Making the sunshine vitamin - How much sun exposure is needed to maintain 25-hydroxy vitamin D concentration?

Our objective was to calculate the time in the sun necessary to maintain existing 25-hydroxyvitamin D (25(OH)D) concentration at locations across Australia and New Zealand. We used a microsimulation model to estimate changes in monthly 25(OH)D concentration using data on standard erythemal dose, solar zenith angle, and climatological ozone. We estimated the number of standard vitamin D doses per 10-min interval and used a dose-response equation to determine the average time in the sun to maintain existing 25(OH)D concentration according to month and time of day. Across all locations in summer, 5-10 min outdoors between 8 a.m. and 4 p.m. on most days of the week, with 35% of the body surface area exposed, is sufficient to maintain existing 25(OH)D concentration. In winter, at mid-to-high latitudes, time outdoors during the middle of the day is required. In winter, with 10% of the body surface area exposed, greater than 45 min in the middle of the day is required in most locations to maintain existing 25(OH)D concentration. These data can be used to inform guidelines regarding maintaining vitamin D via sun exposure and may help health practitioners identify patients who may be vitamin D deficient.

Early cost-utility analysis of genetically guided therapy for patients with drug-resistant epilepsy.

OBJECTIVE: Existing gene panels were developed to understand the etiology of epilepsy, and further benefits will arise from an effective pharmacogenomics panel for personalizing therapy and achieving seizure control. Our study assessed the cost-effectiveness of a pharmacogenomics panel for patients with drug-resistant epilepsy, compared with usual care. METHODS: A cost-utility analysis was employed using a discrete event simulation model. The microsimulation model aggregated the costs and benefits of genetically guided treatment versus usual care for 5000 simulated patients. The 10-year model combined data from various sources including genomic databases on prevalence of variants, population-level pharmaceutical claims on antiseizure medications, published long-term therapy retention rates, patient-level cost data, and systematic reviews. Incremental cost per quality-adjusted life-year (QALY) gained was computed. Deterministic and probabilistic sensitivity analyses were undertaken to address uncertainty in model parameters. RESULTS: The mean cost of the genetically guided treatment option was AU$98 199 compared with AU$95 386 for usual care. Corresponding mean QALYs were 4.67 compared with 4.28 for genetically guided and usual care strategies, respectively. The incremental cost per QALY gained was AU$7381. In probabilistic sensitivity analyses, the incremental cost per QALY gained was AU$6321 (95% uncertainty interval = AU$3604-AU$9621), with a 100% likelihood of being cost-effective in the Australian health care system. The most influential drivers of the findings were the monthly health care costs associated with reduced seizures, costs when seizures continued, and the quality-of-life estimates under genetically guided and usual care strategies. SIGNIFICANCE: This early economic evaluation of a pharmacogenomics panel to guide treatment for drug-resistant epilepsy could potentially be cost-effective in the Australian health care system. Clinical trial evidence is necessary to confirm these findings.

Estimated Healthcare Costs of Melanoma and Keratinocyte Skin Cancers in Australia and Aotearoa New Zealand in 2021.

Australia and Aotearoa New Zealand have the highest incidence of melanoma and KC in the world. We undertook a cost-of-illness analysis using Markov decision-analytic models separately for melanoma and keratinocyte skin cancer (KC) for each country. Using clinical pathways, the probabilities and unit costs of each health service and medicine for skin cancer management were applied. We estimated mean costs and 95% uncertainty intervals (95% UI) using Monte Carlo simulation. In Australia, the mean first-year costs of melanoma per patient ranged from AU$644 (95%UI: $642, $647) for melanoma in situ to AU$100,725 (95%UI: $84,288, $119,070) for unresectable stage III/IV disease. Australian-wide direct costs to the Government for newly diagnosed patients with melanoma were AU$397.9 m and AU$426.2 m for KCs, a total of AU$824.0 m. The mean costs per patient for melanoma ranged from NZ$1450 (95%UI: $1445, $1456) for melanoma in situ to NZ$77,828 (95%UI $62,525, $94,718) for unresectable stage III/IV disease. The estimated total cost to New Zealand in 2021 for new patients with melanoma was NZ$51.2 m, and for KCs, was NZ$129.4 m, with a total combined cost of NZ$180.5 m. These up-to-date national healthcare costs of melanoma and KC in Australia and New Zealand accentuate the savings potential of successful prevention strategies for skin cancer.

Unexpected benefit of COVID-19 hospital restrictions: Reduction in patients isolating with multidrug resistant organisms after restrictions were lifted.

BACKGROUND: During the COVID-19 pandemic, measures to prevent microorganism transmission were implemented across hospitals, including wearing compulsory surgical masks, minimising non-urgent procedures and restricting visitors. Previously, concerns have been raised that MRO-associated deaths could rise during a future pandemic through superimposed bacterial infections, inappropriate antibiotic use and reduced focus on preventing MRO infections. METHODS: In the state of Queensland, Australia with a population of 5 million, only a short first wave of coronavirus cases occurred and restrictions were quickly scaled back. This presented a natural experiment of pre-, during and post-COVID-19 restriction timings to evaluate the effectiveness of heightened prevention measures on multidrug resistant organism (MRO) infections. Patient isolation days and MRO types were collected weekly from routine infection control reports, at a large public hospital, from 28th January 2020 to 24th July 2020. In this interrupted time series design, we employed Poisson mixed effect regression modelling to evaluate the difference in incidence of patient isolation days between time periods. RESULTS: Compared to pre-COVID, patient isolation days reduced during COVID restrictions (incidence rate ratio 0.65, 95%CI: 0.59, 0.70; p < 0.001) and increased again post-COVID restrictions, but did not return to pre-COVID levels (0.87, 95%CI: 0.80, 0.95; p = 0.001). The efficiency of isolating patients improved after COVID-19 with fewer bed closures required. CONCLUSION: Heightened infection control awareness, hand sanitation and mask wearing after COVID-19 restrictions were lifted appear to effectively prevent common hospital-acquired MRO infections.

Healthcare costs of investigations for stillbirth from a population-based study in Australia.

Objective Stillbirth investigations incur healthcare costs, but these investigations are necessary to provide information that will help reduce the risk of a recurrent stillbirth, as well as advice regarding family planning and future pregnancies. The aims of this study were to determine the healthcare costs of investigations for stillbirths, identify drivers and assess cost differences between explained and unexplained stillbirths. Methods Data from 697 stillbirths were extracted from the Stillbirth Causes Study covering the period 2013-18. The dataset comprised all investigations related to stillbirth on the mother, baby and placenta. Unit costs applied were sourced from the Australian Medicare Benefits Schedule, local hospital estimates and published literature. Multivariable regression analyses were used to assess key factors in cost estimates. Results In all, 200 (28.7%) stillbirths were unexplained and 76.8% of these had between five and eight core investigations. Unexplained stillbirths were twice as likely to have eight core investigations as explained stillbirths (16.5% vs 7.7%). The estimated aggregated cost of stillbirth investigations for 697 stillbirths was A$2.13 million (mean A$3060, median A$4246). The main cost drivers were autopsies or cytogenetic screening. Mean costs were similar when stillbirths had known or unknown causes and by reason for stillbirth among cases with definable causes. Conclusion Investigations for stillbirth in Australia cost approximately A$4200 per stillbirth on average and are critical for managing future pregnancies and preventing more stillbirths. These findings improve our understanding of the costs that may be averted if stillbirths can be prevented through primary prevention initiatives. What is known about the topic? Approximately 2000 stillbirths occur each year in Australia, and this trend has not changed for several decades. Stillbirth investigations incur healthcare costs, but these investigations are necessary to provide information to help reduce the risk of a recurrent stillbirth and advice regarding family planning and future pregnancies. Recommendations for the core set of stillbirth investigations have recently been agreed upon by consensus. What does this paper add? The costs of stillbirth investigations are unknown in Australia. The assessment of these costs is challenging because not all investigations involved in stillbirths are recorded within formal administrative systems because a stillborn baby is not formally recognised as a patient. The present population-based analysis of 697 stillbirths in Australia estimated that, on average, A$4200 was spent on investigations for each stillbirth, with key drivers being autopsies and cytogenetic screening. These costs are typical, with most cases having between five and eight of the core eight recommended investigations. What are the implications for practitioners? There are cost implications for stillbirth investigations, and this analysis gives a true account of current practice in Australia. Together with the high downstream economic costs of stillbirths, the cost burden of stillbirth investigations is high but ultimately avoidable when practitioners adhere to the core investigations, build knowledge around preventable risk factors and use this information to reduce the number of stillbirths.

Budget impact analysis of routinely using whole-genomic sequencing of six multidrug-resistant bacterial pathogens in Queensland, Australia.

OBJECTIVE: To predict the cost and health effects of routine use of whole-genome sequencing (WGS) of bacterial pathogens compared with those of standard of care. DESIGN: Budget impact analysis was performed over the following 5 years. Data were primarily from sequencing results on clusters of multidrug-resistant organisms across 27 hospitals. Model inputs were derived from hospitalisation and sequencing data, and epidemiological and costing reports, and included multidrug resistance rates and their trends. SETTING: Queensland, Australia. PARTICIPANTS: Hospitalised patients. INTERVENTIONS: WGS surveillance of six common multidrug-resistant organisms (Staphylococcus aureus, Escherichia coli, Enterococcus faecium, Klebsiella pneumoniae, Enterobacter sp and Acinetobacter baumannii) compared with standard of care or routine microbiology testing. PRIMARY AND SECONDARY OUTCOMES: Expected hospital costs, counts of patient infections and colonisations, and deaths from bloodstream infections. RESULTS: In 2021, 97 539 patients in Queensland are expected to be infected or colonised with one of six multidrug-resistant organisms with standard of care testing. WGS surveillance strategy and earlier infection control measures could avoid 36 726 infected or colonised patients and avoid 650 deaths. The total cost under standard of care was $A170.8 million in 2021. WGS surveillance costs an additional $A26.8 million but was offset by fewer costs for cleaning, nursing, personal protective equipment, shorter hospital stays and antimicrobials to produce an overall cost savings of $30.9 million in 2021. Sensitivity analyses showed cost savings remained when input values were varied at 95% confidence limits. CONCLUSIONS: Compared with standard of care, WGS surveillance at a state-wide level could prevent a substantial number of hospital patients infected with multidrug-resistant organisms and related deaths and save healthcare costs. Primary prevention through routine use of WGS is an investment priority for the control of serious hospital-associated infections.

Cost-effectiveness analysis of whole-genome sequencing during an outbreak of carbapenem-resistant Acinetobacter baumannii.

Background: Whole-genome sequencing (WGS) shotgun metagenomics (metagenomics) attempts to sequence the entire genetic content straight from the sample. Diagnostic advantages lie in the ability to detect unsuspected, uncultivatable, or very slow-growing organisms. Objective: To evaluate the clinical and economic effects of using WGS and metagenomics for outbreak management in a large metropolitan hospital. Design: Cost-effectiveness study. Setting: Intensive care unit and burn unit of large metropolitan hospital. Patients: Simulated intensive care unit and burn unit patients. Methods: We built a complex simulation model to estimate pathogen transmission, associated hospital costs, and quality-adjusted life years (QALYs) during a 32-month outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB). Model parameters were determined using microbiology surveillance data, genome sequencing results, hospital admission databases, and local clinical knowledge. The model was calibrated to the actual pathogen spread within the intensive care unit and burn unit (scenario 1) and compared with early use of WGS (scenario 2) and early use of WGS and metagenomics (scenario 3) to determine their respective cost-effectiveness. Sensitivity analyses were performed to address model uncertainty. Results: On average compared with scenario 1, scenario 2 resulted in 14 fewer patients with CRAB, 59 additional QALYs, and $75,099 cost savings. Scenario 3, compared with scenario 1, resulted in 18 fewer patients with CRAB, 74 additional QALYs, and $93,822 in hospital cost savings. The likelihoods that scenario 2 and scenario 3 were cost-effective were 57% and 60%, respectively. Conclusions: The use of WGS and metagenomics in infection control processes were predicted to produce favorable economic and clinical outcomes.

Evaluating the economic effects of genomic sequencing of pathogens to prioritise hospital patients competing for isolation beds.

Objective This study compared the costs and patient movements of a new hospital protocol to discontinue contact precautions for patients with non-multiresistant methicillin-resistant Staphylococcus aureus (nmMRSA), based on whole-genome sequencing (WGS) of pathogens with current practice. Methods A hybrid simulation model was constructed and analysed over a 12-month time horizon. Six multidrug-resistant organisms and influenza were modelled concurrently where infected patients competed for isolation beds. Model inputs included pathogen incidence, resources for WGS, staff and contact precautions, hospital processes, room allocations and their associated costs. Data were sourced from aggregated records of patient admissions during 2017-18, clinical records and published reports. Results The WGS protocol resulted in 389 patients isolated (44% of current practice), 5223 'isolation bed days' (56%) and 268 closed-bed days (88%). Over 1 year, the mean (±s.d.) total cost for the WGS protocol was A$749243±126667; compared with current practice, the overall cost savings were A$690864±300464. Conclusion Using WGS to inform infection control teams of pathogen transmission averts patients from isolation rooms and reduces significant resources involved in implementing contact precautions. What is known about the topic? There are an estimated 265000 hospital-acquired infections (HAI) in Australia each year. WGS can accurately identify the genetic lineage among HAIs and determine transmission clusters that can help infection control staff manage patients. Economic appraisals are lacking to inform whether pathogen genomics services should be adopted within already-stretched hospital budgets. What does this paper add? An isolation protocol using pathogen genomics to provide additional information on the relatedness of a pathogen between colonised patients showed favourable results for healthcare costs and patient flow. Using WGS, in a confirmatory role, to discontinue certain patients from contact precautions and isolation rooms resulted in cost savings of A$690864 across 1 year for a single major hospital. What are the implications for practitioners? Using pathogen WGS services for infection control potentially curbs hospital spending, averts patient isolations and improves patient flow within hospitals.

Clinical and Economic Outcomes of Genome Sequencing Availability on Containing a Hospital Outbreak of Resistant Escherichia coli in Australia.

OBJECTIVES: To evaluate the outbreak size and hospital cost effects of bacterial whole-genome sequencing availability in managing a large-scale hospital outbreak. METHODS: We built a hybrid discrete event/agent-based simulation model to replicate a serious bacterial outbreak of resistant Escherichia coli in a large metropolitan public hospital during 2017. We tested the 3 strategies of using whole-genome sequencing early, late (actual outbreak), or not using it and assessed their associated outbreak size and hospital cost. The model included ward dynamics, pathogen transmission, and associated hospital costs during a 5-month outbreak. Model parameters were determined using data from the Queensland Hospital Admitted Patient Data Collection (N = 4809 patient admissions) and local clinical knowledge. Sensitivity analyses were performed to address model and parameter uncertainty. RESULTS: An estimated 197 patients were colonized during the outbreak, with 75 patients detected. The total outbreak cost was A$460 137 (US$317 117), with 6.1% spent on sequencing. Without sequencing, the outbreak was estimated to result in 352 colonized patients, costing A$766 921 (US$528 547). With earlier detection from use of routine sequencing, the estimated outbreak size was 3 patients and cost A$65 374 (US$45 054). CONCLUSIONS: Using whole-genome sequencing in hospital outbreak management was associated with smaller outbreaks and cost savings, with sequencing costs as a small fraction of total hospital costs, supporting the further investigation of the use of routine whole-genome sequencing in hospitals.

Estimating the costs of genomic sequencing in cancer control.

BACKGROUND: Despite the rapid uptake of genomic technologies within cancer care, few studies provide detailed information on the costs of sequencing across different applications. The objective of the study was to examine and categorise the complete costs involved in genomic sequencing for a range of applications within cancer settings. METHODS: We performed a cost-analysis using gross and micro-costing approaches for genomic sequencing performed during 2017/2018 across different settings in Brisbane, Australia. Sequencing was undertaken for patients with lung, breast, oesophageal cancers, melanoma or mesothelioma. Aggregated resource data were captured for a total of 1433 patients and point estimates of per patient costs were generated. Deterministic sensitivity analyses addressed the uncertainty in the estimates. Estimated costs to the public health system for resources were categorised into seven distinct activities in the sequencing process: sampling, extraction, library preparation, sequencing, analysis, data storage and clinical reporting. Costs were also aggregated according to labour, consumables, testing, equipment and 'other' categories. RESULTS: The per person costs were AU$347-429 (2018 US$240-297) for targeted panels, AU$871-$2788 (2018 US$604-1932) for exome sequencing, and AU$2895-4830 (2018 US$2006-3347) for whole genome sequencing. Cost proportions were highest for library preparation/sequencing materials (average 76.8% of total costs), sample extraction (8.1%), data analysis (9.2%) and data storage (2.6%). Capital costs for the sequencers were an additional AU$34-197 (2018 US$24-67) per person. CONCLUSIONS: Total costs were most sensitive to consumables and sequencing activities driven by commercial prices. Per person sequencing costs for cancer are high when tumour/blood pairs require testing. Using the natural steps involved in sequencing and categorising resources accordingly, future evaluations of costs or cost-effectiveness of clinical genomics across cancer projects could be more standardised and facilitate easier comparison of cost drivers.

Exploratory cost-effectiveness analysis of 68Gallium-PSMA PET/MRI-based imaging in patients with biochemical recurrence of prostate cancer.

Men treated for prostate cancer with curative intent face a recurrence rate of up to 53% at 10 years. 68Ga-PSMA imaging is a new technique that can more accurately stage cancer recurrences and facilitate personalised treatment. We evaluated the cost-effectiveness of 68Ga-PSMA PET/MRI for staging men with prostate cancer biochemical recurrence. A cost-effectiveness analysis using a decision-analytic model with Markov chains was constructed. 68Ga-PSMA PET/MRI was compared with usual care in staging of men with suspected prostate cancer recurrence. Men with biochemical recurrence from a study in Brisbane, Australia (n = 30) provided key estimates for the model. The primary outcomes were health system costs and years of life (survival) over 10 years. Deterministic and probabilistic sensitivity analyses were undertaken to address uncertainty in model estimates. On average, a strategy of 68Ga-PSMA was expected to cost AU$56 961(US$39 426) and produce 7.48 life years compared with AU$64 499 (US$44 667) and 7.41 life years in usual care. Therefore, 68Ga-PSMA was potentially cost saving (- AU$7 592 95% UI - $24 846, $7 825) (- US$5 258) and slightly more effective 0.07 life years (95% UI - 0.01, 0.16). The likelihood that 68Ga-PSMA strategy was cost-effective at acceptable thresholds was 87%. The findings were sensitive to the lesion detection rate of the 68Ga-PSMA strategy (52-75%) and the cost of follow up in usual care (AU$1 947 to $2 635). In this exploratory economic evaluation, using 68Ga-PSMA PET/MRI to detect prostate cancer recurrence appears to be cost-effective relative to usual care.

Prevention versus early detection for long-term control of melanoma and keratinocyte carcinomas: a cost-effectiveness modelling study.

OBJECTIVE: To compare the long-term economic impact of melanoma prevention by sun protection, with the corresponding impact of early detection of melanoma to decrease melanoma deaths. DESIGN: Cost-effectiveness analysis using Markov cohort model. Data were primarily from two population-based randomised controlled trials, epidemiological and costing reports, and included flow-on effects for keratinocyte cancers (previously non-melanoma skin cancers) and actinic keratoses. SETTING: Queensland, Australia. PARTICIPANTS: Men and women with a mean age 50 years modelled for 30 years. INTERVENTIONS: Daily sunscreen use (prevention) compared with annual clinical skin examinations (early detection) and comparing these in turn with the status quo. PRIMARY AND SECONDARY OUTCOMES: Costs, counts of melanoma, melanoma deaths, keratinocyte cancers, life years and quality-adjusted life years. RESULTS: Per 100 000 individuals, for early detection, primary prevention and without intervention, there were 2446, 1364 and 2419 new melanomas, 556, 341 and 567 melanoma deaths, 64 452, 47 682 and 64 659 keratinocyte cancers and £493.5, £386.4 and £406.1 million in economic costs, respectively. There were small differences between prevention and early detection in life years saved (0.09%) and quality-adjusted life years gained (0.10%). CONCLUSIONS: Compared with early detection of melanoma, systematic sunscreen use at a population level will prevent substantial numbers of new skin tumours, melanoma deaths and save healthcare costs. Primary prevention through daily use of sunscreen is a priority for investment in the control of melanoma.

The Economic Impact on Australian Patients with Neuroendocrine Tumours.

BACKGROUND AND OBJECTIVE: Little is known about the economic burden to patients and families with neuroendocrine tumours (NETs) for medical out-of-pocket expenses and employment decisions. This study was performed to determine the extent and factors influencing the financial consequences of living with NETs and their effect on quality of life. METHODS: We undertook an online cross-sectional survey using a targeted approach and collected Australian Medicare claims data. Validated surveys measured health-related quality of life (EuroQol 5-dimension 5-level [EuroQol-5D-5L]) and financial toxicity (COmprehenSive Financial Toxicity [COST]), supplemented with questions on employment and retirement, insurance and out-of-pocket medical expenses. Generalised linear models were performed to assess determinants of quality of life and out-of-pocket expenses recorded by Medicare. RESULTS: The survey was answered by 204 patients with a mean age of 59 years who were diagnosed on average 5.2 years ago. Self-reported mean costs were 1698 Australian dollars ($A) (standard deviation [SD] $A2132) over 3 months (median $A877) and were highest for medical tests (mean $A376 [17% of total costs], SD $A722), travel-related expenses (mean $A289 [13%], SD $A559), and specialist visits (mean $A225 [10%], SD $A342) ($A1 = $US0.69). Imaging scans, surgery and travel expenses were the most common cost burdens reported by patients. Having private health insurance was the key determinant of higher out-of-pocket costs. Poorer quality of life was significantly associated with higher financial toxicity, not working due to cancer, nausea/diarrhoea, two or more co-morbidities and younger age. CONCLUSIONS: Medical expenses are substantial for some patients with NETs. Quality of life is adversely affected for patients experiencing financial toxicity and avoiding early retirement is an important issue for supportive care services.

A hybrid simulation model approach to examine bacterial genome sequencing during a hospital outbreak.

BACKGROUND: Hospital infection control requires timely detection and identification of organisms, and their antimicrobial susceptibility. We describe a hybrid modeling approach to evaluate whole genome sequencing of pathogens for improving clinical decisions during a 2017 hospital outbreak of OXA-181 carbapenemase-producing Escherichia coli and the associated economic effects. METHODS: Combining agent-based and discrete-event paradigms, we built a hybrid simulation model to assess hospital ward dynamics, pathogen transmission and colonizations. The model was calibrated to exactly replicate the real-life outcomes of the outbreak at the ward-level. Seven scenarios were assessed including genome sequencing (early or late) and no sequencing (usual care). Model inputs included extent of microbiology and sequencing tests, patient-level data on length of stay, hospital ward movement, cost data and local clinical knowledge. The main outcomes were outbreak size and hospital costs. Model validation and sensitivity analyses were performed to address uncertainty around data inputs and calibration. RESULTS: An estimated 197 patients were colonized during the outbreak with 75 patients detected. The total outbreak cost was US$318,654 with 6.1% of total costs spent on sequencing. Without sequencing, the outbreak was estimated to result in 352 colonized patients costing US$531,109. Microbiology tests were the largest cost component across all scenarios. CONCLUSION: A hybrid simulation approach using the advantages of both agent-based and discrete-event modeling successfully replicated a real-life bacterial hospital outbreak as a foundation for evaluating clinical outcomes and efficiency of outbreak management. Whole genome sequencing of a potentially serious pathogen appears effective in containing an outbreak and minimizing hospital costs.

Evaluating a risk assessment tool to improve triaging of patients to colonoscopies.

BACKGROUND: Colonoscopy is the gold standard in the diagnosis of significant bowel disease (SBD), including colorectal cancer, high-risk adenoma and inflammatory bowel disease. As the demand for colonoscopy services is placing significant pressure on hospital resources, new solutions are needed to manage patients more efficiently and effectively. AIM: We investigated the impact of using a risk assessment tool (RAT) to improve selection of patients for colonoscopy procedures to detect SBD. METHODS: A hybrid simulation model was constructed to replicate the current patient triage bookings and waiting times in a large metropolitan hospital. The model used data on 327 patients who were retrospectively assessed for risk of SBD. Risk assessment incorporated blood and faecal immunochemical test results, gender and age in addition to patient symptoms. The model was calibrated over 12 months to current outcomes and was compared with the RAT and a third scenario where low-risk patients did not proceed to a colonoscopy. One-way sensitivity analyses were undertaken. RESULTS: Using the RAT was expected to shorten waiting times by 153 days for moderately-urgent patients and 138 days for non-urgent patients. If low-risk patients did not proceed to colonoscopy, waiting times were expected to reduce for patients with SBD by 17 days producing cost-savings of AU$373 824 through avoided colonoscopies. CONCLUSIONS: A hybrid model that combines patient-level characteristics with hospital-level resource constraints can demonstrate improved efficiency in a hospital clinic. Further research on risk assessment is required to improve quality patient care and reduce low-value service delivery.

Patient out-of-pocket medical expenses over 2 years among Queenslanders with and without a major cancer.

Medical out-of-pocket costs paid by patients can be problematic when it adversely affects access to care. Survey research involving patients with out-of-pocket expenses may have selection biases, so accurate estimates are unknown. During 2010-11, 419 participants from the QSkin Sun and Health Study (n=43794) had a confirmed diagnosis of either melanoma, prostate, breast, colorectal or lung cancer. These were matched to a general population group (n=421) and a group of high users of GP services (n=419). Medical fees charged and out-of-pocket medical expenses for Medicare services were analysed. Over 2 years, three-quarters of individuals with cancer paid up-front provider fees of up to A$20551 compared with A$10995 for the high GP user group and A$6394 for the general population group. Out-of-pocket expenses were significantly higher for those with cancer (mean A$3514) compared with the high GP-user group (mean A$1837) and general population group (A$1245). Highest expenses were for therapeutic procedures (mean A$2062). Older individuals, those with poor perceived health or private health insurance had the highest costs. Regardless of private insurance status, patients with one of the main five cancers pay significantly higher out-of-pocket costs for health care compared with those without cancer.

Multiplicity of skin cancers in Queensland and their cost burden to government and patients.

OBJECTIVE: To determine the cost burden to government and patients for individuals with multiple skin cancers. METHODS: We used self-reported baseline data on socio-demographics, phenotype and sun exposure behaviours from participants in the QSkin Sun and Health Study with at least one histopathologically confirmed keratinocyte cancer or melanoma (n=5,673). Linkage to Australian Medicare data (2011-2014) provided resource data and government and out-of-pocket patient costs. Generalised linear models examined costs by frequency of skin cancer groups separately for melanoma and keratinocyte cancer. RESULTS: Over three years, 539 participants were diagnosed with melanoma (11% had ≥2 melanomas) and 5,134 participants were treated for keratinocyte cancers (10% had ≥6). Median Medicare costs per person were $1,325 (maximum $6,117) for ≥2 melanomas and $2,126 (maximum $54,618) for ≥6 keratinocyte cancers. Increased costs were associated with private health insurance. CONCLUSIONS: Individuals who are multiply affected by skin cancers are relatively common and the accompanying individual and government cost burden can be substantial. These findings support skin cancer being classified as a chronic disease. Implications for public health: Over time, the economic burden for skin cancer for individuals and health providers is high and investment in prevention remains important from an economic viewpoint.

Erratum to: Estimated Healthcare Costs of Melanoma in Australia Over 3 Years Post-Diagnosis.

The last word in the first paragraph which previously read AU$25 million should read 25 million as this relates to population size.

Estimated Healthcare Costs of Melanoma in Australia Over 3 Years Post-Diagnosis.

BACKGROUND: Skin cancer exerts a large and growing burden on health systems. With new pharmacotherapies for metastatic melanoma now available, a contemporary understanding of the cost burden of melanoma control is warranted. OBJECTIVE: To comprehensively assess the healthcare costs of malignant melanoma diagnosis and treatment in Australia, over 3 years after diagnosis. METHODS: We developed a decision-analytic model and micro-costing method to estimate the mean cost per patient for melanoma, incorporating all diagnostic and treatment modalities used in Australia (2017 AU$). By using the de-identified 10% sample of Medicare Benefits Scheme, we analysed health service use and supplemented our analyses with published estimates. We took a health system cost perspective, and addressed input uncertainty with sensitivity analyses. RESULTS: The mean annual cost per patient for melanoma stage 0/I/II was AU$1681 (US$1175) rising to AU$37,729 (US$26,365) for stage III resectable, and AU$115,109 (US$80,440) for stage III unresectable/IV. Three-year costs for stage III unresectable/IV were AU$187,720. Nationally, the annual estimated cost for treatment of all new cases of in situ and invasive melanomas was AU$201 million (95% CI: AU$187 to AU$216 million). When we included treatments for presumptive melanoma later found to be benign lesions, the estimated annual cost burden reached AU$272 million. CONCLUSION: With rapidly rising treatment costs, there is a need to consider a comprehensive melanoma control strategy that includes primary prevention of skin cancers and cost-effective sun protection initiatives.