Economic evaluation of an Australian nurse home visiting programme: a randomised trial at 3 years.

OBJECTIVES: To investigate the additional programme cost and cost-effectiveness of 'right@home' Nurse Home Visiting (NHV) programme in relation to improving maternal and child outcomes at child age 3 years compared with usual care. DESIGN: A cost-utility analysis from a government-as-payer perspective alongside a randomised trial of NHV over 3-year period. Costs and quality-adjusted life-years (QALYs) were discounted at 5%. Analysis used an intention-to-treat approach with multiple imputation. SETTING: The right@home was implemented from 2013 in Victoria and Tasmania states of Australia, as a primary care service for pregnant women, delivered until child age 2 years. PARTICIPANTS: 722 pregnant Australian women experiencing adversity received NHV (n=363) or usual care (clinic visits) (n=359). PRIMARY AND SECONDARY OUTCOME MEASURES: First, a cost-consequences analysis to compare the additional costs of NHV over usual care, accounting for any reduced costs of service use, and impacts on all maternal and child outcomes assessed at 3 years. Second, cost-utility analysis from a government-as-payer perspective compared additional costs to maternal QALYs to express cost-effectiveness in terms of additional cost per additional QALY gained. RESULTS: When compared with usual care at child age 3 years, the right@home intervention cost $A7685 extra per woman (95% CI $A7006 to $A8364) and generated 0.01 more QALYs (95% CI -0.01 to 0.02). The probability of right@home being cost-effective by child age 3 years is less than 20%, at a willingness-to-pay threshold of $A50 000 per QALY. CONCLUSIONS: Benefits of NHV to parenting at 2 years and maternal health and well-being at 3 years translate into marginal maternal QALY gains. Like previous cost-effectiveness results for NHV programmes, right@home is not cost-effective at 3 years. Given the relatively high up-front costs of NHV, long-term follow-up is needed to assess the accrual of health and economic benefits over time. TRIAL REGISTRATION NUMBER: ISRCTN89962120.

Associations between social adversity and young children's hair cortisol: A systematic review.

Psychosocial and socioeconomic adversity in early childhood (termed 'social adversity') can have lifelong detrimental effects on health and development. Physiological stress is one proposed mechanism by which social adversity 'gets under the skin'. There is substantial research interest in whether hair cortisol, a biomarker proposed to measure the cumulative physiological stress response over time, can illustrate this mechanism. As a result, a growing number of studies have tested for associations between indicators of social adversity and child hair cortisol. The aim of this paper is to conduct a comprehensive, systematic review of the evidence for associations between indicators of social adversity and hair cortisol, specifically in young children (birth to 8 years) published any time up to 31 December 2019. The literature search identified 44 published studies that met inclusion criteria. The studies examined associations between one or more indicators of social adversity and child hair cortisol across 35 independent cohorts comprising 8370 children. Indicators of adversity examined in the identified literature included socioeconomic factors (e.g. low parental education, low income and unemployment), psychosocial factors (e.g. parent stress, poor mental health and family violence), and children's direct exposure to maltreatment, abuse and stressful events. Across all indicators of adversity, a total of 142 associations with hair cortisol were examined. Evidence of associations was limited and inconsistent; 34/142 (24%) showed evidence of a positive association between adversity and higher hair cortisol, 8/142 (6%) showed a negative association, and more than two thirds (100/142, 70%) of all examined associations were null. The collective evidence appears insufficient to conclude that there is a relationship between social adversity and hair cortisol, as a measure of physiological stress response, in young children.

Using Hair Cortisol to Examine the Role of Stress in Children's Health Inequalities at 3 Years.

OBJECTIVE: Children exposed to early adversity (eg, financial hardship, family violence, parent mental health difficulties) are at greater risk of poor health outcomes. Physiological stress is one mechanism thought to explain this pathway. We investigated associations between adversity and young children's health and whether child stress (measured using hair cortisol) mediated these associations. METHODS: This was a cross-sectional study of 3-year-old children whose mothers were recruited during pregnancy, through the right@home trial, for their experience of adversity. Using total counts of 9 sociodemographic and 9 psychosocial indicators of adversity, regression models examined relationships among adversity risk counts, child hair cortisol (potential mediator), and 5 health outcomes: externalizing and internalizing problems, physical and socioemotional wellbeing, and overweight/obesity. RESULTS: Hair cortisol data were available for 297 out of 500 (59%) participating children. When examined separately, sociodemographic adversity risk was associated with higher externalizing problems, and psychosocial adversity risk was associated with higher externalizing problems and poorer physical/socioemotional wellbeing. When examined together in a single model, psychosocial (but not sociodemographic) adversity was associated with higher externalizing problems (unstandardized mean difference [ß], 0.53; P = .002) and poorer physical wellbeing (ß, 1.19; P = .009); higher hair cortisol was associated with higher externalizing problems (ß, 0.76; P = .02). There was no evidence that stress (hair cortisol) mediated associations between adversity and health. CONCLUSIONS: In 3-year-old children, we found no evidence that physiological stress (hair cortisol) mediated associations between adversity risk and children's health. Hair cortisol may be limited as a single measure of stress, or physiological stress may not be a mechanism for explaining the effects of adversity on these young children's health.

Hair cortisol as a measure of the stress response to social adversity in young children.

Hair cortisol has the potential to provide insight into young children's long-term stress response to social adversity. This study investigated associations between children's exposure to adversity from pregnancy to 2 years of age and their hair cortisol at 2 years, using a longitudinal cohort of children enriched for adversity risk, whose mothers were recruited during pregnancy through the "right@home" trial. Exposures were 18 maternal socioeconomic and psychosocial indicators of adversity, examined as concurrent, cumulative, and longitudinal exposure from pregnancy to 2 years. Hair samples were analyzed from 319/603 (53%) children participating at 2 years. Multivariable regression analyses for concurrent exposure showed three indicators of adversity were associated with higher hair cortisol (housing tenure of public rental, paying board or living rent free; not living in a safe place; higher maternal stress symptoms), one with lower hair cortisol (housing problems), and 14 indicators with no evidence of association. There was no evidence of association for the cumulative adversity count. Longitudinal exposure showed "intermittent" and "persistent" high maternal stress symptoms were associated with higher hair cortisol. The small number of associations identified suggests that hair cortisol is limited as a measure of stress response to social adversity in children at 2 years.

The feasibility and acceptability of a population-level antenatal risk factor survey: Cross-sectional pilot study.

AIM: Australian data on the prevalence and distribution of antenatal risk factors are scarce. This study aimed to investigate (i) the feasibility and acceptability of an antenatal risk factor survey collected in public settings and (ii) whether the survey risk factors co-occur with more sensitive risk factors that are privately asked by clinicians. METHODS: Design and setting: study-designed survey linked with clinician-collected risk factors. PARTICIPANTS: pregnant women attending antenatal clinics at two Victorian hospitals. MEASURES: (i) study-designed survey: young pregnancy, no support, poor/fair/good general health, anxious mood, not finishing high school, no income, long-term illness, living without another adult, not employed, never had a job and proxy poverty measures; (ii) Clinician-collected data: smoking, alcohol/marijuana/drug use, domestic violence, social issues, history of mental health problems and depression symptoms. ANALYSES: (i) feasibility and acceptability were assessed through survey completion. Each item was assessed for whether they discriminated risk; dichotomised into risk versus no risk; with a total count calculated. (ii) Co-occurrence was assessed by examining how the risk factor count agreed with clinician-collected items. RESULTS: One hundred and sixty-six of 186 (89%) eligible women completed the survey; 139 of 166 (84%) consented to linking clinician-collected data. The high response and zero missing data demonstrated feasibility and acceptability. Of women with linked data, 92 of 139 (66%) had ≥1 survey risk factor and 30 of 139 (22%) had ≥3; 36 of 139 (26%) had at least one co-occurring clinician-collected risk factor. CONCLUSIONS: This survey provides a simple, rapid approach to gathering antenatal risk data publicly. It may be a helpful addition to clinicians' standard history collection.

Population Outcomes of Three Approaches to Detection of Congenital Hearing Loss.

BACKGROUND: Universal newborn hearing screening was implemented worldwide largely on modeled, not measured, long-term benefits. Comparative quantification of population benefits would justify its high cost. METHODS: Natural experiment comparing 3 population approaches to detecting bilateral congenital hearing loss (>25 dB, better ear) in Australian states with similar demographics and services: (1) universal newborn hearing screening, New South Wales 2003-2005, n = 69; (2) Risk factor screening (neonatal intensive care screening + universal risk factor referral), Victoria 2003-2005, n = 65; and (3) largely opportunistic detection, Victoria 1991-1993, n = 86. Children in (1) and (2) were followed at age 5 to 6 years and in (3) at 7 to 8 years. Outcomes were compared between states using adjusted linear regression. RESULTS: Children were diagnosed younger with universal than risk factor screening (adjusted mean difference -8.0 months, 95% confidence interval -12.3 to -3.7). For children without intellectual disability, moving from opportunistic to risk factor to universal screening incrementally improved age of diagnosis (22.5 vs 16.2 vs 8.1 months, P < .001), receptive (81.8 vs 83.0 vs 88.9, P = .05) and expressive (74.9 vs 80.7 vs 89.3, P < .001) language and receptive vocabulary (79.4 vs 83.8 vs 91.5, P < .001); these nonetheless remained well short of cognition (mean 103.4, SD 15.2). Behavior and health-related quality of life were unaffected. CONCLUSIONS: With new randomized trials unlikely, this may represent the most definitive population-based evidence supporting universal newborn hearing screening. Although outperforming risk factor screening, school entry language still lagged cognitive abilities by nearly a SD. Prompt intervention and efficacy research are needed for children to reach their potential.

Childhood obesity in secondary care: national prospective audit of Australian pediatric practice.

OBJECTIVE: In many countries, pediatricians offer skilled secondary care for children with conditions more challenging than can readily be managed in the primary care sector, but the extent to which this sector engages with the detection and management of obesity remains largely unexplored. This study aimed to audit the prevalence, diagnosis, patient, and consultation characteristics of obesity in Australian pediatric practices. METHODS: This was a national prospective patient audit in Australia. During the course of 2 weeks, members of the Australian Paediatric Research Network prospectively recorded consecutive outpatient consultations by using a brief standardized data collection form. Measures included height, weight, demographics, child and parent health ratings, diagnoses, referrals, investigations, and consultation characteristics. We compared the prevalence of pediatrician-diagnosed and measured obesity (body mass index ≥95th percentile) and top-ranked diagnoses, patient, and consultation characteristics in (a) obese and nonobese children, and (b) obese children with and without a diagnosis. RESULTS: A total of 198 pediatricians recorded 5466 consultations with 2-17 year olds, with body mass index z-scores calculated for 3436 (62.9%). Of the 12.6% obese children, only one-third received an "overweight/obese" diagnosis. Obese children diagnosed as overweight/obese were heavier, older, and in poorer health than those not diagnosed and incurred more Medicare (government-funded health system) cost and referrals. CONCLUSIONS: Obesity is infrequently clinically diagnosed by Australian pediatricians and measurement practices vary widely. Further research could focus on supporting and normalizing clinical obesity activities from which pediatricians and parents could see clear benefits.

Children Attending Paediatricians Study: a national prospective audit of outpatient practice from the Australian Paediatric Research Network.

OBJECTIVE: To audit general paediatric outpatient practice in Australia, including consultation characteristics and management patterns, diagnoses, factors associated with diagnoses, and billing practices. DESIGN, SETTING AND PARTICIPANTS: In October-November 2008, members of the Australian Paediatric Research Network (APRN; a national network of paediatricians established to facilitate multisite secondary care research) were invited to prospectively complete brief standardised data collection forms for 100 consecutive patients or all patients during a 2-week period, whichever came first. MAIN OUTCOME MEASURES: Length of consultation and type of diagnoses made; proportions recorded as having medications, investigations or referral; odds ratios for factors associated with diagnoses; and proportions of Medicare items billed. RESULTS: Of 300 APRN members, 199 (66%) completed data forms for 8345 consultations in which 15 375 diagnoses were made (mean, 1.8 diagnoses per consultation); 46.0%, 30.9% and 22.8% of consultations involved 1, 2 and ≥ 3 diagnoses, respectively. New and review consultations lasted a mean of 41 (SD, 20) and 26 (SD, 15) minutes, respectively. The most common diagnoses were attention deficit hyperactivity disorder (18.3%), baby checks (9.1%), and learning difficulties (7.5%). Patients seen in 47.5% of consultations had medications (eg, prescriptions, vaccinations) recorded, and patients in 27.2% of consultations were referred elsewhere, usually to a subspecialist or psychologist (31.6% and 26.6% of referrals, respectively). Male sex of the child and owning a Health Care Card were associated with most developmental-behavioural diagnoses. Paediatricians tended to bill for single disease/non-complex consultations, even when seeing a child with multiple problems. CONCLUSIONS: Australian paediatricians see children with a range of diagnoses that are often multiple and complex. Our findings provide directions for future secondary care research, and may inform workforce planning and paediatricians' training requirements.