Towards Optimizing Hospitalized Older adults' MEdications (TO HOME): Multi-centre study of medication use and outcomes in routine care.

AIMS: Comprehensively investigate prescribing in usual care of hospitalized older people with respect to polypharmacy; potentially inappropriate medications (PIMs) according to Beers criteria; and cumulative anticholinergic and sedative medication exposure calculated with Drug Burden Index (DBI). Specifically, to quantify exposure to these measures on admission, changes between admission and discharge, associations with adverse outcomes and medication costs. METHODS: Established new retrospective inpatient cohort of 2000 adults aged ≥75 years, consecutively admitted to 6 hospitals in Sydney, Australia, with detailed information on medications, clinical characteristics and outcomes. Conducted cross-sectional analyses of index admission data from cohort. RESULTS: Cohort had mean (standard deviation) age 86.0 (5.8) years, 59% female, 21% from residential aged care. On admission, prevalence of polypharmacy was 77%, PIMs 34% and DBI > 0 in 53%. From admission to discharge, mean difference (95% confidence interval) in total number of medications increased 1.05 (0.92, 1.18); while prevalence of exposure to PIMs (-3.8% [-5.4, -2.1]) and mean DBI score (-0.02 [-0.04, -0.01]) decreased. PIMs and DBI score were associated with increased risks (adjusted odds ratio [95% confidence interval]) of falls (PIMs 1.63 [1.28, 2.08]; DBI score 1.21[1.00, 1.46]) and delirium (PIMs 1.76 [1.38, 1.46]; DBI score 1.42 [1.19, 1.71]). Each measure was associated with increased risk of adverse drug reactions (polypharmacy 1.42 [1.19, 1.71]; PIMs 1.87 [1.40, 2.49]; DBI score 1.90 [1.55, 2.15]). Cost (AU$/patient/hospital day) of medications contributing to PIMs and DBI was low ($0.29 and $0.88). CONCLUSION: In this large cohort of older inpatients, usual hospital care results in an increase in number of medications and small reductions in PIMs and DBI, with variable associations with adverse outcomes.

Patient Preferences for Anxiety and Depression Screening in Cancer Care: A Discrete Choice Experiment.

OBJECTIVES: Screening for anxiety and depression in cancer care is recommended, as identification is the first step in managing anxiety and depression. Nevertheless, patient preferences for anxiety and depression screening in cancer care are unknown. The objective of this study was to investigate and identify the aspects of an anxiety and depression screening program cancer patients value most, to inform decision-makers about ways to improve patient uptake and ultimately, the provision of patient-centered care. METHODS: A discrete choice experiment was designed and implemented within an Australian cancer population sample. Participants were presented with a series of hypothetical screening programs labeled as "screening program 1" and "screening program 2" and were asked to choose their preferred one. The discrete choice experiment was administered using an online survey platform. A mixed logit and a latent class analysis was conducted. RESULTS: Participants (n = 294) preferred screening to be conducted by a cancer nurse, face-to-face, and at regular intervals (monthly or every 3 months). Participants also preferred follow-up care to be delivered by mental health professionals embedded within the cancer care team. Factors that influenced preferences were the low cost and short waiting times for access to care. CONCLUSIONS: Cancer patients prefer cancer services with integrated mental healthcare services. To maximize patient uptake, anxiety and depression screening programs should be routinely offered, delivered by oncology healthcare staff in a face-to-face format, and, postscreening, to be care for by mental health professionals embedded within the cancer service.

Understanding general practitioners' prescribing choices to patients with chronic low back pain: a discrete choice experiment.

BACKGROUND: Although NSAIDs are recommended as a first line analgesic treatment, opioids are very commonly prescribed to patients with low back pain (LBP) despite risks of harms. AIM: This study aimed to determine factors contributing to general practitioners' (GPs') prescribing choices to patients with chronic LBP in a primary care setting. METHOD: This discrete choice experiment (DCE) presented 210 GPs with hypothetical scenarios of a patient with chronic LBP. Participants chose their preferred treatment for each choice set, either the opioid, NSAID or neither. The scenarios varied by two patient attributes; non-specific LBP or LBP with referred leg pain (sciatica) and number of comorbidities. The three treatment attributes also varied, being: the type of opioid or NSAID, degree of pain reduction and number of adverse events. The significance of each attribute in influencing clinical decisions was the primary outcome and the degree to which GPs preferred the alternative based on the number of adverse events or the amount of pain reduction was the secondary outcome. RESULTS: Overall, GPs preferred NSAIDs (45.2%, 95% CI 38.7-51.7%) over opioids (28.8%, 95% CI 23.0-34.7%), however there was no difference between the type of NSAID or opioid preferred. Additionally, the attributes of pain reduction and adverse events did not influence a GP's choice between NSAIDs or opioids for patients with chronic LBP. CONCLUSION: GPs prefer prescribing NSAIDs over opioids for a patient with chronic low back pain regardless of patient factors of comorbidities or the presence of leg pain (i.e. sciatica).

The Cost of Raising Individuals with Fragile X or Chromosome 15 Imprinting Disorders in Australia.

The study characterised differences in costs associated with raising a child between four rare disorders and examined the associations between these costs with clinical severity. Caregivers of 108 individuals with Prader-Willi, Angelman (AS), Chromosome 15q Duplication and fragile X (FXS) syndromes completed a modified Client Services Receipt Inventory and participants completed intellectual/developmental functioning and autism assessments. AS incurred the highest yearly costs per individual ($AUD96,994), while FXS had the lowest costs ($AUD33,221). Intellectual functioning negatively predicted total costs, after controlling for diagnosis. The effect of intellectual functioning on total costs for those with AS was significantly different to the other syndromes. The study highlights the significant costs associated with these syndromes, particularly AS, linked with severity of intellectual functioning.

The costs, health outcomes and cost-effectiveness of interventions for the prevention and treatment of incontinence-associated dermatitis: A systematic review.

BACKGROUND: Incontinence-associated dermatitis is a common, under-recognized painful skin condition associated with poorer quality of life, increased nurse workloads, and costs. OBJECTIVE: To systematically review economic evidence for the prevention and treatment of incontinence-associated dermatitis. DESIGN: Systematic review of quantitative research. DATA SOURCES: PubMed, MEDLINE, EMBASE, Cochrane Library, York Centre for Reviews and Dissemination database, Econlit, Tufts' Cost-Effectiveness Analysis Registry, and Web of Science. REVIEW METHODS: A comprehensive search for studies on resource use (costs), health outcomes, and cost-effectiveness of interventions for incontinence-associated dermatitis was conducted. Screening, data extraction, and initial quality assessment were conducted independently by two reviewers, with disagreements/queries regarding quality settled through consensus with the larger team. Quality evaluated using the Consolidated Health Economic Evaluation Reporting Standards checklist and results narratively arranged. FINDINGS: Seventeen studies (10 for prevention, one for treatment and six for both prevention and treatment) included. All studies measured resource use from a healthcare provider perspective; 14 quantified resources in monetary terms. Considerable variation existed in the resource use data primarily due to differences in the type of resources counted, selected time horizons, valuation methods, and reporting approaches. Ten studies provided evidence of their intervention to be cost saving (or at least cost avoiding). Five studies on barrier products provided evidence to be cost saving: three for prevention, one for treatment, and one for both prevention and treatment. Two studies of cleanser and barrier products provided evidence to be cost saving for the prevention and treatment of incontinence-associated dermatitis. One study found a cleanser to be a cost saving preventative intervention. One bowel management system was found to be cost saving over time only, and one nurse education intervention was found to be cost saving for preventing and treating incontinence-associated dermatitis. One barrier product was found to be cost-effective for preventing and treating the condition. Finally, one study found a cleanser and barrier product was time saving for prevention. None of the studies incorporated a multi-attribute quality of life measure; however, two studies included person-reported outcome measures for pain. A narrow range of resources (mainly products) were considered, and there was limited information on how they were counted and valued. Analyses relating to heterogeneity among patients/hospital wards or health facilities and uncertainty were lacking. CONCLUSIONS: Barrier products are possibly a more cost-effective treatment than others; however, this evidence lacks certainty. Structured health economic evaluations are required for a reliable evidence-base on the interventions for incontinence-associated dermatitis. TWEETABLE ABSTRACT: Most incontinence-associated dermatitis studies lack person-reported outcomes, costs beyond product/staff time, and economic evaluation.

Adding value to clinical trial registries: insights from Australian Cancer Trials Online, a website for consumers.

BACKGROUND: Clinical trials registries are now operating in the USA, Europe, Australia, China, and India and more are planned. Trial registries could be an excellent source of information about clinical trials for patients and others affected by cancer as well as health care professionals, but may be difficult for patients to navigate and use. PURPOSE: An opportunity arose in Australia to develop a consumer friendly cancer clinical trials website (Australian Cancer Trials Online (ACTO), www.australiancancertrials.gov.au) using an automated data feed from two large clinical trial registries. In this article, we describe aspects of this new website, and explore ways in which such a website may add value to clinical trial data which are already collected and held by trial registries. METHODS: The development of ACTO was completed by a Web company working in close association with staff at the Australian New Zealand Clinical Trials Registry (ANZCTR), and with consumer representatives. Data for the website were sourced directly and only from clinical trial registries, thus avoiding the creation of an additional trials database. It receives an automated, daily data feed of newly registered cancer clinical trials from both the ANZCTR and Clinical Trials.gov. RESULTS: The development of ACTO exemplifies the advantage of a local clinical trial registry working with consumers to provide accessible information about cancer clinical trials to meet consumers' information needs. We found that the inclusion of a lay summary added substantial value for consumers, and recommend that consideration be given to adding a lay summary to the mandatory data items collected by all trial registries. Furthermore, improved navigation, decision support tools, and consistency in data collection between clinical trial registries will also enable consumer websites to provide additional value for users. LIMITATIONS: Clinical trial registration is not compulsory in Australia. If the additional cancer items (including a lay summary) are not provided by registrants of cancer trials on ANZCTR, this can compromise the quality and usefulness of the data for the end-user, in this case consumers, as they may encounter gaps in the data. CONCLUSION: Expanding the World Health Organization Trial Registration Data Set to include this additional information, particularly the lay summary, would be valuable. A well-coordinated system of clinical trial registration is critical to the success of efforts to provide better access for all to inform about clinical trials.

Investigating the Association Between Self-Reported Comorbid Anxiety and Depression and Health Service Use in Cancer Survivors.

BACKGROUND: Anxiety and depression have a higher prevalence in cancer survivors than in the general population and are associated with lower quality of life, poorer survival and an increased risk of suicide. Anxiety and depression are also highly comorbid among cancer survivors and associated with increased health service use. As such, it is important to consider both anxiety and depression and health service use in cancer survivors. OBJECTIVE: Our objective was to explore the association between anxiety and depression and health service utilisation, both cancer-specific and general doctor visits, in cancer survivors. METHODS: Data from a Dutch cancer registry were analysed to determine the association between anxiety and depression (measured using the Hospital Anxiety and Depression Scale) and health service use. Negative binomial regression models, controlling for patient demographics, comorbidities and cancer-related variables were estimated. RESULTS: Cancer survivors (n = 2538), with a mean age of 61.1 years and between 0.7 and 10.9 years since diagnosis, were included in the analysis. Increasing levels of anxiety and depression were associated with increased health service use. Having severe levels of anxiety was associated with more frequent visits to the general practitioner (p < 0.001). Severe depression in cancer survivors was associated with more frequent visits to the specialist (p < 0.001). CONCLUSION: Anxiety and depression in cancer survivors, particularly severe anxiety and depression, were associated with increased health service use. Treatment of anxiety and depression in cancer survivors has the potential to reduce overall health service use and associated costs and improve health outcomes for cancer survivors.

Using Discrete-Choice Experiment Methods to Estimate the Value of Informal Care: The Case of Children with Intellectual Disability.

OBJECTIVES: This research produces a preference-based monetary valuation of informal care provided to children with intellectual disability (ID) that can be directly applied in economic evaluations. METHODS: A discrete-choice experiment (DCE) was designed to elicit an individual's willingness to accept compensation for different care tasks. Respondents were presented choice sets that included a care package comprising different amounts and types of care and asked to choose between the care package provided free of charge or providing that care themselves and receiving cash compensation. The care package included personal care, social support, household errands and housework, with the value of compensation, number of care hours provided and types of care varied across the choice sets. Choices were analysed using a generalised multinomial logit model and latent class model. RESULTS: A representative sample of 198 caregivers completed the survey (response rate 52%). Participants were recruited in Australia. Overall, caregivers would accept a minimum of Australian dollars ($A)20.61 to provide 1 h of care. The preferences for assistance varied significantly with different types of care tasks. Individuals placed the highest value on receiving assistance with social support ($A35.96) and the least value on receiving assistance with household errands ($A-0.92) CONCLUSIONS: This study produces a value of informal care provided to children with ID that can be directly applied in economic evaluations. The study shows that informal care tasks are not valued equally. Caregivers placed the most value on receiving assistance with social support, which may reflect the time spent by caregivers on these tasks.

The hidden costs of drug and alcohol use in hospital emergency departments.

INTRODUCTION AND AIMS: This study estimates the burden of drug and alcohol morbidity on hospitals in New South Wales (NSW) by observing a multi-site collective sample utilising survey information and data linkage. Specifically we aimed to determine the prevalence of alcohol and other drug (AOD) problems and to estimate patterns of utilisation of hospital services, costs of presentations, and admissions for patients with AOD problems. DESIGN AND METHODS: Patients were recruited from eight NSW public hospitals presenting to the hospital emergency department over a 10 day period. Participants completed a self-administered survey with demographic characteristics and questions about substance use. More than two-thirds (68%) of participants consented to provide access to their NSW Health medical data for a period spanning 2.5 years. RESULTS: One-third (35%) of the total sample were identified as having problematic AOD use with one in five of these patients requiring a high level of intervention. Those patients requiring a high level of intervention present more often and cost more per presentation. If admitted they were more likely to have longer stays and were also more likely to be admitted to a psychiatric ward and have a longer stay in the ward. DISCUSSION: This study demonstrates a need for AOD interventions in the emergency department setting, both because it represents an opportunity for intervention in a population in which problems with substance use is highly prevalent, and because there is evidence that AOD imposes additional costs on the health system. [Butler K, Reeve R, Arora S, Viney R, Goodall S, van Gool K, Burns L. The hidden costs of drug and alcohol use in hospital emergency departments. Drug Alcohol Rev 2016;35:359-366].

Evaluating the Impact of Hospital Based Drug and Alcohol Consultation Liaison Services.

Consultation liaison (CL) services provide direct access to specialist services for support, treatment advice and assistance with the management of a given condition. Alcohol and other drugs (AOD) CL services aim to improve identification and treatment of patients with AOD morbidity. Our objective was to evaluate the costs and consequences of AOD CL services in hospitals in New South Wales, Australia. Patients were surveyed at eight hospitals and problematic AOD use was identified using the Alcohol, Smoking and Substance Involvement Screening Test (n=1615). For consenting participants, medical record data were obtained from 18 months pre- to 12 months post-survey. We used interrupted time series analyses to compare utilization and costs for patients with and without AOD problems and changes over time between those who received AOD CL and similar patients. Approximately 35% of patients surveyed had AOD problems (excluding tobacco) with 7% requiring intensive treatment. Only 24% of patients requiring intensive treatment were treated by AOD CL. Those treated had relative improvements over time in the cost of presentations to emergency departments, emergency admission performance and increased uptake of appropriate pharmaceuticals. The estimated net benefit of AOD CL services was at least AUD$100,000 savings per hospital per year. Expanding AOD CL services to address current unmet need may lead to even greater cost savings for hospitals.

A cross-sectional analysis of over-the-counter codeine use among an Australian sample of people who regularly inject drugs.

INTRODUCTION AND AIMS: The study aims to examine the medical and non-medical use of over-the-counter (OTC) codeine combination drugs in a sample of people who inject drugs; and to examine risk factors associated with exceeding the recommended dose of OTC codeine, including the experience of pain. DESIGN AND METHODS: This study analysed annual survey data from a convenience sample of people who inject drugs in Australia who are interviewed for the Illicit Drug Reporting System. People who have injected drugs (n = 902) on at least a monthly basis in the preceding six months across Australia were interviewed. Participants were asked about their use of OTC codeine and their experience of pain. RESULTS: One third (35%) of participants had used OTC codeine in the preceding six months and 52% (95% confidence interval 48.7-55.3) of this group had exceeded the recommended dose on their last occasion of use. This clearly places them at increased risk of harms associated with toxicity from the accompanying analgesic found in combination codeine products. Multivariate analyses demonstrated that those exceeding the recommended codeine dose of OTC codeine were more likely to be experiencing moderate to very severe pain. DISCUSSION AND CONCLUSION: There is a need to evaluate the approach to pain management in this population. Greater pharmacist involvement, real-time monitoring of sales, the development of screening tools to identify those at risk of harm and further education of primary care practitioners could be beneficial in reducing the risk of harm associated with these medications for all users of OTC codeine, including people who inject drugs.