experienced due to the drinking of people respondents know and analyze risk and protective factors for harm from the drinking of partners and household members, other relatives and friends and co-workers. DESIGN, SETTING AND PARTICIPANTS: Surveys of 2574 participants' experiences were obtained from two samples: 1000 people responded to random digitally dialled Australian mobile calls and 1574 participants responded from the Life in AustraliaTM panel survey. MEASUREMENTS: Respondents were asked whether they had been negatively affected in the previous 12 months by the drinking of persons they knew who were 'a heavy drinker or drank a lot sometimes' and the nature of these harms. Weighted logistic regressions were used to analyze differences in rates of key negative outcomes from known others' drinking by gender, age and socio-economic status. FINDINGS: Almost two thirds [60.2%; 95% confidence interval (CI) = 57.7%-62.7%] of participants reported having heavy drinkers in their lives and 21.8% (95% CI = 19.8%-23.9%) reported being negatively affected by the drinking of people they knew well in some way. Participants reported a gamut of effects, including, most commonly, adverse social effects: having to transport relatives and friends who had been drinking, role failure and faults, being emotionally hurt or neglected, serious arguments, family problems, having to care for drinkers and verbal abuse. Less commonly, respondents reported physical or sexual harm, property damage, financial stress and threats from others' drinking. Women (odds ratio = 1.49; 95% CI = 1.13-1.95), younger people, rural, Australian-born (vs. respondents born overseas in non-English speaking countries) and more frequent drinkers were more likely to report harm from a drinker they knew than their counterparts after adjusting for other variables in the model. CONCLUSIONS: Australians appear to be commonly adversely affected by the drinking of people they know. Harms from known drinkers are more likely to be experienced by women than men, particularly from the people they live with and other relatives.

Psychometric validation of the Growth and Empowerment Measure (GEM) applied with Indigenous Australians.

OBJECTIVE: Empowerment is a complex process of psychological, social, organizational and structural change. It allows individuals and groups to achieve positive growth and effectively address the social and psychological impacts of historical oppression, marginalization and disadvantage. The Growth and Empowerment Measure (GEM) was developed to measure change in dimensions of empowerment as defined and described by Aboriginal Australians who participated in the Family Well Being programme. METHOD: The GEM has two components: a 14-item Emotional Empowerment Scale (EES14) and 12 Scenarios (12S). It is accompanied by the Kessler 6 Psychological Distress Scale (K6), supplemented by two questions assessing frequency of happy and angry feelings. For validation, the measure was applied with 184 Indigenous Australian participants involved in personal and/or organizational social health activities. RESULTS: Psychometric analyses of the new instruments support their validity and reliability and indicate two-component structures for both the EES (Self-capacity; Inner peace) and the 12S (Healing and enabling growth, Connection and purpose). Strong correlations were observed across the scales and subscales. Participants who scored higher on the newly developed scales showed lower distress on the K6, particularly when the two additional questions were included. However, exploratory factor analyses demonstrated that GEM subscales are separable from the Kessler distress measure. CONCLUSION: The GEM shows promise in enabling measurement and enhancing understanding of both process and outcome of psychological and social empowerment within an Australian Indigenous context.

Drinking water fluoridation in South East Queensland: a cost-effectiveness evaluation.

OBJECTIVE: The aim of this study is to examine cost-effectiveness of fluoridation of drinking water supplies for Brisbane and South East Queensland. The benefits conveyed are expressed in reduced costs of dental treatment and years of life with dental caries as a disability. METHODS: The analysis utilises a developed life table modelling initial cohort of 36,322 newborns, which when applied to the target population equals to 181,925 persons in the age group 2-100 years, 338,617 persons in the age group 7-100 years and 390,524 persons in the age group 12-100 years respectively. The analysis was conducted using a real discount rate of 3%. Sensitivity analyses investigated the effects of varying the parameters such as: discount rate, costs of dental treatment and costs of fluoridation plant. Uncertainty analysis was also conducted on costs and the measure of ratio of decayed, missing, filled teeth surfaces in deciduous dentition between the cities of Brisbane (non-fluoridated) and Townsville (fluoridated). RESULTS: If fluoridation was implemented there would be a total saving of $10,437.43 (95% CI 6,406.50- 14,035.35) disability-adjusted life years (DALYs) and AU$ 665,686,529 (95% CI -$973,573,625- $381,322,176). This result is both desirable and dominant as more DALYs are saved along with significant cost savings. CONCLUSION: Fluoridation remains still a very cost-effective measure for reducing dental decay.

Driving change: A partnership study protocol using shared emergency department data to reduce alcohol-related harm.

BACKGROUND: Sharing anonymised ED data with community agencies to reduce alcohol-related injury and assaults has been found effective in the UK. This protocol document outlines the design of an Australian multi-site trial using shared, anonymised ED data to reduce alcohol-related harm. DESIGN AND METHOD: Nine hospitals will participate in a 36 month stepped-wedge cluster randomised trial. After a 9 month baseline period, EDs will be randomised in five groups, clustered on geographic proximity, to commence the intervention at 3 monthly intervals. 'Last-drinks' data regarding alcohol use in the preceding 12 h, typical alcohol consumption amount, and location of alcohol purchase and consumption, are to be prospectively collected by ED triage nurses and clinicians at all nine EDs as a part of standard clinical process. Brief information flyers will be delivered to all ED patients who self-report risky alcohol consumption. Public Health Interventions to be conducted are: (i) information sharing with venues (via letter), and (ii) with police and other community agencies, and (iii) the option for public release of 'Top 5' venue lists. OUTCOMES: Primary outcomes will be: (i) the number and proportion of ED attendances among patients reporting recent alcohol use; and (ii) the number and proportion of ED attendances during high-alcohol hours (Friday and Saturday nights, 20.00-06.00 hours) assigned an injury diagnosis. Process measures will assess logistical and feasibility concerns, and clinical impacts of implementing this systems-change model in an Australian context. An economic cost-benefit analysis will evaluate the economic impact, or return on investment.

The relationship between alcohol consumption and self-reported health status using the EQ5D: evidence from rural Australia.

Alcohol misuse represents one of the leading causes of preventable death, illness and injury in Australia. Extensive research exists estimating the effect of risky alcohol use on mortality, but little research quantifies the impact of risky alcohol consumption on morbidity. Such estimates are required to more precisely measure the benefit of interventions aimed at reducing risky alcohol use. Ordered probit and tobit models are used in this research to analyse the impact of risky drinking on self-reported health status using questionnaire data from an age and gender stratified sample drawn from 20 rural communities in New South Wales which are part of a large randomised controlled trial of community based alcohol interventions. It is found that risky alcohol use is associated with lower self-reported health; however, the average effect is small apart for those drinking at very-high risk. The effect of alcohol on morbidity, derived from the current analyses, is lower than that commonly used in current economics analyses. If this is accurate for geographical regions other than rural Australia, then from a policy viewpoint, these economic analyses may tend to overemphasise interventions which are morbidity reducing, such as taxation, and place undue focus on alcohol as a risk factor and consequently adversely impact resource allocation decisions.

Caring for Carers of People with Dementia: A Protocol for Harnessing Innovation Through Deploying Leading Edge Technologies to Enable Virtual Support Groups and Services.

In rural Australia, knowledge and utilisation of support by informal carers is lacking. During the caregiving period, socioemotional support from family and friends plays an important role in sustaining caregiving activities. Post-care, these social networks facilitate adjustment to role change and dealing with grief. Developing and improving access to peer support to enable carers to effectively cope with the challenges of caring may positively influence their caring experience. The primary objective of this project is to examine the response of isolated rural carers for older people with dementia to a videoconference (VC) based peer support and information program. Will participation in the program improve self-efficacy, quality of life, and mental health? Secondary objectives are to develop a VC based peer support program for isolated rural carers for older people with dementia, using a co-design approach; and to assess the feasibility of VC technology for enhancing social support to family caregivers in their homes. This project will collaboratively co-design and evaluate a facilitated VC peer support and information program to carers of people with dementia within rural areas. Carers will be recruited through community health and care providers. Program development will use an information sharing approach to facilitate social interaction. A focus of the project is to use off-the-shelf technology which will be more accessible than specialised bespoke solutions that are currently popular in this area of research. A mixed methods repeated measures randomized wait list design will be used to evaluate the project. The primary outcomes are self-efficacy, quality of life, and mental health. Secondary outcomes are perceived social support and user satisfaction with the technology, and intention to continue VC interaction.

'Sly grog' and 'homebrew': a qualitative examination of illicit alcohol and some of its impacts on Indigenous communities with alcohol restrictions in regional and remote Queensland (Australia).

BACKGROUND: Indigenous communities in Queensland (Australia) have been subject to Alcohol Management Plans since 2002/03, with significant penalties for breaching restrictions. 'Sly grog' and 'homebrew' provide access to alcohol despite restrictions. This paper describes how this alcohol is made available and the risks and impacts involved. In affected towns and communities across a large area of rural and remote Queensland, interviews and focus groups documented experiences and views of 255 long-standing community members and service providers. Using an inductive framework, transcribed interviews were analysed to identify supply mechanisms, community and service provider responses and impacts experienced. RESULTS: 'Homebrew' was reportedly manufactured in just a few localities, in locally-specific forms bringing locally-specific harms. However, 'sly grog' sourced from licensed premises located long distances from communities, is a widespread concern across the region. 'Sly grog' sellers circumvent retailers' takeaway liquor license conditions, stockpile alcohol outside restricted areas, send hoax messages to divert enforcement and take extraordinary risks to avoid apprehension. Police face significant challenges to enforce restrictions. On-selling of 'sly grog' appears more common in remote communities with total prohibition. Despite different motives for involvement in an illicit trade 'sly grog' consumers and sellers receive similar penalties. CONCLUSIONS: There is a need for: (a) a more sophisticated regional approach to managing takeaway alcohol sales from licensed suppliers, (b) targeted penalties for 'sly grog' sellers that reflect its significant community impact,

Comparative cost-effectiveness of policy instruments for reducing the global burden of alcohol, tobacco and illicit drug use.

Alcohol, tobacco and illicit drug use together pose a formidable challenge to international public health. Building on earlier estimates of the demonstrated burden of alcohol, tobacco and illicit drug use at the global level, this review aims to consider the comparative cost-effectiveness of evidence-based interventions for reducing the global burden of disease from these three risk factors. Although the number of published cost-effectiveness studies in the addictions field is now extensive (reviewed briefly here) there are a series of practical problems in using them for sector-wide decision making, including methodological heterogeneity, differences in analytical reference point and the specificity of findings to a particular context. In response to these limitations, a more generalised form of cost-effectiveness analysis (CEA) is proposed, which enables like-with-like comparisons of the relative efficiency of preventive or individual-based strategies to be made, not only within but also across diseases or their risk factors. The application of generalised CEA to a range of personal and non-personal interventions for reducing the burden of addictive substances is described. While such a development avoids many of the obstacles that have plagued earlier attempts and in so doing opens up new opportunities to address important policy questions, there remain a number of caveats to population-level analysis of this kind, particularly when conducted at the global level. These issues are the subject of the final section of this review.

Description of an early discharge post-acute care program: length of hospital stay, patient and carer needs and cost.

The objective of the project was to evaluate a pilot Post Acute Community Care (PACC) program for orthopaedic patients. A series of cross-sectional surveys elicited responses of patient and home carer needs and GP and hospital staff acceptability while a cost-minimisation analysis compared the average cost of the PACC program with general orthopaedic hospital care. Patients were classified according to Australian National Diagnosis Related Groups (DRGs). Average length of hospital stay in 1998/99 for PACC patients was 7.7 days compared to 12.3 for general orthopaedic patients. Only 3% of patients had an unplanned readmission to hospital. Patients and carers expressed a number of unmet needs. This study confirms the popularity of early discharge schemes with patients, and provides little evidence of adverse health outcomes or that the burden of care is shifted to carers in a way that is unacceptable for this older population.

How profitable is methamphetamine dealing in Australia?

INTRODUCTION: The illicit drug trade is the largest in value among global illicit commodities, at some $320 billion US dollars, according to the UN World Drug Report. Endeavours to control such a large illicit market would be enhanced by improved understanding of the economics of the trade. However, due to its illicit nature many aspects of the illicit drug market are largely unknown. This study explored one economic aspect of illicit drug dealing, profitability, with the aim of developing a better picture of the financial gains from illicit drug dealing. METHODS: Data were obtained from judges sentencing remarks, key informants from law enforcement, and other published reports which detail the prices paid for methamphetamine in Australia. The financial margins attained from non-crystal methamphetamine dealing in Australia were calculated by examining the best fit for the relationship between prices and quantities: in this case a power law. RESULTS: If it is assumed that a single deal is divided ("cut") between 4 times and 20 times before selling to the next customer, the mark-ups can range from 24% to 59%. The mark-ups appear low compared with those found in US research, but similar to those found in UK research. CONCLUSIONS: To our knowledge, this is the first attempt to analyse profitability of methamphetamine dealing in Australia. The findings of this study will help in understanding the motivations and decisions of drug dealers, and potentially assist drug law enforcement agencies to design better strategies to dismantle supply chain linkages which generate excessive profits.