Estimating the health loss due to poor engagement with cardiac rehabilitation in Australia.

BACKGROUND: Cardiac rehabilitation (CR) programs are effective in reducing cardiovascular mortality and readmissions. However, most patients are denied the benefits of CR due to low referral rates. Of those patients referred, commencement rates vary from 28.4% to 60%. This paper quantifies the scale of health loss in Australia due to poor engagement with the program, and estimates how much public funding can be justifiably reallocated to address the problem. METHODS: Economic decision modelling was undertaken to estimate the expected lifetime health loss and costs to Medicare. Key parameters were derived from Australian databases, CR registries and meta-analyses. Population health gains associated with uptake rates of 60%, and 85% were calculated. RESULTS: CR was associated with a 99.9% probability of being cost-effective, even at a cost-effectiveness threshold lower than conventionally applied. Importantly, an average of 0.52 years of life expectancy are lost due to national uptake being below 60% achieved in some best performing programs in Australia, equivalent to 0.28 quality adjusted life years. The analysis indicates that $12.9 million/year could be justifiably reallocated from public funds to achieve a national uptake rate of 60%, while maintaining cost-effectiveness of CR due to the large health gains that would be expected. CONCLUSION: CR is a cost-effective service for patients with coronary heart disease. In Australia, less than a third of patients commence CR, potentially resulting in avoidable patient harm. Additional investment in CR is vital and should be a national priority as the health gains for patients far outweigh the costs.

Religiosity and the expansion of caregiver stress.

We present a stress process framework as a model for understanding how religiosity may influence the expansion of stress. Survey data from informal caregivers to a spouse with Alzheimer's disease or a related dementia (n = 200) were analyzed to observe the relationships among three variables: (1) care-related stress, (2) religiosity, and (3) depression. This sample, which has a mean age of 73 years, demonstrates high rates of self-described religiosity, church attendance and frequency of prayer. Using these criteria, women and racial/ethnic minority caregivers are the most religious. In a series of multivariate analyses, we found strong evidence to suggest that there is an expansion of care-related stressors leading to depression in this sample. Religiosity, as measured here, appears to be largely unrelated to stress and stress expansion. We found no evidence to suggest that it moderates stress expansion. However, these data do suggest that one stressor--feelings of role overload--is correlated with greater levels of self-perceived religiosity, which among caregivers who have health problems of their own is associated with greater depressive symptomatology. Thus, for a sub-sample of these caregivers, we find weak evidence of a mediation effect wherein one subjective, non-organizational dimension of religiosity is a conduit of the harmful effects of stress (rather than a suppressor). Results and data limitations are discussed in relation to better assessing the role of religiosity and spirituality in the experience of the stress process.

The anal dilator in the conservative management of acute anal fissures.

Patients presenting with acute anal fissure were randomized into two treatment groups in a prospective clinical trial. Both groups received treatment for 3 weeks with a stool softener and lignocaine jelly. Those entered in group 1 (35 patients) were asked in addition to insert an anal dilator (no. 2) twice daily while those in group 2 (31 patients) applied the anaesthetic jelly without a dilator. At 6 weeks 11 (31.4 per cent) patients in group 1 and 12 (38.7 per cent) patients in group 2 had been referred for sphincterotomy owing to failure of the treatment. At 6 months this figure had risen to 14 (40 per cent) in group 1 and 15 (48.4 per cent) in group 2. This difference was not statistically significant, suggesting that the addition of a dilator to the conservative treatment regimen did not diminish the likelihood of surgery.

l-Tyrosine as an immunological adjuvant.

A series of experiments has been carried out to investigate the adjuvant properties of the amino acid L-tyrosine in laboratory animals. Adsorption of various allergenic materials to L-tyrosine was found to enhance the induction of IgG antibodies, but no unusual propensity to stimulate IgE antibody or delayed hypersensitivity was observed. Administration of the amino acid at a site remote from the allergen was found not to augment antibody production. This, together with evidence of reduced bioavailability of the tyrosine-adsorbed allergen, suggested that the adjuvant activity observed resulted from a short-term depot effect.