Action to address the household economic burden of non-communicable diseases.

The economic burden on households of non-communicable diseases (NCDs), including cardiovascular diseases, cancer, respiratory diseases, and diabetes, poses major challenges to global poverty alleviation efforts. For patients with NCDs, being uninsured is associated with 2-7-fold higher odds of catastrophic levels of out-of-pocket costs; however, the protection offered by health insurance is often incomplete. To enable coverage of the predictable and long-term costs of treatment, national programmes to extend financial protection should be based on schemes that entail compulsory enrolment or be financed through taxation. Priority should be given to eliminating financial barriers to the uptake of and adherence to interventions that are cost-effective and are designed to help the poor. In concert with programmes to strengthen national health systems and governance arrangements, comprehensive financial protection against the growing burden of NCDs is crucial in meeting the UN's Sustainable Development Goals.

The health-related quality of life of Indigenous populations: a global systematic review.

PURPOSE: Indigenous conceptions of health have been shown to differ from that of their non-Indigenous counterparts. As a result, there remains uncertainty over the appropriateness and value of using existing health-related quality-of-life (HRQoL) instruments in Indigenous communities. The objective of this review was to identify studies that either measure the HRQoL of an Indigenous population or validated a measure used to elicit the HRQoL in an Indigenous population. METHODS: A systematic review of the published literature was conducted to (1) investigate the extent to which HRQoL instruments are used in Indigenous populations; (2) to identify which instruments have been validated in which populations; and (3) to identify which instruments have been tailored for use with Indigenous populations. RESULTS: Forty-one studies were included in the review. Only three of the 41 studies utilised Indigenous-specific instruments. The remainder (38 studies) utilised generic population or disease-specific instruments. Four studies found specific HRQoL instruments to be valid in these populations and 32 estimated the HRQoL of an Indigenous population. The limited examples of Indigenous-specific instruments highlighted the potential importance to the HRQoL of these populations of domains that lie outside of traditional measures including social and community domains as well as domains relating to culture, diet and land use on top of more traditional HRQoL domains. CONCLUSION: Ensuring that the HRQoL of Indigenous populations is being appropriately measured is vital to prioritising available resources to the most effective interventions. HRQoL instruments present an opportunity to directly elicit and incorporate Indigenous preferences and conceptions of health into these decisions. Further work is required in the field to ensure that this potential is realised.

The economic impact of epilepsy: a systematic review.

BACKGROUND: In this review we aimed to determine the economic impact of epilepsy and factors associated with costs to individuals and health systems. METHODS: A narrative systematic review of incidence and case series studies with prospective consecutive patient recruitment and economic outcomes published before July 2014 were retrieved from Medline, Embase and PsycInfo. RESULTS: Of 322 studies reviewed, 22 studies met the inclusion criteria and 14 were from high income country settings. The total costs associated with epilepsy varied significantly in relation to the duration and severity of the condition, response to treatment, and health care setting. Where assessed, 'out of pocket' costs and productivity losses were found to create substantial burden on households which may be offset by health insurance. However, populations covered ostensibly for the upfront costs of care can still bear a significant economic burden. CONCLUSIONS: Epilepsy poses a substantial economic burden for health systems and individuals and their families. There is uncertainty over the degree to which private health insurance or social health insurance coverage provides adequate protection from the costs of epilepsy. Future research is required to examine the role of different models of care and insurance programs in protecting against economic hardship for this condition, particularly in low and middle income settings.

Exploring the use of economic evidence to inform investment in disease prevention - a qualitative study.

OBJECTIVE: In the context of growing financial pressures on health budgets, cost-effective prevention strategies are needed to address the burden from non-communicable disease in Australia. We explored how decision makers use economic evidence to inform such investment and how such evidence generated can more effectively meet the needs of end users. METHODS: Thematic analysis of in-depth interviews with 15 high level stakeholders (Treasury, state health departments and the insurance industry), supplemented by documentary analysis. RESULTS: Types of prevention approaches and economic evidence relevant to decision makers differed by organisational perspective. Capacity building in understanding economic evaluations and research evidence that addresses the differing criteria for investment used by different organisations is needed. The task of determining investment priorities in disease prevention comes with significant challenges including ideological barriers, delayed outcome measures, and implementation uncertainties. Conclusions and Implications for public health: Promoting the greater use of economic evidence in prevention requires more work on two fronts: tailoring the methods used by economists to better match the organisational imperatives of end users; and promoting greater consideration of broader societal and health sector perspectives among end users. This will require significant infrastructure development, monitoring and evaluation, stronger national leadership and a greater emphasis on evidence coproduction.

Judicial intervention in alcohol regulation: an empirical legal analysis.

OBJECTIVE: While governments draft law and policy to promote public health, it is through cases put before the judiciary that the implementation of law can be challenged and where its practical implications are typically determined. In this paper, we examine the role of court judgements on efforts in Australia to regulate the harmful use of alcohol. METHODS: Australian case law (2010 to June 2015) involving the judicial review of administrative decisions relating to development applications or liquor licences for retail liquor outlets (bottle shops), hotels, pubs and clubs was identified using a case law database (WestLaw AU). Data were extracted and analysed using standard systematic review techniques. RESULTS: A total of 44 cases were included in the analysis. Of these, 90% involved appeals brought by industry actors against local or state government stakeholders seeking to reject applications for development applications and liquor licences. The proportion of judicial decisions resulting in outcomes in favour of industry was 77%. CONCLUSIONS: Public health research evidence appeared to have little or no influence, as there is no requirement for legislation to consider public health benefit. Implications for public health: A requirement that the impact on public health is considered in legislation will help to offset its strong pro-competition emphasis, which in turn has strongly influenced judicial decision making in this area.

Global systematic review of Indigenous community-led legal interventions to control alcohol.

OBJECTIVES: The national and subnational governments of most developed nations have adopted cost-effective regulatory and legislative controls over alcohol supply and consumption with great success. However, there has been a lack of scrutiny of the effectiveness and appropriateness of these laws in shaping the health-related behaviours of Indigenous communities, who disproportionately experience alcohol-related harm. Further, such controls imposed unilaterally without Indigenous consultation have often been discriminatory and harmful in practice. SETTING, PARTICIPANTS AND OUTCOME MEASURES: In this systematic review of quantitative evaluations of Indigenous-led alcohol controls, we aim to investigate how regulatory responses have been developed and implemented by Indigenous communities worldwide, and evaluate their effectiveness in improving health and social outcomes. We included articles from electronic databases MEDLINE, EMBASE, CINAHL, PsycINFO and Web of Science from inception to December 2015. RESULTS: Our search yielded 1489 articles from which 18 met the inclusion criteria. Controls were implemented in rural and remote populations of high-income nations. Communities employed a range of regulatory options including alcohol rationing, prohibition of sale, importation or possession, restrictions on liquor sold, times of sale or mode of sale, Indigenous-controlled liquor licensing, sin tax and traditional forms of control. 11 studies reported interventions that were effective in reducing crime, injury deaths, injury, hospitalisations or lowering per capita consumption. In six studies interventions were found to be ineffective or harmful. The results were inconclusive in one. CONCLUSIONS: Indigenous-led policies that are developed or implemented by communities can be effective in improving health and social outcomes.

Driving in stroke survivors aged 18-65 years: The Psychosocial Outcomes In StrokE (POISE) Cohort Study.

BACKGROUND: There is limited information regarding return to driving after stroke. AIMS: To determine the frequency and predictors of return to driving within 1 month of acute stroke in younger (age 18-65 years) adults. METHODS: POISE (Psychosocial Outcomes In StrokE) was a cohort study conducted in Australia between October 2008 and June 2010. Consecutive patients (age 18-65 years) with a recent (≤28 days) acute stroke were recruited. Validated demographic, clinical, mental health, cognitive, and disability measures including return to driving were obtained. Multivariable logistic regression was used to determine factors associated with return to driving within 1 month of stroke. RESULTS: Among 359 participants who were legally able to drive before stroke, 96 (26.7%) returned to driving within 1 month. Compared to those without an early return to driving (n = 263), drivers were more often male, the main income earner, in paid work before stroke and without symptoms of depression or fatigue. Independence in activities of daily living (odds ratio (OR) 30.05, 95% confidence interval (CI) 3.85-234.45), not recalling receiving advice on driving cessation (OR 5.55, 95% CI 2.86-11.11), and having returned to paid work (OR 3.93, 95% CI 1.94-7.96) were associated with early return to driving. CONCLUSIONS: One in four young adults resumed driving within a month, contrary to guideline recommendations. These data reinforce the importance of deciding who is responsible for determining fitness to drive after stroke, when, and whether it is reasonable to enforce driving restrictions on those with minimal disability who are fit to return to work. REGISTRATION: Australian New Zealand Clinical Trials Registry ANZCTRN 12608000459325.

Global systematic review of the cost-effectiveness of indigenous health interventions.

BACKGROUND: Indigenous populations around the world have consistently been shown to bear a greater burden of disease, death and disability than their non-Indigenous counterparts. Despite this, little is known about what constitutes cost-effective interventions in these groups. The objective of this paper was to assess the global cost-effectiveness literature in Indigenous health to identify characteristics of successful and unsuccessful interventions and highlight areas for further research. METHODS AND FINDINGS: A systematic review of the published literature was carried out. MEDLINE, PSYCINFO, ECONLIT, EMBASE and CINAHL were searched with terms to identify cost-effectiveness evaluations of interventions in Indigenous populations around the world. The WHO definition was followed in identifying Indigenous populations. 19 studies reporting on 27 interventions were included in the review. The majority of studies came from high-income nations with only two studies of interventions in low and middle-income nations. 22 of the 27 interventions included in the analysis were found to be cost-effective or cost-saving by the respective studies. There were only two studies that focused on Indigenous communities in urban areas, neither of which was found to be cost-effective. There was little attention paid to Indigenous conceptions of health in included studies. Of the 27 included studies, 23 were interventions that specifically targeted Indigenous populations. Outreach programs were shown to be consistently cost-effective. CONCLUSION: The comprehensive review found only a small number of studies examining the cost-effectiveness of interventions into Indigenous communities around the world. Given the persistent disparities in health outcomes faced by these populations and commitments from governments around the world to improving these outcomes, it is an area where the health economics and public health fields can play an important role in improving the health of millions of people.