The effect of gun buy-back law reform on homicides and suicides in Australia.

In this paper we use the synthetic control method (SCM) to estimate the causal effects of a national legislative reform accompanied by mandatory gun buy-backs in Australia on both suicide and homicide rates. Using a rich international dataset, we are able to separate not only these two death types, but also to distinguish deaths by firearm and by other means, thereby enabling us to test substitution-of-means hypotheses. Specifically, we apply the SCM to determine whether any reductions in firearm-related death rates where wholly or partly offset by increases in the use of other means (e.g., bladed weapons, poisons) to commit suicides and perpetrate homicides. Our findings show that these gun control policies substantially reduced both homicides and suicides by firearm, but also some evidence of other-means substitution.

Accuracy of self-reported private health insurance coverage.

Studies on health insurance coverage often rely on measures self-reported by respondents, but the accuracy of such measures has not been thoroughly validated. This paper is the first to use linked Australian National Health Survey and administrative population tax data to explore the accuracy of self-reported private health insurance (PHI) coverage in survey data. We find that 11.86% of individuals misreport their PHI coverage status, with 11.57% of true PHI holders reporting that they are uninsured and 12.37% of true non-insured persons self-identifying as insured. Our results show reporting errors are systematically correlated with individual and household characteristics. Our evidence on the determinants of errors is supportive of common reasons for misreporting. We directly investigate biases in the determinants of PHI enrollment using survey data. We find that, as compared to administrative data, survey data depict a quantitatively different picture of PHI enrollment determinants, especially those capturing age, gender, language proficiency, labor force status, disability status, number of children in the household, or household income. We also show that PHI coverage misreporting is subsequently associated with misreporting of reasons for purchasing PHI, type of cover and length of cover.

Interventions for improving clinical outcomes and health-related quality-of-life for people living with skeletal dysplasias: an evidence gap map.

PURPOSE: Skeletal dysplasias are rare genetic disorders that are characterized by abnormal development of bone and cartilage. There are multiple medical and non-medical treatments for specific symptoms of skeletal dysplasias e.g. pain, as well as corrective surgical procedures to improve physical functioning. The aim of this paper was to develop an evidence-gap map of treatment options for skeletal dysplasias, and their impact on patient outcomes. METHODS: We conducted an evidence-gap map to identify the available evidence on the impact of treatment options on people with skeletal dysplasias on clinical outcomes (such as increase in height), and dimensions of health-related quality of life. A structured search strategy was applied to five databases. Two reviewers independently assessed articles for inclusion in two stages: titles and abstracts (stage 1), and full text of studies retained at stage 2. RESULTS: 58 studies fulfilled our inclusion criteria. The included studies covered 12 types of skeletal dysplasia that are non-lethal with severe limb deformities that could result in significant pain and numerous orthopaedic interventions. Most studies reported on the effect of surgical interventions (n = 40, 69%), followed by the effect of treatments on dimensions of health quality-of-life (n = 4, 6.8%) and psychosocial functioning (n = 8, 13.8%). CONCLUSION: Most studies reported on clinical outcomes from surgery for people living with Achondroplasia. Consequently, there are gaps in the literature on the full range of treatment options (including no active treatment), outcomes and the lived experience of people living with other skeletal dysplasias. More research is warranted to examine the impact of treatments on health-related quality-of-life of people living with skeletal dysplasias, including their relatives to enable them to make preference- and valued based decisions about treatment.

Post-traumatic stress disorder is associated with a higher rate of polypectomy independent of an increased frequency of colonoscopy in Australian veterans: a retrospective review.

BACKGROUND: Post-traumatic stress disorder (PTSD) is associated with extensive physical comorbidities, including lower gastrointestinal symptoms. Diagnostic uncertainty and poor therapeutic responses may result in more frequent colonoscopies than clinically necessary. Polypectomy is standard practice when polyps are identified, and if PTSD is a risk factor for polyp formation, one would expect a higher rate of polyp detection and removal in veterans with PTSD than those without PTSD. AIM: To determine the association between PTSD and the rate of colonoscopy and polypectomy in Australian veterans. METHODS: Diagnostic and therapeutic colonoscopy rates in Australian male Veterans aged ≥50 years were examined by reviewing case records of veterans who accessed Department of Veterans' Affairs funded health services between 1 January 2013 and 31 December 2018. RESULTS: A total of 138 471 veterans was included, of whom 28 018 had a diagnosis of PTSD; 56.4% were aged ≥65 years. Twenty-one percent of the entire cohort underwent at least one colonoscopy during the study period. Increased rates of diagnostic colonoscopy and polypectomy were associated with the presence of PTSD across all age brackets. The effect was empirically large as veterans with PTSD experience colonoscopy rates 76-81% greater than those without PTSD. Similarly, veterans with PTSD experienced polypectomy rates 76-81% greater than veterans without PTSD, and this increase persisted when controlling for the increased number of diagnostic colonoscopies they undergo. CONCLUSION: The presence of PTSD has a marked impact on colonoscopy rates in Australian veterans. The increased polypectomy rate independent of increased colonoscopy rate suggests that PTSD is a risk factor for colonic polyp formation.

The impact of posttraumatic stress disorder on upper gastrointestinal investigations in Australian Defence Force veterans: a retrospective review.

Veterans with posttraumatic stress disorder (PTSD) commonly exhibit associated gastrointestinal (GI) symptoms. We compared upper GI endoscopy and abdominal ultrasound rates in veterans with and without PTSD. Veterans with PTSD were 77-81% more likely to undergo these procedures than those without PTSD. PTSD symptomatology influences GI investigation rate and more emphasis on clinician and patient education is recommended regarding stress-related gut symptoms.

Reducing Medical Admissions and Presentations Into Hospital through Optimising Medicines (REMAIN HOME): a stepped wedge, cluster randomised controlled trial.

OBJECTIVE: To investigate whether integrating pharmacists into general practices reduces the number of unplanned re-admissions of patients recently discharged from hospital. DESIGN, SETTING: Stepped wedge, cluster randomised trial in 14 general practices in southeast Queensland. PARTICIPANTS: Adults discharged from one of seven study hospitals during the seven days preceding recruitment (22 May 2017 - 14 March 2018) and prescribed five or more long term medicines, or having a primary discharge diagnosis of congestive heart failure or exacerbation of chronic obstructive pulmonary disease. INTERVENTION: Comprehensive face-to-face medicine management consultation with an integrated practice pharmacist within seven days of discharge, followed by a consultation with their general practitioner and further pharmacist consultations as needed. MAJOR OUTCOMES: Rates of unplanned, all-cause hospital re-admissions and emergency department (ED) presentations 12 months after hospital discharge; incremental net difference in overall costs. RESULTS: By 12 months, there had been 282 re-admissions among 177 control patients (incidence rate [IR], 1.65 per person-year) and 136 among 129 intervention patients (IR, 1.09 per person-year; fully adjusted IR ratio [IRR], 0.79; 95% CI, 0.52-1.18). ED presentation incidence (fully adjusted IRR, 0.46; 95% CI, 0.22-0.94) and combined re-admission and ED presentation incidence (fully adjusted IRR, 0.69; 95% CI, 0.48-0.99) were significantly lower for intervention patients. The estimated incremental net cost benefit of the intervention was $5072 per patient, with a benefit-cost ratio of 31:1. CONCLUSION: A collaborative pharmacist-GP model of post-hospital discharge medicines management can reduce the incidence of hospital re-admissions and ED presentations, achieving substantial cost savings to the health system. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12616001627448 (prospective).

Weather and children's time allocation.

This paper presents the first causal estimates of the effect of weather on children's time allocation. It exploits exogenous variations in local weather observed during the random diary dates of two nationally representative cohorts of Australian children whose time-use diaries were surveyed biennially over 10 years. Unfavorable weather conditions, as represented by cold or hot temperature or rain, cause children to switch activities from outdoors to indoors, mainly by reducing the time allocated to active pursuits and travel and increasing the time allocated to media. Furthermore, the effects of bad weather are more pronounced on weekends and for children with asthma. Our results also provide some evidence of adaptation, as temperature tends to have greater impact not only in winter months but also in colder regions. Our findings are robust to a wide range of sensitivity checks, including controlling for individual fixed effects and using alternative model specifications. Overall, the results suggest that extreme weather conditions may diminish children's health, development and long-term achievements through their effects on children's time allocation.

Who's declining the "free lunch"? New evidence from the uptake of public child dental benefits.

This study provides the first evidence on the determinants of uptake of two recent public dental benefit programs for Australian children and adolescents from disadvantaged families. Using longitudinal data from a nationally representative survey linked to administrative data with accurate information on eligibility and uptake, we find that only a third of all eligible families actually claim their benefits. We provide new and robust evidence consistent with the idea advanced by recent economic literature that cognitive biases and behavioral factors are barriers to uptake. For instance, mothers with worse mental health or riskier lifestyles are much less likely to claim the available benefits for their children. These barriers to uptake are particularly large in magnitude: together, they reduce the uptake rate by up to 10 percentage points (or 36%). We also find some indicative evidence that a lack of information is a barrier to uptake.

Cost of screening for lung cancer in Australia.

BACKGROUND: Lung cancer screening can reduce lung cancer mortality. Australian cost estimates are important to inform policy but remain uncertain. AIM: To describe the first direct medical costs associated with lung cancer screening in Australia. METHODS: Single-centre prospective screening cohort. Healthy volunteers (age 60-74 years, current or former smokers quit <15 years prior to enrolment, ≥30 pack-years exposure) underwent baseline and two annual incidence computed tomography (CT) screening scans. Health status and healthcare usage data were collated for 5 years. The main outcome measures were: rates of lung cancer; individual healthcare resource use derived from multiple data sources adjusted to 2018 Australian Medicare Benefits Schedule values. RESULTS: A total of 256, 239, 233 participants was screened at each round respectively; 12 participants were diagnosed with lung cancer during screening and 2 during follow-up: 9 underwent surgery, 4 received concurrent chemoradiation, 1 received palliative chemotherapy. One surgical case died from lymphoma 1407 days after diagnosis, all other surgical cases survived >5 years. Non-surgical median survival post-diagnosis was 654 days. Gross trial cost was Australian dollar (AU$) 965 665 (AU$397 396 CT scans; AU$29 303 false-positive scan work-up; AU$96 340 true-positive scan workup; AU$336 914 lung cancer treatment; AU$104 712 lung cancer follow-up post-treatment). Average total direct medical cost per participant was AU$3 768. Average direct cost of surgery was AU$22 659; average non-surgical cost was AU$47 395 (radiotherapy, chemotherapy, palliative care). CONCLUSIONS: Advanced cancer cost more to treat and had worse survival than early cancer. Screening costs are similar to international studies and suggest that lung cancer early detection could limit treatment costs and improve outcomes.

Cost-effectiveness analysis of germ-line BRCA testing in women with breast cancer and cascade testing in family members of mutation carriers.

PURPOSE: To evaluate the cost-effectiveness of BRCA testing in women with breast cancer, and cascade testing in family members of BRCA mutation carriers. METHODS: A cost-effectiveness analysis was conducted using a cohort Markov model from a health-payer perspective. The model estimated the long-term benefits and costs of testing women with breast cancer who had at least a 10% pretest BRCA mutation probability, and the cascade testing of first- and second-degree relatives of women who test positive. RESULTS: Compared with no testing, BRCA testing of affected women resulted in an incremental cost per quality-adjusted life-year (QALY) gained of AU$18,900 (incremental cost AU$1,880; incremental QALY gain 0.10) with reductions of 0.04 breast and 0.01 ovarian cancer events. Testing affected women and cascade testing of family members resulted in an incremental cost per QALY gained of AU$9,500 compared with testing affected women only (incremental cost AU$665; incremental QALY gain 0.07) with additional reductions of 0.06 breast and 0.01 ovarian cancer events. CONCLUSION: BRCA testing in women with breast cancer is cost-effective and is associated with reduced risk of cancer and improved survival. Extending testing to cover family members of affected women who test positive improves cost-effectiveness beyond restricting testing to affected women only.

Out of sight but not out of mind: Home countries' macroeconomic volatilities and immigrants' mental health.

We provide the first empirical evidence that better economic performances by immigrants' countries of origin, as measured by lower consumer price index (CPI) or higher gross domestic product, improve immigrants' mental health. We use an econometrically-robust approach that exploits exogenous changes in macroeconomic conditions across immigrants' home countries over time and controls for immigrants' observable and unobservable characteristics. The CPI effect is statistically significant and sizeable. Furthermore, the CPI effect diminishes as the time since emigrating increases. By contrast, home countries' unemployment rates and exchange rate fluctuations have no impact on immigrants' mental health.

Economic evaluation of fecal microbiota transplantation for the treatment of recurrent Clostridium difficile infection in Australia.

BACKGROUND AND AIM: Clostridium difficile is the most common cause of hospital-acquired diarrhea in Australia. In 2013, a randomized controlled trial demonstrated the effectiveness of fecal microbiota transplantation (FMT) for the treatment of recurrent Clostridium difficile infection (CDI). The aim of this study is to evaluate the cost-effectiveness of fecal microbiota transplantation-via either nasoduodenal or colorectal delivery-compared with vancomycin for the treatment of recurrent CDI in Australia. METHODS: A Markov model was developed to compare the cost-effectiveness of fecal microbiota transplantation compared with standard antibiotic therapy. A literature review of clinical evidence informed the structure of the model and the choice of parameter values. Clinical effectiveness was measured in terms of quality-adjusted life years. Uncertainty in the model was explored using probabilistic sensitivity analysis. RESULTS: Both nasoduodenal and colorectal FMT resulted in improved quality of life and reduced cost compared with vancomycin. The incremental effectiveness of either FMT delivery compared with vancomycin was 1.2 (95% CI: 0.1, 2.3) quality-adjusted life years, or 1.4 (95% CI: 0.4, 2.4) life years saved. Treatment with vancomycin resulted in an increased cost of AU$4094 (95% CI: AU$26, AU$8161) compared with nasoduodenal delivery of FMT and AU$4045 (95% CI: -AU$33, AU$8124) compared with colorectal delivery. The mean difference in cost between colorectal and nasoduodenal FMT was not significant. CONCLUSIONS: If FMT, rather than vancomycin, became standard care for recurrent CDI in Australia, the estimated national healthcare savings would be over AU$4000 per treated person, with a substantial increase in quality of life.

Economic evaluation favours physiotherapy but not corticosteroid injection as a first-line intervention for chronic lateral epicondylalgia: evidence from a randomised clinical trial.

AIM: To determine the cost-effectiveness of corticosteroid injection, physiotherapy and a combination of these interventions, compared to a reference group receiving a blinded placebo injection. METHODS: 165 adults with unilateral lateral epicondylalgia of longer than 6 weeks duration from Brisbane, Australia, were randomised for concealed allocation to saline injection (placebo), corticosteroid injection, saline injection plus physiotherapy (eight sessions of elbow manipulation and exercise) or corticosteroid injection plus physiotherapy. Costs to society and health-related quality of life (estimated by EuroQol-5D) over the 1 year follow-up were used to generate incremental cost per quality-adjusted life year (QALY) ratios for each intervention relative to placebo. RESULTS: Intention-to-treat analysis was possible for 154 (93%) of trial participants. Physiotherapy was more costly, but was the only intervention that produced a statistically significant improvement in quality of life relative to placebo (MD, 95% CI 0.035, 0.003 to 0.068). Similar cost/QALY ratios were found for physiotherapy ($A29 343; GBP18 962) and corticosteroid injection ($A31 750; GBP20 518); however, the probability of being more cost-effective than placebo at values above $A50 000 per quality-adjusted life year was 81% for physiotherapy and 53% for corticosteroid injection. Cost/QALY was far greater for a combination of corticosteroid injection and physiotherapy ($A228 000; GBP147 340). SUMMARY: Physiotherapy was a cost-effective treatment for lateral epicondylalgia. Corticosteroid injection was associated with greater variability, and a lower probability of being cost-effective if a willingness to pay threshold of $A50 000 is assumed. A combination of corticosteroid injection and physiotherapy was ineffective and cost-ineffective. Physiotherapy, not corticosteroid injection, should be considered as a first-line intervention for lateral epicondylalgia. TRIAL REGISTRATION NUMBER: anzctr.org Trial identifier: ACTRN12609000051246.

Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial.

BACKGROUND: Evidence suggests that brief physiotherapy programmes are as effective for acute whiplash-associated disorders as more comprehensive programmes; however, whether this also holds true for chronic whiplash-associated disorders is unknown. We aimed to estimate the effectiveness of a comprehensive exercise programme delivered by physiotherapists compared with advice in people with a chronic whiplash-associated disorder. METHODS: PROMISE is a two group, pragmatic randomised controlled trial in patients with chronic (>3 months and <5 years) grade 1 or 2 whiplash-associated disorder. Participants were randomly assigned by a computer-generated randomisation schedule to receive either the comprehensive exercise programme (20 sessions) or advice (one session and telephone support). Sealed opaque envelopes were used to conceal allocation. The primary outcome was pain intensity measured on a 0-10 scale. Outcomes were measured at baseline, 14 weeks, 6 months, and 12 months by a masked assessor. Analysis was by intention to treat, and treatment effects were calculated with linear mixed models. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12609000825257. FINDINGS: 172 participants were allocated to either the comprehensive exercise programme (n=86) or advice group (n=86); 157 (91%) were followed up at 14 weeks, 145 (84%) at 6 months, and 150 (87%) at 12 months. A comprehensive exercise programme was not more effective than advice alone for pain reduction in the participants. At 14 weeks the treatment effect on a 0-10 pain scale was 0·0 (95% CI -0·7 to 0·7), at 6 months 0·2 (-0·5 to 1·0), and at 12 months -0·1 (-0·8 to 0·6). CNS hyperexcitability and symptoms of post-traumatic stress did not modify the effect of treatment. We recorded no serious adverse events. INTERPRETATION: We have shown that simple advice is equally as effective as a more intense and comprehensive physiotherapy exercise programme. The need to identify effective and affordable strategies to prevent and treat acute through to chronic whiplash associated disorders is an important health priority. Future avenues of research might include improving understanding of the mechanisms responsible for persistent pain and disability, investigating the effectiveness and timing of drugs, and study of content and delivery of education and advice. FUNDING: The National Health and Medical Research Council of Australia, Motor Accidents Authority of New South Wales, and Motor Accident Insurance Commission of Queensland.

What roles do contemporaneous and cumulative incomes play in the income-child health gradient for young children? Evidence from an Australian panel.

The literature to date shows that children from poorer households tend to have worse health than their peers, and the gap between them grows with age. We investigate whether and how health shocks (as measured by the onset of chronic conditions) contribute to the income-child health gradient and whether the contemporaneous or cumulative effects of income play important mitigating roles. We exploit a rich panel dataset with three panel waves called the Longitudinal Study of Australian children. Given the availability of three waves of data, we are able to apply a range of econometric techniques (e.g. fixed and random effects) to control for unobserved heterogeneity. The paper makes several contributions to the extant literature. First, it shows that an apparent income gradient becomes relatively attenuated in our dataset when the cumulative and contemporaneous effects of household income are distinguished econometrically. Second, it demonstrates that the income-child health gradient becomes statistically insignificant when controlling for parental health and health-related behaviours or unobserved heterogeneity.

Determinants of foodservice satisfaction for patients in geriatrics/rehabilitation and residents in residential aged care.

BACKGROUND: Poor satisfaction with institutional food is a significant moderator of food intake in geriatrics/rehabilitation and residential aged care. PURPOSE: To quantify the relationship between foodservice satisfaction, foodservice characteristics, demographic and contextual variables in geriatrics/rehabilitation and residential aged care. METHODS: The Resident Foodservice Satisfaction Questionnaire was administered to 103 patients of 2 geriatrics/rehabilitation units and 210 residents of nine residential aged care facilities in Brisbane, Australia. Ordered probit regression analysis measured the association of age, gender, ethnicity and appetite, timing and amount of meal choice, menu selectivity, menu cycle, production system, meal delivery system and therapeutic diets with foodservice satisfaction. RESULTS: Patient and resident appetite (P < 0.01), the amount and timing of meal choice (P < 0.01), self-rated health (P < 0.01), accommodation style (P < 0.05) and age (P < 0.10) significantly moderated foodservice satisfaction. High protein/high energy therapeutic diets (P < 0.01), foodservice production (P < 0.01) and delivery systems (P > 0.01) were significant moderators for those with 'fair' self-rated health. CONCLUSIONS: Patient and resident characteristics and structural and systems-related foodservice variables were more important for influencing foodservice satisfaction than characteristics of food quality. The results suggest modifications to current menu planning and foodservice delivery methods: reducing the time-lapse between meal choice and consumption, augmenting the number of meals at which choice is offered, and revising food production and delivery systems.It is important that residents in poorer health who are a high risk of under-nutrition are provided with sufficient high protein/high energy therapeutic diets. Diets that restrict macro- and micro-nutrients should be minimized for all patients and residents.

The impact of weather on time allocation to physical activity and sleep of child-parent dyads.

PURPOSE: Previous studies showed that unfavourable weather conditions discourage physical activity. However, it remains unclear whether unfavourable weather conditions have a differential impact on physical activity in children compared with adults. We aim to explore the differential impact of weather on time allocation to physical activity and sleep by children and their parents. METHOD: We use nationally representative data with time use indicators objectively measured on multiple occasions for >1100 Australian pairs of 12-13-year-old children and their middle-aged parents, coupled with daily meteorological data. We employ an individual fixed effects regression model to estimate the causal impact of weather. RESULTS: We find that unfavourable weather conditions, as measured by cold or hot temperatures or rain, cause children to reduce moderate- and vigorous-intensity physical activity time and increase sedentary time. However, such weather conditions have little impact on children's sleep time or the time allocation of their parents. We also find substantial differential weather impact, especially on children's time allocation, by weekdays/weekends and parental employment status, suggesting that these factors may contribute to explaining the differential weather impact that we observed. Our results additionally provide evidence of adaptation, as temperature appears to have a more pronounced impact on time allocation in colder months and colder regions. CONCLUSION: Our finding of a negative impact of unfavourable weather conditions on the time allocated to physical activity by children indicates a need to design policies to encourage them to be more physically active on days with unfavourable weather conditions and hence improve child health and wellbeing. Evidence of a more pronounced and negative impact on the time allocated to physical activity by children than their parents suggests that extreme weather conditions, including those associated with climate change, could make children vulnerable to reduced physical activity.

Recommendations for a core outcome measurement set for clinical trials in whiplash associated disorders.

ABSTRACT: Inconsistent reporting of outcomes in clinical trials of treatments for whiplash associated disorders (WAD) hinders effective data pooling and conclusions about treatment effectiveness. A multidisciplinary International Steering Committee recently recommended 6 core outcome domains: Physical Functioning, Perceived Recovery, Work and Social Functioning, Psychological Functioning, Quality of Life and Pain. This study aimed to reach consensus and recommend a core outcome set (COS) representing each of the 6 domains. Forty-three patient-reported outcome measures (PROMs) were identified for Physical Functioning, 2 for perceived recovery, 37 for psychological functioning, 17 for quality of life, and 2 for pain intensity. They were appraised in 5 systematic reviews following COSMIN methodology. No PROMs of Work and Social Functioning in WAD were identified. No PROMs had undergone evaluation of content validity in patients with WAD, but some had moderate-to-high-quality evidence for sufficient internal structure. Based on these results, the International Steering Committee reached 100% consensus to recommend the following COS: Neck Disability Index or Whiplash Disability Questionnaire (Physical Functioning), the Global Rating of Change Scale (Perceived Recovery), one of the Pictorial Fear of Activity Scale-Cervical, Pain Self-Efficacy Questionnaire, Pain Catastrophizing Scale, Harvard Trauma Questionnaire, or Posttraumatic Diagnostic Scale (Psychological Functioning), EQ-5D-3L or SF-6D (Quality of Life), numeric pain rating scale or visual analogue scale (Pain), and single-item questions pertaining to current work status and percent of usual work (Work and Social Functioning). These recommendations reflect the current status of research of PROMs of the 6 core outcome domains and may be modified as evidence grows.

Implementation of a risk-stratified, guideline-based clinical pathway of care to improve health outcomes following whiplash injury (Whiplash ImPaCT): a multicentre, randomized, controlled trial.

ABSTRACT: Current pathways of care for whiplash follow a "stepped care model," result in modest treatment outcomes and fail to offer efficient management solutions. This study aimed to evaluate the effectiveness of a risk-stratified clinical pathway of care (CPC) compared with usual care (UC) in people with acute whiplash. We conducted a multicentre, 2-arm, parallel, randomised, controlled trial in primary care in Australia. Participants with acute whiplash (n = 216) were stratified for risk of a poor outcome (low vs medium/high risk) and randomised using concealed allocation to either the CPC or UC. In the CPC group, low-risk participants received guideline-based advice and exercise supported by an online resource, and medium-risk/high-risk participants were referred to a whiplash specialist who assessed modifiable risk factors and then determined further care. The UC group received care from their primary healthcare provider who had no knowledge of risk status. Primary outcomes were neck disability index (NDI) and Global Rating of Change (GRC) at 3 months. Analysis blinded to group used intention-to-treat and linear mixed models. There was no difference between the groups for the NDI (mean difference [MD] [95% confidence interval (CI)] -2.34 [-7.44 to 2.76]) or GRC (MD 95% CI 0.08 [-0.55 to 0.70]) at 3 months. Baseline risk category did not modify the effect of treatment. No adverse events were reported. Risk-stratified care for acute whiplash did not improve patient outcomes, and implementation of this CPC in its current form is not recommended.

Cost minimization analysis of laparoscopic sacral colpopexy and total vaginal mesh.

OBJECTIVE: The objective of the study was a cost minimization analysis of the laparoscopic sacral colpopexy (LSC) and total vaginal mesh (TVM). STUDY DESIGN: Primary clinical costs were derived from our randomized control trial comparing LSC and TVM and were compared using prices from privately- and publicly-conducted procedures. Womens' opportunity cost of time were added to these estimates to produce estimates of the primary economic costs of the procedures. Reoperation costs were added to estimate the economic cost per subject. RESULTS: LSC has lower mean primary clinical cost as compared with the TVM in both the public (mean difference, $1102.96; 95% confidence interval [CI], 468.52-1737.385) and private models (mean difference, $1176.68; 95% CI, 1116.85-1236.51), respectively. Mean total economic costs were significantly lower in the LSC group as compared with the TVM ($4013.07; 95% CI, 3107.77-4918.37). Labor costs were significantly greater in the LSC but were offset by lower consumable, inpatient, opportunity, and reoperation costs as compared with the TVM. CONCLUSION: The LSC has lower economic cost than TVM.