Using the EQ-5D-5L to investigate quality-of-life impacts of disease-modifying therapy policies for people with multiple sclerosis (MS) in New Zealand.

BACKGROUND: Health state utilities (HSU) are a health-related quality-of-life (HRQoL) input for cost-utility analyses used for resource allocation decisions, including medication reimbursement. New Zealand (NZ) guidelines recommend the EQ-5D instruments; however, the EQ-5D-5L may not sufficiently capture psychosocial health. We evaluated HRQoL among people with multiple sclerosis (MS) in NZ using the EQ-5D-5L and assessed the instrument's discriminatory sensitivity for a NZ MS cohort. METHODS: Participants were recruited from the NZ MS Prevalence Study. Participants self-completed a 45-min online survey that included the EQ-5D-5L/EQ-VAS. Disability severity was classified using the Expanded Disability Status Scale (EDSS) to categorise participant disability as mild (EDSS: 0-3.5), moderate (EDSS: 4.0-6.0) and severe (EDSS: 6.5-9.5). Anxiety/depression were also measured using the Hospital Anxiety and Depression Score (HADS). In the absence of an EQ-5D-5L NZ tariff, HSUs were derived using an Australian tariff. We evaluated associations between HSUs and participant characteristics with linear regression models. RESULTS: 254 participants entered the study. Mean age was 55.2 years, 79.5% were female. Mean (SD) EQ-5D-5L HSU was 0.58 (0.33). Mean (SD) HSUs for disability categories were: mild 0.80 ± 0.17, moderate 0.57 ± 0.21 and severe 0.14 ± 0.32. Twelve percent reported HSU = 1.0 (i.e., no problems in any domain). Participants who had never used a disease-modifying therapy reported a lower mean HSU. Multivariable modelling found that the HADS anxiety score was not associated with EQ-5D-5L. CONCLUSIONS: HRQoL for people with MS in NZ was lower than comparable countries, including Australia. We suggest a comparison with other generic tools that may have improved sensitivity to mental health.

Urban-rural prostate cancer disparities in a regional state of Australia.

Men living in regional and remote areas experience disparities in prostate cancer (PrCa) diagnosis, clinical characteristics and treatment modalities. We sought to determine whether such disparities exist in PrCa patients from Tasmania; a regional state of Australia with the second-highest rate of diagnosis and where over a third of residents live in outer regional and remote areas. Our study included clinicopathological data from 1526 patients enrolled in the Prostate Cancer Outcomes Registry-Tasmania. Regression analyses were undertaken to determine whether demographic, clinical and treatment variables differed between inner regional and outer regional/remote patients. Men from outer regional/remote areas were significantly more likely to reside in lower socio-economic areas, be diagnosed at a later age and with more clinically aggressive features. However, in contrast to previous studies, there were no overall differences in diagnostic or treatment method, although men from outer regional/remote areas took longer to commence active treatment and travelled further to do so. This study is the first to investigate PrCa disparities in a wholly regional Australian state and highlights the need to develop systematic interventions at the patient and healthcare level to improve outcomes in outer regional and remote populations in Australia and across the globe.

The effect of national disease-modifying therapy subsidy policy on long-term disability outcomes in people with multiple sclerosis.

BACKGROUND: Disease-modifying therapies (DMTs) are used to treat people with relapsing-onset multiple sclerosis (ROMS), but our knowledge is largely limited to their short-term effects. OBJECTIVE: To determine (1) the impact of national-level DMT subsidy policy on DMT use and health outcomes in people with MS (PwMS) and (2) the long-term effects of DMT on disability and quality of life (QoL; 5-level EQ-5D version (EQ-5D-5L) utility value). METHODS: This observational cohort study compared Australian and New Zealand populations with different levels of DMT availability 10-20 years post-ROMS diagnosis. Between-country differences were assessed using standardised differences. Associations were assessed with multivariable linear regression models. RESULTS: We recruited 328 Australians and 256 New Zealanders. The Australian cohort had longer DMT treatment duration, greater proportion of disease course treated and shorter duration between diagnosis and starting DMT. The Australian cohort had lower median Expanded Disability Status Scale (EDSS) (3.5 vs 4.0) and Multiple Sclerosis Severity Score (MSSS) (3.05 vs 3.71) and higher QoL (0.71 vs 0.65). In multivariable models, between-country differences in disability and QoL were largely attributed to differential use of DMT. CONCLUSIONS: This study provides evidence for the impact of national-level DMT policy on disability outcomes in PwMS. Where DMTs are more accessible, PwMS experienced less disability progression and improved QoL 10-20 years post-diagnosis.

Alcohol Consumption in Vietnam, and the Use of 'Standard Drinks' to Measure Alcohol Intake.

AIMS: To provide nationally representative data on alcohol consumption in Vietnam and to assess whether reported numbers of 'standard drinks' consumed have evidence of validity (particularly in rural areas where home-made alcohol is consumed from cups of varying size). METHODS: A nationally representative population-based survey of 14,706 participants (46.5% males, response proportion 64.1%) aged 25-64 years in Vietnam. Measurements were made in accordance with WHO STEPS protocols. Data were analysed using complex survey methods. RESULTS: Among men, 80% reported drinking alcohol during the last year, and 40% were hazardous/harmful drinkers. Approximately 60% of men and <5% of women had consumed alcohol during the last week, with one-in-four of the men reporting having consumed at least five standard drinks on at least one occasion. Numbers of standard drinks reported by men were associated with blood pressure/hypertension, particularly in rural areas (P < 0.001 for trend). Most of the calibration and discrimination possible from self-reported information on alcohol consumption was provided by binary responses to questions on whether or not alcohol had been consumed during the reference period. CONCLUSION: Alcohol use and harmful consumption were common among Vietnamese men but less pronounced than in Western nations. Self-reports of quantity of alcohol consumed in terms of standard drinks had predictive validity for blood pressure and hypertension even in rural areas. However, using detailed measures of consumption resulted in only minor improvements in prediction compared to simple measures.

A decision tree model for the implementation of a safety strategy in the horse-racing industry.

OBJECTIVES: The profession of a horse-racing jockey is a dangerous one. We developed a decision tree model quantifying the effects of implementing different safety strategies on jockey fall and injury rates and their associated costs. METHODS: Data on race-day falls were obtained from stewards' reports from August 2002 to July 2009. Insurance claim data were provided by Principal Racing Authorities and workers' compensation authorities in each jurisdiction. Fall and claim incidence data were used as baseline rates. The model considered (1) the status quo, in which policy was unchanged; and (2) compared it with four hypothetical changes in policy that restricted apprentice jockeys from riding less-accomplished horses, with the aim of improving safety by reducing incidence of injurious jockey falls. Second-order Monte Carlo simulations were conducted to account for uncertainties. RESULTS: The point estimate for mean costs of falls under the status quo was $30.73/ride, with falls by apprentice jockeys with <250 career race rides riding horses with less than five race starts contributing the highest costs ($98.49/ride). The hypothetical safety strategies resulted in a 1.04%-5.07% decrease in fall rates versus status quo. For three of the four strategies, significant reductions of 8.74%-13.13% in workers' compensation costs over one single race season were predicted. Costs were highly sensitive to large claims. CONCLUSIONS: This model is a useful instrument for comparing potential changes in cost and risks associated with implementing new safety strategies in the horseracing industry.

The relationship between return on investment and quality of study methodology in workplace health promotion programs.

OBJECTIVE: To determine the relationship between return on investment (ROI) and quality of study methodology in workplace health promotion programs. DATA SOURCE: Data were obtained through a systematic literature search of National Health Service Economic Evaluation Database (NHS EED), Database of Abstracts of Reviews of Effects (DARE), Health Technology Database (HTA), Cost Effectiveness Analysis (CEA) Registry, EconLit, PubMed, Embase, Wiley, and Scopus. STUDY INCLUSION AND EXCLUSION CRITERIA: Included were articles written in English or German reporting cost(s) and benefit(s) and single or multicomponent health promotion programs on working adults. Return-to-work and workplace injury prevention studies were excluded. DATA EXTRACTION: Methodological quality was graded using British Medical Journal Economic Evaluation Working Party checklist. Economic outcomes were presented as ROI. DATA SYNTHESIS: ROI was calculated as ROI = (benefits - costs of program)/costs of program. Results were weighted by study size and combined using meta-analysis techniques. Sensitivity analysis was performed using two additional methodological quality checklists. The influences of quality score and important study characteristics on ROI were explored. RESULTS: Fifty-one studies (61 intervention arms) published between 1984 and 2012 included 261,901 participants and 122,242 controls from nine industry types across 12 countries. Methodological quality scores were highly correlated between checklists (r = .84-.93). Methodological quality improved over time. Overall weighted ROI [mean ± standard deviation (confidence interval)] was 1.38 ± 1.97 (1.38-1.39), which indicated a 138% return on investment. When accounting for methodological quality, an inverse relationship to ROI was found. High-quality studies (n = 18) had a smaller mean ROI, 0.26 ± 1.74 (.23-.30), compared to moderate (n = 16) 0.90 ± 1.25 (.90-.91) and low-quality (n = 27) 2.32 ± 2.14 (2.30-2.33) studies. Randomized control trials (RCTs) (n = 12) exhibited negative ROI, -0.22 ± 2.41(-.27 to -.16). Financial returns become increasingly positive across quasi-experimental, nonexperimental, and modeled studies: 1.12 ± 2.16 (1.11-1.14), 1.61 ± 0.91 (1.56-1.65), and 2.05 ± 0.88 (2.04-2.06), respectively. CONCLUSION: Overall, mean weighted ROI in workplace health promotion demonstrated a positive ROI. Higher methodological quality studies provided evidence of smaller financial returns. Methodological quality and study design are important determinants.

The association between jockey experience and race-day falls in flat racing in Australia.

OBJECTIVES: Apprentice thoroughbred racing jockeys have a higher fall rate than their more experienced counterparts. The authors describe rates of occurrence and investigate risk factors for falls among less-experienced thoroughbred flat racing jockeys in Australia who commenced their race riding career between August 2002 and July 2009. METHODS: Data on race-day falls were extracted from stewards' reports. Denominator data were provided by Racing Information Services Australia on races conducted in Australia. HRs were estimated using time-to-event (survival analysis) methods. RESULTS: Factors found to be associated with falls by less-experienced jockeys (as indicated by number of career rides or career stage) were older jockey age at commencement of career (p=0.001), fewer previous rides this meeting (p<0.001), fewer previous starts by the horse (p<0.001), younger horse age (p<0.001), lower race grade (p<0.001), lower prize money (p<0.001), shorter race distance (p<0.001) and drier track rating (p<0.001). Apprentice experience was inversely and strongly associated with increased rates of falls (p<0.001). Three indicators of less accomplished horses (lower race grade, fewer previous starts by the horse and less prize money at stake) and two race conditions (drier tracks and shorter race distance) were found to be associated with a progressively higher hazard of falls for less-experienced jockeys. CONCLUSIONS: This study identified factors that preferentially contribute to falls by inexperienced jockeys. The authors suggest that consideration be given to restricting apprentice jockeys with little race-riding experience from riding horses that have not yet won a race (maiden) or that have had few previous race starts.

Changes in cystic fibrosis mortality in Australia, 1979-2005.

OBJECTIVE: To assess mortality trends among people with cystic fibrosis (CF) in Australia. DESIGN AND SETTING: We augmented Australian summary data for deaths from CF registered during 1979-2005 with information from Australian transplant centres on lung transplantation among CF patients for 1989-2005 to allow us to follow trends in all "mortality events" (death or lung transplantation). MAIN OUTCOME MEASURE: Age at death or lung transplantation. RESULTS: Between 1979 and 2005, the mean age at death increased from 12.2 years to 27.9 years for males and from 14.8 years to 25.3 years for females. Overall, female deaths in childhood (0-14 years) occurred at an age-standardised rate of 0.40 per 100,000 (95% CI, 0.34-0.45) during 1979-2005, which exceeded the corresponding rate for males of 0.24 (95% CI, 0.20-0.28) per 100,000. Among 0-14-year-old boys, event rates declined markedly after 1989, but they declined later and more gradually for girls, with the result that the age-standardised rate for girls was 2.38 times that of boys during 1989-2005 (95% CI, 1.69-3.36). CONCLUSIONS: The pattern of CF mortality in Australia has changed substantially. Mortality rates continue to be higher for girls than for boys, but death in childhood has become uncommon. Survival has increased since 1979, but females continue to have reduced length of life.

Longitudinal associations of adiposity with adult lung function in the Childhood Determinants of Adult Health (CDAH) study.

Childhood BMI has been reported to be positively associated with adult lung function. The aim of this study was to investigate the effect of childhood BMI on young adult lung function independently of the effects of lean body mass (LBM). Clinical and questionnaire data were collected from 654 young Australian adults (aged 27-36 years), first studied when age 9, 12, or 15 years. Adult lung function was measured by forced vital capacity (FVC), forced expiratory volume in 1 s (FEV(1)), FEV(1)/FVC ratio, and the forced expiratory flow in the middle 50% of FVC (FEF(25-75)). BMI and LBM were derived from anthropometric measures at baseline (1985) and at follow-up (2004-2006). Multivariable models were used to investigate the effect of age and sex standardized BMI in childhood on adult lung function, before and after adjustment for LBM. Adult adiposity had a strong deleterious effect on lung function, irrespective of childhood BMI, and adjustment for childhood LBM eliminated any apparent beneficial effect of childhood BMI on adult FEV(1) or FVC. This suggests that the beneficial effect of increased BMI in childhood on adult FEV(1) and FVC observed in previous longitudinal studies is likely to be attributable to greater childhood LBM not adiposity. Obese children who become obese adults can expect to have poorer lung function than those who maintain healthy weight but large deficits in lung function are also likely for healthy weight children who become obese adults. This highlights the importance of lifetime healthy weight maintenance.

The incidence of race-day jockey falls in Australia, 2002-2006.

OBJECTIVES: To describe rates of occurrence of falls, injuries and fatalities to horse-racing jockeys in Australia. DESIGN AND SETTING: Retrospective analysis of data on race-day falls from stewards' reports provided by the Principal Racing Authority of each state and territory of Australia, August 2002 - July 2006. MAIN OUTCOME MEASURES: Fall, injury and fatality incidence rates; comparison with overseas rates. RESULTS: There were 3360 jockey falls from 748 367 rides. Falls occurred at a rate of 0.42 per 100 rides in flat races and 5.26 per 100 rides in jumps races. In flat racing, 54.6% (1694/3101) of falls occurred before the start of the race and 11.1% (344/3101) of falls occurred post-race. The 34.3% (1063/3101) of falls that occurred during flat races resulted in 61.7% (516/836) of the injuries sustained. In jumps racing, most falls occurred at a jump and 9.7% (25/259) of jockeys who fell were transported to hospital and/or declared unfit to ride. There were five fatalities resulting from falls during the study period, all in flat racing. Fall and injury rates were comparable with those found in the United Kingdom, Ireland, France and Japan. CONCLUSIONS: Being a jockey carries a substantial risk of injury and death. Although rates of injury in Australia are not exceptional by international standards, there can be improvement to safety standards in the Australian racing industry.

The lack of effect of isoflavones on high-density lipoprotein cholesterol concentrations in adolescent boys: a 6-week randomised trial.

BACKGROUND: A substantial fall in high-density lipoprotein cholesterol (HDL-C) during puberty in boys, but not girls, has been reported in Western populations. The fall in boys is believed to be due to hormonal changes--androgens have been shown to be associated with lower HDL-C, whereas oestrogens are associated with higher HDL-C. The fall in HDL-C during puberty was not observed, however, in a study of Moslem boys in Israel, nor in a group of Japanese boys. A diet high in phyto-oestrogens may account for the lack of a fall in HDL-C in these populations. OBJECTIVE: To examine the effect of dietary supplementation with phyto-oestrogens on the HDL-C concentration of adolescent boys from a Western population. We hypothesised that dietary supplementation of 50 mg of the isoflavones daidzein and genistein would produce a 12% higher HDL-C concentration than in controls at the end of a 6-week intervention period. DESIGN: A randomised controlled trial. SETTING: Hellyer College in Burnie (Tasmania, Australia). SUBJECTS: Adolescent boys (aged 16-18 years) were recruited through a letter sent to parents. A total of 132 eligible participants enrolled and five subjects withdrew from the trial. RESULTS: No significant increase in HDL-C was observed in the treatment group (-0.02 mmol l(-1), standard error (SE)=0.03, P = 0.53) or the placebo group (0.05 mmol l(-1), SE = 0.03, P = 0.11). CONCLUSIONS: Factors other than isolated dietary isoflavones may be responsible for the lack of fall in HDL-C during puberty in Japanese and Moslem boys.

Practical considerations when using pedometers to assess physical activity in population studies: lessons from the Burnie Take Heart Study.

The aim of this study was to summarize both practical and methodological issues in using pedometers to assess physical activity in a large epidemiologic study. As part of a population-based survey of cardiovascular disease risk factors, physical activity was assessed using pedometers and activity diaries in 775 men and women ages 25-64 years who were residents of Burnie, Tasmania, 1998-99. Common data problems were classified by type. The frequency of each problem and the methods used to identify it are reported along with strategies to correct or prevent each problem type. Pedometer data from 15 (1.9%) participants could not be used due to errors in completing the pedometer protocol. Among 760 participants with usable data, the median number of steps was 9,729 for men and 10,388 for women. Pedometer steps per day were modestly correlated (r = .20, p < .0001) with the duration of pedometer wear, which ranged from 4.50 to 21.75 hr. Adjustment for wear time, however, did not alter observed correlations between pedometer steps and cardiovascular risk factors. The authors conclude that pedometers can be used in large population studies with a relatively low frequency of data errors. However guidelines for consistent data collection and interpretation are needed.

Persistent iodine deficiency in a cohort of Tasmanian school children: associations with socio-economic status, geographical location and dietary factors.

OBJECTIVE: To determine the adequacy of iodine nutrition of Tasmanian primary school-aged children and to examine possible associations with socio-economic status (SES), location and dietary factors. METHODS: Urinary iodine levels and measures of SES, geographical information and dietary habits were surveyed in a population-based sample of 170 children (4 to 12 years) at baseline (1998/99) and at follow-up (2000/01). RESULTS: Median urinary iodine concentration in 1989--99 and 2000--01 were 75 microg/L (range 15 microg/L to 240 microg/L) and 76 microg/L (range 18 microg/L to 480 microg/L) respectively. No significant associations with SES or geographical location were found. More frequent or recent intake of foods that are likely to be dietary sources of iodine tended to be associated with greater prevalence of adequate urinary iodine, particularly consumption of yoghurt and 'fruche' (p=0.04). CONCLUSIONS: After several decades of iodine sufficiency, Tasmanian primary school-aged children are again mildly iodine-deficient by WHO criteria. Despite reduction in iodophor use by the dairy industry in the past decade, consumption of dairy products continues to be associated with higher levels of iodine nutrition. IMPLICATIONS: The lack of association of iodine levels with SES and geographical location within Tasmania found in our study, and the results of studies of iodine levels in Melbourne and Sydney, suggest that inadequate iodine nutrition is a widespread problem in south-eastern Australia. Our study suggests that milk-containing products continue to be an important source of iodine for children.