Marj Moodie

'Traffic-light' nutrition labelling and 'junk-food' tax: a modelled comparison of cost-effectiveness for obesity prevention.

Introduction:Cost-effectiveness analyses are important tools in efforts to prioritise interventions for obesity prevention. Modelling facilitates evaluation of multiple scenarios with varying assumptions. This study compares the cost-effectiveness of conservative scenarios for two commonly proposed policy-based interventions: front-of-pack ‘traffic-light’ nutrition labelling (traffic-light labelling) and a tax on unhealthy foods (‘junk-food’ tax).Methods:For traffic-light labelling, estimates of changes in energy intake were based on an assumed 10% shift in consumption towards healthier options in four food categories (breakfast cereals, pastries, sausages and preprepared meals) in 10% of adults. For the ‘junk-food’ tax, price elasticities were used to estimate a change in energy intake in response to a 10% price increase in seven food categories (including soft drinks, confectionery and snack foods). Changes in population weight and body mass index by sex were then estimated based on these changes in population energy intake, along with subsequent impacts on disability-adjusted life years (DALYs). Associated resource use was measured and costed using pathway analysis, based on a health sector perspective (with some industry costs included). Costs and health outcomes were discounted at 3%. The cost-effectiveness of each intervention was modelled for the 2003 Australian adult population.Results:Both interventions resulted in reduced mean weight (traffic-light labelling: 1.3 kg (95% uncertainty interval (UI): 1.2; 1.4); ‘junk-food’ tax: 1.6 kg (95% UI: 1.5; 1.7)); and DALYs averted (traffic-light labelling: 45 100 (95% UI: 37 700; 60 100); ‘junk-food’ tax: 559 000 (95% UI: 459 500; 676 000)). Cost outlays were AUD81 million (95% UI: 44.7; 108.0) for traffic-light labelling and AUD18 million (95% UI: 14.4; 21.6) for ‘junk-food’ tax. Cost-effectiveness analysis showed both interventions were ‘dominant’ (effective and cost-saving).Conclusion:Policy-based population-wide interventions such as traffic-light nutrition labelling and taxes on unhealthy foods are likely to offer excellent ‘value for money’ as obesity prevention measures.

Effect of bronchoalveolar lavage-directed therapy on Pseudomonas aeruginosa infection and structural lung injury in children with cystic fibrosis: A randomized trial

CONTEXT Early pulmonary infection in children with cystic fibrosis leads to increased morbidity and mortality. Despite wide use of oropharyngeal cultures to identify pulmonary infection, concerns remain over their diagnostic accuracy. While bronchoalveolar lavage (BAL) is an alternative diagnostic tool, evidence for its clinical benefit is lacking. OBJECTIVE To determine if BAL-directed therapy for pulmonary exacerbations during the first 5 years of life provides better outcomes than current standard practice relying on clinical features and oropharyngeal cultures. DESIGN, SETTING, AND PARTICIPANTS The Australasian Cystic Fibrosis Bronchoalveolar Lavage (ACFBAL) randomized controlled trial, recruiting infants diagnosed with cystic fibrosis through newborn screening programs in 8 Australasian cystic fibrosis centers. Recruitment occurred between June 1, 1999, and April 30, 2005, with the study ending on December 31, 2009. INTERVENTIONS BAL-directed (n = 84) or standard (n = 86) therapy until age 5 years. The BAL-directed therapy group underwent BAL before age 6 months when well, when hospitalized for pulmonary exacerbations, if Pseudomonas aeruginosa was detected in oropharyngeal specimens, and after P. aeruginosa eradication therapy. Treatment was prescribed according to BAL or oropharyngeal culture results. MAIN OUTCOME MEASURES Primary outcomes at age 5 years were prevalence of P. aeruginosa on BAL cultures and total cystic fibrosis computed tomography (CF-CT) score (as a percentage of the maximum score) on high-resolution chest CT scan. RESULTS Of 267 infants diagnosed with cystic fibrosis following newborn screening, 170 were enrolled and randomized, and 157 completed the study. At age 5 years, 8 of 79 children (10%) in the BAL-directed therapy group and 9 of 76 (12%) in the standard therapy group had P. aeruginosa in final BAL cultures (risk difference, -1.7% [95% confidence interval, -11.6% to 8.1%]; P = .73). Mean total CF-CT scores for the BAL-directed therapy and standard therapy groups were 3.0% and 2.8%, respectively (mean difference, 0.19% [95% confidence interval, -0.94% to 1.33%]; P = .74). CONCLUSION Among infants diagnosed with cystic fibrosis, BAL-directed therapy did not result in a lower prevalence of P. aeruginosa infection or lower total CF-CT score when compared with standard therapy at age 5 years. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12605000665639.

Priority setting in health: Origins, description and application of the Australian Assessing Cost–Effectiveness initiative

This article reports on the ‘Assessing Cost–Effectiveness’ (ACE) initiative in priority setting from Australia. It commences with why priority setting is topical and notes that a wide variety of approaches are available. In assessing these various approaches, it is argued that a useful first step is to consider what constitutes an ‘ideal’ approach to priority setting. A checklist to guide priority setting is presented based on guidance from economic theory, ethics and social justice, lessons from empirical experience and the needs of decision-makers. The checklist is seen as an important contribution because it is the first time that criteria from such a broad range of considerations have been brought together to develop a framework for priority setting that endeavors to be both realistic and theoretically sound. The checklist will then be applied to a selection of existing approaches in order to illustrate their deficiencies and to provide the platform for explaining the unique features of the ACE approach. A case study (ACE-Cancer) will then be presented and assessed against the checklist, including reaction from stakeholders in the cancer field. The article concludes with an overview of the full body of ACE research completed to date, together with some reflections on the ACE experience.

Simulation models of obesity: a review of the literature and implications for research and policy.

Simulation models (SMs) combine information from a variety of sources to provide a useful tool for examining how the effects of obesity unfold over time and impact population health. SMs can aid in the understanding of the complex interaction of the drivers of diet and activity and their relation to health outcomes. As emphasized in a recently released report of the Institute or Medicine, SMs can be especially useful for considering the potential impact of an array of policies that will be required to tackle the obesity problem. The purpose of this paper is to present an overview of existing SMs for obesity. First, a background section introduces the different types of models, explains how models are constructed, shows the utility of SMs and discusses their strengths and weaknesses. Using these typologies, we then briefly review extant obesity SMs. We categorize these models according to their focus: health and economic outcomes, trends in obesity as a function of past trends, physiologically based behavioural models, environmental contributors to obesity and policy interventions. Finally, we suggest directions for future research.

Reduction in overweight and obesity from a 3-year community-based intervention in Australia: the 'It's Your Move!' project.

‘Its Your Move!’ was a 3‐year intervention study implemented in secondary schools in Australia as part of the Pacific Obesity Prevention In Communities Project. This paper reports the outcome results of anthropometric indices and relevant obesity‐related behaviours. The interventions focused on building the capacity of families, schools and communities to promote healthy eating and physical activity. Baseline response rates and follow‐up rates were 53% and 69% respectively for the intervention group (n = 5 schools) and 47% and 66% respectively for the comparison group (n = 7 schools). Statistically significant relative reductions in the intervention versus comparison group were observed: weight (−0.74 kg, P < 0.04), and standardized body mass index (−0.07, P < 0.03), and non‐significant reductions in prevalence of overweight and obesity (0.75 odds ratio, P = 0.12) and body mass index (−0.22, P = 0.06). Obesity‐related behavioural variables showed mixed results with no pattern of positive intervention outcomes. In conclusion, this is the first study to show that long‐term, community‐based interventions using a capacity‐building approach can prevent unhealthy weight gain in adolescents. Obesity prevention efforts in this important transitional stage of life can be successful and these findings need to be translated to scale for a national effort to reverse the epidemic in children and adolescents.

A very early rehabilitation trial (AVERT)

Inthedevelopedworld,oneinfourmenandoneinfivewomencan expect to suffer a stroke if they live to 85 years (1). Strokeresults in both premature death and disability however, incontrast tocoronaryheartdiseaseand cancer,its major burdenis chronicdisability rather than death (2). We know that strokepatients who have received organised multidisciplinary care inaStrokeCareUnit(SCU)environmenthavereducedmortalityand dependency (3). However, it is uncertain which compo-nents of the SCU management strategies are responsible forimproved outcomes. The strongest evidence for the benefit ofstarting mobilisation as early as possible after stroke comesfrom a post hoc analysis of the Norwegian randomized trial ofSCU vs. general medical ward care and using discharge at sixweeks as a surrogate outcome measure (4). Patients managedin the SCU (and receiving very early mobilisation, hereafterknown as VEM) were 64% less likely to be dead or disabled.Of the factors that distinguished stroke unit from generalmedical care, VEM was found to be the strongest predictor ofimprovedoutcometogetherwithbetter bloodpressurecontrol(5).Thisanalysis indicatedthatVEMmayaccountforas muchas 78% of the SCU benefit. Starting mobilisation (i.e. sittingout of bed, standing and walking) very early after stroke andcontinuing it at frequent intervals until discharge, may reducethe levelofdisabilityexperienced by strokepatients and reducethe number of patients requiring nursing home care (5).Although preliminary, the evidence from these studies hasprompted the inclusion of early mobilisation in acute strokecare best practice guidelines both in Australia (6) and inter-nationally (7). As there is only a low level of evidence tosupporttheseguidelinesthereisanobviousneedtoconductaninterventional trial of early mobilisation to determine whetherearly mobilisation of stroke patients is safe, improves out-comes and is cost effective. In order to do this we havecommenced A Very Early Rehabilitation Trial (AVERT). Ouris to determine the efficacy and cost effectiveness of this earlyintervention.AVERT differs from many previous rehabilitation trials on anumber of levels. First, it has been designed to mirror otheracute interventional trials of stroke such as thrombolysis andneuroprotection. This design objective was imperative giventhe frequently poor methodological quality of rehabilitationtrials. Second, AVERT is a large, multicentre randomisedcontrolled trial, adequately powered to detect a benefit ofsimilar magnitude to other proven interventions, with broadinclusion criteria to be assured that the result is generalisable.Finally, a detailed economic evaluation is included to allow acost effectiveness assessment to be made to assist in healthplanning and to allow comparison with other proven inter-ventions. If positivethese features should helpdrivechanges inclinical practice.The trial design is a randomised controlled trial of VEM(intervention) vs. standard care (control), with blinded assess-ment of outcome and intention-to-treat analysis.The hypothesis is that VEM of stroke patients (in addi-tion to standard care), compared with standard care alonewill:reduce death and disability at 3-month post stroke,reduce the number and severity of complications experi-enced by stroke patients,result in better quality of life at 12 months, andbe cost-effective.The study includes patients over 18 years with confirmedstroke admitted to hospital within 24h of onset of strokesymptoms. Patients must be rouseable. Patients who aremoderately to severely disabled before stroke (modified Ran-kin Scale (8) 42) will be excluded. In addition, we will excludethoseshowingrapidearlydeteriorationofsymptoms,orwithaconcurrent diagnosis of rapidly deteriorating disease (e.g.terminal cancer). Patients with unstable coronary or othermedical conditions that would impose hazard to the patientwill also be excluded. Physiological variables (e.g. heart rate,blood pressure, O

Prespecified dose-response analysis for A Very Early Rehabilitation Trial (AVERT)

Objective: Our prespecified dose-response analyses of A Very Early Rehabilitation Trial (AVERT) aim to provide practical guidance for clinicians on the timing, frequency, and amount of mobilization following acute stroke. Methods: Eligible patients were aged ≥18 years, had confirmed first (or recurrent) stroke, and were admitted to a stroke unit within 24 hours of stroke onset. Patients were randomized to receive very early and frequent mobilization, commencing within 24 hours, or usual care. We used regression analyses and Classification and Regression Trees (CART) to investigate the effect of timing and dose of mobilization on efficacy and safety outcomes, irrespective of assigned treatment group. Results: A total of 2,104 patients were enrolled, of whom 2,083 (99.0%) were followed up at 3 months. We found a consistent pattern of improved odds of favorable outcome in efficacy and safety outcomes with increased daily frequency of out-of-bed sessions (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.09 to 1.18, p < 0.001), keeping time to first mobilization and mobilization amount constant. Increased amount (minutes per day) of mobilization reduced the odds of a good outcome (OR 0.94, 95% CI 0.91 to 0.97, p < 0.001). Session frequency was the most important variable in the CART analysis, after prognostic variables age and baseline stroke severity. Conclusion: These data suggest that shorter, more frequent mobilization early after acute stroke is associated with greater odds of favorable outcome at 3 months when controlling for age and stroke severity. Classification of evidence: This study provides Class III evidence that shorter, more frequent early mobilization improves the chance of regaining independence after stroke.

Prospective evaluation of respiratory exacerbations in children with cystic fibrosis from newborn screening to 5 years of age

Background Newborn screening allows novel treatments for cystic fibrosis (CF) to be trialled in early childhood before irreversible lung injury occurs. As respiratory exacerbations are a potential trial outcome variable, we determined their rate, duration and clinical features in preschool children with CF; and whether they were associated with growth, lung structure and function at age 5 years. Methods Respiratory exacerbations were recorded prospectively in Australasian CF Bronchoalveolar Lavage trial subjects from enrolment after newborn screening to age 5 years, when all participants underwent clinical assessment, chest CT scans and spirometry. Results 168 children (88 boys) experienced 2080 exacerbations, at an average rate of 3.66 exacerbations per person-year; 80.1% were community managed and 19.9% required hospital admission. There was an average increase in exacerbation rate of 9% (95% CI 4% to 14%; p<0.001) per year of age. Exacerbation rate differed by site (p<0.001) and was 26% lower (95% CI 12% to 38%) in children receiving 12 months of prophylactic antibiotics. The rate of exacerbations in the first 2 years was associated with reduced forced expiratory volume in 1 s z scores. Ever having a hospital-managed exacerbation was associated with bronchiectasis (OR 2.67, 95% CI 1.13 to 6.31) in chest CT scans, and lower weight z scores at 5 years of age (coefficient −0.39, 95% CI −0.74 to −0.05). Conclusions Respiratory exacerbations in young children are markers for progressive CF lung disease and are potential trial outcome measures for novel treatments in this age group.

The Pacific Obesity Prevention in Communities project: project overview and methods.

Obesity is increasing worldwide with the Pacific region having the highest prevalence among adults. The most common precursor of adult obesity is adolescent obesity making this a critical period for prevention. The Pacific Obesity Prevention in Communities project was a four‐country project (Fiji, Tonga, New Zealand and Australia) designed to prevent adolescent obesity. This paper overviews the project and the methods common to the four countries. Each country implemented a community‐based intervention programme promoting healthy eating, physical activity and healthy weight in adolescents. A community capacity‐building approach was used, with common processes employed but with contextualized interventions within each country. Changes in anthropometric, behavioural and perception outcomes were evaluated at the individual level and school environments and community capacity at the settings level. The evaluation tools common to each are described. Additional analytical studies included economic, socio‐cultural and policy studies. The project pioneered many areas of obesity prevention research: using multi‐country collaboration to build research capacity; testing a capacity‐building approach in ethnic groups with very high obesity prevalence; costing complex, long‐term community intervention programmes; systematically studying the powerful socio‐cultural influences on weight gain; and undertaking a participatory, national, priority‐setting process for policy interventions using simulation modelling of cost‐effectiveness of interventions.

Health care and lost productivity costs of overweight and obesity in New Zealand

Objective: To estimate the costs of health care and lost productivity attributable to overweight and obesity in New Zealand (NZ) in 2006.