The effects of self-assessed health: Dealing with and understanding misclassification bias.

Self-assessed health (SAH) is often used in health econometric models as the key explanatory variable or as a control variable. However, there is evidence questioning its test-retest reliability, with up to 30% of individuals changing their response. Building on recent advances in the econometrics of misclassification, we develop a way to consistently estimate and account for misclassification in reported SAH by using data from a large representative longitudinal survey where SAH was elicited twice. From this we gain new insights into the nature of SAH misclassification and its potential for biasing health econometric estimates. The results from applying our approach to nonlinear models of long-term mortality and chronic morbidities reveal that there is substantial heterogeneity in misclassification patterns. We find that adjusting for misclassification is important for estimating the impact of SAH. For other explanatory variables of interest, we find significant but generally small changes to their estimates when SAH misclassification is ignored.

Predicting the Long-Term Gains in Health-Related Quality of Life After Total Knee Arthroplasty.

BACKGROUND: We investigated the predictors of long-term gains in quality-adjusted life years (QALYs) from total knee arthroplasty (TKA) and the patient attributes that predicted cost-effective TKA. METHODS: Data on TKA patients (n = 570) from 2006 to 2007 were extracted from a single-institution registry. QALY gains over 7 years post surgery were calculated from health-related quality of life (HrQoL) scores measured preoperatively and annually postoperatively using the short-form health survey (SF-12) instrument. Multivariate linear regression analysis investigated the predictors of QALY gain from TKA from a broad range of preoperative patient characteristics and was used to predict QALY gains for each individual. Patients were grouped into deciles according to their predicted QALY gain, and the cost-effectiveness of each decile was plotted on the cost-effectiveness plane. Patient attribute differences between deciles were decomposed. RESULTS: After exclusions and dropout, data were available for 488 patients. The average estimated QALY gain over 7 years was 0.77 (95% confidence interval [CI] 0.70-0.83). Predictors significantly associated with smaller QALY gains were comorbidities (Charlson comorbidity index 3+ coefficient -0.54 CI -0.15 to -0.92), the absence of severe osteoarthritis in the ipsilateral knee (-0.51 CI -0.16 to -0.85), preoperative HrQoL (standardized coefficient -0.34 CI -0.26 to -0.43), the requirement for an interpreter (-0.24 CI -0.05 to -0.44), and age (-0.01 CI -0.01 to -0.02). The largest difference between cost-effective and non-cost-effective deciles was relatively high preoperative HrQoL in the non-cost-effective decile. CONCLUSION: TKA is likely to be cost-effective for most patients except those with unusually high preoperative HrQoL or a lack of severe osteoarthritis. The poorer outcomes for those requiring an interpreter requires further research.

Growth of linked hospital data use in Australia: a systematic review.

Objective The aim of the present study was to quantify and understand the utilisation of linked hospital data for research purposes across Australia over the past two decades. Methods A systematic review was undertaken guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 checklist. Medline OVID, PsycINFO, Embase, EconLit and Scopus were searched to identify articles published from 1946 to December 2014. Information on publication year, state(s) involved, type of data linkage, disease area and purpose was extracted. Results The search identified 3314 articles, of which 606 were included; these generated 629 records of hospital data linkage use across all Australian states and territories. The major contributions were from Western Australia (WA; 51%) and New South Wales (NSW; 32%) with the remaining states and territories having significantly fewer publications (total contribution only 17%). WA's contribution resulted from a steady increase from the late 1990s, whereas NSW's contribution is mostly from a rapid increase from 2010. Current data linkage is primarily used in epidemiological research (73%). Conclusion More than 80% of publications were from WA and NSW, whereas other states significantly lag behind. The observable growth in these two states clearly demonstrates the underutilised opportunities for data linkage to add value in health services research in the other states. What is known about the topic? Linking administrative hospital data to other data has the potential to be a cost-effective method to significantly improve health policy. Over the past two decades, Australia has made significant investments in improving its data linkage capabilities. However, several articles have highlighted the many barriers involved in using linked hospital data. What does this paper add? This paper quantitatively evaluates the performance across all Australian states in terms of the use of their administrative hospital data for research purposes. The performance of states varies considerably, with WA and NSW the clear stand-out performers and limited outputs currently seen for the other Australian states and territories. What are the implications for practitioners? Given the significant investments made into data linkage, it is important to continue to evaluate and monitor the performance of the states in terms of translating this investment into outputs. Where the outputs do not match the investment, it is important to identify and overcome those barriers limiting the gains from this investment. More generally, there is a need to think about how we improve the effective and efficient use of data linkage investments in Australia.

The effects of reduced copayments on discontinuation and adherence failure to statin medication in Australia.

This paper assesses whether the concession card, which offers discounted out-of-pocket costs for prescription medicines in Australia, affects discontinuation and adherence to statin therapy. The analysis uses data from the Australian Hypertension and Absolute Risk Study (AusHEART), which involves patients aged 55 years and over who visited a GP between April and June 2008. Socioeconomic and clinical information was collected and linked to administrative data on pharmaceutical use. Patients without a concession card were 63% more likely (hazard ratio (HR) 95% confidence interval (CI): 1.14-2.33) to discontinue and 60% (odds ratio (OR) CI: 1.04-2.44) more likely to fail to adhere to therapy compared to concessional patients. Smokers were 2.12 (HR CI: 1.39-3.22) times more likely to discontinue use and 2.23 (OR CI: 1.35-3.71) times more likely to fail to adhere compared to non-smokers. Patients who had recently initiated statin medication were also 2.28 (HR CI: 1.22-4.28) times more likely to discontinue use. In conclusion, higher copayments act as a disincentive for persistent and adherent use of statin medication.

The economic cost of bereavement in Scotland.

Aspects of the socioeconomic costs of bereavement in Scotland were estimated using 3 sets of data. Spousal bereavement was associated with increased mortality and longer hospital stays, with additional annual cost of around £20 million. Cost of bereavement coded consultations in primary care was estimated at around £2.0 million annually. In addition, bereaved people were significantly less likely to be employed in the year of and 2 years after bereavement than non-bereaved matched controls, but there were no significant differences in income between bereaved people and matched controls before and after bereavement.

Effective Feedback to Improve Primary Care Prescribing Safety (EFIPPS) a pragmatic three-arm cluster randomised trial: designing the intervention (ClinicalTrials.gov registration NCT01602705).

BACKGROUND: High-risk prescribing in primary care is common and causes considerable harm. Feedback interventions have small/moderate effects on clinical practice, but few trials explicitly compare different forms of feedback. There is growing recognition that intervention development should be theory-informed, and that comprehensive reporting of intervention design is required by potential users of trial findings. The paper describes intervention development for the Effective Feedback to Improve Primary Care Prescribing Safety (EFIPPS) study, a pragmatic three-arm cluster randomised trial in 262 Scottish general practices. METHODS: The NHS chose to implement a feedback intervention to utilise a new resource, new Prescribing Information System (newPIS). The development phase required selection of high-risk prescribing outcome measures and design of intervention components: (1) educational material (the usual care comparison), (2) feedback of practice rates of high-risk prescribing received by both intervention arms and (3) a theory-informed behaviour change component to be received by one intervention arm. Outcome measures, educational material and feedback design, were developed with a National Health Service Advisory Group. The behaviour change component was informed by the Theory of Planned Behaviour and the Health Action Process Approach. A focus group elicitation study and an email Delphi study with general practitioners (GPs) identified key attitudes and barriers of responding to the prescribing feedback. Behaviour change techniques were mapped to the psychological constructs, and the content was informed by the results of the elicitation and Delphi study. RESULTS: Six high-risk prescribing measures were selected in a consensus process based on importance and feasibility. Educational material and feedback design were based on current NHS Scotland practice and Advisory Group recommendations. The behaviour change component was resource constrained in development, mirroring what is feasible in an NHS context. Four behaviour change interventions were developed and embedded in five quarterly rounds of feedback targeting attitudes, subjective norms, perceived behavioural control and action planning (2×). CONCLUSIONS: The paper describes a process which is feasible to use in the resource-constrained environment of NHS-led intervention development and documents the intervention to make its design and implementation explicit to potential users of the trial findings. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01602705.

Neurobehavioral consequences of chronic intrauterine opioid exposure in infants and preschool children: a systematic review and meta-analysis.

BACKGROUND: It is assumed within the accumulated literature that children born of pregnant opioid dependent mothers have impaired neurobehavioral function as a consequence of chronic intrauterine opioid use. METHODS: Quantitative and systematic review of the literature on the consequences of chronic maternal opioid use during pregnancy on neurobehavioral function of children was conducted using the Meta-analysis of Observational Studies in Epidemiology (MOOSE) and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We searched Cinahl, EMBASE, PsychINFO and MEDLINE between the periods of January 1995 to January 2012. RESULTS: There were only 5 studies out of the 200 identified that quantitatively reported on neurobehavioral function of children after maternal opioid use during pregnancy. All 5 were case control studies with the number of exposed subjects within the studies ranging from 33-143 and 45-85 for the controls. This meta-analysis showed no significant impairments, at a non-conservative significance level of p < 0.05, for cognitive, psychomotor or observed behavioural outcomes for chronic intra-uterine exposed infants and pre-school children compared to non-exposed infants and children. However, all domains suggested a trend to poor outcomes in infants/children of opioid using mothers. The magnitude of all possible effects was small according to Cohen's benchmark criteria. CONCLUSIONS: Chronic intra-uterine opioid exposed infants and pre-school children experienced no significant impairment in neurobehavioral outcomes when compared to non-exposed peers, although in all domains there was a trend to poorer outcomes. The findings of this review are limited by the small number of studies analysed, the heterogenous populations and small numbers within the individual studies. Longitudinal studies are needed to determine if any neuropsychological impairments appear after the age of 5 years and to help investigate further the role of environmental risk factors on the effect of 'core' phenotypes.

Does increasing community and liquor licensees' awareness, police activity, and feedback reduce alcohol-related violent crime? A benefit-cost analysis.

Approximately half of all alcohol-related crime is violent crime associated with heavy episodic drinking. Multi-component interventions are highly acceptable to communities and may be effective in reducing alcohol-related crime generally, but their impact on alcohol-related violent crime has not been examined. This study evaluated the impact and benefit-cost of a multi-component intervention (increasing community and liquor licensees' awareness, police activity, and feedback) on crimes typically associated with alcohol-related violence. The intervention was tailored to weekends identified as historically problematic in 10 experimental communities in NSW, Australia, relative to 10 control ones. There was no effect on alcohol-related assaults and a small, but statistically significant and cost-beneficial, effect on alcohol-related sexual assaults: a 64% reduction in in the experimental relative to control communities, equivalent to five fewer alcohol-related sexual assaults, with a net social benefit estimated as AUD$3,938,218. The positive benefit-cost ratio was primarily a function of the value that communities placed on reducing alcohol-related harm: the intervention would need to be more than twice as effective for its economic benefits to be comparable to its costs. It is most likely that greater reductions in crimes associated with alcohol-related violence would be achieved by a combination of complementary legislative and community-based interventions.

The cost-effectiveness of tailored, postal feedback on general practitioners' prescribing of pharmacotherapies for alcohol dependence.

AIMS: The aims of this study were to conduct a randomised controlled trial to evaluate the cost-effectiveness of tailored, postal feedback on general practitioners' (GPs) prescribing of acamprosate and naltrexone for alcohol dependence relative to current practice and its impact on alcohol dependence morbidity. METHODS: Rural communities in New South Wales, Australia, were randomised into experimental (N=10) and control (N=10) communities. Tailored feedback on their prescribing of alcohol pharmacotherapies was mailed to GPs from the experimental communities (N=115). Segmented regression analysis was used to examine within and between group changes in prescribing and alcohol dependence hospitalisation rates compared to the control communities. Incremental cost-effectiveness ratios (ICERs) were estimated per additional prescription of pharmacotherapies and per alcohol dependence hospitalisation(s) averted. RESULTS: Post-intervention changes, relative to the control communities, in GPs' prescribing rate trends in the experimental communities significantly increased for acamprosate (ß=0.24, 95% CI: 0.13-0.35, p<0.001), and significantly decreased for naltrexone (ß = -0.12, 95% CI: -0.17 to -0.06) per quarter. Quarterly hospitalisation trend rates for alcohol dependence, as principal diagnosis, significantly decreased (ß=-0.07, 95% CI: -0.13 to -0.01, p<0.05), compared to control communities. The median ICER per quarterly hospitalisation(s) averted due to intervention was dominant (dominant--$12,750). CONCLUSION: Postal, tailored feedback to GPs on their prescribing of acamprosate and naltrexone for alcohol dependence was a cost-effective intervention, in rural communities of NSW, to increase the overall prescribing of pharmacotherapies with a plausible effect on incidence reduction of hospitalisations for alcohol dependence as principal diagnosis.

The efficiency of a volumetric alcohol tax in Australia.

BACKGROUND: In Australia and elsewhere, fiscal measures such as alcohol taxation are a commonly used intervention and cost-effective strategy to reduce alcohol consumption and associated harm. However, alcohol taxation policies distort the market for alcohol, specifically increasing the marginal cost of alcohol. It is proposed that a volumetric tax, which taxes alcohol equally across all beverage types, is less distortive of consumer preferences and more efficient at reducing alcohol consumption than the current Australian tax model, where taxes are charged at varying amounts per litre of pure alcohol, depending on the beverage type. OBJECTIVE: This paper quantifies the effect of four different alcohol taxation systems, relative to the current Australian system: two different types of volumetric taxation (deadweight loss neutral and tax revenue neutral); the recent strategy trialled in Australia of increasing the tax only on ready-to-drink alcoholic beverages (i.e. premixed spirits); and a tiered tax system, which may be more politically acceptable. METHODS: A partial equilibrium approach was used to measure taxation revenue, consumer welfare and consumption in alcohol markets. Estimates of taxation revenue, consumer welfare and consumption were first calculated for 2008 and then compared with the four scenarios considered. RESULTS: Relative to the previous alcohol taxation scheme in Australia, the taxation strategy that increased the tax solely on ready-to-drink alcoholic beverages increased taxation revenue by 479 million Australian dollars ($A), reduced pure alcohol consumption by 754 000 litres and increased the net deadweight loss of taxation by $A62 million. For a tax-neutral approach, for the same level of taxation revenue as is currently generated, a volumetric tax could substantially reduce the cost of taxation (as described by the net loss in consumer welfare) by $A177 million and reduce pure alcohol consumption by 4 68 000 litres. Under a deadweight loss-neutral scenario, for the same amount of deadweight loss generated from the previous taxation scenario, taxation revenue could be increased by $A1153 million, in addition to reducing pure alcohol consumption by 4 316 000 litres. A tiered taxation regime, as modelled here, could decrease pure alcohol consumption by 2 616 000 litres whilst increasing taxation revenue by $A1101 million. However, this scenario would also increase the deadweight loss of taxation by $A113 million. CONCLUSION: From these scenarios, it can be shown that, for the same tax revenue, consumer welfare can be reduced or, for the same level of loss to consumer welfare, taxation revenue can be increased. Both these scenarios result in a reduction of pure alcohol consumption.

The potential cost-effectiveness of general practitioner delivered brief intervention for alcohol misuse: evidence from rural Australia.

OBJECTIVE: This paper aims to model General Practitioner (GP) delivered screening and brief intervention (BI), and to identify the costs per additional risky drinker who reduces alcohol consumption to low-risk levels, relative to current practice. METHOD: A decision model and nine different scenarios were developed to assess outcomes and costs of GP-delivered screening and BI on the potential number of risky drinkers who reduce their alcohol consumption to low-risk levels in 10 rural communities in New South Wales, Australia. FINDINGS: Based on evidence from current practice, approximately 19% of all risky drinkers visiting GPs annually would reduce alcohol consumption to low-risk levels, of which 0.7% would do so because of GP-delivered screening and BI. If rates of screening and BI are increased to 100%, 36% of these risky drinkers would reduce their drinking to low risk-levels. Alternatively, increments of 10% and 20% in GP-delivered screening and BI would reduce the proportion of risky drinkers by 2.1% and 4.2% respectively. The most cost-effective outcome per additional risky drinker reducing their drinking relative to current practice would be if all of these risky drinkers are screened alone with an ICER of AUD$197. CONCLUSION: These findings indicate that increments in rates of screening and BI delivered by GPs can result in cost-effective reductions per additional risky drinkers reducing their drinking to low-risk levels, relative to current practice. They also imply that achieving substantial reductions in the prevalence of risky drinking in a community will require strategies other than opportunistic screening and BIs by GPs.

The relationship between risky alcohol consumption, crime and traffic accidents in Australian rural communities.

AIM: To estimate the alcohol-attributable crime and traffic accidents for rural communities in Australia, controlling for potential bias. METHOD: For 20 rural communities in New South Wales, Australia, crime and traffic accident data was obtained from police records along with risky alcohol use estimated from a postal questionnaire. The relationship between community levels of risky drinking and crime and traffic accidents that occur in alcohol-related times is analysed controlling for the underlying level of crime by using the rate of incidents that occur in non-alcohol-related times. FINDINGS: For the 20 rural communities, it was estimated that risky alcohol use is likely to have attributed to between 1.4 and 7.7 common assaults per 1000 population and between 0.6 and 1.8 serious traffic injuries or fatalities per 1000 population, every year. CONCLUSIONS: Rural communities in Australia are experiencing a sizeable amount of potentially avoidable harm due to risky alcohol use. Reducing the population levels of those drinking at risk of acute harm or improving the settings in which drinking takes place may have benefits for these communities, especially in terms of crime and traffic accidents.

Households' willingness to pay for a motorcycle helmet in Hanoi, Vietnam.

BACKGROUND: Injuries caused by both non-use of and substandard helmets in motorcycle accidents place a substantial cost on both the Vietnamese government and on victims and their families who are unfortunate enough to experience such an event. OBJECTIVE: To estimate Vietnamese households' willingness to pay (WTP) for a standard motorcycle helmet and to determine factors that affect the households' decision regarding the price at which they would purchase a motorcycle helmet. METHOD: A contingent valuation survey was administered to 420 households in two urban districts and one suburban district of Hanoi from January 2007 to February 2007. Both discrete-choice format and open-ended questions were used to examine households' WTP for a motorcycle helmet. Descriptive analysis and multivariate analysis were used to estimate possible predictors of households' WTP. RESULT: A total of 414 households agreed to participate in the study, giving a response rate of 98%. Eighty-seven percent of respondents owned a motorcycle helmet. Sixty-two percent of respondents agreed to purchase a helmet at the market price of Vietnamese Dong (VND)150 000 ($ US 9.38) [year 2007 values]. Households' WTP varied from VND81 635 to VND289 674 ($US 5.1-18.1), with a mean of VND163 794 ($US 10.24) and a median of VND161 718 ($US 10.11). It was estimated that if the government subsidizes VND61 043 ($US 3.82) for a helmet, 99% of the study population are willing to pay the additional cost for a standard helmet. Those households with a higher income and where the respondents were aged 40-55 years were more likely to purchase a helmet than those with a lower income and those of other ages. CONCLUSION: Respondents were prepared to pay a higher price than the market price of a standard helmet. To improve the quality of helmets in Vietnam, it is recommended that the government subsidize a helmet programme in conjunction with other programmes (such as education and strict enforcement policies) in order to increase the ownership of quality helmets in Vietnam and thereby reduce the severity of motorcycle road traffic injuries.