Context-Specific Economic Evaluation for Molecular Pathology Tests: An Application in Colorectal Cancer in the West of Scotland.

OBJECTIVES: The cost-effectiveness of molecular pathology testing is highly context dependent. The field is fast-moving, and national health technology assessment may not be relevant or timely for local decision makers. This study illustrates a method of context-specific economic evaluation that can be carried out in a limited timescale without extensive resources. METHODS: We established a multi-disciplinary group including an oncologist, pathologists and a health economist. We set out diagnostic and treatment pathways and costs using registry data, health technology assessments, guidelines, audit data, and estimates from the group. Sensitivity analysis varied input parameters across plausible ranges. The evaluation setting was the West of Scotland and UK NHS perspective was adopted. The evaluation was assessed against the AdHopHTA checklist for hospital-based health technology assessment. RESULTS: A context-specific economic evaluation could be carried out on a timely basis using limited resources. The evaluation met all relevant criteria in the AdHopHTA checklist. Health outcomes were expected to be at least equal to the current strategy. Annual cost savings of £637,000 were estimated resulting primarily from a reduction in the proportion of patients receiving intravenous infusional chemotherapy regimens. The result was not sensitive to any parameter. The data driving the main cost saving came from a small clinical audit. We recommended this finding was confirmed in a larger population. CONCLUSIONS: The method could be used to evaluate testing changes elsewhere. The results of the case study may be transferable to other jurisdictions where the organization of cancer services is fragmented.

The health and cost implications of high body mass index in Australian defence force personnel.

BACKGROUND: Frequent illness and injury among workers with high body mass index (BMI) can raise the costs of employee healthcare and reduce workforce maintenance and productivity. These issues are particularly important in vocational settings such as the military, which require good physical health, regular attendance and teamwork to operate efficiently. The purpose of this study was to compare the incidence of injury and illness, absenteeism, productivity, healthcare usage and administrative outcomes among Australian Defence Force personnel with varying BMI. METHODS: Personnel were grouped into cohorts according to the following ranges for (BMI): normal (18.5 - 24.9 kg/m2; n = 197), overweight (25-29.9 kg/m2; n = 154) and obese (≥30 kg/m2) with restricted body fat (≤28% for females, ≤24% for males) (n = 148) and with no restriction on body fat (n = 180). Medical records for each individual were audited retrospectively to record the incidence of injury and illness, absenteeism, productivity, healthcare usage (i.e., consultation with medical specialists, hospital stays, medical investigations, prescriptions) and administrative outcomes (e.g., discharge from service) over one year. These data were then grouped and compared between the cohorts. RESULTS: The prevalence of injury and illness, cost of medical specialist consultations and cost of medical scans were all higher (p < 0.05) in both obese cohorts compared with the normal cohort. The estimated productivity losses from restricted work days were also higher (p < 0.05) in the obese cohort with no restriction on body fat compared with the normal cohort. Within the obese cohort, the prevalence of injury and illness, healthcare usage and productivity were not significantly greater in the obese cohort with no restriction on body fat compared with the cohort with restricted body fat. The number of restricted work days, the rate of re-classification of Medical Employment Classification and the rate of discharge from service were similar between all four cohorts. CONCLUSIONS: High BMI in the military increases healthcare usage, but does not disrupt workforce maintenance. The greater prevalence of injury and illness, greater healthcare usage and lower productivity in obese Australian Defence Force personnel is not related to higher levels of body fat.

Mortality risk factors during the 1918-1919 influenza pandemic in the Australian army.

BACKGROUND: Understanding the risk of mortality during the 1918-1919 influenza pandemic could inform preparations for a future pandemic. METHODS: Prospectively collected demographic, hospitalization, and death data from all individuals who served in the Australian Imperial Force from 1914 through 1919 in Europe and the Middle East were abstracted from archived records. Analyses were conducted to determine mortality risk factors. RESULTS: Hospitalization with a respiratory illness during the spring-summer of 1918 protected soldiers from death (odds ratio, 0.37 [95% confidence interval, 0.25-0.53]; P < .001) but not from hospitalization during the fall-winter of 1918-1919. During the fall-winter of 1918-1919, there was a strong inverse relationship between risk of dying of pneumonia-influenza and time in military service. The pneumonia-influenza death rate among men who enlisted in 1918 (6.33 deaths per 100 person-years) was 9 times higher than that among the 1917 enlistment cohort (0.72 deaths per 100 person-years) and >14 times higher than that among the 1916 cohort (0.43 deaths per 100 person-years), 1915 cohort (0.29 deaths per 100 person-years), and 1914 cohort (0.28 deaths per 100 person-years). CONCLUSION: There was a strong inverse relationship between length of service in the Australian Imperial Force and mortality risk from pneumonia-influenza during the fall-winter of 1918-1919. The protective effect of increased service likely reflected increased acquired immunity to influenza viruses and endemic bacterial strains that caused secondary pneumonia and most of the deaths during the 1918-1919 influenza pandemic.

Australian military primary care practitioners do not believe clinical practice guidelines are needed for postdeployment medically unexplained symptoms.

In Australia, little research has been undertaken on the development of clinical practice guidelines (CPGs) to assist with the impact of postdeployment ill-health including medically unexplained symptoms (MUS) and it has been unclear whether such a development is desired by Australian primary care practitioners. In response an empirical investigation into the perceptions and experiences of 24 medical officers from the Australian military with regard to postdeployment ill-health, medically unexplained symptoms, and the potential development of CPGs in this area was undertaken. The analysis suggests that although MUS are accepted as common in general practice they are not perceived by practitioners to be as prevalent in the Australian Defense Forces. Although the medical officers do not perceive clinical practice guidelines as the best tool for managing MUS, there was interest in the development of practical tools to assist in the diagnosis of medically unexplained symptoms. The response by practitioners is of critical importance for the potential implementation of clinical practice guidelines in this area.

An evaluation of the effect of military service on mortality: quantifying the healthy soldier effect.

PURPOSE: The healthy soldier effect denotes the proposition that military populations are likely to be healthier than other populations. A systematic review was conducted which aimed to quantify the magnitude of the healthy soldier effect. METHODS: Studies containing mortality rates of military personnel were identified from multiple electronic databases. Studies were included in the meta-analyses if they reported all-cause, cancer, or external-cause mortality in a military population and compared the rates to the general population. Fifty-nine studies were initially identified and 12 were included in the meta-analyses. RESULTS: The overall meta-standardized mortality ratios (SMRs) for all-cause mortality for deployed veterans was 0.76 (95% confidence interval [CI]: 0.65-0.89) and 0.73 (95% CI: 0.56-1.97) for non-deployed veterans based on a mean follow-up of 7.0 and 2.4 years, respectively; for cancer mortality, the SMRs were 0.78 (95% CI: 0.63-0.98) for deployed veterans and 0.75 (95% CI: 0.50-1.14) for non-deployed veterans based on 6.7 and 3.1 years follow-up, respectively; for external-cause mortality, the SMRs were 0.90 (95% CI: 0.72-1.13) for deployed veterans and 0.80 (95% CI: 0.63-1.01) for non-deployed veterans based on 4.8 and 2.0 years follow-up, respectively. CONCLUSION: Military personnel do display a healthy soldier effect that decreases their risk of mortality compared to the general population. The overall healthy soldier effect estimated ranges from 10% to 25%, depending on the cause of death studied and the period of follow-up.

The B'Active programme for overweight primary school children in Glasgow: determining the prevalence of overweight and obesity and piloting an activity intervention.

The aim of this study was to determine the prevalence of overweight and obesity in primary school children in Glasgow and to evaluate a pilot activity programme for overweight and obese children. BMI was measured in 1548 children. Overweight, obesity and severe obesity were defined as BMI > or =85th, 95th and 98th centile, respectively. Overweight and obese children were then invited to participate in a 10-week school-based activity programme. The programme was evaluated by recording weekly attendance, intensity (using the Children's Effort Rating Scale) and enjoyment (scale 1-10). Focus groups were used to explore the experiences and views of the children, teachers, coaches and parents. Of the 1548 children, 31.4% were overweight, 19.1% were obese and 12.4% were severely obese; 38% of those invited attended the activity programme. Weekly programme attendance was 83% (range 56-99%). Mean enjoyment rating (scale 1-10) was 8 for boys and 9 for girls. The intensity of activity sessions were rated 'very easy' by boys and 'just feeling a strain' by girls. Common themes emerging from the focus groups related to perceived positive and negative aspects of the programme (fun, concerns about stigmatising children); physical and psychological outcomes (fitter, more confident); and future recommendations (involve parents). In summary, the prevalence of overweight and obesity was high. The activity programme was successful in terms of attendance and enjoyment, and overall views of the initiative were positive and there was compelling support for its continuation.