Surgical wound dehiscence in an Australian community nursing service: time and cost to healing.

OBJECTIVE: Surgical wound dehiscence (SWD) increases the length of hospital stay and impacts on patient wellbeing and health-care costs. Globally, the health-care costs associated with SWD are poorly reported and those reported are frequently associated with surgical site infection (SSI), rather than dehiscence of non-microbial cause. This retrospective study describes and reports on the costs and time to healing associated with a number of surgical patients who were referred to a community nursing service for treatment of an SWD following discharge from a metropolitan hospital, in Perth, Western Australia. METHOD: Descriptive statistical analysis was carried out to describe the patient, wound and treatment characteristics. A costing analysis was conducted to investigate the cost of healing these wounds. RESULTS: Among the 70 patients referred with a SWD, 55% were treated for an infected wound dehiscence which was a significant factor (p=0.001). Overall, the cost of treating the 70 patients with a SWD in a community nursing service was in excess of $56,000 Australian dollars (AUD) (£28,705) and did not include organisational overheads or travel costs for nurse visits. The management of infection contributed to 67% of the overall cost. CONCLUSION: SWD remains an unquantified aspect of wound care from a prevalence and fiscal point of view. Further work needs to be done in the identification of SWD and which patients may be 'at risk'. DECLARATION OF INTEREST: The authors declare they have no competing interests.

Towards more efficient burn care: Identifying factors associated with good quality of life post-burn.

BACKGROUND: As minor burn patients constitute the vast majority of a developed nation case-mix, streamlining care for this group can promote efficiency from a service-wide perspective. This study tested the hypothesis that a predictive nomogram model that estimates likelihood of good long-term quality of life (QoL) post-burn is a valid way to optimise patient selection and risk management when applying a streamlined model of care. METHOD: A sample of 224 burn patients managed by the Burn Service of Western Australia who provided both short and long-term outcomes was used to estimate the probability of achieving a good QoL defined as 150 out of a possible 160 points on the Burn Specific Health Scale-Brief (BSHS-B) at least six months from injury. A multivariate logistic regression analysis produced a predictive model provisioned as a nomogram for clinical application. A second, independent cohort of consecutive patients (n=106) was used to validate the predictive merit of the nomogram. RESULTS AND DISCUSSION: Male gender (p=0.02), conservative management (p=0.03), upper limb burn (p=0.04) and high BSHS-B score within one month of burn (p<0.001) were significant predictors of good outcome at six months and beyond. A Receiver Operating Curve (ROC) analysis demonstrated excellent (90%) accuracy overall. At 80% probability of good outcome, the false positive risk was 14%. The nomogram was validated by running a second ROC analysis of the model in an independent cohort. The analysis confirmed high (86%) overall accuracy of the model, the risk of false positive was reduced to 10% at a lower (70%) probability. This affirms the stability of the nomogram model in different patient groups over time. An investigation of the effect of missing data on sample selection determined that a greater proportion of younger patients with smaller TBSA burns were excluded due to loss to follow up. CONCLUSION: For clinicians managing comparable burn populations, the BSWA burns nomogram is an effective tool to assist the selection of patients to a streamlined care pathway with the aim of improving efficiency of service delivery.

Enhancing the clinical utility of the burn specific health scale-brief: not just for major burns.

INTRODUCTION: Like many other Western burn services, the proportion of major to minor burns managed at Royal Perth Hospital (RPH) is in the order of 1:10. The Burn Specific Health Scale-Brief (BSHS-B) is an established measure of recovery after major burn, however its performance and validity in a population with a high volume of minor burns is uncertain. Utilizing the tool across burns of all sizes would be useful in service wide clinical practice. AIM: This study was designed to examine the reliability and validity of the BSHS-B across a sample of mostly minor burn patients. METHOD: BSHS-B scores of patients, obtained between January 2006 and February 2013 and stored on a secure hospital database were collated and analyzed Cronbach's alpha, factor analysis, logistic regression and longitudinal regression were used to examine reliability and validity of the BSHS-B. RESULTS: Data from 927 burn patients (2031 surveys) with a mean % total burn surface area (TBSA) of 6.7 (SD 10.0) were available for analysis. The BSHS-B demonstrated excellent reliability with a Cronbach's alpha of 0.95. First and second order factor analyses reduced the 40 item scale to four domains: Work; Affect and Relations; Physical Function; Skin Involvement, as per the established construct. TBSA, length of stay and burn surgery all predicted burn specific health in the first three months of injury (p<0.001, p<0.001, p=0.03). BSHS-B whole scale and domain scores showed significant improvement over 24 months from burn (p<0.001). DISCUSSION: The results from this study show that the structure and performance of the BSHS-B in a burn population consisting of 90% minor burns is consistent with that demonstrated in major burns. CONCLUSION: The BSHS-B can be employed to track and predict recovery after burns of all sizes to assist the provision of targeted burn care.

Reducing the burden of road traffic injury: translating high-income country interventions to middle-income and low-income countries.

OBJECTIVE: To increase seat belt restraint use in Guangzhou City, People's Republic of China. DESIGN: Comparison group pre-test, post-test design. SETTING: Guangzhou City. INTERVENTIONS: Interventions to increase the prevalence of seat belt use in high-income countries (enhanced training and enforcement practices along with raising of public awareness) were adapted and implemented in Guangzhou. The prevalence of seat belt use was determined before and after the introduction of the 12-month intervention. Seat belt prevalence was also examined over the same time period in the neighboring city of Nanning, and an incremental cost-effectiveness analysis of the intervention was undertaken. MAIN OUTCOME MEASURES: Prevalence rates and incremental cost effectiveness ratios. RESULTS: A 12% increase in seat belt use was observed in Guangzhou over the study period, increasing from a prevalence of 50% before (error range 30-62%) to 62% after (error range 60-67%) (p<0.001) the intervention; an absolute change difference between the intervention and reference city of 20% was achieved. The incremental cost-effectiveness ratio of the intervention was yen 3246 (US dollars 418) per disability-adjusted life year saved. CONCLUSIONS: This city-wide intervention demonstrates that it is possible to increase the prevalence of seat belt use using similar methods to those used in high-income countries and, importantly, that such an approach is cost-effective.

The obesity-driven rising costs of type 2 diabetes in Australia: projections from the Fremantle Diabetes Study.

BACKGROUND: The cost of diabetes is high for both the individual and society. Future health-care planning requires patient-level diabetes-attributable health-care cost data that have not previously been available for Australia. AIM: To determine Australian national direct diabetes-attributable health-care costs for known type 2 diabetes in 2000 and project these to 2051. METHODS: A total of 1294 patients with type 2 diabetes was recruited to the Fremantle Diabetes Study between 1993 and 1996. A bottom-up, prevalence-based approach using diabetes-attributable costs provided average annual per patient health-care costs (in year 2000 A$). Costs were extrapolated to 2051 using Australian type 2 diabetes prevalence figures and Australian Bureau of Statistics population projections, assuming that prevalence rates (i) remain at current levels and (ii) rise steadily. RESULTS: Total annual direct diabetes-attributable health-care costs in 2000 in Australia for people > or =25 years with known type 2 diabetes were estimated at A$636 million. As a result of ageing, the number of people with type 2 diabetes will double between 2000 and 2051 with a 2.5-fold increase in diabetes-attributable health-care costs. If obesity and inactivity prevalence rates continue to rise, prevalence rates of type 2 diabetes will further increase. The number of people with type 2 diabetes in 2051 may be 3.5 times higher than in 2000 with a 3.7-fold cost increase. CONCLUSIONS: The financial burden of treating type 2 diabetes could quadruple by 2051 unless more is done to prevent type 2 diabetes and its complications. A smaller proportion of the population will have the capacity to fund these rising health-care costs.

Child and family safety device affordability by country income level: an 18 country comparison.

OBJECTIVE: To compare availability, urban price, and affordability of child/family safety devices between 18 economically diverse countries. DESIGN: Descriptive: urban price surveys by local safety organisations or shoppers. SETTING: Retail stores and internet vendors. MAIN OUTCOME MEASURES: Prices expressed in US dollars, and affordability measured by hours of factory work needed to buy a child safety seat, a belt-positioning booster seat, a child bicycle helmet, and a smoke alarm. RESULTS: Prices of child and family safety devices varied widely between countries but the variation for child safety seats and bicycle helmets did not relate strongly to country income. Safety devices were expensive, often prohibitively so, in lower income countries. Far more hours of factory work were required to earn a child safety device in lower income than middle income, and middle income than higher income, countries. A bicycle helmet, for example, cost 10 hours of factory work in lower income countries but less than an hour in higher income countries. Smoke alarms and booster seats were not available in many lower income countries. CONCLUSIONS: Bicycles and two-axle motor vehicles were numerous in lower and middle income countries, but corresponding child safety devices were often unaffordable and sometimes not readily available. The apparent market distortions and their causes merit investigation. Advocacy, social marketing, local device production, lowering of tariffs, and mandatory use legislation might stimulate market growth. Arguably, a moral obligation exists to offer subsidies that give all children a fair chance of surviving to adulthood.

A randomized trial of interactive group sessions achieved greater improvements in nutrition and physical activity at a tiny increase in cost.

OBJECTIVE: Weight gain may follow altered eating habits and decreased physical activity in couples beginning to live together. Mutual support and willingness to accept changes in lifestyle at this stage may facilitate positive responses to health promotion. We aimed to compare the effects of a diet and physical activity program in couples using a randomized controlled trial. STUDY DESIGN AND SETTING: Couples were randomized to a control group or to one of two intervention groups in whom the program was either delivered mainly by mail or with a combination of mail-outs and interactive group sessions. RESULTS: Diets, physical fitness, and blood cholesterol improved up to 12 months after beginning the 4-month program, mainly in the interactive group. In that group, at the end of the program, the estimated cost was 445.30 dollars (111.33 dollars/month) per participant per unit change in outcome variables, only 0.03 dollars per participant per month more than the group receiving the program mainly by mail. One year after beginning the program, costs per participant per month were 38.37 dollars in the interactive group and 38.22 dollars in the group receiving the program mainly by mail-out. CONCLUSION: The changes observed in cardiovascular risk factors could translate to a substantial cost-savings relating to health.

Shifting the balance between in-patient and out-patient care for tuberculosis results in economic savings.

SETTING: Although hospitalisation is not always necessary for the treatment of tuberculosis (TB), in Australia 90% of TB patients have treatment initiated in hospital. OBJECTIVE: To calculate and compare the costs of in-patient and out-patient tuberculosis treatment, and to measure the impact of shifting care from in-patient to out-patient settings. METHODS: In a costing study performed in Victoria, Australia, the proportion of all notified TB cases who were hospitalised was calculated by matching coded state hospital morbidity data with the Victoria Notifiable Diseases database for the financial year 1994-1995. In-patient and out-patient costs were calculated using data obtained from a number of sources. The effect on health care costs of varying the proportion of TB cases treated as in-patients and out-patients was calculated using Excel. RESULTS: Nearly 90% (239/269) of notified TB cases received hospitalised care in 1994-1995. The cost of treatment for hospitalised patients (mean length of stay 2 weeks) was AU$5447 per patient, with a total cost of $1,301,833. Hospitalisation comprised 60% of the total cost of treatment. The cost of out-patient treatment was $2260 per patient. If 90% of patients were treated on an out-patient basis, the total cost would be $693,670. We estimated that it would be feasible to treat at least 55% of TB patients as out-patients, reducing costs by nearly 30%. CONCLUSIONS: Routine hospitalisation for patients with uncomplicated TB is not necessary, but is often used in industrialised countries. More cost-effective use of resources can be achieved by giving initial TB treatment on an out-patient basis rather than in hospital for a greater proportion of cases.

The cost-effectiveness of evidence-based guidelines and practice for screening and prevention of tuberculosis.

INTRODUCTION: The potential cost-effectiveness of screening depends on the risk of tuberculosis (TB) in the population being screened and the rate at which the screening outcome (prevention) is achieved. AIMS: To compare the cost-effectiveness of contact screening for TB for: (1) contact screening as it actually occurred in Victoria in 1991 (Model 1); (2) the process which should have occurred had the 1991 contact screening guidelines been followed (Model 2); (3) a hypothetical evidence-based model (Model 3). METHODS: Three models were constructed according to the aims. The cost-effectiveness of contact screening is presented as costs to government per unit outcome (in the form of cases prevented, cases found and contacts traced) for each model. Assumptions about disease behaviour were consistent between models. A sensitivity analysis was performed to examine the effect of the assumptions made in Model 3 about rates of referral and treatment of infected contacts, and about the efficacy of isoniazid (INH) in preventing TB. RESULTS: The total cost of Model 1 was greater than that of the other Models. Model 1 is the least cost-effective, costing $309 065 per case prevented, and Model 3 is the most cost-effective, costing $32 210 per case prevented. The cost of Model 2 was $58 742 per case prevented. The incremental cost-effectiveness of Model 3 compared to Model 2 is $107 per additional contact screened, and $3881 per additional case prevented. Case finding is not as cost-effective as best-practice case prevention, ranging from $231 799 per case found in Model 1 to $205 596 per case found in Model 2. The sensitivity analysis shows that the cost-effectiveness of Model 3 decreases with lower referral rates, lower rates of preventive therapy, and lower efficacy of INH. However, even allowing for reduced programme parameters, Model 3 is most cost-effective. DISCUSSION: Costing policy options is an important component of programme delivery, but needs to be considered in the context of the product being purchased, e.g. the prevention of disease, or case finding. Case finding as a product of contact screening is expensive in all three models. Prevention of TB, on the other hand, can be cost-effective, as shown in Model 3. It was least cost-effective in Model 1, largely because prevention was not considered a priority, and few infected contacts actually received preventive therapy. Clear programme aims, adherence to guidelines and high rates of preventive therapy are essential in order to achieve cost-effectiveness.

Hospital inpatient costs resulting from road crashes in Western Australia.

The purpose of this study was to estimate the inpatient costs of road crashes in Western Australia, and to investigate factors relating to casualties and their injuries that affect the hospital costs resulting from road crashes. All road crash casualties who were injured severely enough to be hospitalised in Western Australia in 1988 were included. A casemix classification system was used to classify patients into diagnostic related groups. Hospital costs were assigned to individual patients on the basis of their diagnostic related group and length of hospital stay. The annual cost of hospital treatment for road crash casualties was estimated as $13.9 million, and 33 per cent of this was incurred by those with lower extremity injuries and 27 per cent by those with head injuries. Hospital costs per casualty ranged from an average of $1388 for those sustaining minor (Abbreviated Injury Scale severity score of 1 or 2) spinal injuries to $16,580 and $33,424, respectively, for those sustaining severe (Abbreviated Injury Scale severity score of 4 or 5) head and spinal injuries. A multivariate analysis of variance revealed the following factors as having a significant independent effect on the hospital inpatient costs of road crash casualties: type of hospital (teaching or nonteaching), body region of injury, injury severity level and road user group. There were also significant interaction effects between different factors. Since hospital inpatient costs vary considerably across factors, using average cost data in the specific economic evaluation of road safety interventions for groups of road users is inappropriate.

Sequelae of Haemophilus influenzae type b meningitis in aboriginal and non-aboriginal children under 5 years of age.

Between 1984 and 1990, 257 cases of Haemophilus influenzae type b (Hib) meningitis occurred in children under five years of age in Western Australia. We obtained information on possible sequelae in 131 cases (all non-Aboriginal) by medical record review and parental interview, and in a further 116 cases (60 non-Aboriginal, 56 Aboriginal) by medical record review only; no follow-up information was available for ten children (nine non-Aboriginal, 1 Aboriginal). The incidence of Hib meningitis in children under five years of age was 26.3 per 100,000 for non-Aboriginal and 152.2 per 100,000 for Aboriginal children. The case fatality rate was 3.5% for non-Aboriginal children and 14.0% for Aboriginal children. Sequelae were recorded for 17.1% of non-Aboriginal and 22.4% of Aboriginal children who survived Hib meningitis. Surviving Aboriginal children experienced severe sequelae following Hib meningitis almost three times more frequently than surviving non-Aboriginal children (10.5% vs 3.6%), although mild and moderate sequelae were not more common in Aboriginal children. The information on incidence and severity of sequelae in this study was obtained by chart review and parental interview, and hence may be subject to error or bias, particularly for mild and moderate disabilities. Outcomes like death and severe sequelae, such as cerebral palsy and profound intellectual and physical disability, are less subject to bias. Of Aboriginal children who contracted Hib meningitis in Western Australia over the study period, 22.8% either died or had severe sequelae, while only 7.0% of non-Aboriginal children experienced these severe outcomes.

The burden of Haemophilus influenzae type b disease in Australia and an economic appraisal of the vaccine PRP-OMP.

OBJECTIVES: To estimate the incidence and sequelae of Haemophilus influenzae type b disease (Hib) in the Australian population, and to evaluate the costs and outcomes of a vaccination program using the vaccine PRP-OMP at two, four and 12 months. DESIGN: The evaluation was based on a decision analytic model developed by Merck Sharp and Dohme (Australia) Pty Ltd, to predict the number of children who would contract Hib, and suffer mild or severe sequelae or die as a result. The state of health of a cohort of children was modelled each month over a five-year period. A survey of medical records and interviews with parents of children who contracted meningitis in Western Australia from 1984-1990 was undertaken to provide data on the extent and costs of sequelae. RESULTS: The incidence of Hib among non-Aboriginal Australians under five years of age was estimated as 53 per 100,000, and 460 per 100,000 among Aborigines. In a single year at least 630 children may contract Hib, up to 19 may die, and a further 46 may have neurological damage, this being severe in up to 18 children. The number of deaths could be reduced by 17 per year and a further 25 cases of severe and 16 cases of mild disability could be averted. At a price of $20 per dose, and a 5% discount rate, the expected cost per year of life extended by a vaccination program is $3148. When adjusted for the increased number of years without neurological impairment, the incremental cost per quality adjusted life year (QALY) is $1965. Compared with a single vaccine at 18 months, the incremental cost per additional QALY gained is $5047. A separate analysis of the Aboriginal population showed that the proposed vaccination program would be of significant benefit, leading to a saving of resources.