Cost driver analysis of statin expenditure on Australia's Pharmaceutical Benefits Scheme.

INTRODUCTION: The Australian Pharmaceutical Benefits Scheme (PBS) provides universal access to subsidized medicines. In 2013, statins as a class had the highest expenditure on the PBS. OBJECTIVES: To assess the influence of policies and drivers affecting PBS statin utilization and expenditure between 1992 and 2013. METHODS: Analyses conducted from 1992 to 2013 and over three distinct time periods, including monthly expenditure/prescription, annual utilization (calculated as Defined Daily Doses/1000 inhabitants/day) and statin strengths dispensed. RESULTS: The major driver of increased PBS expenditure for statins was increased volumes. After adjusting for inflation, the average PBS expenditure on statin prescriptions was the major negative driver. Other influential drivers included the increased use of newer statins and increased strength of statins dispensed. DISCUSSION: Whilst the inflation-adjusted reimbursed price of statins decreased, increased utilization, including increased use of patented statins, increased total statin expenditure. Successful measures adopted by other countries could be applied to Australia to decrease total medicines expenditure.

Exploring policy makers' perspectives on a clinical controversy: airway surgery for adult obstructive sleep apnoea.

BACKGROUND AND OBJECTIVES: Worldwide, there is increasing focus on measures to reduce ineffective healthcare practices. Upper airway surgeries for the treatment of adult obstructive sleep apnoea (OSA) represent a case-study in this area, given recent publications that draw into question their efficacy. Policy stakeholders were canvassed to assess their perspectives on this. DESIGN AND SETTING: Senior health policy stakeholders from Australia were criterion and snowball sampled (to identify opinion leaders). Participants were presented with preparatory material and took part in individual semistructured interviews. These focused on eliciting responses to recently published evidence and a relevant Cochrane review. Questions were posed relating to clinical effectiveness and associated policy implications. Interviews were taped and transcribed for thematic analysis. Participant comments were de-identified. FINDINGS: Ten stakeholders were interviewed before saturation was reached. Thematic analysis highlighted participant concern with the diversity of procedures on offer, coupled with limited effectiveness (suggesting potential clinical uncertainty) and considerations therefore of resource allocation (potential opportunity cost). Stakeholders seem aware of the methodological complexities, the ethical issues raised and the role of patients in considerations regarding appropriateness. Finally, policy stakeholders acknowledge that these procedures appear appropriate only for a minority, with consensus that policy level restrictions to government funding for these procedures may be warranted. CONCLUSION: This report highlights that this clinical controversy is of interest and relevance from a policy perspective with lessons and potential implications for clinical practice. It further highlights the need for clinical consensus on definitions of surgical "success" in treating this condition, as this forms an important pretext to policy considerations.

Efficiency measurement for hospitals owned by the Iranian social security organisation.

This study used Data Envelopment Analysis (DEA) to examine the relative efficiency of hospitals owned by the Iranian Social Security Organization, which is the second largest institutional source of hospital care in that country. Using data for the year 2002, 26 of the 53 hospitals were deemed to be efficient. Inefficient hospitals had an average score of 90%, implying a potential reduction in all inputs on average by about 10% with no impact on output levels. In addition to the conventional DEA measurement, efficient hospitals were ranked by calculating super-efficiency scores, by identifying weak efficient hospitals, and by determining the frequency of peers. The study provides useful information for improving hospital management, rationalizing resource allocation, and improving services provided by hospitals.

Domiciliary oxygen for chronic obstructive pulmonary disease.

BACKGROUND: Domiciliary oxygen therapy has become one of the major forms of treatment for hypoxaemic chronic obstructive pulmonary disease (COPD) patients. OBJECTIVES: To determine the effect of domiciliary oxygen therapy on survival and quality of life in patients with COPD. SEARCH STRATEGY: Randomised controlled trials (RCTs) were identified using the Cochrane Airways Group COPD register using the search terms: home OR domiciliary AND oxygen. Searches were current as of January 2005. SELECTION CRITERIA: Any RCT in patients with hypoxaemia and COPD that compared long term domiciliary or home oxygen therapy with a control treatment. DATA COLLECTION AND ANALYSIS: Data extraction was performed independently by two reviewers. MAIN RESULTS: Six randomised controlled trials were identified. Survival data was aggregated from two trials of the treatment of nocturnal oxygen therapy in patients with mild to moderate COPD and arterial desaturation at night. Survival data was also aggregated from two trials of continuous oxygen therapy versus no oxygen therapy in mild to moderate COPD. Data could not be aggregated for the other two trials because of differences in trial design and patient selection. Nott 1980: continuous oxygen therapy versus nocturnal oxygen therapy: there was a significant improvement in mortality after 24 months (Peto odds ratio 0.45, 95% confidence interval 0.25 to 0.81). MRC 1981: domiciliary oxygen therapy versus no oxygen therapy: there was a significant improvement over five years in mortality in the group receiving oxygen therapy (Peto odds ratio 0.42, 95% confidence interval 0.18 to 0.98). In the two studies of nocturnal oxygen versus no oxygen therapy in patients with COPD and arterial desaturation at night: there was no difference in mortality between treated and non treated groups for either trial or when the trials were aggregated. In the two trials of long-term oxygen therapy versus no oxygen therapy in COPD patients with mild to moderate hypoxaemia: there was no effect on survival for up to three years of follow up. AUTHORS' CONCLUSIONS: Long-term home oxygen therapy improved survival in a selected group of COPD patients with severe hypoxaemia (arterial PaO2 less than 55 mm Hg (8.0 kPa)). Home oxygen therapy did not appear to improve survival in patients with mild to moderate hypoxaemia or in those with only arterial desaturation at night.

Implementation of a split-night protocol to improve efficiency in assessment and treatment of obstructive sleep apnoea.

In Australia, unmet demand for sleep study services is resulting in protracted waiting lists and treatment delays for those in need. This present study gauged efficiency gains that could be achieved by implementing a split-night protocol within the laboratory. Results demonstrate improved technical efficiency by at least 15%, reducing time to treatment for the most severe cases and increasing patient throughput within the clinic. With over 56,000 sleep studies carried out annually, this technique has significant utility in evidence-based practice.

Survival on long-term oxygen therapy in chronic airflow limitation: from evidence to outcomes in the routine clinical setting.

BACKGROUND: Two previous randomized controlled trials (RCT) demonstrated that the administration of long-term oxygen therapy (LTOT) improved survival in selected patients with hypoxic chronic obstructive pulmonary disease (COPD) or chronic airflow limitation (CAL). AIMS: The aim of the present study was to investigate whether the survival of CAL patients prescribed LTOT at Flinders Medical Centre (FMC) was gender and age related, and equivalent to that of the previous RCT. METHODS: A list of patients prescribed domiciliary oxygen therapy for CAL at FMC was generated from Respiratory Unit records and hospital financial records for the supply of this therapy. Survival was compared with that reported for the original RCT, and for Swedish and Belgian COPD patients. Factors influencing survival were studied. RESULTS: Five hundred and five (249 males, 256 females) patients were prescribed LTOT for CAL at FMC during the study period and included in the survival analysis. The patients were elderly with multiple comorbidities. Survival was less than for the control arms of the previous RCT (apart from the Medical Research Council Working Party (MRC) female group) but comparable with recent overseas data. Overall crude survival was 75.1%, 51.3%, 18.9% and 1.1% at 1, 2, 5 and 10 years respectively. Females experienced longer survival than males. Multivariate analysis indicated that age, forced expiratory volume in 1 s, body mass index (BMI) and the number of comorbidities were prognostic indicators for females; BMI was a prognostic indicator for males. A survival advantage existed for females using at least 19 h concentrator oxygen per day. CONCLUSIONS: In routine practice, survival of unselected CAL patients with multiple comorbidities is less than that reported in the original RCT.

A review of long-term oxygen therapy for chronic obstructive pulmonary disease.

This study aimed to review the evidence for the use of long-term oxygen therapy for patients with chronic obstructive pulmonary disease (COPD). The design was a systematic Cochrane review of randomized controlled trials (RCTs) of long-term oxygen therapy for COPD and main outcome measure was survival on home oxygen therapy. Five RCTs were identified. Data from two trials of nocturnal oxygen therapy in mild to moderate hypoxaemia were aggregated. Data from the other three trials could not be aggregated because of differences in trial design and patient selection. Treatment with continuous versus nocturnal oxygen therapy produced a significant improvement in mortality after 24 months [Peto odds ratio 0.45, 95% confidence interval (95% CI) 0.25-0.81] for the continuous therapy group. Treatment with oxygen therapy versus no oxygen therapy showed a significant improvement in mortality after five years in the group receiving oxygen therapy (Peto odds ratio 0.42, 95% CI 0.18-0.98). There was no difference in mortality for patients with COPD and mild to moderate daytime hypoxaemia and nocturnal desaturation receiving nocturnal oxygen therapy versus no oxygen therapy or sham treatment. Long-term oxygen therapy versus no oxygen therapy in patients with COPD and moderate hypoxaemia had no effect on survival. In conclusion, long-term oxygen therapy improved survival in a selected group of COPD patients with severe hypoxaemia but few co-morbidities. Long-term oxygen therapy did not improve survival in patients with moderate hypoxaemia or in those with mild to moderate hypoxaemia and arterial desaturation at night.

A randomised controlled trial comparing birthing centre care with delivery suite care in Adelaide, Australia.

Birthing centre care offers women with a low risk of complication in pregnancy an alternative to conventional care for the birthing of their baby. It is important these two forms of care are appropriately assessed. A randomised controlled trial comparing the newly opened birthing centre with the established conventional delivery suite was conducted at the then Queen Victoria Hospital, Adelaide, South Australia. The outcomes measured included maternal satisfaction, costs and clinical outcomes both for mother and baby which related to the need for Caesarean section, episiotomy or tear rate and method of feeding. Two hundred and one women attending the hospital's antenatal clinic were randomly allocated to either birthing centre or delivery suite care. One hundred women were allocated to the birthing centre. No differences were found in either group related to clinical outcomes or costs. The only difference in maternal satisfaction was the choice women made for their next birth. More women in the birthing centre group felt they were encouraged to breastfeed immediately after birth. While the numbers in this study were too small to detect any but large differences in outcome, birthing centre care should remain an option for women and further studies undertaken with larger numbers.

Domiciliary oxygen for chronic obstructive pulmonary disease.

BACKGROUND: Domiciliary oxygen therapy has become one of the major forms of treatment for hypoxaemic chronic obstructive pulmonary disease (COPD) patients. OBJECTIVES: To determine the effect of domiciliary oxygen therapy on survival and quality of life in patients with COPD. SEARCH STRATEGY: Randomised controlled trials (RCTs) were identified using the Cochrane Airways Group COPD register using the search terms: home OR domiciliary AND oxygen. SELECTION CRITERIA: Any RCT in patients with hypoxaemia and COPD that compared long term domiciliary or home oxygen therapy with a control treatment. DATA COLLECTION AND ANALYSIS: Data extraction was performed independently by two reviewers. MAIN RESULTS: Five randomised controlled trials were identified. Data was aggregated from two trials of the treatment of nocturnal oxygen therapy in patients with mild to moderate COPD and arterial desaturation at night. Data could not be aggregated for the other three trials because of differences in trial design and patient selection. Nott 1980: continuous oxygen therapy versus nocturnal oxygen therapy: there was a significant improvement in mortality after 24 months (Peto odds ratio 0.45, 95% confidence interval 0.25 to 0.81). MRC 1981: domiciliary oxygen therapy versus no oxygen therapy: there was a significant improvement over five years in mortality in the group receiving oxygen therapy (Peto odds ratio 0.42, 95% confidence interval 0.18 to 0.98). In two studies of nocturnal oxygen versus no oxygen in patients with COPD and arterial desaturation at night: there was no difference in mortality between treated and non treated groups for either trial or when the trials were aggregated. In one study of long term oxygen versus no oxygen in moderate hypoxaemia: there was no effect on survival for up to three years of follow up. REVIEWER'S CONCLUSIONS: Long term oxygen therapy improved survival in a selected group of COPD patients with severe hypoxaemia (arterial PO2 less than 8.0 kPa). Long term oxygen did not appear to improve survival in patients with moderate hypoxaemia or in those with only arterial desaturation at night.

Domicilary oxygen for chronic obstructive pulmonary disease.

BACKGROUND: Long-term domiciliary oxygen therapy has become one of the major forms of treatment for hypoxaemic chronic obstructive pulmonary disease (COPD) patients. OBJECTIVES: To determine the effect of domiciliary oxygen therapy on survival and quality of life in patients with COPD. SEARCH STRATEGY: Randomised controlled trials (RCTs) were identified using the Cochrane Airways Group COPD register using the search terms: (home OR domiciliary) AND oxygen. SELECTION CRITERIA: Any RCT in patients with hypoxaemia and COPD that compared long term domiciliary or home oxygen therapy with a control treatment. DATA COLLECTION AND ANALYSIS: Data extraction was performed independently by two reviewers. MAIN RESULTS: Four randomised controlled trials were identified. Data from none of these trials could be aggregated because of differences in trial design and patient selection. NOTT 1980, continuous oxygen therapy versus nocturnal oxygen therapy: there was a significant improvement in mortality after 24 months (Peto odds ratio 0.45, 95% confidence interval 0.25 to 0.81). MRC 1981, domiciliary oxygen therapy versus no oxygen therapy: there was a significant improvement over five years in mortality in the group receiving oxygen therapy (Peto odds ratio 0.42, 95% confidence interval 0.18 to 0.98). Fletcher 1992, nocturnal oxygen versus no oxygen in patients with COPD and arterial desaturation at night: there was no difference in mortality at 36 months. Gorecka 1997, long term oxygen versus no oxygen in moderate hypoxaemia: there was no effect on survival for up to three years of follow up. REVIEWER'S CONCLUSIONS: Long term oxygen therapy improved survival in a selected group of COPD patients with severe hypoxaemia (arterial PO2 less than 8.0 kPa). Long term oxygen did not appear to improve survival in patients with moderate hypoxaemia or in those with only arterial desaturation at night.

An association between length of stay and co-morbidity in chronic airflow limitation.

OBJECTIVE: To examine factors which impact on the length of stay and readmission for patients with chronic airflow limitation at a South Australian hospital from December 1996 until March 1998. DESIGN: Discharges from Flinders Medical Centre for patients aged > or = 18 years, where chronic airflow limitation was an active problem, and including a subset with a primary diagnosis of chronic airflow limitation, were identified, retrospectively, by the center's Clinical Coding Service from the hospital's in-patient separation database. SETTING: Flinders Medical Centre, Adelaide, South Australia. OUTCOME MEASURES: Length of stay; number of co-morbidities; readmission within 28 days. RESULTS: Five-hundred and twenty discharges (male:female, 258:262) with a primary diagnosis of chronic airflow limitation (ANDRG-3 177, chronic obstructive airways disease) were identified. Readmission within 28 days was related to the number of co-morbidities and to age. A relationship between length of stay and the number of co-morbidities was identified. A mean length of stay of 6.39 days was found for patients with less than five co-morbidities, 5.36 at their first admission to Flinders Medical Centre and 3.25 at their first admission to Flinders Medical Centre with no co-morbidities. These mean lengths of stay fall below overseas data previously published and are consistent with Kong's estimate of an ideal mean length of stay of 3.2 days when a clinical management guideline is used in low-risk chronic airflow limitation patients. CONCLUSIONS: Length of stay and readmission to hospital within 28 days of patients with a primary diagnosis of chronic airflow limitation is at least partly related to the number of co-morbidities and to age. The study has highlighted the difficulty of relying on changes to aggregate data as outcome measures for these patients.

Discharge planning quality from the carer perspective.

Discharge planning endeavours to assist the transition of patients from the acute hospital setting into the community. We examined the quality of discharge planning from the perspective of the carer. Spouses were the most common carers for the elderly patients in our study. Many carers were also elderly, with their own health problems. Using a new instrument (entitled PREPARED) (K. Grimmer and J. Moss, Int J Qual Health Care (in press)), carers rated the quality of planning for discharge much lower than did the patient, indicating that their needs were often not met when discharge was being planned. In free text responses, carers expressed their dissatisfaction over communication about how the family would cope once the patient went home. Carers generally had lower summary mental quality of life scores than the Australian norms (as measured by the SF-36 health survey (J. Ware and R. Sherbourne, Med Care 1992; 30: 473-483)), suggesting that the caring role may have impacted upon their emotional wellbeing. The rate of use of community services in the first week post-discharge was low, suggesting that carers and patients carried the majority of the burden immediately after discharge. We suggest that planning for hospital discharge requires more consideration of the carer.

Effects of long-term oxygen therapy on quality of life and survival in chronic airflow limitation.

Chronic airflow limitation (CAL) is a major contributor to the burden of ill-health in Australia and, where hypoxia is present, can be treated with home oxygen therapy (HOT). At Flinders Medical Centre, a prospective longitudinal study was undertaken to examine the impact of HOT on the health-related quality of life (HRQoL) of subjects with CAL. All eligible adult patients, aged < 80 yrs, with a primary diagnosis of CAL who met the prescription guidelines of the Thoracic Society of Australia and New Zealand were offered HOT and invited to participate. After baseline assessment, subjects were followed-up 3, 6 and 12 months after commencement of HOT. Physiological assessment and three validated HRQoL measures were applied, the Nottingham Health Profile (NHP), the Chronic Respiratory Questionnaire (CRQ) and, for a subset of the patients, the Medical Outcomes Study short-form 36-item questionnaire (SF-36). This study reports the results from January 1, 1991 to July 31, 1997. One hundred and fourteen CAL patients were included in the study. Female subjects experienced significant improvements from baseline in the energy, emotional reactions, sleep and physical mobility areas of the NHP, in the fatigue, emotional function and mastery dimensions of the CRQ and in the role-physical, vitality, role-emotional, and mental health dimensions of the SF-36. Males experienced significant improvements in the emotional reactions, sleep and social isolation areas of the NHP, in the fatigue dimension of the CRQ and in the vitality dimension of the SF-36. Some of the improvements in the various domains persisted for > 6 months. Female patients prescribed home oxygen therapy appear to have a greater overall improvement in health-related quality of life and survival than males. Follow-up is continuing.

The MOS SF-36 health survey questionnaire in severe chronic airflow limitation: comparison with the Nottingham Health Profile.

This study documents the cross-sectional, health-related quality of life (HRQOL) measures obtained at baseline for patients with severe chronic airways limitation (CAL) being assessed for home oxygen therapy (HOT) at the Flinders Medical Centre, Adelaide, South Australia. Two generic quality of life instruments, the Nottingham Health Profile (NHP) and the Medical Outcomes Study (MOS) short form 36-item questionnaire (SF-36), were administered by interview to the same patients to permit comparisons to be made between the two instruments. SF-36 mean scores were also compared with scores obtained in separate studies of a South Australian elderly general population and of groups of Australian subjects with various medical and psychiatric conditions. NHP mean scores were compared with scores from an elderly group of Adelaide residents from a household survey. HRQOL measures were obtained for 60 patients, 32 males and 28 females. At assessment for HOT, patients with severe CAL were experiencing severe impairment in their quality of life in comparison to age-matched South Australian norms, with physical disability the major limitation. There were several significant correlations between the domains of the SF-36 and the NHP which were predominantly gender-specific. Only small decrements in mental health were found with the SF-36 questionnaire. The SF-36 and the NHP appear to provide discrepant information for severely disabled CAL patients for the subjective domains of emotional and mental health.

Abatement of tropospheric ozone: effects of strategies to improve air quality on public health and other sectors.

The National Health and Medical Research Council's air quality goal for ozone in the troposphere (near the earth's surface) is 0.12 parts per million (ppm), averaged over one hour, similar to the United States standard, but less stringent than the guideline for Europe. We aimed to identify the environmental, economic and social changes that would be associated with changing the goal. Methods included literature review, economic assessments and group interviews. The group to benefit from lower exposures may include outdoor workers, school children and people not in regular day-time work indoors, because ozone is most prevalent during the daylight hours of the warmer months. A lower level could improve the yield of some crops. The causes and effects of tropospheric ozone are not appreciated except among groups with relevant commercial, industrial or scientific experience. However, the consultations identified frustration about the social problems caused by dependence on private motor vehicles. Short-term costs of compliance with a more stringent goal would fall principally on the users of transport. The value of the benefits was enough for many to support making the ozone goal more stringent, but those who required a demonstration of financial benefit (even including savings of health care costs) did not support any change to the goal. Based primarily on averted detriment to health, we recommend the more stringent level of 0.08 ppm (one-hour average) as the goal for the year 2005 in Australia and elsewhere. The addition of a goal with longer averaging time is also proposed.

Initial trends in quality of life and survival in CAL patients on domiciliary oxygen therapy.

Domiciliary oxygen therapy has become a major form of treatment for chronic airflow limitation (CAL), and has been demonstrated to increase survival and reduce hospitalization. The impact of long-term domiciliary oxygen therapy on health-related quality of life is less clear. This study was conducted to document prospectively the quality of life and survival of patients with CAL after being prescribed domiciliary oxygen therapy at the Flinders Medical Centre in South Australia. The study sample consisted of 57 adult patients (29 males and 28 females, aged 80 yrs or less) with severe CAL referred to the Respiratory Unit for domiciliary oxygen therapy. Prior to the commencement of oxygen therapy, baseline physiological assessment was performed and the Nottingham Health Profile (NHP), the Chronic Respiratory Disease Questionnaire (CRDQ), a Quality of Life Thermometer (QOLTH) and Life Satisfaction Index (LSI) were used to measure the health-related quality of life (HR-QOL). Follow-ups occurred at 3 and 6 months after the commencement of home oxygen therapy. Quality of life at baseline was not correlated with the physiological parameters of lung function and blood gas analysis. However, considerable correlation was found between two of the quality of life instruments used. The female patients on home oxygen therapy experienced some improvement in several dimensions of quality of life measured by the instruments. The observations were less clearcut for males. By the time the patients' physiological and clinical condition has deteriorated for them to fulfil prescription guidelines for home oxygen therapy, patients with chronic airflow limitation are experiencing a marked reduction in quality of life. However, the strength of the reported findings must be tempered by remaining questions over the validity of the instruments and their responsiveness to change; and by the small number of enrolments so far, and the relatively short period of follow-up.

Trends in chronic obstructive pulmonary disease mortality in Australia.

OBJECTIVE: To examine trends in mortality from chronic obstructive pulmonary disease in the Australian population from 1964 to 1990. DESIGN: Review of national data on deaths from chronic obstructive pulmonary disease. We calculated direct annual age-standardised mortality rates for women and men (based on the 1976 age distribution of the Australian population), cumulative mortality rates and future mortality trends. Age-standardised mortality rates based on the world standard population were calculated and compared with mortality rates from lung cancer. RESULTS: Male age-standardised mortality increased 1.6-fold from 1964 to 1970 and subsequently declined. In 1990 the male mortality rate was 5% less than in 1964. Female age-standardised mortality has shown a 2.6-fold increase from 1964 to 1990. CONCLUSIONS: Chronic obstructive pulmonary disease seems likely to be a major health problem in Australia for many years to come. If present trends continue, female mortality from chronic obstructive pulmonary disease may equal male mortality by the middle of the next decade.

Home oxygen therapy: an audit of survival.

A retrospective audit of the medical records and respiratory function data of 186 subjects placed on long term continuous home oxygen therapy between 1979 and 1988 was undertaken. Kaplan-Meier survival curves were constructed for subjects with Chronic Obstructive Airways Disease (COAD) and Interstitial Lung Disease (ILD). There was an almost twofold greater mortality rate for COAD subjects at 12 months when compared to the Medical Research Council Working Party (MRC) and the Nocturnal Oxygen Therapy multicentre clinical trials (NOTT). However, the mean values of the baseline physiological parameters were similar to these major studies of long term oxygen therapy. Survival of ILD patients was significantly less than COAD patients (p less than 0.001). Within both disease categories, females survived significantly longer than males. Within the COAD category the observed sex difference was not abolished when the data was controlled for age, Pco2, Po2 and pack-years (as an estimate of total cigarette consumption). However, prior smoking history appeared to modify the male-female difference in COAD survival. These are the first Australian survivorship data for patients on long term oxygen therapy. The more adverse survival figures compared with the overseas studies may reflect the co-existence of other diseases.