Assessing health state utilities for people with myalgic encephalomyelitis/chronic fatigue syndrome in Australia using the EQ-5D-5L, AQoL-8D and EQ-5D-5L-psychosocial instruments.

PURPOSE: Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a chronic condition with a constellation of symptoms presenting as severe and profound fatigue of ≥ 6 months not relieved by rest. ME/CFS affects health-related quality of life (HRQoL), which can be measured using multi-attribute health state utility (HSU) instruments. The aims of this study were to quantify HSUs for people living with ME/CFS, and to identify an instrument that is preferentially sensitive for ME/CFS. METHODS: Cross-sectional national survey of people with ME/CFS using the AQoL-8D and EQ-5D-5L. Additional questions from the AQoL-8D were used as 'bolt-ons' to the EQ-5D-5L (i.e., EQ-5D-5L-Psychosocial). Disability and fatigue severity were assessed using the De Paul Symptom Questionnaire-Short Form (DSQ-SF). HSUs were generated using Australian tariffs. Mean HSUs were stratified for sociodemographic and clinical factors. Bland-Altman plots were used to compare the three HSU instruments. RESULTS: For the 198 participants, mean HSUs (95% confidence intervals) were EQ-5D-5L: 0.46 (0.42-0.50); AQoL-8D: 0.43 (0.41-0.45); EQ-5D-5L-Psychosocial: 0.44 (0.42-0.46). HSUs were substantially lower than population norms: EQ-5D-5L: 0.89; AQoL-8D: 0.77. As disability and fatigue severity increased, HSUs decreased in all three instruments. Bland-Altman plots revealed interchangeability between the AQoL-8D and EQ-5D-5LPsychosocial. Floor and ceiling effects of 13.5% and 2.5% respectively were observed for the EQ-5D-5L instrument only. CONCLUSIONS: ME/CFS has a profound impact on HRQoL. The AQoL-8D and EQ-5D-5L-Psychosocial can be used interchangeably: the latter represents a reduced participant burden.

The economic burden of myalgic encephalomyelitis/chronic fatigue syndrome in Australia.

Objective This study aimed to estimate costs of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) to patients, government and Australian society. Methods Australian ME/CFS patients and their carers were recruited using convenience sampling. Patients completed an online retrospective cost diary, providing ME/CFS-related direct medical, non-medical and indirect costs. Informal care costs were collected directly from carers. Data from the Pharmaceutical Benefits Scheme and Medicare Benefits Schedule were linked to participant survey data. Annual per patient and total societal costs were estimated, broken down by category and presented in 2021 AUD. Factors associated with higher costs were investigated using generalised linear models. Results One hundred and seventy five patients (mean age 49 years s.d. 14, 79.4% female) completed the cost diary. Estimated total annual societal costs of ME/CFS in Australia ranged between $1.38 and $10.09 billion, with average annual total costs of $63 400/patient. Three-quarters of these costs were due to indirect costs ($46 731). Disability severity was the key factor associated with higher costs, particularly for indirect costs (being 2.27-fold higher for severe disability than no/mild disability). Conclusions ME/CFS poses a significant economic burden in Australia, owing mainly to high indirect and informal care costs.

Challenges for Medicare and universal health care in Australia since 2000.

OBJECTIVES: To identify the financing and policy challenges for Medicare and universal health care in Australia, as well as opportunities for whole-of-system strengthening. STUDY DESIGN: Review of publications on Medicare, the Pharmaceutical Benefits Scheme, and the universal health care system in Australia published 1 January 2000 - 14 August 2021 that reported quantitative or qualitative research or data analyses, and of opinion articles, debates, commentaries, editorials, perspectives, and news reports on the Australian health care system published 1 January 2015 - 14 August 2021. Program-, intervention- or provider-specific articles, and publications regarding groups not fully covered by Medicare (eg, asylum seekers, prisoners) were excluded. DATA SOURCES: MEDLINE Complete, the Health Policy Reference Centre, and Global Health databases (all via EBSCO); the Analysis & Policy Observatory, the Australian Indigenous HealthInfoNet, the Australian Public Affairs Information Service, Google, Google Scholar, and the Organisation for Economic Co-operation and Development (OECD) websites. RESULTS: The problems covered by the 76 articles included in our review could be grouped under seven major themes: fragmentation of health care and lack of integrated health financing, access of Aboriginal and Torres Strait Islander people to health services and essential medications, reform proposals for the Pharmaceutical Benefits Scheme, the burden of out-of-pocket costs, inequity, public subsidies for private health insurance, and other challenges for the Australian universal health care system. CONCLUSIONS: A number of challenges threaten the sustainability and equity of the universal health care system in Australia. As the piecemeal reforms of the past twenty years have been inadequate for meeting these challenges, more effective, coordinated approaches are needed to improve and secure the universality of public health care in Australia.

Use of General Practitioner Telehealth Services During the COVID-19 Pandemic in Regional Victoria, Australia: Retrospective Analysis.

BACKGROUND: In March 2020, the Australian Government expanded general practitioner (GP) telehealth services in response to the COVID-19 pandemic. OBJECTIVE: This study sought to assess use patterns of GP telehealth services in response to changing circumstances (before and during the COVID-19 pandemic and with or without a lockdown) in regional Victoria, Australia. METHODS: We conducted a secondary analysis of monthly Medicare claims data from July 2019 to June 2021 from 140 regional GP practices in Western Victoria. The longitudinal patterns of proportion of GP telehealth consultations stratified by type of consultation (ie, videoconference vs telephone) and by geographical, consumer, and consultation characteristics were analyzed. RESULTS: Telehealth comprised 25.8% (522,932/2,025,615) of GP consultations over the 2-year period. After the introduction of the Australian telehealth expansion policy in March 2020, there was a rapid uptake in GP telehealth services (including telephone and video services), from 0% before COVID-19 to 15% (11,854/80,922) of all consultations in March 2020, peaking at 55% (50,828/92,139) in August 2020. Thereafter, the use of telehealth declined steadily to 31% (23,941/77,344) in January 2021 and tapered off to 28% (29,263/103,798) in June 2021. Telephone services and shorter consultations were the most dominant form, and those aged 15-64 years had higher telehealth use rates than younger or older age groups. The proportion of video consultations was higher during periods with government-imposed lockdowns and higher in the most socioeconomically advantaged areas compared to less socioeconomically advantaged areas. CONCLUSIONS: Our findings support the continuation of telehealth use in rural and regional Australia post pandemic. Future policy must identify mechanisms to reduce existing equity gaps in video consultations and consider patient- and system-level implications of the dominant use of short telephone consultations.

Prevalence of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) in Australian primary care patients: only part of the story?

BACKGROUND: ME/CFS is a disorder characterized by recurrent fatigue and intolerance to exertion which manifests as profound post-exertional malaise. Prevalence studies internationally have reported highly variable results due to the 20 + diagnostic criteria. For Australia, the prevalence of ME/CFS based on current case definitions is unknown. OBJECTIVES: To report prevalence of ME/CFS in patients aged ≥ 13 years attending Australian primary care settings for years 2015-2019, and provide context for patterns of primary care attendance by people living with ME/CFS. METHODOLOGY: Conducted in partnership with the Patient Advisory Group, this study adopted a mixed methods approach. De-identified primary care data from the national MedicineInsight program were analyzed. The cohort were regularly attending patients, i.e. 3 visits in the preceding 2 years. Crude prevalence rates were calculated for years 2015-2019, by sex, 10-year age groups, remoteness and socioeconomic status. Rates are presented per 100,000population (95% confidence intervals (CI)). Qualitative data was collected through focus groups and in-depth 1:1 interview. RESULTS: Qualitative evidence identified barriers to reaching diagnosis, and limited interactions with primary care due to a lack of available treatments/interventions, stigma and disbelief in ME/CFS as a condition. In each year of interest, crude prevalence in the primary care setting ranged between 94.9/100,000 (95% CI: 91.5-98.5) and 103.9/100,000 population (95%CI: 100.3-107.7), equating to between 20,140 and 22,050 people living with ME/CFS in Australia in 2020. Higher rates were observed for age groups 50-59 years and 40-49 years. Rates were substantially higher in females (130.0-141.4/100,000) compared to males (50.9-57.5/100,000). In the context of the qualitative evidence, our prevalence rates likely represent an underestimate of the true prevalence of ME/CFS in the Australian primary care setting. CONCLUSION: ME/CFS affects a substantial number of Australians. Whilst this study provides prevalence estimates for the Australian primary care setting, the qualitative evidence highlights the limitations of these. Future research should focus on using robust case ascertainment criteria in a community setting. Quantification of the burden of disease can be used to inform health policy and planning, for this understudied condition.

Obesity and Bariatric Surgery in Australia: Future Projection of Supply and Demand, and Costs.

INTRODUCTION: The prevalence of obesity is increasing in developed countries, including Australia. There is evidence that bariatric surgery is effective in losing weight and reducing risk of chronic diseases. However, access to bariatric surgery remains limited in the public health sector. METHOD: We modelled population-based estimates of the likely numbers of people eligible for bariatric surgery in Australia using the recent Australian New Zealand Metabolic and Obesity Surgery Society (ANZMOSS) framework and estimated the potential costs that would be incurred from primary and subsequent reoperations in both public and private sector. RESULTS: The annual number of newly eligible patients is expected to rise, and hence the gap in demand is increasing relative to current baseline supply. If a 5-year program to treat all currently eligible patients was implemented, the maximum yearly demand is projected to be 341,343 primary surgeries, more than eight times the existing capacity of public and private sector, which can only offer 41,534 surgeries/year. A nine-fold increase is expected if we treat currently eligible patients over a 5-year program and all newly eligible patients as they occur each year. CONCLUSION: Our results highlighted the currently highly skewed distribution of bariatric surgeries between the private and public sectors. Improving access would bring substantial benefits to many Australians, given the demonstrated cost-effectiveness and cost savings. This requires a major increase in resourcing for publicly-funded access to bariatric surgery in the first instance. A national review of priorities and resourcing for all modes of obesity treatment is required in Australia.

Long-Term Inpatient Hospital Utilisation and Costs (2007-2008 to 2015-2016) for Publicly Waitlisted Bariatric Surgery Patients in an Australian Public Hospital System Based on Australia's Activity-Based Funding Model.

BACKGROUND: Within the Australian public hospital setting, no studies have previously reported total hospital utilisation and costs (pre/postoperatively) and costed patient-level pathways for primary bariatric surgery and surgical sequelae (including secondary surgery) informed by Australia's Independent Hospital Pricing Authority's activity-based funding (ABF) model. OBJECTIVE: We aimed to provide our Tasmanian state government partner with information regarding key evidence gaps about the resource use and costs of bariatric surgery (including pre- and postoperatively, types of surgery and comorbidities), the costs of surgical sequelae and policy direction regarding the types of bariatric surgery offered within the Tasmanian public hospital system. METHODS: Hospital inpatient length of stay (days), episodes of care (number) and aggregated cost data were extracted for people who were waiting for and subsequently received bariatric surgery (for the fiscal years 2007-2008 to 2015-2016) from administrative sources routinely collected, clinically coded/costed according to ABF. Aggregated ABF costs were expressed in 2016-2017 Australian dollars ($A). Sensitivity (cost outliers) and subgroup analyses were conducted. RESULTS: A total of 105 patients entered the study. Total costs (pre/postoperative over 8 years) for all inpatient episodes of care (n = 779 episodes of care) were $A6,018,349. When the ten cost outliers were omitted from the total cost, this cost reduced to $A4,749,265. Mean costs for primary laparoscopic adjustable gastric band (LAGB) and sleeve gastrectomy (SG) bariatric surgery were $A14,622 and $A15,014, respectively. The average cost/episode of care for people with diabetes decreased in the first year postoperatively, from $A7258 to $A5830/episode of care. In total, 27 LAGB patients (30%) required surgery due to surgical sequelae (including revisional/secondary surgery; n = 58 episodes of care) and 56% of these episodes of care were secondary LAGB device related (mostly port/reservoir related), with a mean cost of $A6267. CONCLUSIONS: Taking into account our small SG sample size and the short time horizon for investigating surgical sequalae for SG, costs may be mitigated in the Tasmanian public hospital system by substituting LAGB with SG when clinically appropriate due to costs associated with the LAGB device for some patients. At 3 years postoperatively versus preoperatively, episodes of care and costs reduced substantially, particularly for people with diabetes/cardiovascular disease. We recommend that a larger confirmatory study of bariatric surgery including LAGB and SG be undertaken of disaggregated ABF costs in the Tasmanian public hospital system.

Rates and reasons for emergency department presentations of patients wait-listed for public bariatric surgery in Tasmania, Australia.

BACKGROUND: Demand for bariatric surgery in the public hospital setting in Australia is high with prolonged wait-list times. Policy-makers need to consider the consequences of expanding public bariatric surgery including on emergency department (ED) presentations. AIMS: To describe and evaluate public ED presentation rates and reasons for presenting in a cohort of patients wait-listed for public surgery. METHODS: All Tasmanians placed on the public wait-list for primary bariatric surgery in 2008-2013 were identified using administrative datasets along with their ED presentations in 2000-2014. The presentations were assigned to one of three periods: before wait-list placement, whilst on the wait-list, and after wait-list removal for publicly-funded surgery or drop-out. A negative binomial mixed-effects regression model was used to derive ED presentation incidence rate ratios (IRR) to compare observation periods and patient groups. RESULTS: 652 wait-listed patients had 5149 public ED presentations. 178 patients had publicly-funded bariatric surgery - all as laparoscopically adjustable gastric banding (LAGB). Overall, ED presentation rates did not change significantly post-surgery compared with the waiting period (IRR 1.19, 95%CI 0.90-1.56). Presentation rates significantly increased for digestive system (IRR 2.02, 95%CI 1.19-3.45) and psychiatric diseases (IRR 4.85, 95%CI 1.06-22.26) after surgery. The likelihood of being admitted from the ED significantly increased after surgery (31.7%-38.9%, p<0.05). CONCLUSION: ED presentations were common for patients wait-listed for public bariatric surgery and rates did not decrease over an average of three years post-LAGB. The likelihood of being admitted to the hospital from the ED increased after surgery.

A qualitative investigation of the health economic impacts of bariatric surgery for obesity and implications for improved practice in health economics.

Obesity is an economic problem. Bariatric surgery is cost-effective for severe and resistant obesity. Most economic evaluations of bariatric surgery use administrative data and narrowly defined direct medical costs in their quantitative analyses. Demand far outstrips supply for bariatric surgery. Further allocation of health care resources to bariatric surgery (particularly public) could be stimulated by new health economic evidence that supports the provision of bariatric surgery. We postulated that qualitative research methods would elicit important health economic dimensions of bariatric surgery that would typically be omitted from the current economic evaluation framework, nor be reported and therefore not considered by policymakers with sufficient priority. We listened to patients: Focus group data were analysed thematically with software assistance. Key themes were identified inductively through a dialogue between the qualitative data and pre-existing economic theory (perspective, externalities, and emotional capital). We identified the concept of emotional capital where participants described life-changing desires to be productive and participate in their communities postoperatively. After self-funding bariatric surgery, some participants experienced financial distress. We recommend a mixed-methods approach to the economic evaluation of bariatric surgery. This could be operationalised in health economic model conceptualisation and construction, through to the separate reporting of qualitative results to supplement quantitative results.

An Exploratory Study: A Head-to-Head Comparison of the EQ-5D-5L and AQoL-8D for Long-Term Publicly Waitlisted Bariatric Surgery Patients Before and 3 Months After Bariatric Surgery.

BACKGROUND: Choice of a multi-attribute utility instrument (MAUI) that appropriately assesses an intervention's health-related quality-of-life (HRQoL) impacts is a vital part of healthcare resource allocation and clinical assessment. OBJECTIVE: Our exploratory study compared the EuroQol (EQ)-5D-5L and Assessment of Quality of Life (AQoL)-8D MAUIs, which were used to assess the effect of bariatric surgery for a cohort of long-term publicly waitlisted, severely obese patients. METHODS: The study was conducted at the Hobart Private Hospital (Tasmania, Australia). To compare the sensitivity and instrument content of the two MAUIs, we used dimensional comparisons by investigating the distribution of patient-reported responses (number/percentage) across the MAUIs' levels and dimensions; summary health-state utility valuations (utilities); and individual/super-dimension scores (AQoL-8D) to investigate discriminatory power and HRQoL improvements preoperatively and 3 months postoperatively. RESULTS: Participants' (n = 23) overall MAUI completion rate was 74%. Postoperative total weight loss was 9.9%. EQ-5D-5L utilities were relatively higher pre- and postoperatively than AQoL-8D utilities [mean standard deviation (SD) EQ-5D-5L 0.70 (0.25) to 0.80 (0.25); AQoL-8D 0.51 (0.24) to 0.61 (0.24)]. AQoL-8D Psychosocial super dimension was relatively low postoperatively [0.37 (0.25)], driving the instrument's lower utility. These results were supported by the dimensional comparisons that revealed an overall greater dispersion for the AQoL-8D. Nevertheless, there were clinical improvements in utilities for both instruments. AQoL-8D utilities were lower than population norms; not so the EQ-5D-5L utilities. The AQoL-8D dimensions of Happiness, Coping, and Self-worth improved the most. CONCLUSIONS: AQoL-8D more fully captured the impact of obesity and bariatric surgery on HRQoL (particularly psychosocial impacts) for long-term waitlisted bariatric surgery patients, even 3 months postoperatively. AQoL-8D preoperative utility revealed our population's HRQoL was lower than people with cancer or heart disease.

An Exploratory Study of Long-Term Publicly Waitlisted Bariatric Surgery Patients' Quality of Life Before and 1 Year After Bariatric Surgery, and Considerations for Healthcare Planners.

BACKGROUND: Long-term publicly waitlisted bariatric surgery patients typically experience debilitating physical/psychosocial obesity-related comorbidities that profoundly affect their quality of life. OBJECTIVES: We sought to measure quality-of-life impacts in a study population of severely obese patients who had multiyear waitlist times and then underwent bariatric surgery. METHODS: Participants were recruited opportunistically following a government-funded initiative to provide bariatric surgery to morbidly obese long-term waitlisted patients. Participants self-completed the EQ-5D-5L and AQoL-8D questionnaires pre- and postoperatively. Utility valuations (utilities) and individual/super dimension scores (AQoL-8D only) were generated. RESULTS: Participants' (n = 23) waitlisted time was mean [standard deviation (SD)] 6.5 (2) years, body mass index reduced from 49.3 (9.35) kg/m2 preoperatively to 40.8 (7.01) 1 year postoperatively (p = 0.02). One year utilities revealed clinical improvements (both instruments). AQoL-8D improved significantly from baseline to 1 year, with the change twice that of the EQ-5D-5L [EQ-5D-5L: mean (SD) 0.70 (0.25) to 0.78 (0.25); AQoL-8D: 0.51 (0.24) to 0.67 (0.23), p = 0.04], despite the AQoL-8D's narrower algorithmic range. EQ-5D-5L utility plateaued from 3 months to 1 year. AQoL-8D 1-year utility improvements were driven by Happiness/Coping/Self-worth (p < 0.05), and the Psychosocial super dimension score almost doubled at 1 year (p < 0.05). AQoL-8D revealed a wider dispersion of individual utilities. CONCLUSIONS: Ongoing improvements in psychosocial parameters from 3 months to 1 year post-surgery accounted for improvements in overall utilities measured by the AQoL-8D that were not detected by EQ-5D-5L. Selection of a sensitive instrument is important to adequately assess changes in quality of life and to accurately reflect changes in quality-adjusted life-years for cost-utility analyses and resource allocation in a public healthcare resource-constrained environment.

Population estimates and characteristics of Australians potentially eligible for bariatric surgery: findings from the 2011-13 Australian Health Survey.

Objective The aim of the present study was to determine the potential demand for publicly and privately funded bariatric surgery in Australia. Methods Nationally representative data from the 2011-13 Australian Health Survey were used to estimate the numbers and characteristics of Australians meeting specific eligibility criteria as recommended in National Health and Medical Research Council guidelines for the management of overweight and obesity. Results Of the 3352037 adult Australians (aged 18-65 years) estimated to be obese in 2011-13, 882441 (26.3%; 95% confidence interval (CI) 23.0-29.6) were potentially eligible for bariatric surgery (accounting for 6.2% (95% CI 5.4-7.1) of the adult population aged 18-65 years (n=14122020)). Of these, 396856 (45.0%; 95% CI 40.4-49.5) had Class 3 obesity (body mass index (BMI) ≥40kgm-2), 470945 (53.4%; 95% CI 49.0-57.7) had Class 2 obesity (BMI 35-39.9kgm-2) with obesity-related comorbidities or risk factors and 14640 (1.7%; 95% CI 0.6-2.7) had Class 1 obesity (BMI 30-34.9kgm-2) with poorly controlled type 2 diabetes and increased cardiovascular risk; 458869 (52.0%; 95% CI 46.4-57.6) were female, 404594 (45.8%; 95% CI 37.3-54.4) had no private health insurance and 309983 (35.1%; 95% CI 28.8-41.4) resided outside a major city. Conclusion Even if only 5% of Australian adults estimated to be eligible for bariatric surgery sought this intervention, the demand, particularly in the public health system and outside major cities, would far outstrip current capacity. Better guidance on patient prioritisation and greater resourcing of public surgery are needed. What is known about this topic? In the period 2011-13, 4million Australian adults were estimated to be obese, with obesity disproportionately more prevalent in areas of socioeconomic disadvantage. Bariatric surgery is considered to be cost-effective and the most effective treatment for adults with obesity, but is mainly privately funded in Australia (>90%), with 16650 primary privately funded procedures performed in 2015. The extent to which the supply of bariatric surgery is falling short of demand in Australia is unknown. What does this paper add? The present study provides important information for health service planners. For the first time, population estimates and characteristics of those potentially eligible for bariatric surgery in Australia have been described based on the best available evidence, using categories that best approximate the national recommended eligibility criteria. What are the implications for practitioners? Even if only 5% of those estimated to be potentially eligible for bariatric surgery in Australia sought a surgical pathway (44122 of 882441), the potential demand, particularly in the public health system and outside major cities, would still far outstrip current capacity, underscoring the immediate need for better guidance on patient prioritisation. The findings of the present study provide a strong signal that more funding of public surgery and other effective interventions to assist this population group are necessary.

What are the support experiences and needs of patients who have received bariatric surgery?

OBJECTIVE: To explore the support needs and experiences of patients who had received publicly or privately funded bariatric surgery and the importance of this support in mediating outcomes of surgery. METHODS: Seven semi-structured focus groups were conducted. A broad interview schedule guided the discussions which were audio-recorded and transcribed verbatim. Data were analysed thematically. RESULTS: Twenty-six women and 15 men with a mean age of 54 years (range 24-72) participated in the study. Participants described support needs from health professionals, significant others (family and friends), peers (bariatric surgery recipients) and the general community. Peer, dietetic and psychological support were identified as important factors influencing the outcomes (e.g. weight reduction or health improvement) or experience of bariatric surgery but were identified as infrequently received or inadequately provided. Psychological support was proposed as one of the most significant but commonly overlooked components of care. Support needs appeared higher in the first year post-surgery, when subsequent related or unrelated surgeries were required and following significant life change such as worsening health. For some participants, deficits in support appeared to negatively influence the experience or outcomes of surgery. CONCLUSION: Providers of bariatric surgery should discuss support needs and accessibility regularly with patients especially in the first year post-surgery and following significant change in a patient's life (e.g. declined health or childbirth). Nutrition, psychological and peer support (e.g. through support groups) may be especially important for some patients.

"Too much medicine": Insights and explanations from economic theory and research.

Increasing attention has been paid in recent years to the problem of "too much medicine", whereby patients receive unnecessary investigations and treatments providing them with little or no benefit, but which expose them to risks of harm. Despite this phenomenon potentially constituting an inefficient use of health care resources, it has received limited direct attention from health economists. This paper considers "too much medicine" as a form of overconsumption, drawing on research from health economics, behavioural economics and ecological economics to identify possible explanations for and drivers of overconsumption. We define overconsumption of health care as a situation in which individuals consume in a way that undermines their own well-being. Extensive health economics research since the 1960s has provided clear evidence that physicians do not act as perfect agents for patients, and there are perverse incentives for them to provide unnecessary services under various circumstances. There is strong evidence of the existence of supplier-induced demand, and of the impact of various forms of financial incentives on clinical practice. The behavioural economics evidence provides rich insights on why clinical practice may depart from an "evidence-based" approach. Moreover, behavioural findings on health professionals' strategies for dealing with uncertainty, and for avoiding potential regret, provide powerful explanations of why overuse and overtreatment may frequently appear to be the "rational" choice in clinical decision-making, even when they cause harm. The ecological economics literature suggests that status or positional competition can, via the principal-agent relationship in health care, provide a further force driving overconsumption. This novel synthesis of economic perspectives suggests important scope for interdisciplinary collaboration; signals potentially important issues for health technology assessment and health technology management policies; and suggests that cultural change might be required to achieve significant shifts in clinical behaviour.

Review of Publicly-Funded Bariatric Surgery Policy in Australia-Lessons for More Comprehensive Policy Making.

BACKGROUND: The objective of the study was to determine the level of guidance provided by or to government health departments across different regions of Australia on publicly funded bariatric surgery. METHODS: Bariatric surgery policies and guidelines were sought from each Australian state (n = 6) and territory (n = 2) government health department and compared in relation to their origins, level of guidance on patient eligibility and priority, as well as recommendations for patient care, including follow-up surgical services. Comparison with national guidelines on bariatric surgery from Australia, the UK and USA was also made. RESULTS: Five of the eight states and territories had policies or guidelines informing practice. There was little uniformity among regional guidelines and variable consistency with national guidelines (e.g., defining obesity related comorbidity). Recommendations differed on patient eligibility, and none of the state documents mentioned re-operative bariatric or body-contouring surgery. There was limited guidance on prioritisation of eligible patients and gastric banding adjustments. Pre- and post-surgical multidisciplinary care was generally recommended. CONCLUSIONS: Policies and guidelines on publicly funded bariatric surgery are highly variable across Australia and at times inconsistent with national guidelines. Insufficient guidance exists regarding the prioritisation of eligible patients and follow-up surgical services. These findings have implications for policy, research and practice and are particularly important in health service environments with resource constraints and inequitable patient access to services.

The cost of home-based terminal care for people with AIDS in South Africa.

OBJECTIVES: To describe the costs of establishing and operating a home-based care (HBC) project providing palliative care for people with AIDS (PWA), and to project the full costs to the health care system of extending this care model. DESIGN: Data were collected from seven sites participating in the Hospice Association of South Africa integrated community home-based care (ICHC) model, using site records, interviews with personnel, a continuity of care survey of nursing staff supervising the sites, and time logs kept by community caregivers (CCGs). The seven sites were spread across five provinces, with a mix of rural, peri-urban and urban settings. OUTCOME MEASURES: Set-up (training, equipping and planning) costs per HBC site, HBC operating costs (total and average cost per patient), and average hospital inpatient, hospital outpatient and primary care clinic cost per participating patient. Estimates of scaling up this model of HBC to national roll-out are also provided. RESULTS AND CONCLUSIONS: Providing palliative HBC to PWAs in their last year of life using the ICHC model costs R2 840 per patient per year. Even with this level of HBC input, patients still incurred hospital costs of R2 522 and primary care clinic costs of R1 154 per patient per year. HBC costs are increased in rural areas where a vehicle is required for staff transport. HBC shows considerable potential to deal cost-effectively with growing palliative care needs in the face of the AIDS epidemic, but we need to understand better the true extent to which HBC can substitute for hospitalisation.