An integrated multicomponent care model for men affected by prostate cancer: A feasibility study of TrueNTH Australia.

OBJECTIVE: To evaluate the feasibility of implementing an integrated multicomponent survivorship care model for men affected by prostate cancer. METHODS: Using a single arm prospective cohort study design, men with prostate cancer were recruited from two regional public hospitals in Australia for a 6-months program that provided information and decision support, exercise and nutrition management, specialised clinical support, and practical support through localised and central care coordination. Carers of the men were also invited to the program. Data were collected from multiple sources to evaluate: (1) recruitment capability and participant characteristics; (2) appropriateness and feasibility of delivering the specific intervention components using an electronic care management tool; and (3) suitability of data collection procedures and proposed outcome measures. RESULTS: Of the 105 eligible men, 51 (consent rate 49%) participated in the program. Of the 31 carers nominated by the men, 13 consented (consent rate 42%). All carers and 50 (98%) men completed the program. Most (92%) men were newly diagnosed with localised prostate cancer. All men attended initial screening and assessment for supportive care needs; a total of 838 episodes of contact/consultation were made by the intervention team either in person (9%) or remotely (91%). The intervention was implemented as proposed with no adverse events. The proposed outcome measures and evaluation procedures were found to be appropriate. CONCLUSIONS: Our results support the feasibility of implementing this integrated multicomponent care model for men affected by prostate cancer.

A Systematic Review and Meta-Analysis of Prostate Cancer Utility Values of Patients and Partners Between 2007 and 2016.

Background. There is widespread agreement that both the length and quality of life matter when assessing new technologies and/or models of care in the treatment for cancer patients. Quality of life for partners/carers also matters, particularly for prostate cancer. Purpose. This systematic review aims to provide up-to-date utility values along the prostate cancer care continuum (i.e., from prescreening through to palliative care) for use where future trial-based or modelled economic evaluations cannot collect primary data from men and/or partners. Data Sources. A protocol was developed and registered on the international register of systematic reviews-PROSPERO. Databases searched included EBSCO Information Services (CINAHL, EconLit, Global Health, HEED, MEDLINE Complete, PsycINFO), Cochrane Database of Systematic Reviews, Web of Science, and Embase. Study Selection. Study selection terms included health-related quality of life, prostate cancer, and partners or carers. Data Extraction. The authors identified articles published between 2007 and 2016 that provided health state utility values, with statistical uncertainty, for men with or at risk of prostate cancer and/or their partner/carers. Data Synthesis and Results. Study quality and generalizability of utilities was evaluated and meta-analysis conducted against prespecified criteria. From 906 original articles, 29 recent primary studies met the inclusion/exclusion criteria. We tabulate all the utility values with uncertainty, along with considerable methodological detail and patient population characteristics. Limitations. Utility values pertaining to carers/partners were limited to one study. Conclusions. Studies varied in design, measurement instruments utilized, quality, and generalizability. There is sufficient qualitative and quantitative detail for the reported utility values to be readily incorporated into economic evaluations. More research is needed with carers/partners and with newly developing prostate cancer-specific quality of life tools.

Effect of a price discount and consumer education strategy on food and beverage purchases in remote Indigenous Australia: a stepped-wedge randomised controlled trial.

BACKGROUND: Evidence is mounting that price discounts can be effective in improving diet. This study examined the effectiveness of a 20% price discount on food and drink purchases with and without consumer education in remote Indigenous Australia. METHODS: A 20% discount on fruit, vegetables, water, and artificially sweetened soft drinks was applied for 24 weeks in 20 communities in remote Indigenous Australia where the community store was managed by the Arnhem Land Progress Aboriginal Corporation (ALPA) or Outback Stores (OBS) in a stepped-wedge randomised trial. Communities were randomly allocated to a fixed framework of five sets of four stratified by store association; ten stores (two in each set) were randomly assigned to receive consumer education. A store from each of the ALPA and OBS store groups (contained in separate opaque envelopes) was selected, and stores in turn continued to be consecutively allocated to the fixed store set framework, starting with the first store slot in the first store set, until all stores had been allocated. The effect of the discount on the weight of fruit and vegetables purchased (the primary endpoint) was assessed using weekly store sales data and mixed models per protocol. We did sensitivity analyses by repeating the analyses with the outliers included and repeating the analyses for the primary outcome measure removing each store one at a time. This trial was registered with Australian New Zealand Clinical Trials Registry, number ACTRN12613000694718. FINDINGS: Weekly store sales data on all food and drink products sold in 20 stores were collected from July 1, 2012, to Dec 28, 2014. Price discount alone was associated with a 12·7% (95% CI 4·1-22·1) increase in purchases in grams of fruit and vegetables combined (primary outcome), and a 19·8% (6·2-35·1) increase post discount (after vs before); an effect of 12 g and 18 g per capita per day. Sensitivity analyses did not modify the results for the primary outcome measure. INTERPRETATION: A 20% discount can only increase fruit and vegetable purchases to help protect against obesity and diet related disease to a certain extent. Large discounts might have a greater impact than small discounts. Creative merchandising approaches to consumer education could also be considered alongside fiscal interventions to achieve marked improvements in diet. FUNDING: Australian National Health and Medical Research Council.

Stores Healthy Options Project in Remote Indigenous Communities (SHOP@RIC): a protocol of a randomised trial promoting healthy food and beverage purchases through price discounts and in-store nutrition education.

BACKGROUND: Indigenous Australians suffer a disproportionate burden of preventable chronic disease compared to their non-Indigenous counterparts--much of it diet-related. Increasing fruit and vegetable intakes and reducing sugar-sweetened soft-drink consumption can reduce the risk of preventable chronic disease. There is evidence from some general population studies that subsidising healthier foods can modify dietary behaviour. There is little such evidence relating specifically to socio-economically disadvantaged populations, even though dietary behaviour in such populations is arguably more likely to be susceptible to such interventions.This study aims to assess the impact and cost-effectiveness of a price discount intervention with or without an in-store nutrition education intervention on purchases of fruit, vegetables, water and diet soft-drinks among remote Indigenous communities. METHODS/DESIGN: We will utilise a randomised multiple baseline (stepped wedge) design involving 20 communities in remote Indigenous Australia. The study will be conducted in partnership with two store associations and twenty Indigenous store boards. Communities will be randomised to either i) a 20% price discount on fruit, vegetables, water and diet soft-drinks; or ii) a combined price discount and in-store nutrition education strategy. These interventions will be initiated, at one of five possible time-points, spaced two-months apart. Weekly point-of-sale data will be collected from each community store before, during, and for six months after the six-month intervention period to measure impact on purchasing of discounted food and drinks. Data on physical, social and economic factors influencing weekly store sales will be collected in order to identify important covariates. Intervention fidelity and mediators of behaviour change will also be assessed. DISCUSSION: This study will provide original evidence on the effectiveness and cost-effectiveness of price discounts with or without an in-store nutrition education intervention on food and drink purchasing among a socio-economically disadvantaged population in a real-life setting. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12613000694718.

The societal benefits of reducing six behavioural risk factors: an economic modelling study from Australia.

BACKGROUND: A large proportion of disease burden is attributed to behavioural risk factors. However, funding for public health programs in Australia remains limited. Government and non-government organisations are interested in the productivity effects on society from reducing chronic diseases. We aimed to estimate the potential health status and economic benefits to society following a feasible reduction in the prevalence of six behavioural risk factors: tobacco smoking; inadequate fruit and vegetable consumption; high risk alcohol consumption; high body mass index; physical inactivity; and intimate partner violence. METHODS: Simulation models were developed for the 2008 Australian population. A realistic reduction in current risk factor prevalence using best available evidence with expert consensus was determined. Avoidable disease, deaths, Disability Adjusted Life Years (DALYs) and health sector costs were estimated. Productivity gains included workforce (friction cost method), household production and leisure time. Multivariable uncertainty analyses and correction for the joint effects of risk factors on health status were undertaken. Consistent methods and data sources were used. RESULTS: Over the lifetime of the 2008 Australian adult population, total opportunity cost savings of AUD2,334 million (95% Uncertainty Interval AUD1,395 to AUD3,347; 64% in the health sector) were found if feasible reductions in the risk factors were achieved. There would be 95,000 fewer DALYs (a reduction of about 3.6% in total DALYs for Australia); 161,000 less new cases of disease; 6,000 fewer deaths; a reduction of 5 million days in workforce absenteeism; and 529,000 increased days of leisure time. CONCLUSIONS: Reductions in common behavioural risk factors may provide substantial benefits to society. For example, the total potential annual cost savings in the health sector represent approximately 2% of total annual health expenditure in Australia. Our findings contribute important new knowledge about productivity effects, including the potential for increased household and leisure activities, associated with chronic disease prevention. The selection of targets for risk factor prevalence reduction is an important policy decision and a useful approach for future analyses. Similar approaches could be applied in other countries if the data are available.

Economic benefits of achieving realistic smoking cessation targets in Australia.

OBJECTIVES: We estimated the economic impact of reductions in the prevalence of tobacco smoking on health, production, and leisure in the 2008 Australian population. METHODS: We selected a prevalence target of 15%. Cohort lifetime health benefits were modeled as fewer incident cases of tobacco-related diseases, deaths, and disability-adjusted life-years. We estimated production gains by comparing surveyed participation and absenteeism rates of adult smokers and ex-smokers valued according to the human capital and friction cost approaches. We estimated household production and leisure gains from time use surveys and valued these gains with the appropriate proxy. RESULTS: In the 2008 Australian population, an absolute reduction in smoking prevalence of 8% would result in 158,000 fewer incident cases of disease, 5000 fewer deaths, 2.2 million fewer lost working days, and 3000 fewer early retirements and would reduce health sector costs by AUD 491 million. The gain in workforce production was AUD 415 million (friction cost) or AUD 863 million (human capital), along with gains of 373,000 days of household production and 23,000 days of leisure time. CONCLUSIONS: Lowering smoking prevalence rates can lead to substantial economic savings and health benefits.

Priority setting in health: origins, description and application of the Australian Assessing Cost-Effectiveness initiative.

This article reports on the 'Assessing Cost-Effectiveness' (ACE) initiative in priority setting from Australia. It commences with why priority setting is topical and notes that a wide variety of approaches are available. In assessing these various approaches, it is argued that a useful first step is to consider what constitutes an 'ideal' approach to priority setting. A checklist to guide priority setting is presented based on guidance from economic theory, ethics and social justice, lessons from empirical experience and the needs of decision-makers. The checklist is seen as an important contribution because it is the first time that criteria from such a broad range of considerations have been brought together to develop a framework for priority setting that endeavors to be both realistic and theoretically sound. The checklist will then be applied to a selection of existing approaches in order to illustrate their deficiencies and to provide the platform for explaining the unique features of the ACE approach. A case study (ACE-Cancer) will then be presented and assessed against the checklist, including reaction from stakeholders in the cancer field. The article concludes with an overview of the full body of ACE research completed to date, together with some reflections on the ACE experience.

Assessing cost-effectiveness of drug interventions for schizophrenia.

OBJECTIVE: To assess from a health sector perspective the incremental cost-effectiveness of eight drug treatment scenarios for established schizophrenia. METHOD: Using a standardized methodology, costs and outcomes are modelled over the lifetime of prevalent cases of schizophrenia in Australia in 2000. A two-stage approach to assessment of health benefit is used. The first stage involves a quantitative analysis based on disability-adjusted life years (DALYs) averted, using best available evidence. The robustness of results is tested using probabilistic uncertainty analysis. The second stage involves application of 'second filter' criteria (equity, strength of evidence, feasibility and acceptability) to allow broader concepts of benefit to be considered. RESULTS: Replacing oral typicals with risperidone or olanzapine has an incremental cost-effectiveness ratio (ICER) of 48,000 Australian dollars and 92,000 Australian dollars/DALY respectively. Switching from low-dose typicals to risperidone has an ICER of 80,000 Australian dollars. Giving risperidone to people experiencing side-effects on typicals is more cost-effective at 20,000 Australian dollars. Giving clozapine to people taking typicals, with the worst course of the disorder and either little or clear deterioration, is cost-effective at 42,000 Australian dollars or 23,000 Australian dollars/DALY respectively. The least cost-effective intervention is to replace risperidone with olanzapine at 160,000 Australian dollars/DALY. CONCLUSIONS: Based on an 50,000 Australian dollars/DALY threshold, low-dose typical neuroleptics are indicated as the treatment of choice for established schizophrenia, with risperidone being reserved for those experiencing moderate to severe side-effects on typicals. The more expensive olanzapine should only be prescribed when risperidone is not clinically indicated. The high cost of risperidone and olanzapine relative to modest health gains underlie this conclusion. Earlier introduction of clozapine however, would be cost-effective. This work is limited by weaknesses in trials (lack of long-term efficacy data, quality of life and consumer satisfaction evidence) and the translation of effect size into a DALY change. Some stakeholders, including SANE Australia, argue the modest health gains reported in the literature do not adequately reflect perceptions by patients, clinicians and carers, of improved quality of life with these atypicals.

Burden of disease and injury in Aboriginal and non-Aboriginal populations in the Northern Territory.

OBJECTIVE: To quantify the burden of disease and injury for the Aboriginal and non-Aboriginal populations in the Northern Territory. DESIGN AND SETTING: Analysis of Northern Territory data for 1 January 1994 to 30 December 1998 from multiple sources. MAIN OUTCOME MEASURES: Disability-adjusted life-years (DALYs), by age, sex, cause and Aboriginality. RESULTS: Cardiovascular disease was the leading contributor (14.9%) to the total burden of disease and injury in the NT, followed by mental disorders (14.5%) and malignant neoplasms (11.2%). There was also a substantial contribution from unintentional injury (10.4%) and intentional injury (4.9%). Overall, the NT Aboriginal population had a rate of burden of disease 2.5 times higher than the non-Aboriginal population; in the 35-54-year age group their DALY rate was 4.1 times higher. The leading causes of disease burden were cardiovascular disease for both Aboriginal men (19.1%) and women (15.7%) and mental disorders for both non-Aboriginal men (16.7%) and women (22.3%). CONCLUSIONS: A comprehensive assessment of fatal and non-fatal conditions is important in describing differentials in health status of the NT population. Our study provides comparative data to identify health priorities and facilitate a more equitable distribution of health funding.