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1.
Pharmacoeconomics ; 2021 Apr 09.
Artigo em Inglês | MEDLINE | ID: mdl-33834425

RESUMO

Governments and health insurers often make funding decisions based on health gains from randomised controlled trials. These decisions are inherently uncertain because health gains in trials may not translate to practice owing to differences in the population, treatment use and setting. Post-market analysis of real-world data can provide additional evidence but estimates from standard matching methods may be biased when unobserved characteristics explain whether a patient is treated and their outcomes. We propose a new untreated matching approach that can reduce this bias. Our approach utilises the outcomes of contemporaneous untreated patients to improve the matching of treated and historical control patients. We assess the performance of this new approach compared to standard matching using a simulation study and demonstrate the steps required using a funding decision for prostate cancer treatments in Australia. Our simulation study shows that our new matching approach eliminates nearly all bias when unobserved treatment selection is related to outcomes, and outperforms standard matching in most scenarios. In our empirical example, standard matching overestimated survival by 15% (95% confidence interval 2-34) compared to our untreated matching approach. The health gains estimated using our approach were slightly lower than expected based on the trial evidence, but we also found evidence that in practice prescribers ceased prior therapies earlier, treated a more vulnerable population and continued treatment for longer. Our untreated matching approach offers researchers a new tool for reducing uncertainty in healthcare funding decisions using real-world data.

2.
J Occup Rehabil ; 2021 Mar 03.
Artigo em Inglês | MEDLINE | ID: mdl-33656699

RESUMO

Purpose To determine if losing work during the COVID-19 pandemic is associated with mental and physical health status. To determine if social interactions and financial resources moderate the relationship between work loss and health. Methods Participants were Australians aged 18 + years that were employed in paid work prior to the COVID-19 pandemic who responded to an online or telephone survey from 27th March to 12th June 2020 as part of a prospective longitudinal cohort study. Outcome measures include Kessler-6 score > 18 indicating high psychological distress, and Short Form 12 (SF-12) mental health or physical health component score < = 45 indicating poor mental or physical health. Results The cohort consisted of 2,603 respondents, including groups who had lost their job (N = 541), were not working but remained employed (N = 613), were working less (N = 660), and whose work was unaffected (N = 789). Three groups experiencing work loss had greater odds of high psychological distress (AOR = 2.22-3.66), poor mental (AOR = 1.78-2.27) and physical health (AOR = 2.10-2.12) than the unaffected work group. Poor mental health was more common than poor physical health. The odds of high psychological distress (AOR = 5.43-8.36), poor mental (AOR = 1.92-4.53) and physical health (AOR = 1.93-3.90) were increased in those reporting fewer social interactions or less financial resources. Conclusion Losing work during the COVID-19 pandemic is associated with mental and physical health problems, and this relationship is moderated by social interactions and financial resources. Responses that increase financial security and enhance social connections may alleviate the health impacts of work loss. Registration Australian New Zealand Clinical Trials Registry: ACTRN12620000857909.

3.
Artigo em Inglês | MEDLINE | ID: mdl-33253057

RESUMO

Background: Although evaluations of breast cancer screening programs frequently estimate quality-adjusted life-year (QALY) losses by stage, other breast cancer characteristics influence treatment and vary by mode of detection - i.e. whether the cancer is detected through a screening program (screen-detected), in between screening rounds (interval-detected) or outside the screening program (community-detected). Here, we estimate the association between early-stage invasive breast cancer (ESIBC) characteristics and treatment-related QALY losses. Methods: Using clinicopathological and treatment information from 675 women managed for ESIBC, we estimated the average five-year treatment-related QALY loss by detection group. We then used regression analysis to estimate the extent to which known cancer characteristics and the mode of detection, are associated with treatment and treatment-related QALY losses. Results: Community-detected cancers had the largest average QALY loss (0.76 QALYs [95%CI 0.73;0.80]), followed by interval-detected cancers (0.75 QALYs [95%CI 0.68;0.82]) and screen-detected cancers (0.69 QALYs [95%CI 0.67;0.71]). Adverse prognostic factors more common in community-detected and interval-detected breast cancers (large tumour sizes, lymph node involvement, high grade) were largely associated with QALY losses from mastectomies and chemotherapy. Receptor positive subtypes, more common in screen-detected cancers, were associated with QALY losses related to endocrine therapy. Conclusions: The associations between ESIBC characteristics and treatment-related QALY losses should be considered when evaluating breast cancer screening and treatment strategies.

4.
Diabetes Care ; 43(8): 1741-1749, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32532756

RESUMO

OBJECTIVE: To develop a patient-level simulation model for predicting lifetime health outcomes of patients with type 1 diabetes and as a tool for economic evaluation of type 1 diabetes treatment based on data from a large, longitudinal cohort. RESEARCH DESIGN AND METHODS: Data for model development were obtained from the Swedish National Diabetes Register. We derived parametric proportional hazards models predicting the absolute risk of diabetes complications and death based on a wide range of clinical variables and history of complications. We used linear regression models to predict risk factor progression. Internal validation was performed, estimates of life expectancies for different age-sex strata were computed, and the impact of key risk factors on life expectancy was assessed. RESULTS: The study population consisted of 27,841 patients with type 1 diabetes with a mean duration of follow-up of 7 years. Internal validation showed good agreement between the predicted and observed cumulative incidence of death and 10 complications. Simulated life expectancy was ∼13 years lower than that of the sex- and age-matched general population, and patients with type 1 diabetes could expect to live with one or more complications for ∼40% of their remaining life. Sensitivity analysis showed the importance of preventing renal dysfunction, hypoglycemia, and hyperglycemia as well as lowering HbA1c in reducing the risk of complications and death. CONCLUSIONS: Our model was able to simulate risk factor progression and event histories that closely match the observed outcomes and to project events occurring over patients' lifetimes. The model can serve as a tool to estimate the impact of changing clinical risk factors on health outcomes to inform economic evaluations of interventions in type 1 diabetes.

5.
Soc Sci Med ; 255: 113027, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32408084

RESUMO

This study explores the extent to which structural stigma (which encompasses sociocultural and institutional constraining factors) is associated with sexual orientation disparities in healthcare service and prescription medicine use. Using the responses to the 2017 Australian Marriage Law Postal Survey, we use the regional percentage of votes against legalising same-sex marriage as a measure of structural stigma. We then map these results to Census-linked-administrative data, including 83,519 individuals in same-sex relationships - one of the largest administrative datasets to date where individuals in same-sex relationships are identified. Controlling for regional and individual-level confounders, we find that structural stigma is associated with increased use of nervous system medications (which largely comprise antidepressants) but reduced GP visits for both females and males in same-sex relationships. More regional stigma is also associated with reduced use of pathology services and anti-infective prescriptions for males in same-sex relationships. Altogether, our results suggest that individuals in same-sex relationships living in stigmatised regions are in poorer health but are less likely to access primary healthcare.

6.
Aust N Z J Public Health ; 44(3): 219-226, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32311194

RESUMO

OBJECTIVE: To determine the government and out-of-pocket community costs (out-of-hospital medical services and prescription medicines) associated with screen-detected and community-detected cancers (i.e. cancers detected outside of Australia's organised screening program [BreastScreen]). METHODS: We analyse administrative data on government-subsidised medical services and prescription medicines for 568 Victorian women diagnosed with breast cancer or ductal carcinoma in situ (DCIS). Using multivariable regression analysis, we estimate the government and out-of-pocket community costs incurred in the three years after diagnosis for screen-detected cancers and community-detected cancers. Additionally, we estimate the government costs associated with diagnosis within and outside of BreastScreen. RESULTS: Average government costs for breast cancer diagnosis were similar within and outside of BreastScreen [$808 (lower limit 676; upper limit 940) vs $837 (95%CI 671; 1,003) respectively]; however, women with community-detected cancers incurred an additional $254 (95%CI 175; 332) out-of-pocket. Controlling for differences in known cancer characteristics, compared to screen-detected cancers, community-detected breast cancers were associated with an additional $2,622 (95%CI 644; 4,776) in government expenditure in the three years following diagnosis. Adverse cancer characteristics that were more prevalent in community-detected cancers (high grade, lymph node involvement, HER2 positive receptor status) were associated with increased government and out-of-pocket costs. CONCLUSIONS: Community-detected breast cancers were associated with increased government and out-of-pocket costs. Implications for public health: These costs should be considered when evaluating current and alternative breast cancer screening strategies.


Assuntos
Neoplasias da Mama/diagnóstico , Carcinoma Intraductal não Infiltrante/diagnóstico , Detecção Precoce de Câncer/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Serviços de Saúde/estatística & dados numéricos , Mamografia/economia , Programas de Rastreamento/economia , Adulto , Idoso , Austrália/epidemiologia , Neoplasias da Mama/epidemiologia , Carcinoma Intraductal não Infiltrante/epidemiologia , Estudos de Coortes , Feminino , Serviços de Saúde/economia , Humanos , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Sistema de Registros
7.
Vox Sang ; 115(4): 275-287, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32043603

RESUMO

BACKGROUND AND OBJECTIVES: Blood services are tasked with efficiently maintaining a reliable blood supply, and there has been much debate over the use of incentives to motivate prosocial activities. Thus, it is important to understand the relative effectiveness of interventions for increasing donations. MATERIALS AND METHODS: This systematic review used a broad search strategy to identify randomized controlled trials comparing interventions for increasing blood donations. After full-text review, 28 trials from 25 published articles were included. Sufficient data for meta-analysis were available from 27 trials. Monetary incentives were assumed to be equivalent regardless of value, and non-monetary incentives were assumed to be equivalent regardless of type. Non-incentive-based interventions identified included existing practice, letters, telephone calls, questionnaires, and the combination of a letter & telephone call. A network meta-analysis was used to pool the results from identified trials. A subgroup analysis was performed in populations of donors and non-donors as sensitivity analyses. RESULTS: The best performing interventions were letter & telephone call and telephone call-only with odds ratios of 3·08 (95% CI: 1·99, 4·75) and 1·99 (95% CI: 1·47, 2·69) compared to existing practice, respectively. With considerable uncertainty around the pooled effect, we found no evidence that monetary incentives were effective at increasing donations compared to existing practice. Non-monetary incentives were only effective in the donor subgroup. CONCLUSION: When pooling across modes of interventions, letter & telephone call and telephone call-only are effective at increasing blood donations. The effectiveness of incentives remains unclear with limited, disparate evidence identified.


Assuntos
Doadores de Sangue/psicologia , Motivação , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Recompensa , Inquéritos e Questionários
9.
Epidemiology ; 31(2): 282-289, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31868828

RESUMO

BACKGROUND: International comparisons of social inequalities in health outcomes and behaviors are challenging. Due to the level of disaggregation often required, data can be sparse and methods to make adequately powered comparisons are lacking. We aimed to illustrate the value of a hierarchical Bayesian approach that partially pools country-level estimates, reducing the influence of sampling variation and increasing the stability of estimates. We also illustrate a new way of simultaneously displaying the uncertainty of both relative and absolute inequality estimates. METHODS: We used the 2014 European Social Survey to estimate smoking prevalence, absolute, and relative inequalities for men and women with and without disabilities in 21 European countries. We simultaneously display smoking prevalence for people without disabilities (x-axis), absolute (y-axis), and relative inequalities (contour lines), capturing the uncertainty of these estimates by plotting a 2-D normal approximation of the posterior distribution from the full probability (Bayesian) analysis. RESULTS: Our study confirms that across Europe smoking prevalence is generally higher for people with disabilities than for those without. Our model shifts more extreme prevalence estimates that are based on fewer observations, toward the European mean. CONCLUSIONS: We demonstrate the utility of partial pooling to make adequately powered estimates of inequality, allowing estimates from countries with smaller sample sizes to benefit from the increased precision of the European average. Including uncertainty on our inequality plot provides a useful tool for evaluating both the geographical patterns of variation in, and strength of evidence for, differences in social inequalities in health.

10.
Int J Drug Policy ; 76: 102633, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31869656

RESUMO

BACKGROUND: Hepatitis C virus elimination may be possible by scaling up direct-acting antiviral (DAA) treatment. Due to the safety and simplicity of DAA treatment, primary care-based treatment delivery is now feasible, efficacious and may be cheaper than hospital-based specialist care. In this paper, we use Prime Study data - a randomised controlled trial comparing the uptake of DAA treatment between primary and hospital-based care settings amongst people who inject drugs (PWID) - to estimate the cost of initiating treatment for PWID diagnosed with hepatitis C in primary care compared to hospital-based care. METHODS: The total economic costs associated with delivering DAA treatment (post hepatitis C diagnosis) within the Prime study - including health provider time/training, medical tests, equipment, logistics and pharmacy costs - were collected. Appointment data were used to estimate the number/type of appointments required to initiate treatment in each case, or the stage at which loss to follow up occurred. RESULTS: Among the hepatitis C patients randomised to be treated within primary care, 43/57 (75%) commenced treatment at a mean cost of A$885 (95% CI: A$850-938) per patient initiating treatment. In hospital-based care, 18/53 hepatitis C patients (34%) commenced treatment at a mean cost of A$2078 (range: A$2052-2394) per patient initiating treatment - more than twice as high as primary care. The lower cost in the primary care arm was predominantly the result of increased retention in care compared to the hospital-based arm. CONCLUSIONS: Compared to hospital-based care, providing hepatitis C services for PWID in primary care can improve treatment uptake and approximately halve the average cost of treatment initiation. To improve treatment uptake and cure, countries should consider primary care as the main model for hepatitis C treatment scale-up.

11.
J Thorac Cardiovasc Surg ; 160(2): 437-445.e20, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31711621

RESUMO

OBJECTIVE: In March 2012, Australia's National Blood Authority published national patient blood-management guidelines for perioperative care developed by a systematic review and clinical expert opinion. This study assesses how blood transfusions and patient outcomes in cardiac surgery changed after the guidelines were published. METHODS: Blood transfusions and patient outcomes in cardiac surgery were compared before and after implementation of the guidelines using an interrupted time series analysis. The evaluation included red blood cells, platelets, cryoprecipitate, fresh-frozen plasma, 30-day mortality, 30-day readmissions, and hospital and intensive care length of stay. Patient characteristics were controlled for along with hospital characteristics using fixed effects. Different responses across institutional settings were assessed with an expanded difference-in-differences model. RESULTS: After the guidelines were published, our model found a significant reduction in red blood cell, platelet, and fresh-frozen plasma transfusions. There was also a significant reduction in hospital length of stay but no significant impact on cryoprecipitate, 30-day mortality, 30-day readmissions, or intensive care unit length of stay. The subgroup analyses found no differences with regards to institutional settings. CONCLUSIONS: Following the publication of the guidelines, there was a measurable reduction in perioperative blood transfusions in cardiac surgery with an associated reduction in hospital length of stay but no detectable differences in other patient outcomes.


Assuntos
Transfusão de Sangue/normas , Procedimentos Cirúrgicos Cardíacos/normas , Fidelidade a Diretrizes/normas , Guias de Prática Clínica como Assunto/normas , Padrões de Prática Médica/normas , Idoso , Austrália , Transfusão de Sangue/mortalidade , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Bases de Dados Factuais , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
12.
Appl Health Econ Health Policy ; 18(2): 311-324, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31410773

RESUMO

BACKGROUND: Universal suicide education and awareness training in schools are promising suicide prevention initiatives. This study aims to evaluate a suicide awareness training (safeTALK) and to model potential return on investment (ROI) on a population basis. SafeTALK, comprises a 3-h education session, and has been delivered to secondary school students (aged 15-16 years) in Mackay, located in the Australian state of Queensland. METHODS: Evaluation consisted of two phases, ex-post and ex-ante. Phase I was a pre-post, follow-up analysis using a mixed-method questionnaire administered immediately prior (Time 1), immediately after (Time 2), and 4 weeks after training (Time 3). Phase II involved decision analytic modelling comparing safeTALK to the status quo. ROI was modelled using Markov chains for a hypothetical population of students aged 15-19 years in Mackay (n = 2561; suicide rate 78.1 per 100,000), Queensland (n = 296,287; 10.2) and Australia (n = 1,421,595; 8.3). Model parameters, including rates of hospitalised self-harm and suicide, cost implications and effectiveness of safeTALK were drawn from published literature. The baseline model adapted a health and justice system's perspective, with an alternative model incorporating a societal perspective. All costs were adjusted to reflect AU$2017-2018. RESULTS: Students reported seeking help mostly from friends (79%) or parents (68%); in the last 6 months 61% considered another student's behaviour as suicidal, but only 21% reported asking about this. The main barriers to help-seeking were (i) being too embarrassed, (ii) shy or (iii) being judged. Students who attended safeTALK gained suicide-related knowledge (p < 0.001), confidence (p < 0.001), willingness (p = 0.006), and likelihood of seeking help (p = 0.044) and retained these up until follow-up assessment 4 weeks later with the exception of seeking help. From a health and justice system's perspective, the model estimated a cumulative return of AU$1.45 per AU$1 invested in safeTALK in Mackay; AU$0.19 in Queensland; AU$0.15 across Australia. From a societal perspective, ROI increased to AU$31.21, AU$4.05 and AU$3.28, respectively. CONCLUSION: Results strengthen the premise that safeTALK is feasible to implement within a school setting. The economic case for implementation of safeTALK is promising on a population basis, especially in high-risk communities, but further research is required to confirm the study results.

13.
Clin Infect Dis ; 70(9): 1900-1906, 2020 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-31233117

RESUMO

BACKGROUND: To achieve the World Health Organization hepatitis C virus (HCV) elimination targets, it is essential to increase access to direct-acting antivirals (DAAs), especially among people who inject drugs (PWID). We aimed to determine the effectiveness of providing DAAs in primary care, compared with hospital-based specialist care. METHODS: We randomized PWID with HCV attending primary care sites in Australia or New Zealand to receive DAAs at their primary care site or local hospital (standard of care [SOC]). The primary outcome was to determine whether people treated in primary care had a noninferior rate of sustained virologic response at Week 12 (SVR12), compared to historical controls (consistent with DAA trials at the time of the study design); secondary outcomes included comparisons of treatment initiation, SVR12 rates, and the care cascade by study arm. RESULTS: We recruited 140 participants and randomized 136: 70 to the primary care arm and 66 to the SOC arm. The SVR12 rate (100%, 95% confidence interval [CI] 87.7-100) of people treated in primary care was noninferior when compared to historical controls (85% assumed). An intention-to-treat analysis revealed that the proportion of participants commencing treatment in the primary care arm (75%, 43/57) was significantly higher than in the SOC arm (34%, 18/53; P < .001; relative risk [RR] 2.48, 95% CI 1.54-3.95), and the proportion of participants with SVR12 was significantly higher in the primary care arm, compared to in the SOC arm (49% [28/57] and 30% [16/53], respectively; P = .043; RR 1.63, 95% CI 1.0-2.65). CONCLUSIONS: Providing HCV treatment in primary care increases treatment uptake and cure rates. Approaches that increase treatment uptake among PWID will accelerate elimination strategies. CLINICAL TRIALS REGISTRATION: NCT02555475.

14.
Soc Psychiatry Psychiatr Epidemiol ; 55(2): 197-204, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31456028

RESUMO

PURPOSE: Stigma and discrimination are central concerns for people with mental health problems. The aim of the study was to carry out a follow-up survey of a national survey of experiences of avoidance, discrimination and positive treatment in people with mental health problems to explore how those experiences relate to health service use. METHODS: In 2017, telephone interviews were carried out with 655 Australians aged 18+, who had participated in a 2014 survey and reported a mental health problem or scored highly on a symptom screening questionnaire. Questions covered mental health, disclosure, health service utilisation, and experiences of avoidance, discrimination and positive treatment in a variety of different settings. Regression analyses were used to assess the extent to which count of settings of experiences of avoidance, discrimination or positive treatment at baseline (2014) or follow-up (2017) predicted health service use at follow-up. RESULTS: An increase in past experiences of discrimination was associated with a greater number of visits to hospital or specialist doctors and an increase in positive treatment was associated with a greater number of visits to a mental health professional. Increases in both positive and negative experiences were associated with greater healthcare costs, but the costs were greatest for discrimination at follow-up (concurrent discrimination), primarily due to the cost of nights in hospital. CONCLUSIONS: While both discrimination and positive treatment are associated with greater healthcare costs, concurrent experiences were shown to be more important correlates of health service use than past experiences. Moreover, those in supportive environments may be more willing to engage in earlier evidence-based treatment for mental health problems.


Assuntos
Utilização de Instalações e Serviços/estatística & dados numéricos , Transtornos Mentais/psicologia , Serviços de Saúde Mental/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Discriminação Social/psicologia , Adolescente , Adulto , Austrália , Revelação , Feminino , Seguimentos , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Estigma Social , Inquéritos e Questionários
15.
Eur J Cancer ; 123: 130-137, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31689678

RESUMO

BACKGROUND: Mammographic screening reduces breast cancer mortality but may lead to the overdiagnosis and overtreatment of low-risk breast cancers. Conservative management may reduce the potential harm of overtreatment, yet little is known about the impact upon quality of life. OBJECTIVES: To quantify women's preferences for managing low-risk screen detected ductal carcinoma in situ (DCIS), including the acceptability of active monitoring as an alternative treatment. METHODS: Utilities (cardinal measures of quality of life) were elicited from 172 women using visual analogue scales (VASs), standard gambles, and the Euro-Qol-5D-5L questionnaire for seven health states describing treatments for low-risk DCIS. Sociodemographics and breast cancer history were examined as predictors of utility. RESULTS: Both patients and non-patients valued active monitoring more favourably on average than conventional treatment. Utilities were lowest for DCIS treated with mastectomy (VAS: 0.454) or breast conserving surgery (BCS) with adjuvant radiotherapy (VAS: 0.575). The utility of active monitoring was comparable to BCS alone but was rated more favourably as progression risk was reduced from 40% to 10%. Disutility for active monitoring was likely driven by anxiety around progression, whereas conventional management impacted other dimensions of quality of life. The heterogeneity between individual preferences could not be explained by sociodemographic variables, suggesting that the factors influencing women's preferences are complex. CONCLUSIONS: Active monitoring of low-risk DCIS is likely to be an acceptable alternative for reducing the impact of overdiagnosis and overtreatment in terms of quality of life. Further research is required to determine subgroups more likely to opt for conservative management.


Assuntos
Neoplasias da Mama/terapia , Carcinoma Intraductal não Infiltrante/terapia , Preferência do Paciente , Qualidade de Vida , Conduta Expectante , Idoso , Neoplasias da Mama/diagnóstico por imagem , Carcinoma Intraductal não Infiltrante/diagnóstico por imagem , Gerenciamento Clínico , Detecção Precoce de Câncer , Feminino , Humanos , Masculino , Mastectomia , Mastectomia Segmentar , Sobremedicalização , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde , Radioterapia Adjuvante
16.
Int J Equity Health ; 18(1): 57, 2019 04 16.
Artigo em Inglês | MEDLINE | ID: mdl-30992000

RESUMO

BACKGROUND: Income-related inequality measures such as the concentration index are often used to describe the unequal distribution of health, health care access, or expenditure in a single measure. This study demonstrates the use of such measures to evaluate the distributional impact of changes in health insurance coverage. We use the example of Medicare Part D in the United States, which increased access to prescription medications for Medicare beneficiaries from 2006. METHODS: Using pooled cross-sectional samples from the Medical Expenditure Panel Survey for 1997-2011, we estimated income-related inequality in drug expenditures over time using the concentration and generalised concentration indices. A difference-in-differences analysis investigated the change in inequality in drug expenditures, as measured using the concentration index and generalised concentration index, between the elderly (over 65 years) and near-elderly (54-63 years) pre- and post-implementation of Medicare Part D. RESULTS: Medicare Part D increased public drug expenditure while out-of-pocket and private spending fell. Public drug expenditures favoured the poor during all study periods, but the degree of pro-poorness declined in the years immediately following the implementation of Part D, with the poor gaining less than the rich in both relative and absolute terms. Part D also appeared to result in a fall in the pro-richness of private insurance drug expenditure in absolute terms but have minimal distributional impact on out-of-pocket expenditure. These effects appeared to be short lived, with a return to the prevailing trends in both concentration and generalised concentration indices several years following the start of Part D. CONCLUSIONS: The implementation of Medicare Part D significantly reduced the degree of pro-poorness in public drug expenditure. The poor gained less of the increased public drug expenditure than the rich in both relative and absolute terms. This study demonstrates how income-related inequality measures can be used to estimate the impact of health system changes on inequalities in health expenditure and provides a guide for future evaluations.


Assuntos
Gastos em Saúde/estatística & dados numéricos , Renda/estatística & dados numéricos , Medicare Part D , Medicamentos sob Prescrição/economia , Idoso , Estudos Transversais , Feminino , Acesso aos Serviços de Saúde/economia , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos
17.
Crit Care Med ; 47(7): e572-e579, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31008734

RESUMO

OBJECTIVES: Trials comparing the effects of transfusing RBC units of different storage durations have considered mortality or morbidity as outcomes. We perform the first economic evaluation alongside a full age of blood clinical trial with a large population assessing the impact of RBC storage duration on quality-of-life and costs in critically ill adults. DESIGN: Quality-of-life was measured at 6 months post randomization using the EuroQol 5-dimension 3-level instrument. The economic evaluation considers quality-adjusted life year and cost implications from randomization to 6 months. A generalized linear model was used to estimate incremental costs (2016 U.S. dollars) and quality-adjusted life years, respectively while adjusting for baseline characteristics. SETTING: Fifty-nine ICUs in five countries. PATIENTS: Adults with an anticipated ICU stay of at least 24 hours when the decision had been made to transfuse at least one RBC unit. INTERVENTIONS: Patients were randomized to receive either the freshest or oldest available compatible RBC units (standard practice) in the hospital transfusion service. MEASUREMENTS AND MAIN RESULTS: EuroQol 5-dimension 3-level utility scores were similar at 6 months-0.65 in the short-term and 0.63 in the long-term storage group (difference, 0.02; 95% CI, -0.00 to 0.04; p = 0.10). There were no significant differences in resource use between the two groups apart from 3.0 fewer hospital readmission days (95% CI, -5.3 to -0.8; p = 0.01) during follow-up in the short-term storage group. There were no significant differences in adjusted total costs or quality-adjusted life years between the short- and long-term storage groups (incremental costs, -$2,358; 95% CI, -$5,586 to $711) and incremental quality-adjusted life years: 0.003 quality-adjusted life years (95% CI, -0.003 to 0.008). CONCLUSIONS: Without considering the additional supply cost of implementing a freshest available RBC strategy for critical care patients, there is no evidence to suggest that the policy improves quality-of-life or reduces other costs compared with standard transfusion practice.


Assuntos
Estado Terminal/terapia , Transfusão de Eritrócitos/economia , Transfusão de Eritrócitos/métodos , Unidades de Terapia Intensiva/estatística & dados numéricos , Análise Custo-Benefício , Estado Terminal/mortalidade , Feminino , Humanos , Masculino , Anos de Vida Ajustados por Qualidade de Vida , Fatores de Tempo
18.
Occup Environ Med ; 76(5): 295-301, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30852492

RESUMO

OBJECTIVES: There is strong evidence of a relationship between psychosocial job stressors and mental health at the population level. There has been no longitudinal research on whether the experience of job stressors is also associated with greater mental health service use. We seek to fill this gap. METHODS: The Household Income Labour Dynamics in Australia survey cohort was used to assess the relationship between exposure to self-reported psychosocial job quality and reporting attendance at a mental health professional during the past 12 months. We adjusted for time-varying and time-invariant confounders. The study was conducted in 2009 and 2013. RESULTS: In the random effects logistic regression model, increasing exposure to psychosocial job stressors was associated with an increased odds of mental health service use after adjustment (one stressor: OR 1.26, 95% CI 1.01 to 1.56; two stressors: OR 1.33, 95% CI 1.02 to 1.73; three stressors: OR 1.82, 95% CI 1.28 to 2.57). However, once the between person effects were controlled in a fixed effects model, the within-person association between change in job stressors and change in mental health service use was estimated to be close to zero and not significant. CONCLUSIONS: More work is needed to understand the relationship between job stressors and service use. However, when taken with past findings on job stressors and mental health, these findings highlight the importance of considering policy and clinical practice responses to adverse working contexts.


Assuntos
Serviços de Saúde Mental/estatística & dados numéricos , Estresse Ocupacional/complicações , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adolescente , Adulto , Austrália/epidemiologia , Estudos de Coortes , Feminino , Humanos , Modelos Logísticos , Estudos Longitudinais , Masculino , Serviços de Saúde Mental/normas , Pessoa de Meia-Idade , Estresse Ocupacional/epidemiologia , Estresse Ocupacional/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Estresse Psicológico/complicações , Estresse Psicológico/epidemiologia , Estresse Psicológico/psicologia , Inquéritos e Questionários , Local de Trabalho/psicologia , Local de Trabalho/normas , Local de Trabalho/estatística & dados numéricos
19.
Soc Sci Med ; 228: 142-154, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30913528

RESUMO

Policy decisions regarding breast cancer screening and treatment programmes may be misplaced unless the decision process includes the appropriate utilities and disutilities of mammography screening and its sequelae. The objectives of this study were to critically review how economic evaluations have valued the health states associated with breast cancer screening, and appraise the primary evidence informing health state utility values (cardinal measures of quality of life). A systematic review was conducted up to September 2018 of studies that elicited or used utilities relevant to mammography screening. The methods used to elicit utilities and the quality of the reported values were tabulated and analysed narratively. 40 economic evaluations of breast cancer screening programmes and 10 primary studies measuring utilities for health states associated with mammography were reviewed in full. The economic evaluations made different assumptions about the measures used, duration applied and the sequalae included in each health state. 22 evaluations referenced utilities based on assumptions or used measures that were not methodologically appropriate. There was significant heterogeneity in the utilities generated by the 10 primary studies, including the methods and population used to derive them. No study asked women to explicitly consider the risk of overdiagnosis when valuing the health states described. Utilities informing breast screening policy are restricted in their ability to reflect the full benefits and harms. Evaluating the true cost-effectiveness of breast cancer screening will remain problematic, unless the methodological challenges associated with valuing the disutilities of screening are adequately addressed.


Assuntos
Neoplasias da Mama/diagnóstico , Programas de Rastreamento/economia , Adulto , Detecção Precoce de Câncer/economia , Detecção Precoce de Câncer/métodos , Feminino , Financiamento da Assistência à Saúde , Humanos , Programas de Rastreamento/métodos , Programas de Rastreamento/tendências , Pessoa de Meia-Idade , Anos de Vida Ajustados por Qualidade de Vida
20.
Addiction ; 114(5): 923-933, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30589984

RESUMO

BACKGROUND AND AIMS: Smoking cessation medications are effective, but often underutilized because of costs and side effects. Cytisine is a plant-based smoking cessation medication with more than 50 years of use in central and eastern Europe. While cytisine has been found to be well-tolerated and more effective than nicotine replacement therapy, direct comparisons with varenicline have not been conducted. This study evaluates the effectiveness, safety and cost-effectiveness of cytisine compared with varenicline. DESIGN: Two-arm, parallel group, randomized, non-inferiority trial, with allocation concealment and blinded outcome assessment. SETTING: Australian population-based study. PARTICIPANTS: Adult daily smokers (n = 1266) interested in quitting will be recruited through advertisements and Quitline telephone-based cessation support services. INTERVENTION AND COMPARATOR: Eligible participants will be randomized (1 : 1 ratio) to receive either cytisine capsules (25-day supply) or varenicline tablets (12-week supply), prescribed in accordance with the manufacturer's recommended dosing regimen. The medication will be mailed to each participant's nominated residential address. All participants will also be offered standard Quitline behavioural support (up to six 10-12-minute sessions). MEASUREMENTS: Assessments will be undertaken by telephone at baseline, 4 and 7 months post-randomization. Participants will also be contacted twice (2 and 4 weeks post-randomization) to ascertain adverse events, treatment adherence and smoking status. The primary outcome will be self-reported 6-month continuous abstinence from smoking, verified by carbon monoxide at 7-month follow-up. We will also evaluate the relative safety and cost-effectiveness of cytisine compared with varenicline. Secondary outcomes will include self-reported continuous and 7-day point prevalence abstinence and cigarette consumption at each follow-up interview. COMMENTS: If cytisine is as effective as varenicline, its lower cost and natural plant-based composition may make it an acceptable and affordable smoking cessation medication that could save millions of lives world-wide.


Assuntos
Alcaloides/economia , Alcaloides/uso terapêutico , Abandono do Hábito de Fumar/economia , Abandono do Hábito de Fumar/métodos , Vareniclina/economia , Vareniclina/uso terapêutico , Adulto , Alcaloides/efeitos adversos , Austrália , Azocinas/efeitos adversos , Azocinas/economia , Azocinas/uso terapêutico , Análise Custo-Benefício , Método Duplo-Cego , Estudos de Equivalência como Asunto , Feminino , Humanos , Masculino , Quinolizinas/efeitos adversos , Quinolizinas/economia , Quinolizinas/uso terapêutico , Resultado do Tratamento , Vareniclina/efeitos adversos
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