Development and validation of an individual-based state-transition model for the prediction of frailty and frailty-related events.

Frailty is a biological syndrome that is associated with increased risks of morbidity and mortality. To assess the value of interventions to prevent or manage frailty, all important impacts on costs and outcomes should be estimated. The aim of this study is to describe the development and validation of an individual-based state transition model that predicts the incidence and progression of frailty and frailty-related events over the remaining lifetime of older Australians. An individual-based state transition simulation model comprising integrated sub models that represent the occurrence of seven events (mortality, hip fracture, falls, admission to hospital, delirium, physical disability, and transitioning to residential care) was developed. The initial parameterisation used data from the Survey of Health, Ageing, and Retirement in Europe (SHARE). The model was then calibrated for an Australian population using data from the Household, Income and Labour Dynamics in Australia (HILDA) Survey. The simulation model established internal validity with respect to predicting outcomes at 24 months for the SHARE population. Calibration was required to predict longer terms outcomes at 48 months in the SHARE and HILDA data. Using probabilistic calibration methods, over 1,000 sampled sets of input parameter met the convergence criteria across six external calibration targets. The developed model provides a tool for predicting frailty and frailty-related events in a representative community dwelling Australian population aged over 65 years and provides the basis for economic evaluation of frailty-focussed interventions. Calibration to outcomes observed over an extended time horizon would improve model validity.

An Economic Evaluation of Government-Funded COVID-19 Testing in Australia.

OBJECTIVE: Easy and equitable access to testing has been a cornerstone of the public health response to COVID-19. Currently in Australia, testing using polymerase chain reaction (PCR) tests for COVID-19 is free to the user, but government funding for rapid antigen tests (RATs) is limited. We conduct an economic analysis of alternative government policies regarding the funding of COVID-19 testing in Australia. METHODS: A decision tree model was developed to describe COVID-19 testing pathways for the Australian population over a 1-week period. The model outputs were analysed to estimate R numbers associated with alternative funding policies, which were used to estimate COVID-19 cases over a 6-month time horizon. Healthcare costs and quality-adjusted life-year (QALY) effects were applied to new COVID-19 cases. The model was populated using responses to a de novo population survey and published data sources. RESULTS: Compared with no government-funded COVID-19 testing, government-funded testing is estimated to generate large incremental net monetary benefits (INMBs), up to A$15 billion in the base-case analyses. Government-funded PCR testing and RATs for all is predicted to maximise INMBs in most tested scenarios, though funding RATs for all and not PCR tests has similar INMBs in many scenarios and generates higher benefits to costs ratios. CONCLUSIONS: Our interpretation of the modelled analysis is that at the time of writing (July 2022), with high vaccination uptake in Australia and few other public health measures in place, Australian governments should consider reducing funding of PCR testing, for example, limiting capacity to essential workers and individuals with known risk factors for serious symptoms, and fund RATs for all.

Adolescent values for immunisation programs in Australia: A discrete choice experiment.

OBJECTIVES: The importance of adolescent engagement in health decisions and public health programs such as immunisation is becoming increasingly recognised. Understanding adolescent preferences and further identifying barriers and facilitators for immunisation acceptance is critical to the success of adolescent immunisation programs. This study applied a discrete choice experiment (DCE) to assess vaccination preferences in adolescents. METHODS: This study was conducted as a cross-sectional, national online survey in Australian adolescents. The DCE survey evaluated adolescent vaccination preferences. Six attributes were assessed including disease severity, target for protection, price, location of vaccination provision, potential side effects and vaccine delivery method. A mixed logit model was used to analyse DCE data. RESULTS: This survey was conducted between December 2014 and January 2015. Of 800 adolescents aged 15 to 19 years, stronger preferences were observed overall for: vaccination in the case of a life threatening illness (p<0.001), lower price vaccinations (p<0.001), mild but common side effects (p = 0.004), delivery via a skin patch (p<0.001) and being administered by a family practitioner (p<0.001). Participants suggested that they and their families would be willing to pay AU$394.28 (95%CI: AU$348.40 to AU$446.92) more for a vaccine targeting a life threatening illness than a mild-moderate illness, AU$37.94 (95%CI: AU$19.22 to AU$57.39) more for being vaccinated at a family practitioner clinic than a council immunisation clinic, AU$23.01 (95%CI: AU$7.12 to AU$39.24) more for common but mild and resolving side effects compared to rare but serious side effects, and AU$51.80 (95%CI: AU$30.42 to AU$73.70) more for delivery via a skin patch than injection. CONCLUSIONS: Consideration of adolescent preferences may result in improved acceptance of, engagement in and uptake of immunisation programs targeted for this age group.

Is the Counterweight Program a feasible and acceptable option for structured weight management delivered by practice nurses in Australia? A mixed-methods study.

Nurse-led weight management programs, like the Counterweight Program in the United Kingdom, may offer a way for Australian general practices to provide weight management support to adults who are overweight or obese. During Counterweight, nurses provide patients with six fortnightly education sessions and three follow-up sessions to support weight maintenance. This study examined the feasibility, acceptability and perceived value of the Counterweight Program in the Australian primary care setting using a mixed-methods approach. Six practice nurses, from three general practices, were trained and subsidised to deliver the program. Of the 65 patients enrolled, 75% (n=49) completed the six education sessions. General practitioners and practice nurses reported that the training and resource materials were useful, the program fitted into general practices with minimal disruption and the additional workload was manageable. Patients reported that the program created a sense of accountability and provided a safe space to learn about weight management. Overall, Counterweight was perceived as feasible, acceptable and valuable by Australian practice staff and patients. The key challenge for future implementation will be identifying adequate and sustainable funding. An application to publically fund Counterweight under the Medicare Benefits Schedule would require stronger evidence of effectiveness and cost-effectiveness in Australia.

A Cost-Effectiveness Model for Frail Older Persons: Development and Application to a Physiotherapy-Based Intervention.

INTRODUCTION: The clinical importance of frailty is increasing. Existing economic evaluations of interventions to manage frailty have limited time horizons, but even in older populations there may be important longer-term differences in costs and outcomes. This paper reports on the development of a cost-effectiveness model to predict publicly funded health and aged care costs and quality-adjusted life years (QALYs) over the remaining lifetime of frail Australians and a model-based cost-utility analysis of a physiotherapy-based intervention for frail individuals. METHODS: A cohort-based state transition (Markov) model was developed to predict costs and QALYs over the remaining lifetime of a frail population. Frailty is defined using the phenotypic definition of frailty, and the model comprises health states that describe frailty status, residential status, the experience of bone fractures and depression, and death. Model input parameters were estimated and calibrated using the Dynamic Analyses to Optimise Ageing dataset, supplemented with data from the published literature. RESULTS: The cost-effectiveness model was subject to a range of validation approaches, which did not negate the validity of the model. The evaluated physiotherapy-based frailty intervention has an expected incremental cost per QALY gained of Australian $8129 compared to usual care, but there is a probability of 0.3 that usual care is more effective and less costly than the intervention. DISCUSSION: Frailty reduces quality of life, is costly to manage and it's prevalence is increasing, but new approaches to managing frailty need to demonstrate value for money. The value of the reported cost-effectiveness model is illustrated through the estimation of all important costs and effects of a physiotherapy-based frailty intervention, which facilitates comparisons with funding decisions for other new technologies in Australia.

Adolescent confidence in immunisation: Assessing and comparing attitudes of adolescents and adults.

INTRODUCTION: There is limited knowledge of adolescent views and attitudes towards immunisation. Our study investigated adolescent attitudes to immunisation and compared differences in vaccination attitudes between adolescents and adults. METHODS: This study was a cross-sectional, national online survey. Recruitment was stratified by state and gender to ensure findings were nationally representative. Regression analyses were performed to assess and compare adolescent and adult views on vaccine benefits, community protection, risks, side effects, sources of information, and decision-making preference. RESULTS: In 2013, 502 adolescents and 2003 adults completed the online survey. Lower levels of vaccine confidence were observed in adolescents with adolescents less likely to believe vaccines are beneficial and/or safe compared to adults (p=0.043). Compared to females, males were less confident of vaccine benefits (p<0.05) but less concern about vaccine side effects (p<0.05). Adolescents were more concerned about vaccine side effects than adults for pain (p<0.001), redness or swelling (p<0.001), and fever (p=0.006). Adolescents were less likely than adults to consider health professionals (p<0.001) and the media (e.g. internet) (p=0.010) as important sources of information, and were more likely to seek information from social networks (p<0.001) including families and schools. Although 62.0% of adolescents agreed that parents should make the decision about vaccination for them, adolescents were more likely to prefer a joint decision with parents (p<0.001) or by themselves (p=0.007) compared with adults. CONCLUSION: Adolescents have a lesser understanding of vaccine safety and benefits than adults and have higher concerns about potential vaccine reactions. Improving adolescent awareness and knowledge of the benefits and risks of vaccination through school-based educational programs may improve confidence in and uptake of vaccines for adolescents and increase vaccine confidence in the next generation of parents.

Exploring structural uncertainty in model-based economic evaluations.

Given the inherent uncertainty in estimates produced by decision analytic models, the assessment of uncertainty in model-based evaluations is an essential part of the decision-making process. Although the impact of uncertainty around the choice of model structure and making incorrect structural assumptions on model predictions is noted, relatively little attention has been paid to characterising this type of uncertainty in guidelines developed by national funding bodies such as the Australian Pharmaceutical Benefits Advisory Committee (PBAC). The absence of a detailed description and evaluation of structural uncertainty can add further uncertainty to the decision-making process, with potential impact on the quality of funding decisions. This paper provides a summary of key elements of structural uncertainty describing why it matters and how it could be characterised. Five alternative approaches to characterising structural uncertainty are discussed, including scenario analysis, model selection, model averaging, parameterization and discrepancy. We argue that the potential effect of structural uncertainty on model predictions should be considered in submissions to national funding bodies; however, the characterisation of structural uncertainty is not well defined within the guidelines of these bodies. There has been little consideration of the forms of structural sensitivity analysis that might best inform applied decision-making processes, and empirical research in this area is required.

Practice nurse involvement in general practice clinical care: policy and funding issues need resolution.

In Australia, primary care-based funding initiatives have been implemented to encourage general practices to employ practice nurses. The aim of this paper is to discuss limitations of the current funding and policy arrangements in enhancing the clinical role of practice nurses in the management of chronic conditions. This paper draws on the results of a real-world economic evaluation, the Primary Care Services Improvement Project (PCSIP). The PCSIP linked routinely collected clinical and resource use data to undertake a risk-adjusted cost-effectiveness analysis of increased practice nurse involvement in clinical-based activities for the management of diabetes and obesity. The findings of the PCSIP suggested that the active involvement of practice nurses in collaborative clinical-based activities is cost-effective, as well as addressing general practice workforce issues. Although primary healthcare organisations (e.g. Medicare Locals) can play a key role in supporting enhanced practice nurse roles, improvements to practice nurse funding models could further encourage more efficient use of an important resource.

Community, parental and adolescent awareness and knowledge of meningococcal disease.

OBJECTIVE: To assess knowledge of invasive meningococcal disease (IMD) and concern about the disease in the South Australian Community including adolescents, adults, parents and non-parents. METHODS: This cross-sectional study was conducted by face to face interviews in South Australia in 2012. Participants were scored on their knowledge and concern about IMD. Univariate and multivariate regression analyses were performed with the survey data weighted by age and gender in accordance with 2011 Census data. RESULTS: Of 5200 households randomly selected and stratified by metropolitan or rural location, 3055 participants were interviewed with a response rate of 60.3%. The majority were Australian born (74.2%, n=2267) with 31.8% (n=972) of those interviewed being parents, and 15.9% (n=487) adolescents (15-24 years). Almost a quarter of participants (23.5%, n=717) do not know what meningococcal disease is, with 9.1% (n=278) believing incorrectly that IMD is a viral infection. 36.6% (n=1114) had low overall knowledge of IMD. Adolescents (p<0.050), non-Australian born (p<0.001), low educational attainment (p=0.019), low household income (p=0.011), low/medium socio-economic status (p<0.050) or living in a metropolitan area (p=0.006) were more likely to have lower overall knowledge of IMD. Participants who were not parents (p<0.001), male gender (p<0.001), single (p<0.001), highly educated (p=0.022) or had high household income (p=0.015), had lower concern about IMD. CONCLUSION: Large community knowledge gaps for IMD were observed, particularly amongst adolescents and adults with low educational attainment and low socio-economic status. Improving community knowledge of IMD could help ensure optimal uptake of a new meningococcal vaccine. Our study results can help guide development of community tailored immunisation education programs.

The clinical burden and predictors of sequelae following invasive meningococcal disease in Australian children.

Of 109 children admitted to a tertiary paediatric hospital with a diagnosis of invasive meningococcal disease from 2000-2011, 37.6% (n = 41) developed sequelae; for serogroup B, 41.3% developed sequelae. Independent predictors of sequelae included: fever ≥ 39 °C on hospital presentation [odds ratio (OR): 4.5; P = 0.012] and a diagnosis of septicemia with meningitis compared with septicemia alone (OR: 15.5; P < 0.001) and meningitis alone (OR: 7.8; P = 0.002).

Melanoma follow up: time to generate the evidence.

Research is needed into current melanoma follow-up practices and their implications for patients and society. We highlight the need and suggest a way forward.

Improving the accuracy and comparability of model-based economic evaluations of health technologies for reimbursement decisions: a methodological framework for the development of reference models.

Increasingly, decision analytic models are used within economic evaluations of health technologies (e.g., pharmaceuticals) submitted to national reimbursement bodies in countries like Australia and UK, where such models play a fundamental role in informing public funding decisions. Concerns regarding the accuracy of model outputs and hence the credibility of national reimbursement decisions are frequently raised. We propose a framework for developing reference models for specific diseases to inform economic evaluations of health technologies and their appraisal. The structure of a reference model reflects the natural history of the condition under study and defines the clinical events to be represented, the relationships between the events, and the effect of patient characteristics on the probability and timing of events. We contend that the use of reference models will improve the accuracy and comparability of public funding decisions. This can lead to the more efficient allocation of public funds.

A model-based evaluation of collaborative care in management of patients with type 2 diabetes in Australia: an initial report.

OBJECTIVES: To analyse the short- and long-term costs and benefits of alternative models of primary care for the management of patients with type 2 diabetes in Australia. The models of care reflect differential uptake of primary care-based incentive programs, including reminder systems and involvement of practice nurses in management. This paper describes our study protocol and its progress. METHODS: We are undertaking an observational study using a cluster sample design that links retrospective patient data from a range of sources to estimate costs and intermediate outcomes (such as the level of glycosylated haemoglobin (HbA1c)) over a 3-year time horizon. We use the short-term data as a basis to estimate lifetime costs and benefits of alternative models of care using a decision analytic model. INITIAL REPORT: We recruited 15 practices from a metropolitan area (Adelaide) and allocated them to three models of care. Three hundred and ninety-nine patients agreed to participate. We use multilevel analysis to evaluate the association between different models of care and patient-level outcomes, while controlling for several covariates. DISCUSSION/CONCLUSIONS: Given the large amount of funding currently used to maintain primary care-based incentives in general practices in Australia, the results of this study generate the knowledge required to promote investment in the most cost-effective incentives.

Exploring health professionals' perspectives on factors affecting Iranian hospital efficiency and suggestions for improvement.

While numerous studies have been undertaken in many developed countries and in a few developing countries, there has so far been no systematic attempt to identify factors affecting efficiency in the Iranian hospitals. This study was designed to elicit the perspectives of a group of health professionals and managers so as to analyse factors affecting the efficiency of hospitals owned by the Iranian Social Security Organization (SSO), which is the second largest institutional source of hospital care in that country. This study also aimed to identify actions that would improve efficiency. Using purposive sampling (to identify key informants), interviews with seventeen health professionals and hospital managers involved in the SSO health system were conducted. The respondents identified a number of organizational factors affecting efficiency, particularly the hospital budgeting and payment system used to fund physicians, and the lack of the managerial skills needed to manage complex facilities such as hospitals. The interviewees stressed the necessity for reforms of the regulatory framework to improve efficiency. A few participants recommended the concept of a funder-provider split. The results of this exploratory study have provided meaningful insight into Iranian health professionals views of factors affecting efficiency, and of possible remedial actions. It is expected that the findings will provide guidance for health policy makers and hospital managers in the Iranian SSO to analyse factors affecting efficiency and to identify remedial actions to improve efficiency. Hospitals in other developing countries may be affected by similar factors.

A conceptual framework for selecting the most appropriate variables for measuring hospital efficiency with a focus on Iranian public hospitals.

Over the past few decades, there has been an increasing interest in the measurement of hospital efficiency in developing countries and in Iran. While the choice of measurement methods in hospital efficiency assessment has been widely argued in the literature, few authors have offered a framework to specify variables that reflect different hospital functions, the quality of the process of care and the effectiveness of hospital services. However, without the knowledge of hospital objectives and all relevant functions, efficiency studies run the risk of making biased comparisons, particularly against hospitals that provide higher quality services requiring the use of more resources. Undertaking an in-depth investigation regarding the multi-product nature of hospitals, various hospital functions and the values of various stakeholders (patient, staff and community) with a focus on the Iranian public hospitals, this study has proposed a conceptual framework to select the most appropriate variables for measuring hospital efficiency using frontier-based techniques. This paper contributes to hospital efficiency studies by proposing a conceptual framework and incorporating a broader set of variables in Iran. This can enhance the validity of hospital efficiency studies using frontier-based methods in developing countries.