Prevalence of opioid use in adults with spinal cord injury: A systematic review and meta-analysis.

OBJECTIVE: To determine the prevalence, reported harms and factors associated with opioid use among adults with spinal cord injury (SCI) living in the community. STUDY DESIGN: Systematic review and meta-analysis. METHODS: Comprehensive literature searches were conducted in PubMed (MEDLINE), EMBASE, CINAHL, Web of Science and Scopus for articles published between 2000 and 2023. Risk of bias was assessed using a prevalence-specific tool. Random-effects meta-analyses were conducted to pool prevalence data for any context of opioids. Sensitivity and subgroup analyses were also performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the study protocol was registered via Prospero (CRD42022350768). RESULTS: Of the 4969 potential studies, 38 were included in the review. Fifty-three percent of studies had a low risk of bias, with a high risk of bias in 5% of studies. The pooled prevalence for the 38 studies included in the meta-analysis (total cohort size of 50,473) across any opioid context was 39% (95% confidence interval [CI], 32-47). High heterogeneity was evident, with a prediction interval twice as wide as the 95% CI (prediction interval, 7-84%). Mean or median opioid dose was unreported in 95% of studies. Opioid dose and factors related to opioids were also rarely explored in the SCI populations. CONCLUSIONS: Results should be interpreted with caution based on the high heterogeneity and imprecise pooled prevalence of opioids. Contextual details including pain, cohort-specific injury characteristics and opioid dosage were inconsistently reported, indicating a clear need for additional studies in a population at greater risk of experiencing opioid-related adverse effects.

Hybrid cardiac telerehabilitation for coronary artery disease in Australia: a cost-effectiveness analysis.

BACKGROUND: Traditional cardiac rehabilitation programs are centre-based and clinically supervised, with their safety and effectiveness well established. Notwithstanding the established benefits, cardiac rehabilitation remains underutilised. A possible alternative would be a hybrid approach where both centre-based and tele-based methods are combined to deliver cardiac rehabilitation to eligible patients. The objective of this study was to determine the long-term cost-effectiveness of a hybrid cardiac telerehabilitation and if it should be recommended to be implemented in the Australian context. METHODS: Following a comprehensive literature search, we chose the Telerehab III trial intervention that investigated the effectiveness of a long-term hybrid cardiac telerehabilitation program. We developed a decision analytic model to estimate the cost-effectiveness of the Telerehab III trial using a Markov process. The model included stable cardiac disease and hospitalisation health states and simulations were run using one-month cycles over a five-year time horizon. The threshold for cost-effectiveness was set at $AU 28,000 per quality-adjusted life-year (QALY). For the base analysis, we assumed that 80% completed the programme. We tested the robustness of the results using probabilistic sensitivity and scenario analyses. RESULTS: Telerehab III intervention was more effective but more costly and was not cost-effective, at a threshold of $28,000 per QALY. For every 1,000 patients who undergo cardiac rehabilitation, employing the telerehabilitation intervention would cost $650,000 more, and 5.7 QALYs would be gained, over five years, compared to current practice. Under probabilistic sensitivity analysis, the intervention was cost-effective in only 18% of simulations. Similarly, if the intervention compliance was increased to 90%, it was still unlikely to be cost-effective. CONCLUSION: Hybrid cardiac telerehabilitation is highly unlikely to be cost-effective compared to the current practice in Australia. Exploration of alternative models of delivering cardiac telerehabilitation is still required. The results presented in this study are useful for policymakers wanting to make informed decisions about investment in hybrid cardiac telerehabilitation programs.

Cost-Effectiveness of Screening to Identify Patients With Atrial Fibrillation: A Systematic Review.

BACKGROUND: Screening for Atrial Fibrillation (AF) is recommended for people aged above 65 years. Screening for AF in asymptomatic individuals can be beneficial by enabling earlier diagnosis and the commencement of interventions to reduce the risk of early events, thus improving patient outcomes. This study systematically reviews the literature about the cost-effectiveness of various screening methods for previously undiagnosed AF. METHODS: Four databases were searched to identify articles that are cost-effectiveness studies conducted on screening for AF published from January 2000 to August 2022. The Consolidated Health Economic Evaluation Reporting Standards 2022 checklist was used to assess the quality of the selected studies. A previously published approach was used to assess the usefulness of each study for health policy makers. RESULTS: The database search yielded 799 results, with 26 articles meeting the inclusion criteria. Articles were categorised into four subgroups: (i) population screening, (ii) opportunistic screening, (iii) targeted, and (iv) mixed methods of screening. Most of the studies screened adults ≥65 years of age. Most studies were performed from a 'health care payer perspective' and almost all studies used 'not screening' as a comparator. Almost all screening methods assessed were found to be cost-effective in comparison to 'not screening'. The reporting quality varied between 58% to 89%. The majority of the studies were found to be of limited usefulness for health policy makers, as none of the studies made any clear statements about policy change or implementation direction. CONCLUSION: All approaches of AF screening were found to be cost-effective compared with no screening, while opportunistic screening was found to be the optimal approach in some studies. However, screening for AF in asymptomatic individuals is context specific and likely to be cost-effective depending on the population screened, screening approach, frequency, and the duration of screening.

Understanding compensable and non-compensable patient profiles, pathways and physical outcomes for transport and work-related injuries in Queensland, Australia through data linkage.

INTRODUCTION: In many jurisdictions, people experiencing an injury often pursue compensation to support their treatment and recovery expenses. Healthcare costs form a significant portion of payments made by compensation schemes. Compensation scheme regulators need accurate and comprehensive data on injury severity, treatment pathways and outcomes to enable scheme modelling, monitoring and forecasting. Regulators routinely rely on data provided by insurers which have limited healthcare information. Health data provide richer information and linking health data with compensation data enables the comparison of profiles, patterns, trends and outcomes of injured patients who claim and injured parties who are eligible but do not claim. METHODS AND ANALYSIS: This is a retrospective population-level epidemiological data linkage study of people who have sought ambulatory, emergency or hospital treatment and/or made a compensation claim in Queensland after suffering a transport or work-related injury, over the period 1 January 2011 to 31 December 2021. It will use person-linked data from nine statewide data sources: (1) Queensland Ambulance Service, (2) Emergency Department, (3) Queensland Hospital Admitted Patients, (4) Retrieval Services, (5) Hospital Costs, (6) Workers' Compensation, (7) Compulsory Third Party Compensation, (8) National Injury Insurance Scheme and (9) Queensland Deaths Registry. Descriptive, parametric and non-parametric statistical methods and geospatial analysis techniques will be used to answer the core research questions regarding the patient's health service use profile, costs, treatment pathways and outcomes within 2 years postincident as well as to examine the concordance and accuracy of information across health and compensation databases. ETHICS AND DISSEMINATION: Ethics approval was obtained from the Royal Brisbane and Women's Hospital Human Research Ethics Committee, and governance approval was obtained via the Public Health Act 2005, Queensland. The findings of this study will be used to inform key stakeholders across the clinical, research and compensation regulation area, and results will be disseminated through peer-reviewed journals, conference presentations and reports/seminars with key stakeholders.

Prevalence of alcohol consumption in emergency presentations: Novel approach using two biomarkers, ethanol and phosphatidylethanol.

INTRODUCTION: The aim was to determine the prevalence of alcohol-related presentations to an emergency department (ED) in a major Australian hospital, through a novel surveillance approach using two biomarkers, blood ethanol and phosphatidylethanol (PEth). METHODS: Observational study using secondary testing of blood samples collected during routine clinical care of ED patients presenting to the Royal Brisbane and Women's Hospital in Queensland, Australia, between 22 January and 2 February 2021. Data were collected from 1160 patients during the 10-day study period. The main outcomes were the prevalence of acute alcohol intake, as determined by blood ethanol, and recent use over 2-4 weeks, as determined by PEth concentrations, for all ED presentations and different diagnostic groups. RESULTS: The overall prevalence for blood ethanol was 9.3% (95% confidence interval [CI] 7.8%, 11.1%), 5.3% for general medical presentations, increasing four-fold to 22.2% for injury presentations. The overall prevalence of PEth positive samples was 32.5% (95% CI 29.9%, 35.3%) and 41.4% for injury presentations. There were 263 (25.3%) cases that tested negative for acute blood ethanol but positive for PEth concentrations indicative of significant to heavy medium-term alcohol consumption. DISCUSSION AND CONCLUSIONS: This novel surveillance approach demonstrates that using blood ethanol tests in isolation significantly underestimates the prevalence of medium-term alcohol consumption in ED presentations. Prevalence of alcohol use was higher for key diagnostic groups such as injury presentations. Performing periodic measurement of both acute and medium-term alcohol consumption accurately and objectively in ED presentations, would be valuable for informing targeted public health prevention and control strategies.

Characteristics and Effectiveness of Postoperative Rehabilitation Strategies in Ankle Fractures: A Systematic Review.

OBJECTIVES: To explore the characteristics and to report on the effectiveness of postoperative rehabilitation strategies for people with an ankle fracture. DATA SOURCES: PubMed, Cochrane Library, EMBASE, Web of Science, and CINAHL were searched to identify studies published from January 2010 to November 2021. STUDY SELECTION: Studies that described or evaluated postoperative rehabilitation strategies for surgically repaired ankle fractures were included. DATA EXTRACTION: Data on postoperative rehabilitation were extracted in accordance with the Template for Intervention Description and Replication guide. Quality was assessed using the National Heart, Lung, and Blood Institute's Study Quality Assessment Tools. DATA SYNTHESIS: Meta-analysis was planned to look at the effectiveness of postoperative rehabilitation strategies. Forty studies described postoperative rehabilitation strategies without evaluating effectiveness, whereas 15 studies focused on evaluating effectiveness. Because of the large variety in postoperative strategies and outcomes, narrative synthesis was deemed most suitable to answer our aims. Characteristics of postoperative rehabilitation strategies varied widely and were poorly described in a way that could not be replicated. Most of the studies (48%) used a late weight-bearing approach, although definitions and details around weight-bearing were unclear. CONCLUSIONS: Late weight-bearing has been the most common postoperative approach reported in the past 10 years. The variety of definitions around weight-bearing and the lack of details of rehabilitation regimens limit replication and affect current clinical practice. The authors propose to adopt consistent definitions and terminology around postoperative practices such as weight-bearing to improve evidence for effectiveness and ultimately patient outcomes. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Costs and 30-day readmission after lower limb fractures from motorcycle crashes in Queensland, Australia: A linked data analysis.

BACKGROUND: Lower limb trauma is the most common injury sustained in motorcycle crashes. There are limited data describing this cohort in Australia and limited international data establishing costs due to lower limb trauma following motorcycle crashes. METHODS: This retrospective cohort study utilised administrative hospitalisation data from Queensland, Australia from 2011-2017. Eligible participants included those admitted with a principal diagnosis coded as lower extremity or pelvic fracture following a motorcycle crash (defined as the index admission). Multiply injured motorcyclists where the lower limb injury was not coded as the primary diagnosis (i.e. principal diagnosis was rather coded as head injury, internal organ injures etc.) were not included in the study. Hospitalisation data were also linked to clinical costing data. Logistic regression was used to determine risk factors for 30-day readmission. Costing data were compared between those readmitted and those who weren't, using bootstrapped t-tests and ANVOA. RESULTS: A total of 3342 patients met eligibility, with the most common lower limb fracture being tibia/fibula fractures (40.8%). 212 participants (6.3%) were readmitted within 30-days of discharge. The following were found to predict readmission: male sex (OR 1.84, 95% CI 1.01-1.94); chronic anaemia (OR 2.19, 95% CI 1.41-3.39); current/ex-smoker (OR 1.60, 95% CI 1.21-2.12); emergency admission (OR 2.77, 95% CI 1.35-5.70) and tibia/fibula fracture type (OR 1.46, 95% CI 1.10-1.94). The most common reasons for readmission were related to ongoing fracture care, infection or post-operative complications. The average hospitalisation cost for the index admission was AU$29,044 (95% CI $27,235-$30,853) with significant differences seen between fracture types. The total hospitalisation cost of readmissions was almost AU$2 million over the study period, with an average cost of $10,977 (95% CI $9,131- $13,059). CONCLUSIONS: Unplanned readmissions occur in 6.3% of lower limb fractures sustained in motorcycle crashes. Independent predictors of readmission within 30 days of discharge included male sex, chronic anaemia, smoking status, fracture type and emergency admission. Index admission and readmission hospitalisation costs are substantial and should prompt health services to invest in ways to reduce readmission.

Community Opioid Dispensing After Injury (CODI): Protocol for a Population-Based Data Linkage Study.

BACKGROUND: There is an urgent need to reduce preventable deaths and hospitalizations from prescription opioid harms and minimize the negative effect opioid misuse can have on injured individuals, families, and the wider community. Data linkage between administrative hospitalization records for injured patients and community opioid dispensing can improve our understanding of the health and surgical trajectories of injured persons and generate insights into corresponding opioid dispensing patterns. OBJECTIVE: The Community Opioid Dispensing after Injury (CODI) study aims to link inpatient hospitalization data with opioid dispensing data to examine the distribution and predictive factors associated with high or prolonged community opioid dispensing among adults, for 2 years following an injury-related hospital admission. METHODS: This is a retrospective population-based cohort study of adults aged 18 years or older hospitalized with an injury in Queensland, Australia. The study involves the linkage of statewide hospital admissions, opioid prescription dispensing, and mortality data collections. All adults hospitalized for an injury between January 1, 2014, and December 31, 2015, will be included in the cohort. Demographics and injury factors are recorded at the time of the injury admission. Opioid dispensing data will be linked and extracted for 3 months prior to the injury admission date to 2 years after the injury separation date (last date December 31, 2017). Deaths data will be extracted for the 2-year follow-up period. The primary outcome measure will be opioid dispensing (frequency and quantity) in the 2 years following the injury admission. Patterns and factors associated with community opioid dispensing will be examined for different injury types, mechanisms, and population subgroups. Appropriate descriptive statistics will be used to describe the cohort. Regression models will be used to examine factors predictive of levels and duration of opioid use. Nonparametric methods will be applied when the data are not normally distributed. RESULTS: The project is funded by the Royal Brisbane and Women's Hospital Foundation. As of November 2021, all ethics and data custodian approvals have been granted. Data extraction and linkage has been completed. Data management and analysis is underway with results relating to an analysis for blunt chest trauma patients expected to be published in 2022. CONCLUSIONS: Little is currently known of the true prevalence or patterns of opioid dispensing following injury across Queensland. This study will provide new insights about factors associated with high and long-term opioid dispensing at a population level. This information is essential to inform targeted public policy and interventions to reduce the risk of prolonged opioid use and dependence for those injured. The novel work undertaken for this project will be vital to planning, delivering, monitoring, and evaluating health care services for those injured. The findings of this study will be used to inform key stakeholders as well as clinicians and pain management services. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/36357.

Reducing waste in collection of quality-of-life data through better reporting: a case study.

PURPOSE: This study describes the reporting of the preference-based health-related quality-of-life (HRQOL) instrument, the EQ-5D, and proposes strategies to improve reporting and reduce research waste. The EQ-5D is a validated instrument widely used for health economic evaluation and is useful for informing health policy. METHODS: As part of a systematic review of papers reporting EQ-5D utility weights in patients with coronary artery disease, we noted the reasons data from some papers could not be reused in a meta-analysis, including whether health utility weights and sufficient statistical details were reported. Research waste was quantified using: (1) the percentage of papers and sample size excluded, and (2) researcher time and cost reviewing poorly reported papers. RESULTS: Our search strategy found 5942 papers. At title and abstract screening 93% were excluded. Of the 379 full text papers screened, 130 papers reported using EQ-5D. Only 46% (60/130) of those studies reported utility weights and/or statistical properties enabling meta-analysis. Only 67% of included papers had reported EQ-5D in the title or abstract. A total sample size of 133,298 was excluded because of poor reporting. The cost of researcher time wasted estimated to be between $3816 and $13,279 for our review. CONCLUSIONS: Poor reporting of EQ-5D data creates research waste where potentially useful data are excluded from meta-analyses and economic evaluations. Poor reporting of HRQOL instruments also creates waste due to additional time spent reviewing papers for systematic reviews that are subsequently excluded. RECOMMENDATIONS: Studies using the EQ-5D should report utility weights with appropriate summary statistics to enable reuse in meta-analysis and more robust evidence for health policy. We recommend authors report the HRQOL instrument in the title or abstract in line with current reporting guidelines (CONSORT-PRO and SPIRIT-PRO Extensions) to make it easier for other researchers to find. Validated instruments should also be listed in the Medical Subject Headings (MeSH) to improve cataloguing and retrieval of previous research.

Long-term Patient and Health Service Outcomes of Ablation and Antiarrhythmic Drugs in Atrial Fibrillation: A Comparative Systematic Review.

Atrial fibrillation (AF) is a prevalent problem worldwide and a common cause of hospitalization, poor quality of life, and increased mortality. Although several treatments are used, the use of ablation and antiarrhythmic drug therapy has increased in the past decade. However, debate continues on the most suitable option for heart rhythm control in patients. Previous studies have largely focused on short-term outcome effects of these treatments. This systematic review aims to determine the effect of ablation compared to antiarrhythmic drugs for AF on long-term patient and health service outcomes of mortality, hospitalization, and quality of life. Three databases were systematically searched-studies were included if they reported long-term outcomes of more than 12 months comparing the 2 treatments. Title and abstract screening and subsequent full-text screening was done by 2 reviewers. Data were extracted from the final studies identified. The details of the search were recorded according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses report. A total of 2224 records were identified. After removing duplicates and screening the titles and abstracts, 68 records required full-text screening. Finally, 12 papers were included in the analysis. Eight studies reported mortality indicating ablation was superior, 2 studies reported hospitalization with opposing outcomes, and 5 quality of life studies indicating ablation was a better treatment. In studies assessing long-term outcomes, beyond 12 months, following ablation or rhythm control drugs for AF, most found a lower risk of death and greater improvement in quality of life in the ablation group.

Prevalence of Alcohol Consumption in Emergency department presentations (PACE) in Queensland, Australia, using alcohol biomarkers ethanol and phosphatidylethanol: an observational study protocol.

INTRODUCTION: Alcohol use in patients presenting to the emergency department (ED) is a significant problem in many countries. There is a need for valid and reliable surveillance of the prevalence of alcohol use in patients presenting to the ED, to provide a more complete picture of the risk factors and inform targeted public health interventions. This PACE study will use two biomarkers, blood ethanol and phosphatidylethanol (PEth), to determine the patterns, presence and level of alcohol use in patients presenting to an Australian ED. METHODS AND ANALYSIS: This is an observational prevalence study involving the secondary use of routinely collected blood samples from patients presenting to the Royal Brisbane and Women's Hospital (RBWH) Emergency and Trauma Centre (ETC). Samples will be tested for acute and medium-term alcohol intake using the two biomarkers blood ethanol and PEth respectively, over one collection period of 10-12 days. Descriptive statistics such as frequencies, percentages, means, SD, medians and IQRs, will be used to describe the prevalence, pattern and distribution of acute and medium-term alcohol intake in the study sample. The correlation between acute and medium-term alcohol intake levels will also be examined. ETHICS AND DISSEMINATION: This study has been approved by the RBWH Human Research Ethics Committee (reference, LNR/2019/QRBW/56859). Findings will be disseminated to key stakeholders such as RBWH ETC, Australasian College for Emergency Medicine, Royal Australasian College of Surgeons, Statewide Clinical Networks, and used to inform clinicians and hospital services. Findings will be submitted for publication in peer-reviewed journals and presentation at appropriate conferences.

Three Es of linked injury data: Episodes, Encounters and Events.

BACKGROUND: Treatment and recovery times following injury can be lengthy, comprising multiple interactions with the hospital system for initial acute care, subsequent rehabilitation and possible re-presentation due to complications. AIMS: This article aims to promote the use of consistent terminology in injury data linkage studies, suggest important factors to consider when managing linked injury data, and encourage thorough documentation and a robust discourse around different approaches to data management to ensure reproducibility, consistency and comparability of analyses arising from linked injury data. APPROACH: This paper is presented in sections describing: (1) considerations for identifying injury cohorts, (2) considerations for grouping Episodes into Encounters and (3) considerations for grouping Encounters into Events. Summary tools are provided to aid researchers in the management of linked injury data. DISCUSSION: Careful consideration of decisions made when identifying injury cohorts and grouping data into units of analysis (Episodes/Encounters/Events) is essential when using linked injury data. Choices made have the potential to significantly impact the epidemiological and clinical findings derived from linked injury data studies, which ultimately affect the quality of injury prevention initiatives and injury management policy and practice. It is intended that this paper will act as a call to action for injury linkage methodologists, and those using linked data, to critique approaches, share tools and engage in a robust discourse to further advance the use of linked injury data, and ultimately enhance the value of linked injury data for clinicians and health and social policymakers.

Cost-effectiveness analysis of percutaneous coronary intervention for single-vessel coronary artery disease: an economic evaluation of the ORBITA trial.

OBJECTIVE: To evaluate the cost-effectiveness of percutaneous coronary intervention (PCI) compared with placebo in patients with single-vessel coronary artery disease and angina despite anti-anginal therapy. DESIGN: A cost-effectiveness analysis comparing PCI with placebo. A Markov model was used to measure incremental cost-effectiveness, in cost per quality-adjusted life-years (QALYs) gained, over 12 months. Health utility weights were estimated using responses to the EuroQol 5-level questionnaire, from the Objective Randomised Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina trial and UK preference weights. Costs of procedures and follow-up consultations were derived from Healthcare Resource Group reference costs and drug costs from the National Health Service (NHS) drug tariff. Probabilistic sensitivity analysis was undertaken to test the robustness of results to parameter uncertainty. Scenario analyses were performed to test the effect on results of reduced pharmaceutical costs in patients undergoing PCI, and the effect of patients crossing over from placebo to PCI due to refractory angina within 12 months. SETTING: Five UK NHS hospitals. PARTICIPANTS: 200 adult patients with stable angina and angiographically severe single-vessel coronary artery disease on anti-anginal therapy. INTERVENTIONS: At recruitment, patients received 6 weeks of optimisation of medical therapy for angina after which they were randomised to PCI or a placebo procedure. OUTCOME MEASURES: Incremental cost-effectiveness ratio (ICER) expressed as cost (in £) per QALY gained for PCI compared with placebo. RESULTS: The estimated ICER is £90 218/QALY gained when using PCI compared with placebo in patients receiving medical treatment for angina due to single-vessel coronary artery disease. Results were robust under sensitivity analyses. CONCLUSIONS: The ICER for PCI compared with placebo, in patients with single-vessel coronary artery disease and angina on anti-anginal medication, exceeds the threshold of £30 000 used by the National Institute of Health and Care Excellence when undertaking health technology assessment for the NHS context.Trial registration: The ORBITA study is registered with ClinicalTrials.gov, number NCT02062593.

Quality of life measured by EQ-5D at different treatment time points for coronary artery disease: protocol for a systematic review and meta-analysis.

INTRODUCTION: Cardiovascular disease is estimated to affect 423 million people globally. It caused 18 million deaths in 2017 and is projected to cost US$1 trillion by 2030 worldwide. Coronary artery disease (CAD) is the most common type of cardiovascular disease; CAD treatments can affect patients' quality of life. Valuations of quality of life or health utilities are important for economic evaluations to ascertain relative health benefit when comparing treatments, and can be expected to change for individuals over time. The purpose of this systematic review is to estimate the quality of life of patients with CAD reported through the EuroQol 5 Dimension (EQ-5D) questionnaire, from short to longer term time points following different treatments. METHODS AND ANALYSIS: PubMed, Embase, Web of Science, the Cochrane Database of Systematic Reviews and the EuroQol website will be systematically searched from January 2003-March 2020. Published, peer-reviewed, English language studies assessing quality of life of patients with CAD using the EQ-5D will be included. One researcher will conduct the search; two researchers will independently screen titles and abstracts for potential inclusion. Full texts of potentially eligible studies will be retrieved for a second round of independent screening against inclusion and exclusion criteria by two researchers. The final list of included studies will be assessed for risk of bias using the RoB 2 and Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I) tools for randomised and non-randomised studies, respectively. Data extraction will be done by one researcher, with data extraction for a random 10% of included studies checked by a second researcher. Mean utility weights for individual studies will be combined using random effects model meta-analyses. A model will be run separately for each time point and treatment. Treatment time points of interest include baseline, 30 days, 6 months, 12-24 months and more than 24 months. Subgroup analysis of patients with diabetes who received interventional treatments-coronary artery bypass graft or percutaneous coronary intervention with or without stents, will be conducted for the same selected time points. ETHICS AND DISSEMINATION: Ethics approval is not required for systematic reviews. Results of the review will be disseminated via publication in a peer-reviewed journal.

Pharmaceutical use and costs in patients with coronary artery disease, using Australian observational data.

OBJECTIVES: We aimed to estimate the annual pharmaceutical costs for patients with stable coronary artery disease, using Australian administrative data, comparing patients who had undergone interventional treatment with those had not. We also aimed to compare the duration of dual antiplatelet therapy (DAPT) prescription in the real-world, with recommended guidelines. DESIGN: An observational study using administrative data. PARTICIPANTS: We used data from the QSkin study, a population-based prospective study assessing skin cancer risk. Participants were invited from the Queensland population, not based on perceived skin cancer risk, and had consented to future use of their data for approved research projects. MAIN OUTCOME MEASURES: We calculated 12-month costs of pharmaceutical therapy for coronary artery disease for patients in each of three clinically relevant groups: medical therapy only, following coronary stent implantation and following coronary artery bypass graft surgery. We measured the duration of DAPT following stent implantation and total duration of DAPT, where it was prescribed, in the medical therapy only group. RESULTS: Estimated mean annual pharmaceutical costs were highest in the stent group at AUD$1920, compared with AUD$1481 in the medical therapy group, and AUD$881 in the coronary artery bypass group. There were similar rates of prescriptions of symptom relief drugs following stent insertion, compared with the medical therapy only group. The median duration of DAPT in the stent group was 16, and 31 months in the medical therapy group. CONCLUSIONS: Our results suggest that despite the common expectation that the burden of medical therapy is reduced following coronary stent insertion for stable coronary artery disease, this does not occur in practice. Many patients also appear to continue DAPT longer than guidelines recommend, which may put them at unnecessarily elevated risk of bleeding events.

A systematic review and critical analysis of cost-effectiveness studies for coronary artery disease treatment.

Background: Cardiovascular disease remains the primary cause of death among Australians, despite dramatic improvements in overall cardiovascular health since the 1980s. Treating cardiovascular disease continues to place a significant economic strain on the Australian health care system, with direct healthcare costs exceeding those of any other disease. Coronary artery disease accounts for nearly one third of these costs and spending continues to rise. A range of treatments is available for coronary artery disease yet evidence of cost-effectiveness is missing, particularly for the Australian context. Cost-effectiveness evidence can signal waste and inefficiency and so is essential for an efficient allocation of healthcare resources. Methods: We used systematic review methods to search the literature across several electronic databases for economic evaluations of treatments for coronary artery disease.  We critically appraised the literature found in searches, both against the CHEERS statement for quality reporting of economic evaluations and in terms of its usefulness for policy and decision-makers. Results: We retrieved a total of 308 references, 229 once duplicates were removed. Of these, 26 were excluded as they were not full papers (letters, editorials etc.), 55 were review papers, 50 were not cost-effectiveness analyses and 93 related to a highly specific patient sub-group or did not consider all treatment options.  This left five papers to be reviewed in full. Conclusions: The current cost-effectiveness evidence does not support the increased use of PCI that has been seen in Australia and internationally. Due to problems with accessibility, clarity and relevance to policy and decision-makers, some otherwise very scientifically rigorous analyses have failed to generate any policy changes.

An economic analysis of the benefits of sterilizing medical instruments in low-temperature systems instead of steam.

BACKGROUND: Hydrogen peroxide-based, low-temperature sterilization has been shown to do less damage to medical instruments than steam autoclaves. However, low-temperature systems are more expensive to run. Higher costs need to be balanced against savings from reduced repair costs to determine value for money when choosing how to sterilize certain instruments, which are able to be reprocessed in either system. METHODS: This analysis examines the economic effects of using low-temperature sterilization systems to reprocess rigid and semi-rigid endoscopes, which are sensitive to heat and moisture, but still able to be sterilized using steam. It examines the changes to costs and frequency of repairs expected over 10 years, resulting from a choice to sterilize these instruments in a low-temperature system instead of steam. RESULTS: Overall, the results showed that increased sterilization costs are outweighed by the savings associated with less frequent repairs. Over a 10-year period, in large health care facilities, the probability of achieving an internal rate of return of at least 6% is 0.81. CONCLUSIONS: Our model shows it is likely to be a good decision for large health care facilities to invest in low-temperature sterilization systems.

A cost-effectiveness modelling study of strategies to reduce risk of infection following primary hip replacement based on a systematic review.

BACKGROUND: A deep infection of the surgical site is reported in 0.7% of all cases of total hip arthroplasty (THA). This often leads to revision surgery that is invasive, painful and costly. A range of strategies is employed in NHS hospitals to reduce risk, yet no economic analysis has been undertaken to compare the value for money of competing prevention strategies. OBJECTIVES: To compare the costs and health benefits of strategies that reduce the risk of deep infection following THA in NHS hospitals. To make recommendations to decision-makers about the cost-effectiveness of the alternatives. DESIGN: The study comprised a systematic review and cost-effectiveness decision analysis. SETTING: 77,321 patients who had a primary hip arthroplasty in NHS hospitals in 2012. INTERVENTIONS: Nine different treatment strategies including antibiotic prophylaxis, antibiotic-impregnated cement and ventilation systems used in the operating theatre. MAIN OUTCOME MEASURES: Change in the number of deep infections, change in the total costs and change in the total health benefits in quality-adjusted life-years (QALYs). DATA SOURCES: Literature searches using MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Central Register of Controlled Trials were undertaken to cover the period 1966-2012 to identify infection prevention strategies. Relevant journals, conference proceedings and bibliographies of retrieved papers were hand-searched. Orthopaedic surgeons and infection prevention experts were also consulted. REVIEW METHODS: English-language papers only. The selection of evidence was by two independent reviewers. Studies were included if they were interventions that reported THA-related deep surgical site infection (SSI) as an outcome. Mixed-treatment comparisons were made to produce estimates of the relative effects of competing infection control strategies. RESULTS: Twelve studies, six randomised controlled trials and six observational studies, involving 123,788 total hip replacements (THRs) and nine infection control strategies, were identified. The quality of the evidence was judged against four categories developed by the National Institute for Health and Care Excellence Methods for Development of NICE Public Health Guidance ( http://publications.nice.org.uk/methods-for-the-development-of-nice-public-health-guidance-third-edition-pmg4 ), accessed March 2012. All evidence was found to fit the two highest categories of 1 and 2. Nine competing infection control interventions [treatments (Ts) 1-9] were used in a cohort simulation model of 77,321 patients who had a primary THR in 2012. Predictions were made for cases of deep infection and total costs, and QALY outcomes. Compared with a baseline of T1 (no systemic antibiotics, plain cement and conventional ventilation) all other treatment strategies reduced risk. T6 was the most effective (systemic antibiotics, antibiotic-impregnated cement and conventional ventilation) and prevented a further 1481 cases of deep infection, and led to the largest annual cost savings and the greatest gains to QALYs. The additional uses of laminar airflow and body exhaust suits indicate higher costs and worse health outcomes. CONCLUSIONS: T6 is an optimal strategy for reducing the risk of SSI following THA. The other strategies that are commonly used among NHS hospitals lead to higher cost and worse QALY outcomes. Policy-makers, therefore, have an opportunity to save resources and improve health outcomes. The effects of laminar air flow and body exhaust suits might be further studied if policy-makers are to consider disinvesting in these technologies. LIMITATIONS: A wide range of evidence sources was synthesised and there is large uncertainty in the conclusions. FUNDING: The National Institute for Health Research Health Technology Assessment programme and the Queensland Health Quality Improvement and Enhancement Programme (grant number 2008001769).