A Web-Based Mental Health Intervention to Improve Social and Occupational Functioning in Adults With Type 2 Diabetes (The Springboard Trial): 12-Month Outcomes of a Randomized Controlled Trial.

BACKGROUND: People with type 2 diabetes mellitus (T2DM) often experience mental health symptoms that exacerbate illness and increase mortality risk. Access to psychological support is low in people with T2DM. Detection of depression is variable in primary care and can be further hampered by mental health stigma. Electronic mental health (eMH) programs may provide an accessible, private, nonstigmatizing mental health solution for this group. OBJECTIVE: This study aims to evaluate the efficacy over 12 months of follow-up of an eMH program (myCompass) for improving social and occupational functioning in a community sample of people with T2DM and self-reported mild-to-moderate depressive symptoms. myCompass is a fully automated and self-guided web-based public health program for people with depression or anxiety. The effects of myCompass on depressive symptoms, diabetes-related distress, anxiety symptoms, and self-care behavior were also examined. METHODS: Adults with T2DM and mild-to-moderate depressive symptoms (N=780) were recruited via online advertisements, community organizations, and general practices. Screening, consent, and self-report questionnaires were administered online. Eligible participants were randomized to receive either myCompass (n=391) or an attention control generic health literacy program (Healthy Lifestyles; n=379) for 8 weeks. At baseline and at 3, 6, and 12 months postintervention, participants completed the Work and Social Adjustment Scale, the Patient Health Questionnaire-9 item, the Diabetes Distress Scale, the Generalized Anxiety Disorder Questionnaire-7 item, and items from the Self-Management Profile for Type 2 Diabetes. Glycosylated hemoglobin measurements were obtained at baseline and 6 and 12 months postintervention. RESULTS: A total of 38.9% (304/780) of the trial participants completed all postintervention assessments. myCompass users logged in on an average of 6 times and completed an average of 0.29 modules. Healthy Lifestyles users logged in on an average of 4 times and completed an average of 1.37 modules. At baseline, the mean scores on several outcome measures, including the primary outcome of work and social functioning, were close to the normal range, despite a varied and extensive recruitment process. Intention-to-treat analyses revealed slightly greater improvement at 12 months in work and social functioning for the Healthy Lifestyles group relative to the myCompass group. All participants reported equivalent improvements in depression anxiety, diabetes distress, diabetes self-management, and glycemic control across the trial. CONCLUSIONS: The Healthy Lifestyles group reported higher ratings of social and occupational functioning than the myCompass group, but no differences were observed for any secondary outcome. Although these findings should be interpreted in light of the near-floor symptom scores at baseline, the trial yields important insights into how people with T2DM might be engaged in eMH programs and the challenges of focusing specifically on mental health. Several avenues emerge for continued investigation into how best to deal with the growing mental health burden in adults with T2DM. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry Number (ACTRN) 12615000931572; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368109&isReview=true.

The influence of personality on trajectories of distress, health and functioning in mild-to-moderately depressed adults with type 2 diabetes.

Identification of mental health risk is important for optimising diabetes care in type 2 diabetes mellitus (T2DM). Personality is linked to diabetes health and may assist detection of individuals with T2DM most at risk of chronic mental health difficulties. This study examined the moderator effect of personality factors on changes in psychological distress and functioning in adults with T2DM and mild-to-moderate depressive symptoms across a 12-month period. Data were obtained from participants in a randomised controlled trial of adults with T2DM.  Participants completed measures of depression (Patient Health Questionnaire-9), anxiety (General Anxiety Disorder-7), general functioning (Work and Social Adjustment Scale), diabetes distress (Diabetes Distress Scale), and diabetes self-management (Self-Management Profile for Type 2 Diabetes) at baseline, 3-, 6- and 12-months. Glycaemic control (HbA1c) was measured at baseline, 6- and 12-months. Two hundred trial completers agreed to complete a personality inventory (Big Five Inventory). Low neuroticism was linked with reduced depression, anxiety, functional impairment and diabetes distress over the year. High extraversion was associated with decreased anxiety and functional impairment. High conscientiousness was linked to increased healthy eating. No personality trait moderated HbA1c levels. Personality screening may help identify mental health risk and guide medical carer approach in T2DM patients.

Recruiting to a Randomized Controlled Trial of a Web-Based Program for People With Type 2 Diabetes and Depression: Lessons Learned at the Intersection of e-Mental Health and Primary Care.

BACKGROUND: E-mental health (eMH) interventions are now widely available and they have the potential to revolutionize the way that health care is delivered. As most health care is currently delivered by primary care, there is enormous potential for eMH interventions to support, or in some cases substitute, services currently delivered face to face in the community setting. However, randomized trials of eMH interventions have tended to recruit participants using online recruitment methods. Consequently, it is difficult to know whether participants who are recruited online differ from those who attend primary care. OBJECTIVE: This paper aimed to document the experience of recruiting to an eMH trial through primary care and compare the characteristics of participants recruited through this and other recruitment methods. METHODS: Recruitment to the SpringboarD randomized controlled trial was initially focused on general practices in 2 states of Australia. Over 15 months, we employed a comprehensive approach to engaging practice staff and supporting them to recruit patients, including face-to-face site visits, regular contact via telephone and trial newsletters, and development of a Web-based patient registration portal. Nevertheless, it became apparent that these efforts would not yield the required sample size, and we therefore supplemented recruitment through national online advertising and promoted the study through existing networks. Baseline characteristics of participants recruited to the trial through general practice, online, or other sources were compared using the analysis of variance and chi square tests. RESULTS: Between November 2015 and October 2017, 780 people enrolled in SpringboarD, of whom 740 provided information on the recruitment source. Of these, only 24 were recruited through general practice, whereas 520 were recruited online and 196 through existing networks. Key barriers to general practice recruitment included perceived mismatch between trial design and diabetes population, prioritization of acute health issues, and disruptions posed by events at the practice and community level. Participants recruited through the 3 different approaches differed in age, gender, employment status, depressive symptoms, and diabetes distress, with online participants being distinguished from those recruited through general practice or other sources. However, most differences reached only a small effect size and are unlikely to be of clinical importance. CONCLUSIONS: Time, labor, and cost-intensive efforts did not translate into successful recruitment through general practice in this instance, with barriers identified at several different levels. Online recruitment yielded more participants, who were broadly similar to those recruited via general practice.

A Web-Based Cognitive Behavior Therapy Intervention to Improve Social and Occupational Functioning in Adults With Type 2 Diabetes (The SpringboarD Trial): Randomized Controlled Trial.

BACKGROUND: Depressive symptoms are common in people with type 2 diabetes mellitus (T2DM). Effective depression treatments exist; however, access to psychological support is characteristically low. Web-based cognitive behavioral therapy (CBT) is accessible, nonstigmatizing, and may help address substantial personal and public health impact of comorbid T2DM and depression. OBJECTIVE: The aim of this study was to evaluate the Web-based CBT program, myCompass, for improving social and occupational functioning in adults with T2DM and mild-to-moderate depressive symptoms. myCompass is a fully automated, self-guided public health treatment program for common mental health problems. The impact of treatment on depressive symptoms, diabetes-related distress, anxiety symptoms, and self-care behavior was also examined. METHODS: Participants with T2DM and mild-to-moderate depressive symptoms (N=780) were recruited online via Google and Facebook advertisements targeting adults with T2DM and via community and general practice settings. Screening, consent, and self-report scales were all self-administered online. Participants were randomized using double-blind computerized block randomization to either myCompass (n=391) for 8 weeks plus a 4-week tailing-off period or an active placebo intervention (n=379). At baseline and postintervention (3 months), participants completed the Work and Social Adjustment Scale, the primary outcome measure. Secondary outcome measures included the Patient Health Questionnaire-9 item, Diabetes Distress Scale, Generalized Anxiety Disorder Questionnaire-7 item, and items from the Self-Management Profile for Type 2 Diabetes. RESULTS: myCompass users logged in an average of 6 times and completed an average of .29 modules. Healthy Lifestyles users logged in an average of 4 times and completed an average of 1.37 modules. At baseline, mean scores on several outcome measures, including the primary outcome of work and social functioning, were near to the normal range, despite an extensive recruitment process. Approximately 61.6% (473/780) of participants completed the postintervention assessment. Intention-to-treat analyses revealed improvement in functioning, depression, anxiety, diabetes distress, and healthy eating over time in both groups. Except for blood glucose monitoring and medication adherence, there were no specific between-group effects. Follow-up analyses suggested the outcomes did not depend on age, morbidity, or treatment engagement. CONCLUSIONS: Improvement in social and occupational functioning and the secondary outcomes was generally no greater for myCompass users than for users of the control program at 3 months postintervention. These findings should be interpreted in light of near-normal mean baseline scores on several variables, the self-selected study sample, and sample attrition. Further attention to factors influencing uptake and engagement with mental health treatments by people with T2DM, and the impact of illness comorbidity on patient conceptualization and experience of mental health symptoms, is essential to reduce the burden of T2DM. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12615000931572; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368109&isReview=true (Archived by WebCite at http://www.webcitation.org/7850eg8pi).

A Web-Based Public Health Intervention to Reduce Functional Impairment and Depressive Symptoms in Adults With Type 2 Diabetes (The SpringboarD Trial): Randomized Controlled Trial Protocol.

BACKGROUND: Depressive symptoms are common in people with type 2 diabetes and contribute to adverse health consequences that substantially impact social and vocational function. Despite the existence of effective depression treatments, the majority of people with type 2 diabetes do not access these when needed. Web-based alternatives to more traditional psychotherapies offer a potential solution to reducing the personal and economic burdens of type 2 diabetes. OBJECTIVE: This paper outlines the protocol for a randomized controlled trial (RCT) of myCompass, a Web-based public health psychotherapy intervention, in people with type 2 diabetes. Fully automated, interactive, and delivered via the Internet without clinician support, myCompass teaches cognitive behavioral therapy-based skills and supports symptom monitoring to improve daily functioning and reduce mild-to-moderate mental health symptoms. METHODS: A two-arm RCT will be conducted. People with type 2 diabetes and mild-to-moderately severe depressive symptoms will be recruited from the community and general practice settings. Screening and enrollment is via an open-access website. Participants will be randomized to use either myCompass or an active placebo program for 8 weeks, followed by a 4-week tailing-off period. The placebo program is matched to myCompass on mode of delivery, interactivity, and duration. Outcomes will be assessed at baseline and at 3-month, 6-month, and 12-month follow-up. The primary study outcome is work and social functioning. Secondary study outcomes include depressive and anxious symptoms, diabetes-related distress, self-care behaviors, and glycemic control. RESULTS: Nationwide recruitment is currently underway with the aim of recruiting 600 people with type 2 diabetes. Recruitment will continue until October 2017. CONCLUSIONS: This is the first known trial of a Web-based psychotherapy program that is not diabetes specific for improving social and vocational function in people with type 2 diabetes and mild-to-moderately severe depressive symptoms. With the increasing prevalence of type 2 diabetes and depression, a potentially scalable public health intervention could play a very large role in reducing unmet mental health need and ameliorating the personal and societal impact of illness comorbidity. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) Number: ACTRN12615000931572; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368109 (Archived by WebCite at http://www.webcitation.org/ 6rh3imVMh).

Patient expectations of hip and knee joint replacement surgery and postoperative health status.

OBJECTIVE: To explore the relationship between preoperative patient expectations and postoperative health status in patients undergoing joint replacement surgery, with particular emphasis on the types of expectations held by patients. METHODS: Respondents completed the Hospital for Special Surgery (HSS) Hip/Knee Replacement Expectations Questionnaires pre-surgery, in addition to the Western Ontario and McMaster Osteoarthritis Index (WOMAC™) and the Short-Form 36-Item (SF-36) Health Survey and the Arthritis Self-Efficacy Scale. The WOMAC™ Index and SF-36 were also completed 3 and 6 months post-surgery. RESULTS: A total of 106 patients (total hip replacement [THR] = 28; total knee replacement [TKR] = 78) completed questionnaires. No differences were seen in overall expectations between males and females or older or younger patients, although some differences between the age groups were seen for individual expectations on the HSS expectations questionnaires. For THR, a higher rating of the importance of expectations was correlated with a lesser improvement in pain from pre-surgery to 3 months post-surgery, whereas for TKR, a higher rating of expectations was associated with a greater improvement in function to 6 months post-surgery. CONCLUSIONS: Patients have high expectations of surgery, which are correlated with post-surgery pain and function. Identifying the broad range of expectations may be helpful in preparation for surgery and gaining greater satisfaction with outcomes.

Association Between Measures of Fatigue and Health-Related Quality of Life in Rheumatoid Arthritis and Osteoarthritis.

OBJECTIVE: To assess the relationship between fatigue and health-related quality of life (HR-QOL) among people with osteoarthritis (OA) and rheumatoid arthritis (RA). METHODS: Community-dwelling people with OA, and OA patients on the waiting list for joint replacement surgery, were recruited. RA patients were recruited from rheumatologists' public and private outpatient clinics. Respondents completed a questionnaire containing demographic detail, the Fatigue Severity Scale (FSS), the Multidimensional Assessment of Fatigue (MAF), the SF-36, Western Ontario and McMaster Universities Osteoarthritis Index, and the Health Assessment Questionnaire (HAQ). RESULTS: There were 137 OA and 52 RA respondents. Neither age nor sex was significantly associated with fatigue for OA or RA. The mean FSS score was 3.36 for RA and 3.63 for OA. Fifty percent of respondents with RA and 58% of those with OA met the FSS >3 cut-point for fatigue. Mean MAF Global Fatigue Index was 20.8 for OA and 20.1 for RA. Correlations between health status and fatigue indicated that for both OA and RA those with greater fatigue reported worse health status. CONCLUSIONS: Few studies have measured the impact of fatigue among respondents with OA, despite it affecting a large proportion of the population. Fatigue was significantly correlated with poorer HR-QOL among OA respondents, suggesting that fatigue is a significant issue in OA as well as RA.

Evidence-based medicine is affordable: the cost-effectiveness of current compared with optimal treatment in rheumatoid and osteoarthritis.

OBJECTIVE: To determine the cost-effectiveness of averting the burden of disease. We used secondary population data and metaanalyses of various government-funded services and interventions to investigate the costs and benefits of various levels of treatment for rheumatoid arthritis (RA) and osteoarthritis (OA) in adults using a burden of disease framework. METHOD: Population burden was calculated for both diseases in the absence of any treatment as years lived with disability (YLD), ignoring the years of life lost. We then estimated the proportion of burden averted with current interventions, the proportion that could be averted with optimally implemented current evidence-based guidelines, and the direct treatment cost-effectiveness ratio in dollars per YLD averted for both treatment levels. RESULTS: The majority of people with arthritis sought medical treatment. Current treatment for RA averted 26% of the burden, with a cost-effectiveness ratio of dollar 19,000 per YLD averted. Optimal, evidence-based treatment would avert 48% of the burden, with a cost-effectiveness ratio of dollar 12,000 per YLD averted. Current treatment of OA in Australia averted 27% of the burden, with a cost-effectiveness ratio of dollar 25,000 per YLD averted. Optimal, evidence-based treatment would avert 39% of the burden, with an unchanged cost-effectiveness ratio of dollar 25,000 per YLD averted. CONCLUSION: While the precise dollar costs in each country will differ, the relativities at this level of coverage should remain the same. There is no evidence that closing the gap between evidence and practice would result in a drop in efficiency.

Selection of patients for inpatient rehabilitation or direct home discharge following total joint replacement surgery: a comparison of health status and out-of-pocket expenditure of patients undergoing hip and knee arthroplasty for osteoarthritis.

OBJECTIVES: To analyse the differences in patient health outcomes and out-of-pocket costs following hip and knee joint replacement for osteoarthritis between patients who went home immediately after the acute care hospital stay and those who were admitted to inpatient rehabilitation care before going home. METHODS: One hundred and eighteen patients undergoing total hip or knee replacement in Sydney, Australia completed cost diaries, SF-36 and WOMAC Index, pre-operatively and for one year post-operatively. RESULTS: The health status of all groups improved significantly from before surgery to 12 months post-surgery. No significant difference in health status at 12 months post-surgery was seen between home and rehabilitation patients for either hip or knee replacement. Both hip replacement home and rehabilitation patients and knee replacement home patients reported lower out-of-pocket expenditure from before surgery to 1 year post-surgery. DISCUSSION: The majority of total joint replacement patients can be discharged directly home and achieve excellent outcomes at 12 months post-surgery. We would recommend more focused randomized studies to explore the most suitable patient selection for rehabilitation.

Costs of managing urinary and faecal incontinence in a sub-acute care facility: a "bottom-up" approach.

AIMS: To measure accurately the direct costs of managing urinary and faecal incontinence in the sub-acute care setting. MATERIALS AND METHODS: Prospective observational study was undertaken in two sub-acute care units in a metropolitan hospital. A consecutive series of 29 consecutive patients with urinary and/or faecal incontinence, who were in-patients in a geriatric rehabilitation or sub-acute neurologic unit underwent routine timed voiding protocol, as per usual care. Face-to-face bedside recordings of all incontinence care, with detailed cost analysis, were undertaken. RESULTS: A total of 3,621 occasions of continence care were costed. The median time per 24 hr spent caring for incontinence per patient was 109 min (interquartile range 88-140). Isolated urinary incontinence episodes occurred in 28 patients (96.5%), mixed urinary/faecal incontinence episodes observed in 79.3%, and episodes of pure faecal incontinence were seen in 62%. The median costs of incontinence care in the sub-acute setting was $49AU per 24 hr, the major share ($41) spent on staff wages. The incontinence tasks of toileting assistance, pad changes, bed changes and catheter care were spread evenly across the three 8 hr shifts of duty. CONCLUSIONS: As our population demographics include an increasingly greater portion of the elderly, for whom long term institutional care is becoming relatively more scarce, provision of care in the sub-acute unit that may allow rehabilitation and return to home warrants scrutiny. This is the first study that delineates the costs of managing urinary and faecal incontinence in the sub-acute care setting. Such costs are substantial and place a heavy burden upon night-time carers.

Using the effect size to model change in preference values from descriptive health status.

OBJECTIVES: This pilot study describes a modelling approach to translate group-level changes in health status into changes in preference values, by using the effect size (ES) to summarize group-level improvement. METHODS: ESs are the standardized mean difference between treatment groups in standard deviation (SD) units. Vignettes depicting varying severity in SD decrements on the SF-12 mental health summary scale, with corresponding symptom severity profiles, were valued by a convenience sample of general practitioners (n = 42) using the rating scale (RS) and time trade-off methods. Translation factors between ES differences and change in preference value were developed for five mental disorders, such that ES from published meta-analyses could be transformed into predicted changes in preference values. RESULTS: An ES difference in health status was associated with an average 0.171-0.204 difference in preference value using the RS, and 0.104-0.158 using the time trade off. CONCLUSIONS: This observed relationship may be particular to the specific versions of the measures employed in the present study. With further development using different raters and preference measures, this approach may expand the evidence base available for modelling preference change for economic analyses from existing data.

Evidence-based care for alcohol use disorders is affordable.

OBJECTIVE: Despite efficacious treatment, alcohol use disorders contribute significantly to the disability burden. Although wider dissemination of evidence-based health care may impact on the population burden, the affordability of this strategy is unknown. This article compares the cost-effectiveness of current treatment for alcohol use disorders with the cost-effectiveness of optimal treatment, a hypothetical treatment scenario that has been informed by evidence-based practice to determine the affordability of such an approach. METHOD: This study calculated the cost-effectiveness in the Australian population of evidence-based health care for alcohol harmful use and alcohol dependence, as defined by the International Classification of Diseases, Injuries, and Causes of Death, 10th Revision. Outcome was calculated as years lived with disability (YLD) averted. Data from the Australian National Survey of Mental Health and Wellbeing, in conjunction with published meta-analyses and expert reviews, were used to estimate 1-year costs (1997-98 Australian dollars) and YLD averted by current health care services as well as costs and outcomes for an optimal strategy of evidence-based health care. RESULTS: Of those currently seeking treatment, approximately 45% of those with alcohol harmful use and 58% of those with alcohol dependence receive an evidence-based intervention. The cost of this care was estimated at 73 million dollars, resulting in a cost per YLD averted of 96,813 dollars for harmful use of alcohol and 98,095 dollars for alcohol dependence. Under optimal care for harmful use, costs declined and health gains doubled, substantially reducing the cost per YLD averted to 8861 dollars. For dependence, costs doubled, but optimal treatment resulted in increased health gains, reducing the cost per YLD to 57,542 dollars. CONCLUSIONS: Evidence-based care for alcohol use disorders would produce greater population health gain at an increased cost for alcohol dependence but at a reduced cost for harmful use of alcohol. For both disorders, there are substantial increases in cost-effectiveness.

Utilising survey data to inform public policy: comparison of the cost-effectiveness of treatment of ten mental disorders.

BACKGROUND: Mental health survey data are now being used proactively to decide how the burden of disease might best be reduced. AIMS: To study the cost-effectiveness of current and optimal treatments for mental disorders and the proportion of burden avertable by each. METHOD: Data for three affective, four anxiety and two alcohol use disorders and for schizophrenia were compared interms of cost, burden averted and efficiency of current and optimal treatment. We then calculated the burden unavertable given current knowledge. The unit of health gain was a reduction in the years lived with disability (YLDs). RESULTS: Summing across all disorders, current treatment averted 13% of the burden, at an average cost of 30,000 Australian dollars per YLD gained. Optimal treatment at current coverage could avert 20% of the burden, at an average cost of 18,000 Australian dollars per YLD gained. Optimal treatment at optimal coverage could avert 28% of the burden, at 16,000 Australian dollars per YLD gained. Sixty per cent of the burden of mental disorders was deemed to be unavertable. CONCLUSIONS: The efficiency of treatment varied more than tenfold across disorders. Although coverage of some of the more efficient treatments should be extended, other factors justify continued use of less-efficient treatments for some disorders.

Reducing the burden of affective disorders: is evidence-based health care affordable?

BACKGROUND: Affective disorders remain the leading cause of disability burden despite the availability of efficacious treatment. A wider dissemination of evidence-based health care is likely to impact this burden, however the affordability of such a strategy at the population level is unknown. This study calculated the cost-effectiveness of evidence-based health care for depression, dysthymia and bipolar disorder in the Australian population, and determined whether it was affordable, based on current mental health-related expenditure and outcomes for these disorders. METHODS: Cost-effectiveness was expressed in costs per years lived with disability (YLDs) averted, a population health summary measure of disability burden. Data from the Australian National Survey of Mental Health and Wellbeing, in conjunction with published randomized trials and direct cost estimates, were used to estimate the 1-year costs and YLDs averted by current health care services, and costs and outcomes for an optimal strategy of evidence-based health care. RESULTS: Current direct mental health-related health care costs for affective disorders in Australia were 615 million dollars (1997-98 Australian dollars). This treatment averted just under 30,000 YLDs giving a cost-effectiveness ratio of 20,633 dollars per YLD. Outcome could be increased by nearly 50% at similar cost with implementation of an evidence-based package of optimal treatment, halving the cost-effectiveness ratio to 10,737 dollars per YLD. LIMITATIONS: The method to estimate YLDs averted from the literature requires replication. The costs of implementing evidence-based health care have not been estimated. CONCLUSIONS: Evidence-based health care for affective disorders should be encouraged on both efficacy and efficiency grounds.

Cost-effectiveness of current and optimal treatment for schizophrenia.

BACKGROUND: This paper is part of a project to identify the proportion of the burden of each mental disorder averted by current and optimal interventions, and the cost-effectiveness of both. AIMS: To use epidemiological data on schizophrenia to model the cost-effectiveness of current and optimal treatment. METHOD: Calculate the burden of schizophrenia in the years lived with disability (YLD) component of disability-adjusted life-years lost, the proportion averted by current interventions, the proportion that could be averted by optimal treatment and the cost-effectiveness of both. RESULTS: Current interventions avert some 13% of the burden, whereas 22% could be averted by optimal treatment. Current interventions cost about AUS 200,000 dollars per YLD averted, whereas optimal treatment at a similar cost could increase the number of YLDs averted by two-thirds. Even so, the majority of the burden of schizophrenia remains unavertable. CONCLUSIONS: Optimal treatment is affordable within the present budget and should be implemented.

Medical workforce issues in Australia: "tomorrow's doctors--too few, too far".

The Australian medical workforce, like those of most developed countries, is increasingly "feminised" and exposed to the global market for doctors. Demand for healthcare services is increasing in the Australian community. Concern in relation to doctor shortages is increasing, particularly in rural areas. There should be greater flexibility for entry of highly-trained overseas doctors. There is an urgent need to increase medical school student intake. Issues of workforce practice, including "task" substitution, should be explored.

The social costs and benefits of gambling: an introduction to the economic issues.

This paper surveys the range of economic issues that need to be addressed in attempting to evaluate the social costs and benefits of gambling. It considers, inter alia, the nature of private and social costs and benefits and their policy significance, the important distinction between real and pecuniary costs, the incidence of gambling costs and benefits and the sources of gambling costs and benefits. Similarities and differences between the analysis of gambling and alcohol are considered. The paper concludes with a consideration of why various estimates of the social costs of gambling have produced such divergent results.

Cost of joint replacement surgery for osteoarthritis: the patients' perspective.

OBJECTIVE: To address costs of total joint replacement surgery from the patients' perspective by determining patient out-of-pocket costs during the first year following joint replacement, and to explore whether health status presurgery or in the immediate 3 months postsurgery were determinants of costs. In light of the different outcomes experienced by patients with total knee replacement (TKR) and total hip replacement (THR), any differences in costs between the 2 groups were also explored. METHODS: Patients with osteoarthritis (OA) scheduled for primary unilateral TKR or THR surgery at 3 Sydney hospitals were approached. Patients completed questionnaires preoperatively to record expenses during the previous 3 months and health status immediately prior to surgery. Patients then maintained detailed prospective cost diaries and completed SF-36 and WOMAC Index every 3 months for the first postoperative year. Arthritis-specific cost inforrmation obtained in the diary included medications (prescription and nonprescription), visits to health professionals, tests (radiographs, scans, blood tests, etc), special equipment, alterations to house, and the use of private or community services. RESULTS: Ninety-eight TKR and 76 THR patients provided cost details for their first postoperative year. For both THR and TKR patients, out-of-pocket costs fell considerably over the first postoperative year, and during the year the proportion of patients who experienced no out-of-pocket costs increased, as did the proportion who made no use of health services such as medical tests or visits to health professionals. Regression analysis for THR patients showed that pension status, preoperative SF-36 Physical Component Score, and 3-month postoperative WOMAC Function were significant independent predictors of postoperative costs. Regression analysis for TKR patients showed that presurgery WOMAC Stiffness and pension status were significant independent predictors of postoperative costs, indicating that those with greater stiffness had greater postsurgery costs and those on a pension had lower costs. CONCLUSION: OA patients undergoing THR and TKR have substantial out-of-pocket costs presurgery, which fall dramatically over the first postoperative year. Poorer presurgery health status predicted greater expenditure during the first postoperative year, which might be taken into consideration when patients are making a choice about the timing of joint surgery.

Using epidemiological data to model efficiency in reducing the burden of depression*

BACKGROUND: The Global Burden of Disease study has suggested that mental disorders are the leading cause of disability burden in the world. This study takes the leading cause of mental disorder burden, depression, and trials an approach for defining the present and optimal efficiency of treatment in an Australian setting. AIMS OF THE STUDY: To examine epidemiological and service use data for depression to trial an approach for modelling (i) the burden that is currently averted from current care, (ii) the burden that is potentially avertable from a hypothetical regime of optimal care, (iii) the efficiency or cost-effectiveness of both current and optimal services for depression and (iv) the potential of current knowledge for reducing burden due to depression, by applying the WHO five-step method for priorities for investment in health research and development. METHODS: Effectiveness and efficiency were calculated in disability adjusted life years (DALYs) averted by adjusting the disability weight for people who received efficacious treatment. Data on service use and treatment outcome were obtained from a variety of secondary sources, including the Australian National Survey of Mental Health and Wellbeing, and efficacy of individual treatments from published meta-analyses expressed in effect sizes. Direct costs were estimated from published sources. RESULTS: Fifty-five percent of people with depression had had some contact with either primary care or specialist services. Effective coverage of depression was low, with only 32% of cases receiving efficacious treatment that could have lessened their severity (averted disability). In contrast, a proposed model of optimal care for the population management of depression provided increased treatment contacts and a better outcome. In terms of efficiency, optimal care dominated current care, with more health gain for less expenditure (28 632 DALYs were averted at a cost of AUD295 million with optimal care, versus 19 297 DALYs averted at a cost of AUD720 million with current care). However, despite the existence of efficacious technologies for treating depression, only 13% of the burden was averted from present active treatment, primarily because of the low effective coverage. Potentially avertable burden is nearly three times this, if effective treatments can be delivered in appropriate amounts to all those who need it. DISCUSSION: This paper reports a method to calculate the burden currently averted from cross-sectional survey data, and to calculate the burden likely to be averted from an optimal programme estimated from randomized controlled trial data. The approach taken here makes a number of assumptions: that people are accurate in reporting their service use, that effect sizes are a suitable basis for modelling improvements in disability and that the method used to translate effect sizes to disability weight change is valid. The robustness of these assumptions is discussed. Nonetheless it would appear that while optimal care could do more than present services to reduce the burden of depression, current technologies for treating depression are insufficient. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: There is an urgent need to educate both clinicians (primary and specialist) and the general public in the effective treatments that are available for depression. IMPLICATIONS FOR HEALTH POLICIES: Over and above implementing treatments of known efficacy, more powerful technologies are needed for the prevention and treatment of depression. IMPLICATIONS FOR FURTHER RESEARCH: Modelling burden averted from a variety of secondary sources can introduce bias at many levels. Future research should examine the validity of approaches that model reductions in disability burden. A powerful treatment to relieve depression and prevent relapse is needed.