Leonie Segal

Comparing the incomparable? A systematic review of competing techniques for converting descriptive measures of health status into QALY-weights

Background . Algorithms for converting descriptive measures of health status into quality-adjusted life year (QALY)—weights are now widely available, and their application in economic evaluation is increasingly commonplace. The objective of this study is to describe and compare existing conversion algorithms and to highlight issues bearing on the derivation and interpretation of the QALY-weights so obtained. Methods . Systematic review of algorithms for converting descriptive measures of health status into QALY-weights. Results . The review identified a substantial body of literature comprising 46 derivation studies and 16 studies that provided evidence or commentary on the validity of conversion algorithms. Conversion algorithms were derived using 1 of 4 techniques: 1) transfer to utility regression, 2) response mapping, 3) effect size translation, and 4) “revaluing” outcome measures using preference-based scaling techniques. Although these techniques differ in their methodological/theoretical tradition, data requirements, and ease of derivation and application, the available evidence suggests that the sensitivity and validity of derived QALY-weights may be more dependent on the coverage and sensitivity of measures and the disease area/patient group under evaluation than on the technique used in derivation. Conclusions . Despite the recent proliferation of conversion algorithms, a number of questions bearing on the derivation and interpretation of derived QALY-weights remain unresolved. These unresolved issues suggest directions for future research in this area. In the meantime, analysts seeking guidance in selecting derived QALY-weights should consider the validity and feasibility of each conversion algorithm in the disease area and patient group under evaluation rather than restricting their choice to weights from a particular derivation technique.

The importance of patient empowerment in health system reform.

Health system reform is on the agenda in Australia, across Europe and North America and elsewhere. Reform is being driven by attempts to meet ever increasing health service demands in the face of cost containment pressures. There is little agreement concerning the preferred features of health funding models. A micro-economic framework is used to define universal performance characteristics for optimal health funding arrangements. Two principle requirements emerge. These are (1) demand side reform to empower consumers and (2) supply side reform, to promote opportunities and incentives for a responsive service system and competition amongst providers. A focus on supply side issues only, without recognition of the fundamental importance of consumer empowerment will fail to promote an efficient solution to the distribution of health resources. Mechanisms to promote active consumer involvement in health care decisions are identified as a central requirement in health system reform.

The cost of obesity: the Australian perspective.

SummaryObesity is a known risk factor for a number of diseases with serious mortality and morbidity implications. Thus, obesity is an economic burden to communities, since it reduces quality of life and leads to premature mortality; in addition, healthcare resources are used to manage obesity-related disease. It was estimated that in 1989, management of disease due to obesity (defined as body mass index > 30) cost A

Parsimonious and efficient assessment of health-related quality of life in osteoarthritis research: validation of the Assessment of Quality of Life (AQoL) instrument

395 million. This estimate covers the healthcare costs for the management of obesity, non-insulin-dependent diabetes mellitus (NIDDM), gallstones, hypertension, coronary heart disease (CHD), breast cancer (among postmenopausal women), and colon cancer. As this estimate excludes the costs of some disease attributable to obesity, it is an underestimate of the true costs. Nonetheless, the estimated cost of the management of obesity-related conditions represents 86% of the healthcare costs used for the management of alcohol-related diseases in Australia. Healthcare costs attributable to obesity have not yet been estimated for countries elsewhere in Asia and the Pacific. However, it is acknowledged that obesity is a major problem in the Pacific, with exceptionally high prevalence rates and concomitant high rates of diseases for which obesity is a major risk factor, particularly NIDDM and CHD. It would, therefore, be useful to explore the cost of disease attributable to obesity in healthcare systems in these communities, and the potential for preventive programmes to reduce these costs.

Effectiveness of general practice based, practice nurse led telephone coaching on glycaemic control of type 2 diabetes: the Patient Engagement And Coaching for Health (PEACH) pragmatic cluster randomised controlled trial

BackgroundThe Assessment of Quality of Life (AQoL) utility instrument was psychometrically developed for the general population. This study aimed to explore its potential as an osteoarthritis (OA) outcome measure.MethodsWOMAC, Lequesne index, SF-36, Visual analogue scales and the AQoL were administered to 222 people with OA. The ability of each questionnaire to detect differences between groups was based on (i) self-rated health (SRH) and, (ii) differences between people on an orthopedic waiting list (WL) vs people with OA in the community (C). Comparisons included effect size, relative efficiency and receiver operator characteristic curves.ResultsAll instruments detected differences between groups; however no one instrument exhibited superior efficiency. The AQoL demonstrated strong psychometric properties.ConclusionThe AQoL has equivalent performance to comparator questionnaires commonly used in OA research and would be a useful adjunct to well-established disease specific scales. The AQoL has important advantages; brevity (12 items), facilitates comparisons between disease groups, and delivers a utility score that can be used in health economic evaluations.

Cost utility analysis of physical activity counselling in general practice

Objective To evaluate the effectiveness of goal focused telephone coaching by practice nurses in improving glycaemic control in patients with type 2 diabetes in Australia. Design Prospective, cluster randomised controlled trial, with general practices as the unit of randomisation. Setting General practices in Victoria, Australia. Participants 59 of 69 general practices that agreed to participate recruited sufficient patients and were randomised. Of 829 patients with type 2 diabetes (glycated haemoglobin (HbA1c) >7.5% in the past 12 months) who were assessed for eligibility, 473 (236 from 30 intervention practices and 237 from 29 control practices) agreed to participate. Intervention Practice nurses from intervention practices received two days of training in a telephone coaching programme, which aimed to deliver eight telephone and one face to face coaching episodes per patient. Main outcome measures The primary end point was mean absolute change in HbA1c between baseline and 18 months in the intervention group compared with the control group. Results The intervention and control patients were similar at baseline. None of the practices dropped out over the study period; however, patient attrition rates were 5% in each group (11/236 and 11/237 in the intervention and control group, respectively). The median number of coaching sessions received by the 236 intervention patients was 3 (interquartile range 1-5), of which 25% (58/236) did not receive any coaching sessions. At 18 months’ follow-up the effect on glycaemic control did not differ significantly (mean difference 0.02, 95% confidence interval −0.20 to 0.24, P=0.84) between the intervention and control groups, adjusted for HbA1c measured at baseline and the clustering. Other biochemical and clinical outcomes were similar in both groups. Conclusions A practice nurse led telephone coaching intervention implemented in the real world primary care setting produced comparable outcomes to usual primary care in Australia. The addition of a goal focused coaching role onto the ongoing generalist role of a practice nurse without prescribing rights was found to be ineffective. Trial registration Current Controlled Trials ISRCTN50662837.

Theory! The Missing Link in Understanding the Performance of Neonate/Infant Home‐Visiting Programs to Prevent Child Maltreatment: A Systematic Review

Objective:To evaluate the economic performance of the ‘Green Prescription’ physical activity counselling program in general practice.

Review of Australian health economic evaluation – 245 interventions: what can we say about cost effectiveness?

CONTEXT Home-visiting programs have been offered for more than sixty years to at-risk families of newborns and infants. But despite decades of experience with program delivery, more than sixty published controlled trials, and more than thirty published literature reviews, there is still uncertainty surrounding the performance of these programs. Our particular interest was the performance of home visiting in reducing child maltreatment. METHODS We developed a program logic framework to assist in understanding the neonate/infant home-visiting literature, identified through a systematic literature review. We tested whether success could be explained by the logic model using descriptive synthesis and statistical analysis. FINDINGS Having a stated objective of reducing child maltreatment-a theory or mechanism of change underpinning the home-visiting program consistent with the target population and their needs and program components that can deliver against the nominated theory of change-considerably increased the chance of success. We found that only seven of fifty-three programs demonstrated such consistency, all of which had a statistically significant positive outcome, whereas of the fifteen that had no match, none was successful. Programs with a partial match had an intermediate success rate. The relationship between program success and full, partial or no match was statistically significant. CONCLUSIONS Employing a theory-driven approach provides a new way of understanding the disparate performance of neonate/infant home-visiting programs. Employing a similar theory-driven approach could also prove useful in the review of other programs that embody a diverse set of characteristics and may apply to diverse populations and settings. A program logic framework provides a rigorous approach to deriving policy-relevant meaning from effectiveness evidence of complex programs. For neonate/infant home-visiting programs, it means that in developing these programs, attention to consistency of objectives, theory of change, target population, and program components is critical.

A systematic review of evidence on the association between hospitalisation for chronic disease related ambulatory care sensitive conditions and primary health care resourcing

BackgroundThere is an increasing body of published cost-utility analyses of health interventions which we sought to draw together to inform research and policy.MethodsTo achieve consistency in costing base and policy context, study scope was limited to Australian-based cost-effectiveness analyses. Through a comprehensive literature review we identified 245 health care interventions that met our study criteria.ResultsThe median cost-effectiveness ratio was A

Understanding Maltreating Mothers: A Synthesis of Relational Trauma, Attachment Disorganization, Structural Dissociation of the Personality, and Experiential Avoidance

18,100 (~US