SCORE: a randomised controlled trial evaluating shared care (general practitioner and oncologist) follow-up compared to usual oncologist follow-up for survivors of colorectal cancer.

Background: SCORE is the first randomised controlled trial (RCT) to examine shared oncologist and general practitioner (GP) follow-up for survivors of colorectal cancer (CRC). SCORE aimed to show that shared care (SC) was non-inferior to usual care (UC) on the EORTC QLQ-C30 Global Health Status/Quality of Life (GHQ-QoL) scale to 12 months. Methods: The study recruited patients from five public hospitals in Melbourne, Australia between February 2017 and May 2021. Patients post curative intent treatment for stage I-III CRC underwent 1:1 randomisation to SC and UC. SC replaced two oncologist visits with GP visits and included a survivorship care plan and primary care management guidelines. Assessments were at baseline, 6 and 12 months. Difference between groups on GHQ-QoL to 12 months was estimated from a mixed model for repeated measures (MMRM), with a non-inferiority margin (NIM) of -10 points. Secondary endpoints included quality of life (QoL); patient perceptions of care; costs and clinical care processes (CEA tests, recurrences). Registration ACTRN12617000004369p. Findings: 150 consenting patients were randomised to SC (N = 74) or UC (N = 76); 11 GPs declined. The mean (SD) GHQ-QoL scores at 12 months were 72 (20.2) for SC versus 73 (17.2) for UC. The MMRM mean estimate of GHQ-QoL across the 6 month and 12 month follow-up was 69 for SC and 73 for UC, mean difference -4.0 (95% CI: -9.0 to 0.9). The lower limit of the 95% CI did not cross the NIM. There was no clear evidence of differences on other QoL, unmet needs or satisfaction scales. At 12 months, the majority preferred SC (40/63; 63%) in the SC group, with equal preference for SC (22/62; 35%) and specialist care (22/62; 35%) in UC group. CEA completion was higher in SC. Recurrences similar between arms. Patients in SC on average incurred USD314 less in health costs versus UC patients. Interpretation: SC seems to be an appropriate and cost-effective model of follow-up for CRC survivors. Funding: Victorian Cancer Agency and Cancer Australia.

Potential cost-effectiveness of e-health interventions for treating overweight and obesity in Australian adolescents.

BACKGROUND: E-health, defined as the use of information and communication technologies to improve healthcare delivery and health outcomes, has been promoted as a cost-effective strategy to treat adolescent overweight and obesity. However, evidence supporting this claim is lacking. OBJECTIVES: Assess the potential cost-effectiveness of a hypothetical e-health intervention for adolescents with overweight and obesity. METHODS: The costs and effect size (BMI reduction) of the hypothetical intervention were sourced from recent systematic reviews. Using a micro-simulation model with a lifetime time horizon, we conducted a modelled cost-utility analysis of the intervention compared to a 'do-nothing' approach. To explore uncertainty, we conducted bootstrapping on individual-level costs and quality-adjusted life years (QALYs) and performed multiple one-way sensitivity analyses. RESULTS: The incremental cost-effectiveness ratio (ICER) for the e-health intervention was dominant (cheaper and more effective), with a 96% probability of being cost-effective at a willingness-to-pay (WTP) of $50 000/QALY. The ICER remained dominant in all sensitivity analyses except when using the lower bounds of the hypothetical intervention effect size, which reduced the probability of cost-effectiveness at a WTP of $50 000/QALY to 51%. CONCLUSION: E-health interventions for treatment of adolescent overweight and obesity demonstrate very good cost-effectiveness potential and should be considered by healthcare decision makers. However, further research on the efficacy of such interventions is warranted to strengthen the case for investment.

Application of a health technology assessment framework to digital health technologies that manage chronic disease: a systematic review.

BACKGROUND: As health services increasingly make investment decisions in digital health technologies (DHTs), a DHT-specific and comprehensive health technology assessment (HTA) process is crucial in assessing value-for-money. Research in DHTs is ever-increasing, but whether it covers the content required for HTA is unknown. OBJECTIVES: To summarize current trends in primary research on DHTs that manage chronic disease at home, particularly the coverage of content recommended for DHT-specific and comprehensive HTA. METHODS: Medline, Embase, Econlit, CINAHL, and The Cochrane Library (1 January 2015 to 20 March 2020) were searched for primary research studies using keywords related to DHT and HTA domains. Studies were assessed for coverage of the most frequently recommended content to be considered in a nine domain DHT-specific HTA previously developed. RESULTS: A total of 178 DHT interventions were identified, predominantly randomized controlled trials targeting cardiovascular disease/diabetes in high- to middle-income countries. A coverage assessment of the cardiovascular and diabetes DHT studies (112) revealed less than half covered DHT-specific content in all but the health problem domain. Content common to all technologies but essential for DHTs was covered by more than half the studies in all domains except for the effectiveness and ethical analysis domains. CONCLUSIONS: Although DHT research is increasing, it is not covering all the content recommended for a DHT-specific and comprehensive HTA. The inability to conduct such an HTA may lead to health services making suboptimal investment decisions. Measures to increase the quality of trial design and reporting are required in DHT primary research.

Relationship between obesity and school absenteeism in Australian children: Implications for carer productivity.

BACKGROUND: Economic evaluations of childhood obesity interventions are often used to assist decision making when presented with alternative course of action. Including indirect costs related to productivity losses is recommended; in children this would include school absenteeism. Our aim was to determine the association between school absenteeism and weight status among Australian children and estimate the indirect costs of this. METHODS: We used data from a nationally representative sample of 8551 Australian children in the Longitudinal study of Australian Children (LSAC) with follow-up between 2006 and 2018. A mixed-effects negative binomial regression model was used to investigate the relationship between school absenteeism and weight status, controlling for age, sex, socio-economic position, indigenous status, rural/remote status and long-term medical conditions. We used average daily wages for the year 2018 to value the indirect costs of school absenteeism (through caregiver lost productivity). RESULTS: Australian children with obesity aged 6-13 years missed on average an extra day of school annually compared to children of a healthy weight (p = 0.004), while adolescents with obesity aged 14-17 years missed on average an extra 0.69 days of school annually (p = 0.006). The estimated national cost for children with obesity aged 6-13 years was approximately $64 million AUD ($43 million USD) or $338 AUD ($230 USD) per child through caregiver lost productivity in 2018. CONCLUSIONS: There is a small but significant association between school absenteeism and childhood obesity in Australia which is estimated to generate a considerable national cost through caregiver productivity losses. Our results will assist health economists evaluating childhood obesity interventions capture the full extent of the associated costs with this condition.

Health technology assessment for digital technologies that manage chronic disease: a systematic review.

OBJECTIVE: A growing number of evaluation frameworks have emerged over recent years addressing the unique benefits and risk profiles of new classes of digital health technologies (DHTs). This systematic review aims to identify relevant frameworks and synthesize their recommendations into DHT-specific content to be considered when performing Health Technology Assessments (HTAs) for DHTs that manage chronic noncommunicable disease at home. METHODS: Searches were undertaken of Medline, Embase, Econlit, CINAHL, and The Cochrane Library (January 2015 to March 2020), and relevant gray literature (January 2015 to August 2020) using keywords related to HTA, evaluation frameworks, and DHTs. Included framework reference lists were searched from 2010 until 2015. The EUNetHTA HTA Core Model version 3.0 was selected as a scaffold for content evaluation. RESULTS: Forty-four frameworks were identified, mainly covering clinical effectiveness (n = 30) and safety (n = 23) issues. DHT-specific content recommended by framework authors fell within 28 of the 145 HTA Core Model issues. A further twenty-two DHT-specific issues not currently in the HTA Core Model were recommended. CONCLUSIONS: Current HTA frameworks are unlikely to be sufficient for assessing DHTs. The development of DHT-specific content for HTA frameworks is hampered by DHTs having varied benefit and risk profiles. By focusing on DHTs that actively monitor/treat chronic noncommunicable diseases at home, we have extended DHT-specific content to all nine HTA Core Model domains. We plan to develop a supplementary evaluation framework for designing research studies, undertaking HTAs, and appraising the completeness of HTAs for DHTs.

Utility Decrements Associated with Adult Overweight and Obesity in Australia: A Systematic Review and Meta-Analysis.

OBJECTIVE: The aim was to conduct a systematic review and meta-analysis of health state utility decrements associated with overweight and obesity in adults 18 years and over, for use in modelled economic evaluations in Australia. METHODS: A systematic review was conducted in nine databases to identify studies that reported health state utility values by weight status. Random-effects meta-analysis was used to synthesise average utility decrements (from healthy weight) associated with overweight, all obesity and obesity classes 1, 2 and 3. Heterogeneity surrounding utility decrements was assessed via sub-group analysis, random-effects meta-regression and sensitivity analyses. RESULTS: Twelve studies were found for which data were used to synthesise utility decrements, estimated as overweight = 0.020 (95% confidence interval 0.010-0.030), all obesity = 0.055 (0.034-0.076), obesity class 1 = 0.047 (0.017-0.077), class 2 = 0.072 (0.028-0.116) and class 3 = 0.084 (0.039-0.130). There was considerable heterogeneity in our results, which could be accounted for by the different ages and utility instruments used in the contributing studies. CONCLUSIONS: Our results demonstrate that elevated weight status is associated with small but statistically significant reductions in utility compared with healthy weight, which will result in reduced quality-adjusted life years when extrapolated across time and used in economic evaluations.

Looking backwards and forwards: tracking and persistence of weight status between early childhood and adolescence.

BACKGROUND/OBJECTIVE: Many studies have shown that child BMI or weight status tracks over time, but the demographic predictors of high tracking have not been investigated. Our objective was to identify demographic predictors of persistence (duration) of healthy weight and overweight/obesity throughout childhood, and to examine whether tracking was age dependent. METHODS: We conducted secondary data analysis of 4606 children from the Birth cohort and 4983 children from the Kindergarten cohort of the Longitudinal Study of Australian Children with follow-up to age 12/13 and 16/17 years, respectively. Retrospective and prospective tracking were examined descriptively. Time-to-event analysis determined demographic predictors of persistence of healthy weight and overweight/obesity beyond age 4-5 years, after controlling for child BMI z-score. Weight status was determined using WHO methods. RESULTS: Tracking of healthy weight was consistently higher than that of overweight/obesity, and incident overweight was equally likely throughout childhood and adolescence. Tracking of overweight was lower for children under 7 years than in middle childhood and adolescence (2-year probability 65%, compared with 80%; 2-year resolution of overweight 35 and 20%). Children of lower socioeconomic position, those from culturally and linguistically diverse backgrounds, and girls were more likely to move into overweight (hazard ratios [95%CI] for incident overweight: 1.39 [1.26-1.52], 1.16 [1.02-1.31] and 1.12 [1.02-1.23], respectively) and less likely to resolve their overweight (hazard ratios for resolution of overweight/obesity: 0.77 [0.69-0.85], 0.8 [0.69-0.92] and 0.79 [0.71-0.81], respectively) during childhood. However, persistence of weight status was not significantly affected by rurality or Indigenous status (P > 0.05). CONCLUSIONS: Lowest tracking and highest natural resolution of overweight in children under 7 years suggests this may be an opportune time for interventions to reduce overweight. Primary and secondary prevention programmes during the school years should be designed with special consideration for lower socioeconomic communities, for culturally and linguistically diverse populations and for girls.