Measuring performance in allied health professional role substitution models of care: a clinician survey.

BACKGROUND: Professional role substitution models of care have emerged as a key strategy to address increasing healthcare demand. Gaining insights from those actively engaged in the process of these models' implementation and evaluation is pivotal to ensuring sustainability and further successful implementation. The purpose of this study was to describe allied-health clinicians' perceptions, practice, and experiences of healthcare performance evaluation in professional role substitution models of care. METHODS: Data were collected via an online platform between 22 June - 22 July 2022 using a combination of convenience and network-based sampling of allied-health clinicians involved or interested in the implementation and evaluation of professional role substitution models of care. Clinicians answered 25 questions which consisted of demographic and targeted questions regarding performance evaluation across six domains of healthcare quality (effectiveness, safety, appropriateness, access & equity, continuity of care, and cost, efficiency, productivity & sustainability). RESULTS: A total of 102 clinicians accessed the survey, with 72 providing complete survey data. Eleven allied-health professions were represented, working across twelve specialities in thirteen hospital and health services. Whilst most allied-health clinicians (93-100%) supported measuring performance in each of the six healthcare quality domains, only 26-58% were measuring these domains in practice. Allied-health leadership support (62.5%), clinician drive (62.5%), consumer engagement (50%) and medical support (46%) were enablers whilst a lack of resources (human, time, financial (47%)), healthcare performance frameworks and/or policies (40%) were identified as barriers. Given the opportunity, clinicians would invest the most financial resources in digital solutions as a core strategy to improve performance evaluation. CONCLUSIONS: Allied-health professionals expressed strong support for principles of performance evaluation, however in practice, performance evaluation is still in its infancy in professional role substitution models of care. Organisations can implement strategies that maximise the enablers whilst addressing barriers identified to improve performance evaluation in these models of care.

Implementing paediatric appropriate use criteria for endotracheal suction to reduce complications in mechanically ventilated children with respiratory infections.

BACKGROUND: Endotracheal suction is used to maintain endotracheal tube patency. There is limited guidance to inform clinical practice for children with respiratory infections. OBJECTIVE: The objective of this study was to determine whether implementation of a paediatric endotracheal suction appropriate use guideline Paediatric AirWay Suction (PAWS) is associated with an increased use of appropriate and decreased use of inappropriate suction interventions. METHODS: A mixed-method, pre-implementation-post-implementation study was conducted between September 2021 and April 2022. Suction episodes in mechanically ventilated children with a respiratory infection were eligible. Using a structured approach, we implemented the PAWS guideline in a single paediatric intensive care unit. Evaluation included clinical (e.g., suction intervention appropriateness), implementation (e.g., acceptability), and cost outcomes (implementation costs). Associations between implementation of the PAWS guideline and appropriateness of endotracheal suction intervention use were investigated using generalised linear models. RESULTS: Data from 439 eligible suctions were included in the analysis. Following PAWS implementation, inappropriate endotracheal tube intervention use reduced from 99% to 58%, an absolute reduction (AR) of 41% (95% confidence interval [CI]: 25%, 56%). Reductions were most notable for open suction systems (AR: 48%; 95% CI: 30%, 65%), 0.9% sodium chloride use (AR: 23%; 95% CI: 8%, 38%) and presuction and postsuction manual bagging (38%; 95% CI: 16%, 60%, and 86%; 95% CI: 73%, 99%), respectively. Clinicians perceived PAWS as acceptable and suitable for use. CONCLUSIONS: Implementation of endotracheal tube suction appropriate use guidelines in a mixed paediatric intensive care unit was associated with a large reduction in inappropriate suction intervention use in paediatric patients with respiratory infections.

Patient Preferences for Attributes that Characterise Alternative Models of Care in Gastroenterology: A Discrete Choice Experiment.

OBJECTIVES: Increased demand for gastroenterology services has resulted in growing waitlists, with patients at risk of exceeding clinically recommended wait-times. Given limited healthcare resources, expanded scope models of care are an option to help address this demand, but little is known about patient preferences for these models of care. METHODS: Low-risk gastroenterology patients (n = 1198) referred to an outpatient tertiary service in Australia over a 2-year period were invited to participate in an unlabelled discrete choice experiment with seven attributes: primary healthcare professional, wait-time, continuity of care, consultation length, manner and communication skills, reassurance, and cost. These were developed using qualitative research, literature review, and stakeholders' experiences. A d-efficient fractional design was used to construct four blocks of 12 choice sets, with two alternatives. A 13th choice set was included as a data and quality check. Latent class and mixed logit regression were used for analysis. The resulting preference parameters for individual attributes were then used to calculate willingness to pay and willingness to wait. RESULTS: Overall, the model based on the 347 respondents suggested no strong preference for professional background. All other attributes were statistically significant predictors of preference (p < 0.001), with respondents willing to make significant trade-offs (time and cost) before accepting deterioration in attributes. There was strong emphasis on manner and communication skills, with a clinician who listens and provides good explanations overwhelmingly the most important attribute. Latent class analysis identified two patient segments who differed in their preference for the primary treating healthcare professional (doctor or dietitian) based on exposure to either traditional medical or non-medical professional role substitution model. CONCLUSIONS: Patients have strong but varied preferences for gastroenterology services based on whether they have been exposed to expanded scope models of care. Design and implementation of new models of care need to consider strategies to overcome any perceived loss in utility or deterioration in healthcare quality for those unfamiliar with professional role substitution.

Role substitution of specialist medical doctors with allied-health professionals: A qualitative exploration of patients' experiences and perceptions of healthcare quality.

RATIONALE, AIMS AND OBJECTIVES: The need to improve patient access, offer increased choice and improve patient outcomes whilst maintaining safe care is driving the healthcare workforce to evolve. Extending allied-health scope of practice by integrating models of care that traverse traditional professional boundaries has been one such strategy. This study explored patients' acceptance and experiences of four allied-health extended scope of practice models of care. The study aimed to identify dimensions of quality healthcare that matter to patients and describe the extent to which they perceived these to be delivered in allied-health professional role substitution models of care. METHODS: Qualitative methodology using semistructured interviews were conducted with 29 participants who had received treatment from an allied-health professional role substitution model. This was a purposeful sample with recruitment across genders, ages and social backgrounds. Interviews were audio recorded, transcribed and independently analysed by two researchers using a thematic approach. RESULTS: Six major themes were identified which revealed dimensions of healthcare quality that were important to participants: Balancing expectations and overall satisfaction; Timely access and convenience; Continuity, integration and coordination of care; Clinician expert skills, professional manner and interpersonal attributes; Financial considerations when receiving care; and Perceptions of treatment outcomes. CONCLUSIONS: This study highlights participants' views and experiences of allied-health extended scope of practice models of care. Service delivery models were an acceptable alternative to traditional specialist medical care with the perception that extended scope of practice models of care delivered many aspects of quality care that mattered to patients.

The Smarter Safer Homes Solution to Support Older People Living in Their Own Homes Through Enhanced Care Models: Protocol for a Stratified Randomized Controlled Trial.

BACKGROUND: An aging population, accompanied by the prevalence of age-related diseases, presents a significant burden to health systems. This is exacerbated by an increasing shortage of aged care staff due to the existing workforce entering their retirement and fewer young people being attracted to work in aged care. In line with consumer preferences and potential cost-efficiencies, government and aged care providers are increasingly seeking options to move care and support to the community or home as opposed to residential care facilities. However, compared to residential care, home environments may provide limited opportunity for monitoring patients' progression/decline in functioning and therefore limited opportunity to provide timely intervention. To address this, the Smarter Safer Homes (SSH) platform was designed to enable self-monitoring and/or management, and to provide aged care providers with support to deliver their services. The platform uses open Internet of Things communication protocols to easily incorporate commercially available sensors into the system. OBJECTIVE: Our research aims to detail the benefits of utilizing the SSH platform as a service in its own right as well as a complementary service to more traditional/historical service offerings in aged care. This work is anticipated to validate the capacity and benefits of the SSH platform to enable older people to self-manage and aged care service providers to support their clients to live functionally and independently in their own homes for as long as possible. METHODS: This study was designed as a single-blinded, stratified, 12-month randomized controlled trial with participants recruited from three aged care providers in Queensland, Australia. The study aimed to recruit 200 people, including 145 people from metropolitan areas and 55 from regional areas. Participants were randomized to the intervention group (having the SSH platform installed in their homes to assist age care service providers in monitoring and providing timely support) and the control group (receiving their usual aged care services from providers). Data on community care, health and social-related quality of life, health service utilization, caregiver burden, and user experience of both groups were collected at the start, middle (6 months), and end of the trial (12 months). RESULTS: The trial recruited its first participant in April 2019 and data collection of the last participant was completed in November 2020. The trial eventually recruited 195 participants, with 98 participants allocated to the intervention group and 97 participants allocated to the control group. The study also received participants' health service data from government data resources in June 2021. CONCLUSIONS: A crisis is looming to support the aging population. Digital solutions such as the SSH platform have the potential to address this crisis and support aged care in the home and community. The outcomes of this study could improve and support the delivery of aged care services and provide better quality of life to older Australians in various geographical locations. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000829213; https://tinyurl.com/2n6a75em. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/31970.

Measuring performance of professional role substitution models of care against traditional medical care in healthcare-A systematic review.

OBJECTIVES: To identify outcome measures used to evaluate performance of healthcare professional role substitution against usual medical doctor or specialist medical doctor care to facilitate our understanding of the adequacy of these measures in assessing quality of healthcare delivery. METHODS: Using a systematic approach, we searched Medline, Cochrane Central Register of Controlled Trials, Embase, CINAHL, and Web of Science from database inception until May 2020. Studies that presented original comparative data on at least one outcome measure were included following screening by two authors. Findings were synthesized, and outcome measures classified into six domains which included: effectiveness, safety, appropriateness, access, continuity of care, efficiency, and sustainability which were informed by the Institute of Medicine dimensions of healthcare quality, the Australian health performance framework, and Levesque and Sutherland's integrated performance measurement framework. RESULTS: One thirty five articles met the inclusion criteria, describing 58 separate outcome measures. Safety of role substitution models of care was assessed in 80 studies, effectiveness (n = 60), appropriateness (n = 40), access (n = 36), continuity of care (n = 6), efficiency and productivity (n = 45). Two-thirds of the studies that assessed productivity and efficiency performed an economic analysis (n = 27). The quality and rigour of evaluations varied substantially across studies, with two-thirds of all studies measuring and reporting outcomes from only one or two of these domains. CONCLUSIONS: There are a growing number of studies measuring the performance of non-medical healthcare professional substitution roles. Few have been subject to robust evaluations, and there is limited evidence on the scientific rigour and adequacy of outcomes measured. A systematic and coordinated approach is required to support healthcare settings in assessing the value of non-medical role substitution healthcare delivery models.

The Impact of Population-Based Disease Management Services on Health Care Utilisation and Costs: Results of the CAPICHe Trial.

BACKGROUND: Disease management programmes may improve quality of care, improve health outcomes and potentially reduce total healthcare costs. To date, only one very large population-based study has been undertaken and indicated reductions in hospital admissions > 10%. OBJECTIVE: We sought to confirm the effectiveness of population-based disease management programmes. The objective of this study was to evaluate the relative impact on healthcare utilisation and cost of participants the Costs to Australian Private Insurance - Coaching Health (CAPICHe) trial. DESIGN: Parallel-group randomised controlled trial, intention-to-treat analysis SETTING: Australian population PARTICIPANTS: Forty-four thousand four hundred eighteen individuals (18-90 years of age) with private health insurance and diagnosis of heart failure, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), diabetes, or low back pain, with predicted high cost claims for the following 12 months. INTERVENTION: Health coaching for disease management from Bupa Health Dialog, vs Usual Care. MAIN OUTCOME MEASURES: Total cost of claims per member to the private health insurer 1 year post-randomisation for hospital admissions, including same-day, medical and prostheses hospital claims, excluding any maternity costs. Analysis was based on the intent-to-treat population. RESULTS: Estimated total cost 1 year post-randomisation was not significantly different (means: intervention group A$4934; 95% CI A$4823-A$5045 vs control group A$4868; 95% CI A$4680-A$5058; p = 0.524). However, the intervention group had significantly lower same-day admission costs (A$468; 95% CI A$454-A$482 vs A$508; 95% CI A$484-A$533; p = 0.002) and fewer same-day admissions per 1000 person-years (intervention group, 530; 95% CI 508-552 vs control group, 614; 95% CI 571-657; p = 0.002). Subgroup analyses indicated that the intervention group had significantly fewer admissions for patients with COPD and fewer same-day admissions for patients with diabetes. CONCLUSIONS: Chronic disease health coaching was not effective to reduce the total cost after 12 months of follow-up for higher risk individuals with a chronic condition. Statistically significant changes were found with fewer same-day admissions; however, these did not translate into cost savings from a private health insurance perspective.

Telephone consultations for general practice: a systematic review.

BACKGROUND: The use of information technology, including internet- and telephone-based resources, is becoming an alternative and supporting method of providing many forms of services in a healthcare and health management setting. Telephone consultations provide a promising alternative and supporting service for face-to-face general practice care. The aim of this review is to utilize a systematic review to collate evidence on the use of telephone consultation as an alternative to face-to-face general practice visits. METHODS: A systematic search of MEDLINE, CINAHL, The Cochrane Library, and the International Clinical Trials Registry Platform was performed using the search terms for the intervention (telephone consultation) and the comparator (general practice). Systematic reviews and randomized control trials that examined telephone consultation compared to normal face-to-face consultation in general practice were included in this review. Papers were reviewed, assessed for quality (Cochrane Collaboration's 'Risk of bias' tool) and data extracted and analysed. RESULTS: Two systematic reviews and one RCT were identified and included in the analysis. The RCT (N = 388) was of patients requesting same-day appointments from two general practices and patients were randomized to a same-day face-to-face appointment or a telephone call back consultation. There was a reduction in the time spent on consultations in the telephone group (1.5 min (0.6 to 2.4)) and patients in the telephone arm had 0.2 (0 to 0.3) more follow-up consultations than the face-to-face group. One systematic review focused on telephone consultation and triage on healthcare use, and included one RCT and one other observational study that examined telephone consultations. The other systematic review focused on patient access and included one RCT and four observational studies that examined telephone consultations. Both systematic reviews provided narrative interpretations of the evidence and concluded that telephone consultations provided an appropriate alternative to telephone consultations and reduced practice work load. CONCLUSION: There is a lack of high level evidence for telephone consultations in a GP setting; however, current evidence suggests that telephone consultations as an alternative to face-to-face general practice consultations offers an appropriate option in certain settings. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015025225.

Long-term cost-effectiveness of home versus clinic-based management of chronic heart failure: the WHICH? study.

BACKGROUND: The cost-effectiveness of a heart failure management intervention can be further informed by incorporating the expected benefits and costs of future survival. METHODS: This study compared the long-term costs per quality-adjusted life year (QALY) gained from home-based (HBI) vs specialist clinic-based intervention (CBI) among elderly patients (mean age = 71 years) with heart failure discharged home (mean intervention duration = 12 months). Cost-utility analysis was conducted from a government-funded health system perspective. A Markov cohort model was used to simulate disease progression over 15 years based on initial data from a randomized clinical trial (the WHICH? study). Time-dependent hazard functions were modeled using the Weibull function, and this was compared against an alternative model where the hazard was assumed to be constant over time. Deterministic and probabilistic sensitivity analyses were conducted to identify the key drivers of cost-effectiveness and quantify uncertainty in the results. RESULTS: During the trial, mortality was the highest within 30 days of discharge and decreased thereafter in both groups, although the declining rate of mortality was slower in CBI than HBI. At 15 years (extrapolated), HBI was associated with slightly better health outcomes (mean of 0.59 QALYs gained) and mean additional costs of AU$13,876 per patient. The incremental cost-utility ratio and the incremental net monetary benefit (vs CBI) were AU$23,352 per QALY gained and AU$15,835, respectively. The uncertainty was driven by variability in the costs and probabilities of readmissions. Probabilistic sensitivity analysis showed HBI had a 68% probability of being cost-effective at a willingness-to-pay threshold of AU$50,000 per QALY. CONCLUSION: Compared with CBI (outpatient specialized HF clinic-based intervention), HBI (home-based predominantly, but not exclusively) could potentially be cost-effective over the long-term in elderly patients with heart failure at a willingness-to-pay threshold of AU$50,000/QALY, albeit with large uncertainty.

Telemedicine for general practice: a systematic review protocol.

BACKGROUND: The use of information technology in healthcare is fast becoming an alternative and supporting method of providing many forms of services in a healthcare and health management setting. Telephone technology is used readily to deliver services such as disease management, consultations and behaviour coaching. Telemedicine provides a promising alternative and supporting service for face-to-face general practice care. The aim of this review is to utilise a systematic review to collate evidence on the use of telemedicine as a lead in and an alternative to general practice visits. METHODS/DESIGN: A systematic search of MEDLINE, CINAHL, the Cochrane Library and the International Clinical Trials Registry Platform will be performed using the search terms for the intervention (telemedicine) and the comparator (general practice) to search the databases. The systematic review aims to identify randomised control trials; however, if none are identified, an updated search will be conducted to identify lower levels of evidence. Papers will be reviewed and assessed for quality and data extracted using two reviewers; if consensus is required, a third reviewer will be consulted. If applicable, a meta-analysis of relevant outcomes will be conducted. The protocol has been reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocols (PRISMA-P) guidelines. DISCUSSION: The intervention and comparator have the potential to provide a vast range of healthcare services to a range of diseases and health conditions. There is likely to be difficulty in identifying relevant clinical outcome measures for the patient population. A range of outcome measures will therefore be collected in the data extraction phase. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015025225.

Medicare rebate for specialist medical practitioners from physiotherapy referrals: analysis of the potential impact on the Australian healthcare system.

UNLABELLED: Abstract OBJECTIVE: To identify and examine the likely impact on referrals to specialist medical practitioners, cost to government and patient out-of-pocket costs by providing a rebate under the Medicare Benefits Scheme to patients who attend a specialist medical practitioner upon referral direct from a physiotherapist. METHODS: A model was constructed to synthesise the costs and benefits of referral with a rebate. Data to inform the model was obtained from administrative sources and from a direct survey of physiotherapists. RESULTS: Given that six referrals per month are made by physiotherapists for a specialist consultation, allowing direct referral to medical specialists and providing patients with a Medicare rebate would result in a likely cost saving to the government ofup to $13 million per year. A range of sensitivity analyses were conducted with all scenarios resulting in some cost savings. CONCLUSIONS: The impact of the proposed policy shift to allow direct referral of patients by physiotherapists to specialist medical practitioners and provide patients with a Medicare rebate would be cost saving.

Estimated impacts of alternative Australian alcohol taxation structures on consumption, public health and government revenues.

OBJECTIVE: To examine health and economic implications of modifying taxation of alcohol in Australia. DESIGN AND SETTING: Economic and epidemiological modelling of four scenarios for changing the current taxation of alcohol products, including: replacing the wine equalisation tax (WET) with a volumetric tax; applying an equal tax rate to all beverages equivalent to a 10% increase in the current excise applicable to spirits and ready-to-drink products; applying an excise tax rate that increases exponentially by 3% for every 1% increase in alcohol content above 3.2%; and applying a two-tiered volumetric tax. We used annual sales data and taxation rates for 2010 as the base case. MAIN OUTCOME MEASURES: Alcohol consumption, taxation revenue, disability-adjusted life-years (DALYs) averted and health care costs averted. RESULTS: In 2010, the Australian Government collected close to $8.6 billion from alcohol taxation. All four of the proposed variations to current rates of alcohol excise were shown to save money and more effectively reduce alcohol-related harm compared with the 2010 base case. Abolishing the WET and replacing it with a volumetric tax on wine would increase taxation revenue by $1.3 billion per year, reduce alcohol consumption by 1.3%, save $820 million in health care costs and avert 59 000 DALYs. The alternative scenarios would lead to even higher taxation receipts and greater reductions in alcohol use and harm. CONCLUSIONS: Our research findings suggest that any of the proposed variations to current rates of alcohol excise would be a cost-effective health care intervention; they thus reinforce the evidence that taxation is a cost-effective strategy. Of all the scenarios, perhaps the most politically feasible policy option at this point in time is to abolish the WET and replace it with a volumetric tax on wine. This analysis supports the recommendation of the National Preventative Health Taskforce and the Henry Review towards taxing alcohol according to alcohol content.

Cost per incident of alcohol-related crime in New South Wales.

INTRODUCTION AND AIMS: The purpose of this paper is to provide a per incident of crime cost measure for New South Wales that is suitable for the use within cost-effectiveness studies of interventions aimed at reducing the burden of alcohol. This paper seeks to quantify the individual cost of an assault, property damage, sexual offence and disorderly conduct in New South Wales. DESIGN AND METHODS: Costs regarding the criminal act, police involvement, prosecution in criminal courts and incarceration are estimated and then using a four-stage probability analysis, the expected cost per incident is calculated. RESULTS: It is found that expected cost per incident for assault, sexual offence, property damage and disorderly conduct (in 2006 dollar values) is $3982, $5976, $1166 and $501 respectively. DISCUSSION AND CONCLUSIONS: A large total cost figure is a powerful policy motivator; however, for the purpose of economic analysis it is often more useful to estimate the per incident cost. This research furthers the existing research on cost of crime estimates and facilitates future cost-effectiveness and other economic analysis of interventions that reduce alcohol-related crime.

The impact of population-based disease management services for selected chronic conditions: the Costs to Australian Private Insurance--Coaching Health (CAPICHe) study protocol.

BACKGROUND: Recent evidence from a large scale trial conducted in the United States indicates that enhancing shared decision-making and improving knowledge, self-management, and provider communication skills to at-risk patients can reduce health costs and utilisation of healthcare resources. Although this trial has provided a significant advancement in the evidence base for disease management programs it is still left for such results to be replicated and/or generalised for populations in other countries and other healthcare environments. This trial responds to the limited analyses on the effectiveness of providing chronic disease management services through telephone health coaching in Australia. The size of this trial and it's assessment of cost utility with respect to potentially preventable hospitalisations adds significantly to the body of knowledge to support policy and investment decisions in Australia as well as to the international debate regarding the effect of disease management programs on financial outcomes. METHODS: Intention to treat study applying a prospective randomised design comparing usual care with extensive outreach to encourage use of telephone health coaching for those people identified from a risk scoring algorithm as having a higher likelihood of future health costs. The trial population has been limited to people with one or more of the following selected chronic conditions: namely, low back pain, diabetes, coronary artery disease, heart failure, and chronic obstructive pulmonary disease. This trial will enrol at least 64,835 sourced from the approximately 3 million Bupa Australia private health insured members located across Australia. The primary outcome will be the total (non-maternity) cost per member as reported to the private health insurer (i.e. charged to the insurer) 12 months following entry into the trial for each person. Study recruitment will be completed in early 2012 and the results will be available in late 2013. DISCUSSION: If positive, CAPICHe will represent a potentially cost-effective strategy to improve health outcomes in higher risk individuals with a chronic condition, in a private health insurance setting. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry reference: ACTRN12611000580976.

Revenue implications to the Vietnamese government of using taxes to curb cigarette smoking.

This study explores the impact on government taxation revenue from increasing excise on cigarettes in Vietnam. A dynamic population model is used to estimate future patterns (both prevalence and consumption) of tobacco use in Vietnam, with and without changes to tobacco excise for the period 2006-2016. Three increases in the base case excise tax rate of 55% are modelled: 65%, 75% and 90%. Various price elasticities are used to examine variations in cigarette consumption while cross price elasticities are used to explore shifts from cigarette to other forms of tobacco. Revenue implications for the period 2006-2016 are reported as discounted net present values (NPV) in 2006 values. The model predicts that smoking rates in 2016, for both males and females, are marginally lower than base case estimates for all taxation excise options with higher price elasticities generating greater reductions in prevalence. In all cases, compared to base case estimates, the results indicate a fall in number of smokers, a reduction in amount of tobacco consumed and an increase in overall taxation revenue. The additional gain in government revenue, expressed in NPV terms, ranges from a low of VND 69,579 billion (or USD $4.35 billion) to a high of VND 108,492 billion (or USD $6.79 billion). Increases in tobacco excise provide an opportunity for the Vietnamese government to increase revenue at the same time as reducing tobacco consumption. Further research into the wider social and economic consequences of increasing tobacco excise in Vietnam is warranted.

Comparing the cost of alcohol-related traffic crashes in rural and urban environments.

CONTEXT: Existing studies have identified that, although to a lesser extent than individual factors such as males and young people, rural (compared to urban) communities represent a disproportionately high-risk of alcohol-related traffic crashes (ARTCs). To date, however, few studies have attempted to apply different costs to alcohol crashes of different severity, to provide more precise, and practically useful, data on which to base public health policy and intervention decisions. OBJECTIVE: The aim of this study is to quantify the per capita prevalence and differential costs of alcohol crashes of different levels of severity to determine the extent to which urban and rural geographical areas may differ in the costs attributable to ARTCs. DESIGN: A cross-sectional analysis of alcohol-related traffic crash and costs data from 2001 to 2007. SETTING AND PARTICIPANTS: Data from New South Wales, Australia. MAIN OUTCOME MEASURES: Modified routinely collected traffic accident data to which costs relevant to alcohol crashes of different severity are applied. RESULTS: Although the rate per 10,000 population of alcohol-related crashes is 1.5 times higher in rural, relative to urban, communities, the attributable cost is four times higher, which largely reflects that rural alcohol-fatalities are seven to eight times more prevalent and costly. CONCLUSIONS: Given that per capita alcohol-related fatal crashes in rural areas account for a disproportionately large proportion of the harms and costs associated with alcohol-related traffic crashes, the cost-effectiveness of public health interventions and public policy initiatives should consider the relative extent of ARTC-harm in rural versus urban communities.

Cost-effectiveness of volumetric alcohol taxation in Australia.

OBJECTIVE: To estimate the potential health benefits and cost savings of an alcohol tax rate that applies equally to all alcoholic beverages based on their alcohol content (volumetric tax) and to compare the cost savings with the cost of implementation. DESIGN AND SETTING: Mathematical modelling of three scenarios of volumetric alcohol taxation for the population of Australia: (i) no change in deadweight loss, (ii) no change in tax revenue, and (iii) all alcoholic beverages taxed at the same rate as spirits. MAIN OUTCOME MEASURES: Estimated change in alcohol consumption, tax revenue and health benefit. RESULTS: The estimated cost of changing to a volumetric tax rate is $18 million. A volumetric tax that is deadweight loss-neutral would increase the cost of beer and wine and reduce the cost of spirits, resulting in an estimated annual increase in taxation revenue of $492 million and a 2.77% reduction in annual consumption of pure alcohol. The estimated net health gain would be 21 000 disability-adjusted life-years (DALYs), with potential cost offsets of $110 million per annum. A tax revenue-neutral scenario would result in an 0.05% decrease in consumption, and a tax on all alcohol at a spirits rate would reduce consumption by 23.85% and increase revenue by $3094 million [corrected]. All volumetric tax scenarios would provide greater health benefits and cost savings to the health sector than the existing taxation system, based on current understandings of alcohol-related health effects. CONCLUSIONS: An equalized volumetric tax that would reduce beer and wine consumption while increasing the consumption of spirits would need to be approached with caution. Further research is required to examine whether alcohol-related health effects vary by type of alcoholic beverage independent of the amount of alcohol consumed to provide a strong evidence platform for alcohol taxation policies.