Costs and outcomes of total hip and knee joint replacement for rheumatoid arthritis.

The objective of the study was to ascertain costs and outcomes of total joint replacement surgery for rheumatoid arthritis (RA) in Australia from the patients' perspective and to explore whether costs were affected by health status pre- or postsurgery. RA patients, scheduled for primary unilateral total knee replacement (TKR) or total hip replacement (THR) surgery at five Sydney hospitals, were approached. Preoperatively, patients retrospectively recorded expenses incurred over the previous 3 months and the health assessment questionnaire (HAQ). Postoperatively, patients completed detailed prospective cost diaries, short form (SF) 36, and HAQ every 3 months during the first postoperative year. In addition, patients were asked to complete a visual analogue measure for pain at 12 months postsurgery. Arthritis-specific cost information included prescription and nonprescription medication, visits to health professionals, tests, special equipment, alterations to the house, and use of private or community services. Thirty-one TKR and 11 THR patients provided cost data for the first postoperative year. Out-of-pocket costs and service utilization decreased over the first postoperative year for both TKR and THR patients. In addition, there was an improvement in the health status as measured by SF-36 but not the HAQ at 3 and 12 months postoperatively. The small sample size of this analysis is reflective of the current national trends of RA joint replacement surgery. Despite the low incidence of RA joint replacement surgery, it was substantiated that patients consider the positive impact on health outcomes and costs important. The generic SF-36 detected improvements in the health status of these RA patients, while total HAQ scores failed to do so. HAQ was found to be insensitive in reflecting improvements following lower limb replacement surgery. Patient out-of-pocket costs significantly decreased postoperatively; however, these costs remain substantial compared to osteoarthritis total joint replacement patients.

Cost of tobacco-related diseases, including passive smoking, in Hong Kong.

BACKGROUND: Costs of tobacco-related disease can be useful evidence to support tobacco control. In Hong Kong we now have locally derived data on the risks of smoking, including passive smoking. AIM: To estimate the health-related costs of tobacco from both active and passive smoking. METHODS: Using local data, we estimated active and passive smoking-attributable mortality, hospital admissions, outpatient, emergency and general practitioner visits for adults and children, use of nursing homes and domestic help, time lost from work due to illness and premature mortality in the productive years. Morbidity risk data were used where possible but otherwise estimates based on mortality risks were used. Utilisation was valued at unit costs or from survey data. Work time lost was valued at the median wage and an additional costing included a value of USD 1.3 million for a life lost. RESULTS: In the Hong Kong population of 6.5 million in 1998, the annual value of direct medical costs, long term care and productivity loss was USD 532 million for active smoking and USD 156 million for passive smoking; passive smoking accounted for 23% of the total costs. Adding the value of attributable lives lost brought the annual cost to USD 9.4 billion. CONCLUSION: The health costs of tobacco use are high and represent a net loss to society. Passive smoking increases these costs by at least a quarter. This quantification of the costs of tobacco provides strong motivation for legislative action on smoke-free areas in the Asia Pacific Region and elsewhere.

Patient self-efficacy and health locus of control: relationships with health status and arthritis-related expenditure.

OBJECTIVE: To explore the relationship between measures of self-efficacy, health locus of control, health status and direct medical expenditure among community-dwelling subjects with rheumatoid arthritis (RA) and osteoarthritis (OA). METHODS: This analysis is part of a larger ongoing study of the costs and outcomes of arthritis and its treatments. Community-dwelling RA and OA respondents completed questionnaires concerning arthritis-related expenditure, health status, arthritis related self-efficacy and health locus of control. RESULTS: Data were obtained from 70 RA respondents and 223 OA respondents. The majority of respondents were female with a mean age of 63 yr for RA respondents and 68 yr for OA respondents. Among the RA respondents, those with higher self-efficacy reported better health status and lower overall costs. Health locus of control was not consistently correlated with health status. OA respondents with higher self-efficacy reported better health status and lower costs. Health locus of control had more influence. OA respondents with higher external locus of control reported worse pain and function. A higher belief in chance as a determinant of health was correlated with more visits to general practitioners and a higher cost to both the respondent and the health system. CONCLUSION: Higher self-efficacy, which is amenable to change through education programmes, was associated with better health status and lower costs to the respondent and the health system in this cross-sectional study. Locus of control had less of an influence; however, the tendency was for those with higher external locus of control to have higher costs and worse health status. As the measurement of these constructs is simple and the outcome potentially affects health status, these results have implications for future intervention studies to improve quality of life and reduce the financial impact of arthritis on both the health-care system and patients.

Use of complementary medicines for osteoarthritis--a prospective study.

BACKGROUND: Patients with osteoarthritis commonly use complementary and alternative medicines (CAM), either as an adjunct to or in place of conventional analgesics. OBJECTIVES: To undertake a prospective investigation of the prevalence of CAM use for osteoarthritis and the direct costs incurred. METHODS: The subjects were 341 patients with osteoarthritis of the knee or hip drawn from central and northern Sydney, Australia, and comprising 83 community based patients and 258 awaiting joint replacement. Information on CAM use was obtained from prospective three monthly diaries. Variables of interest included health related quality of life scores. Prospective out of pocket costs were recorded over a 12 month follow up period. RESULTS: The prevalence of CAM use was 40%, which falls within the range of previous studies. Average annual expenditure on CAM was 32.25 Australian dollars (range 0 to 603.30). CAM users were more likely to be female (odds ratio (OR) 1.8 (95% confidence interval, 1.1 to 3.0)), reported a higher level of bodily pain (OR 0.97 (0.95 to 0.99)), and were less likely to purchase conventional analgesics (OR 3.3 (1.6 to 7.0)), either prescribed or over the counter. Vitamin supplementation was the most common CAM reported, followed by celery extract, fish oils, and garlic extracts. CONCLUSIONS: There are no good quality clinical trials to support the use of most preparations purchased by patients with osteoarthritis. There is a need for patient education on the risks and benefits of complementary medicine in osteoarthritis.

Two knees or not two knees? Patient costs and outcomes following bilateral and unilateral total knee joint replacement surgery for OA.

AIMS: This study aims to address medical and non-medical direct costs and health outcomes of bilateral and unilateral total knee replacement from the patients' perspective during the first year post-surgery. METHODS: Osteoarthritis patients undergoing primary unilateral total knee or bilateral total knee replacement (TKR) surgery at three Sydney hospitals were eligible. Patients completed questionnaires pre-operatively to record expenses during the previous three months and health status immediately prior to surgery. Patients then maintained detailed prospective cost diaries and completed SF-36 and WOMAC Index each three months for the first post-operative year. RESULTS: Pre-operatively, no significant differences in health status were found between patients undergoing unilateral TKR and bilateral TKR. Both unilateral and bilateral TKR patients showed improvements in pain, stiffness and function from pre-surgery to 12 months post-surgery. Patients who had bilateral TKR spent an average of 12.3 days in acute hospital and patients who had unilateral TKR 13.6 days. Totally uncemented prostheses were used in 6% of unilateral replacements and 48% of bilateral replacements. In hospital, patients who had bilateral TKR experienced significantly more complications, mainly thromboembolic, than patients who had unilateral TKR. Regression analysis showed that for every one point increase in the pre-operative SF-36 physical score (i.e. improving physical status) out-of-pocket costs decreased by 94%. Out-of-pocket costs for female patients were 3.3 times greater than for males. CONCLUSION: Patients undergoing bilateral TKR and unilateral TKR had a similar length of stay in hospital and similar out-of-pocket expenditures. Bilateral replacement patients reported better physical function and general health with fewer health care visits one year post procedure. Patients requiring bilateral TKR have some additional information to aid their decision making. While their risk of peri-operative complications is higher, they have an excellent chance of good health outcomes at 12 months and are not going to be doubly "out-of-pocket" for the experience.

Modelling the population cost-effectiveness of current and evidence-based optimal treatment for anxiety disorders.

BACKGROUND: The present paper describes a component of a large population cost-effectiveness study that aimed to identify the averted burden and economic efficiency of current and optimal treatment for the major mental disorders. This paper reports on the findings for the anxiety disorders (panic disorder/agoraphobia, social phobia, generalized anxiety disorder, post-traumatic stress disorder and obsessive compulsive disorder). METHOD: Outcome was calculated as averted 'years lived with disability' (YLD), a population summary measure of disability burden. Costs were the direct health care costs in 1997-8 Australian dollars. The cost per YLD averted (efficiency) was calculated for those already in contact with the health system for a mental health problem (current care) and for a hypothetical optimal care package of evidence-based treatment for this same group. Data sources included the Australian National Survey of Mental Health and Well-being and published treatment effects and unit costs. RESULTS: Current coverage was around 40% for most disorders with the exception of social phobia at 21%. Receipt of interventions consistent with evidence-based care ranged from 32% of those in contact with services for social phobia to 64% for post-traumatic stress disorder. The cost of this care was estimated at dollar 400 million, resulting in a cost per YLD averted ranging from dollar 7761 for generalized anxiety disorder to dollar 34 389 for panic/agoraphobia. Under optimal care, costs remained similar but health gains were increased substantially, reducing the cost per YLD to < dollar 20 000 for all disorders. CONCLUSIONS: Evidence-based care for anxiety disorders would produce greater population health gain at a similar cost to that of current care, resulting in a substantial increase in the cost-effectiveness of treatment.

Living with rheumatoid arthritis: expenditures, health status, and social impact on patients.

OBJECTIVE: To determine costs related to living with rheumatoid arthritis (RA), and to identify the association between health status-as measured by the Health Status Questionnaire short form-36 (SF-36) and the disease specific index Health Assessment Questionnaire (HAQ)-and the social impact of RA. METHODS: A prospective cohort study was carried out on 81 patients with RA who completed four consecutive three month cost diaries. The SF-36, HAQ, and social impact at baseline and one year follow up were also assessed. RESULTS: Women reported worse SF-36 physical function and HAQ scores than men and received more assistance from family and friends. Women spent more on non-prescription medication and devices to assist them than men. Older patients had higher expenditure on visits to health professionals, whereas younger patients spent more on prescription medication and tests. Pension status and membership of private health insurance schemes were important determinants in these differences in expenditure. CONCLUSION: Costs increased with duration of disease, those with private health insurance had greater out of pocket costs (excluding membership fees), and those with pension support had fewer costs. Women were more affected by RA than men in health status, social impact, and out of pocket costs.

The effectiveness of local adaptation of nationally produced clinical practice guidelines.

BACKGROUND: Local adaptation is often reported in the literature to be an important strategy in achieving local ownership and relevance of guidelines in order to increase the likelihood of their uptake and implementation. However, the process is also potentially time-consuming and costly. OBJECTIVE: The aim of this study was to determine the impact of local adaptation of nationally produced clinical practice guidelines (CPGs) on the knowledge, attitude and reported practices of GPs. METHODS: Two Divisions of General Practice in Adelaide, Australia were selected and randomized to adapt a nationally produced CPG (on Stroke Prevention) by the National Health and Medical Research Council or use the original version. The order of the interventions was reversed for a second guideline (on management of Lower Urinary Tract Symptoms in Men). An identical multifaceted dissemination strategy was adopted for both sets of guidelines in the two divisions. Prior to the intervention, a random sample of 200 GPs from each Division was sent a postal survey about their knowledge, attitudes and reported practices. This was repeated 3 months after the dissemination phase. RESULTS: Sixty-one per cent (243/400) of the GPs responded to the initial survey and, of these, 76% (184/243) responded to the follow-up survey. Overall, awareness of both sets of guidelines was significantly increased. For stroke, 38% of respondents across both Divisions reported that their practice had changed as a result of the guidelines. For management of lower urinary tract symptoms in men, the corresponding proportion was 52%. Agreement with specific recommendations from both guidelines was also increased following their dissemination. However, these changes were independent of whether or not the guidelines had been locally adapted. The local adaptation process involved no substantive change in content and was estimated to cost AUD$5600 (per Division) independent of the costs of the dissemination process. CONCLUSIONS: Whilst this study found significant changes in knowledge, attitude and reported practice as a result of disseminating guidelines, it did not find any additional effect from the local adaptation process itself. This suggests that the emphasis and investment in promoting guideline implementation should be placed on multifaceted dissemination strategies rather than local adaptation per se.

Living with osteoarthritis: patient expenditures, health status, and social impact.

OBJECTIVE: To determine "out-of-pocket" expenditures related to osteoarthritis (OA) and to explore whether demographic details, health status scores (Medical Outcomes Study 36-item Short Form [SF-36] and Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]), or perception of social effect were expenditure determinants. METHODS: A prospective cohort study of community-dwelling subjects with OA completed 4 consecutive 3-month cost diaries. In addition, subjects completed the SF-36 and WOMAC at baseline and at 12 months. Social impact at baseline was collected. Four groups categorized by age and sex were compared. Patients undergoing joint replacement were excluded. RESULTS: Differences in health status were defined more by age than by sex, especially for physical function. The costs to the patients were high, particularly for women, who spent more on medications and special equipment. Women also reported receiving more assistance from family and friends. Higher disease-related expenditures were associated with greater pain levels, poorer social function and mental health, and longer duration of disease. Significant independent predictors of total patient expenditures related to OA were being female and having joint stiffness. CONCLUSION: Despite having heavily subsidized health care and access to the Pharmaceutical Benefits Scheme, out-of-pocket costs for patients with OA in Australia are considerable. Higher expenditures for patients with OA are related to more advanced disease, especially for women.

What are the costs to society and the potential benefits from the effective management of early rheumatoid arthritis?

Rheumatoid arthritis is a chronic disabling condition associated with a significant long-term loss of function and a significant socio-economic impact on individual sufferers and their families, as well as on society as a whole. There is a suggestion that the incidence and severity of the disease may be abating slightly, which has been attributed to the trend to 'invert the pyramid' and to diagnose and treat rheumatoid disease earlier and more aggressively. Studies have confirmed that the erosions, which lead to subsequent joint damage, occur early in the course of the disease. Ongoing disease activity, both clinically and serologically, has now been linked to increasing morbidity, loss of function and mortality. New agents have been developed and, together with combinations of old and new agents, have been shown to be more effective if used earlier in the course of the disease. The better the early control of the disease, the better the long-term outcome. Early and more vigorous treatment, particularly of those patients with a high joint count, early loss of function and an elevated titre of inflammatory markers, has potential to reduce the twofold increase in mortality seen among rheumatoid arthritis patients. The scene is set to have a greater impact on the long-term disability and associated cost to the individual and society by treating early and treating often. Combination therapy and the new 'biologicals' are, however, far more expensive than the previously available agents, and the direct medical costs associated with medication, as well as the monitoring costs for rheumatoid arthritis, are increasing. It is difficult to value the long-term prevention of pain and suffering, and the maintenance of productivity. However, if the disease were effectively controlled early, there would be long-term benefits to be offset against the higher treatment cost. It behooves the rheumatological community to use the new agents wisely to gain the greatest advantage for all patients as well as to monitor the long-term benefits and drawbacks so that cost-effectiveness can be comprehensively evaluated.

A comparison of outcomes in osteoarthritis patients undergoing total hip and knee replacement surgery.

OBJECTIVE: The aims of this study were to assess changes in physical function and quality of life with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the instrument of the Medical Outcomes Study SF-36 Health Survey (MOS SF-36), respectively, in patients undergoing hip anf knee joint replacement surgery and to compare the responsiveness of these two outcome measures 1 year after surgery. DESIGN: One hundred and ninety-four patients with osteoarthritis (OA knee 108, OA hip 86) admitted to four hospitals in Sydney were followed over a period of 1 year at 3 monthly intervals. RESULTS: WOMAC measures improved significantly after 1 year for OA hip and OA knee: there was reduction in pain of 71% and 53%, reduction of stiffness of 55% and 43% and improvement in physical function of 68% and 43%, respectively. MOS SF-36 measures in those having hip surgery improved significantly for pain (222%), physical function (247%), physical role functioning (402%), general health (110%), vitality (143%0, social functioning (169%) and mental health (114%). For those in the knee surgery group, significant improvement was seen for pain (175%), physical function (197%), physical role functioning (275%), vitality (125%) and social functioning (119%). The WOMAC was a more responsive measure than the MOS SF-36. CONCLUSION: WOMAC and MOS SF-36 detect significant and clinically meaningful changes in outcome after hip and knee replacement. WOMAC requires a smaller sample size and is more responsive in the short term. For a follow-up longer than 6 months MOS SF-36 provides additional information. The improvement in outcomes following hip joint surgery were significantly greater than those following knee surgery.

Screening for colorectal cancer: what is the most cost-effective approach?

In Western countries, including Australia, colorectal cancer is the leading cause of cancer mortality in nonsmokers. Development of most colorectal cancers can be prevented by adenoma removal. The current screening strategies of faecal occult blood testing (FOBT), flexible sigmoidoscopy combined with FOBT and colonoscopy are all cost effective. In clinical practice, a range of options should be offered to allow for individual patients' preferences. A public education program is essential to the success of any screening strategy.

Determinants of willingness to pay for hip and knee joint replacement surgery for osteoarthritis.

OBJECTIVES: To determine whether patients with osteoarthritis (OA) would be willing to pay for joint replacement and whether patient characteristics or health outcomes, including pain, physical function and health-related quality of life, were related to willingness to pay (WTP). METHODS: Patients who had undergone primary total hip replacement (THR) or total knee replacement (TKR) for OA completed a disease-specific questionnaire (Western Ontario and McMaster: WOMAC index), a generic measure of health status (Medical Outcome Study Short Form-36: SF-36) and an Evaluation Questionnaire to measure WTP and satisfaction with the replacement. RESULTS: Responses were obtained from 109 (77%) THR patients and 129 (72%) TKR patients. Mean age of respondents was 67 yr for THR (47% female) and 73 yr for TKR (60% female). Overall, 85% of patients responded to the WTP question. Of the THR patients, 71% were willing to pay something, 11% were not willing to pay anything and 18% did not answer the question. For TKR patients these figures were 70, 16 and 14% respectively. However, of those who responded to the WTP question, only 25% of the THR patients and 18% of the TKR patients indicated they would be willing to pay the actual current average cost of the operation in Australia (>/= A$15 000). A lower postoperative pain score (as measured by the WOMAC index) was a significant predictor of WTP for both THR and TKR patients. Income also significantly predicted WTP in THR patients but not in TKR patients. The other significant predictors for TKR patients were older age, having private health insurance and willingness to recommend joint replacement to others. CONCLUSIONS: Willingness to pay was a measure that was understandable and acceptable to patients, most of whom were willing to pay something. There was a high correlation between WTP, good health outcomes and patient satisfaction, pain relief being the dominant determinant.

Deinstitutionalisation for long-term mental illness: a 2-year clinical evaluation.

OBJECTIVE: The closure of a long-stay psychiatric hospital in Sydney caused the transfer of an initial 40 very long-term patients to four community residences, each with 10 beds, for a continuing process of deinstitutionalisation. Community psychiatric service support and 24-h supervision were provided. This paper describes the residents' clinical progress which was assessed over a 2-year period. METHOD: This study employed a quasi-experimental longitudinal design. Evaluation commenced prior to discharge and continued for 2 years following community relocation using the Brief Psychiatric Rating Scale, Life Skills Profile, Social Behaviour Scale, Montgomery Asberg Depression Rating Scale and Quality Of Life measures. Readmission, demographic, case history and medication data were also collected. RESULTS: Of the 40 patients initially transferred to the community, seven required long-term readmission to hospital (either prior to or after amalgamation) and one patient died of medical causes. Additional patients transferred from the hospital to the community following the readmissions. Three of these additional patients had achieved a 2-year community tenure during the study period and were included in the clinical evaluation. The 35 residents in total who remained in the community for 2 years, demonstrated a significant improvement in psychotic symptoms, without significant change in the level of neuroleptic medication. Importantly, the 2 years of community living resulted in a significant increase in the residents' life satisfaction. There were no statistically significant changes in residents' living skills, depressive symptoms or social behaviour problems over the 2 years, indicative of the need for supervision and community service support following deinstitutionalisation. Over the 2-year period, some 37% of the residents required temporary readmission. CONCLUSION: This study demonstrates the clinical effectiveness of deinstitutionalisation, when planned within a mental health system with adequate community resources.

Deinstitutionalisation for long-term mental illness: an ethnographic study.

OBJECTIVE: Deinstitutionalisation of seriously mentally ill people in the developed world, including Australia, has occurred since the middle of this century. Evaluation of the effects of this change on the lives of individuals is of paramount importance to ensure that policies are acceptable and effective. Increasingly, multifaceted studies are considered essential for comprehensive health research. The qualitative aspect of this study complements the clinical and economic components. METHOD: An ethnographic approach enabled contextual, qualitative data to be gathered from within the social world of 47 hospital residents as they moved to the community. A social anthropologist acting explicitly as a participant observer undertook fieldwork over two and a half years both pre- and post-discharge. Qualitative data were collected, stored and analysed separately from quantitative and economic data. RESULTS: Ethnographic findings generally supported and, in many cases, mirrored clinical results. Of the total cohort of 47 patients transferred to the community, the 40 who continue to live outside of hospital all reported a preference for community living. The importance of freedom and simple liberties cannot be underestimated as factors that enabled this resilient group of people to work creatively through difficult periods. CONCLUSION: Properly planned and resourced deinstitutionalisation not only maintains people with a prolonged mental illness outside of hospital, it also enhances their quality of life. Subjective descriptive material focusing on personal experiences adds meaning to quantitative research data allowing health professionals to more fully understand the implications of health policy on the lives of individuals.

Deinstitutionalisation for long-term mental illness: cost differences in hospital and community care.

OBJECTIVE: This project studied the cost analysis of psychiatric hospital and then community care for long-stay patients with chronic mental illness discharged during the closure of a psychiatric hospital in Sydney. METHOD: Expenditure and income data in both settings were collected. Costs were analysed on an occupied bed-day basis. RESULTS: The hospital setting cost more per patient per day compared with the various community costs which were one-third to one-half of the comparable hospital costs. CONCLUSIONS: The analysis demonstrated overall that hospital care was nearly twice as expensive as care in the community setting. The factors which may have influenced, although not necessarily altered, the substance of the findings largely related to 'organisational efficiency'. The mental hospital as an older, more rigid system was likely to be less efficient than the newer community service provision which was under intensive scrutiny both clinically and financially by all interested parties.

Cost-minimization analysis: radiation treatment with and without a multi-leaf collimator.

PURPOSE: To compare the costs of radiation treatment on a linear accelerator with a multileaf collimator (MLC) versus treatment on a linear accelerator without an MLC. The study was designed to determine whether the increased throughput of fields and decreased block cutting made the MLC cost effective from an institutional perspective. METHODS AND MATERIALS: The number of fields, basic treatment equivalent, equivalent simple treatment visits, and blocks were prospectively collected for the four linear accelerators. Building, equipment, staffing, and service costs were all obtained in 1999 Australian dollars from the manufacturers and hospital department heads. The Joint Radiation Oncology Centre at Westmead and Nepean Hospitals, which are Australian public hospitals, runs as one unit, with the same staff, and currently operates five linear accelerators. Currently, four of the linear accelerators are used for general radiotherapy, operating for exactly the same hours; the final machine operates more limited hours and is used for specialized radiotherapy techniques and emergency cases. RESULTS: The two machines with MLCs, on average, treated 5,169 fields each, while the two machines without MLCs treated 4,543 fields in a 3-month period, a 12% increase in throughput. The two non-MLC machines required 155 premounted trays (PMTs) in total, while the MLC machines required 17 PMTs. Linear accelerators with MLCs were demonstrably more efficient, and while their capital costs were higher, the reduction in labor costs associated with block cutting and, particularly the increased throughput, more than offset these initial costs. The total cost of a radiation field with an MLC was found to be $A101.69 compared to $A106.98 without an MLC. A multiway sensitivity analysis showed the results to be robust. The worst-case scenario was a departmental savings of $A168,000 per year; the best-case scenario was a savings of $A680,000 per year. CONCLUSION: Under the conditions pertaining to the radiation oncology department in this group of hospitals, and in similar departments, the use of an MLC can be justified.

Outcomes after hip or knee replacement surgery for osteoarthritis. A prospective cohort study comparing patients' quality of life before and after surgery with age-related population norms.

OBJECTIVE: To compare the health-related quality of life of people with osteoarthritis before and after primary total hip and knee replacement surgery with that of the general Australian population. DESIGN: A prospective cohort study. SETTING: Three Sydney hospitals, public and private. PARTICIPANTS: Patients with osteoarthritis undergoing primary total hip (n = 59) and knee (n = 92) joint replacement surgery. MAIN OUTCOME MEASURE: Medical Outcomes Study Short Form (SF-36) scores before and 12 months after joint replacement surgery (compared with population norms). RESULTS: Patients in each age group showed a significant improvement in health-related quality of life after joint replacement surgery in most scales of the SF-36, particularly physical function, role physical and bodily pain. SF-36 scores for the 42 hip-replacement patients aged 55-74 years improved to equal or exceed the population norm on all scales. SF-36 scores of the 52 knee replacement patients aged 55-74 years improved, but physical function and bodily pain scores remained significantly worse than the population norm. SF-36 scores for both hip (n = 17) and knee (n = 40) replacement patients aged 75 years and over improved significantly, becoming similar to population norms for this age group. CONCLUSIONS: Total hip or knee replacement for osteoarthritis significantly improves patient health and well-being at 12 months after surgery. Age alone should not be a barrier to surgery.

Cost-effectiveness of strategies to market and train primary health care physicians in brief intervention techniques for hazardous alcohol use.

The cost-effectiveness of strategies to market and train primary care physicians in brief intervention for hazardous alcohol consumption was examined. Physicians were randomly assigned to one of three marketing strategies designed to promote the "uptake" of a brief intervention package for hazardous and harmful alcohol consumption. The strategies were direct mail, tele-marketing, or academic detailing. One hundred and twenty-seven of those physicians who requested the package during the marketing phase (phase 1) and who also agreed to participate in the training and support phase of the project (phase 2) were matched into one of three training and support conditions: training and no support, training and minimal support, training and maximal support. An additional 34 physicians were randomly selected and assigned to a control condition. The ultimate aim of training and support was to maximise physician screening and counselling rates. Tele-marketing was found to be more cost-effective than academic detailing and direct mail in promoting the uptake of the package. For the training and support phase costs and effects increased with the level of support, hence the issue to be considered is whether the additional cost incurred in moving from one strategy to another is warranted given the increase in the level of outcome.