Mortality in the first year of aged care services in Australia.

OBJECTIVE: To examine the one-year mortality of Australians entering aged care services compared with the general population. METHODS: A population-based analysis evaluating one-year mortality among people who received first ever aged care services in 2013 compared with the general population was conducted. RESULTS: In 2013, 3.3 million Australians were ≥ 65 years and 34 919 (1%) entered permanent residential care, 23 288 (0.7%) respite care, 20 265 (0.6%) commenced home care packages, and 15 387 (0.5%) transition care. Individuals receiving aged care services had higher mortality than the general population, with those entering permanent residential care (age and sex direct standardised mortality rate ratio = 10.1, 95% CI: 9.8-10.5) having the greatest difference, followed by people accessing respite (7.2, 95% CI: 6.9-7.6), transition (4.6, 95% CI: 4.4-4.9) and home care (4.1, 95% CI: 3.9-4.4). Significant variation by sex and age was observed. CONCLUSION: Our study has identified significant variations in mortality rates that highlight which cohorts entering aged care are the most vulnerable.

The evidence for services to avoid or delay residential aged care admission: a systematic review.

BACKGROUND: Interventions that enable people to remain in their own home as they age are of interest to stakeholders, yet detailed information on effective interventions is scarce. Our objective was to systematically search and synthesise evidence for the effectiveness of community-based, aged care interventions in delaying or avoiding admission to residential aged care. METHOD: Nine databases were searched from January 2000 to February 2018 for English publications. Reference lists of relevant publications were searched. The databases yielded 55,221 citations and 50 citations were gleaned from other sources. Where there was sufficient homogeneity of study design, population, intervention and measures, meta-analyses were performed. Studies were grouped by the type of intervention: complex multifactorial interventions, minimal/single focus interventions, restorative programs, or by the target population (e.g. participants with dementia). RESULTS: Data from 31 randomised controlled trials (32 articles) that met our inclusion criteria were extracted and analysed. Compared to controls, complex multifactorial interventions in community aged care significantly improved older adults' ability to remain living at home (risk difference - 0.02; 95% CI -0.03, - 0.00; p = 0.04). Commonalities in the 13 studies with complex interventions were the use of comprehensive assessment, regular reviews, case management, care planning, referrals to additional services, individualised interventions, frequent client contact if required, and liaison with General Practitioners. Complex interventions did not have a significantly different effect on mortality. Single focus interventions did not show a significant effect in reducing residential aged care admissions (risk difference 0, 95% CI -0.01, 0.01; p = 0.71), nor for mortality or quality of life. Subgroup analysis of complex interventions for people with dementia showed significant risk reduction for residential aged care admissions (RD -0.05; 95% CI -0.09, -0.01; p = 0.02). Compared to controls, only interventions targeting participants with dementia had a significant effect on improving quality of life (SMD 3.38, 95% CI 3.02, 3.74; p < 0.000001). CONCLUSIONS: Where the goal is to avoid residential aged care admission for people with or without dementia, there is evidence for multifactorial, individualised community programs. The evidence suggests these interventions do not result in greater mortality and hence are safe. Minimal, single focus interventions will not achieve the targeted outcomes. TRIAL REGISTRATION: PROSPERO Registration CRD42016050086 .

Competing Principles for Allocating Health Care Resources.

We clarify options for conceptualizing equity, or what we refer to as justice, in resource allocation. We do this by systematically differentiating, expounding, and then illustrating eight different substantive principles of justice. In doing this, we compare different meanings that can be attributed to "need" and "the capacity to benefit" (CTB). Our comparison is sharpened by two analytical tools. First, quantification helps to clarify the divergent consequences of allocations commended by competing principles. Second, a diagrammatic approach developed by economists Culyer and Wagstaff offers a visual and conceptual aid. Of the eight principles we illustrate, only two treat as relevant both a person's initial health state and a person's CTB per resource unit expended: (1) allocate resources so as to most closely equalize final health states and (2) allocate resources so as to equally restore health states to population norms. These allocative principles ought to be preferred to the alternatives if one deems relevant both a person's initial health state and a person's CTB per resource unit expended. Finally, we examine some possibilities for conceptualizing benefits as relative to how badly off someone is, extending Parfit's thought on Prioritarianism (a prioritizing of the worst off). Questions arise as to how much intervention effects accruing to the worse off count for more and how this changes with improving health. We explicate some recent efforts to answer these questions, including in Dutch and British government circles. These efforts can be viewed as efforts to operationalize need as an allocative principle. Each effort seeks to maximize in the aggregate quanta of effect that are differentially valued in favor of the worst off. In this respect, each effort constitutes one type of Prioritarianism, which Parfit failed to differentiate from other types.

Disinvestment policy and the public funding of assisted reproductive technologies: outcomes of deliberative engagements with three key stakeholder groups.

BACKGROUND: Measures to improve the quality and sustainability of healthcare practice and provision have become a policy concern. In addition, the involvement of stakeholders in health policy decision-making has been advocated, as complex questions arise around the structure of funding arrangements in a context of limited resources. Using a case study of assisted reproductive technologies (ART), deliberative engagements with a range of stakeholder groups were held on the topic of how best to structure the distribution of Australian public funding in this domain. METHODS: Deliberative engagements were carried out with groups of ART consumers, clinicians and community members. The forums were informed by a systematic review of ART treatment safety and effectiveness (focusing, in particular, on maternal age and number of treatment cycles), as well as by international policy comparisons, and ethical and cost analyses. Forum discussions were transcribed and subject to thematic analysis. RESULTS: Each forum demonstrated stakeholders' capacity to understand concepts of choice under resource scarcity and disinvestment, and to countenance options for ART funding not always aligned with their interests. Deliberations in each engagement identified concerns around 'equity' and 'patient responsibility', culminating in a broad preference for (potential) ART subsidy restrictions to be based upon individual factors rather than maternal age or number of treatment cycles. Community participants were open to restrictions based upon measures of body mass index (BMI) and smoking status, while consumers and clinicians saw support to improve these factors as part of an ART treatment program, as distinct from a funding criterion. All groups advocated continued patient co-payments, with measures in place to provide treatment access to those unable to pay (namely, equity of access). CONCLUSIONS: Deliberations yielded qualitative, socially-negotiated evidence required to inform ethical, accountable policy decisions in the specific area of ART and health care more broadly. Notably, reductionist, deterministic characterizations of stakeholder 'self-interest' proved unfounded as each group sought to prioritise universal values (in particular, 'equity' and 'responsibility') over specific, within-group concerns. Our results--from an emotive case study in ART--highlight that evidence-informed disinvestment decision-making is feasible, and potentially less controversial than often presumed.

Should there be a female age limit on public funding for assisted reproductive technology?

Should there be a female age limit on public funding for assisted reproductive technology (ART)? The question bears significant economic and sociopolitical implications and has been contentious in many countries. We conceptualise the question as one of justice in resource allocation, using three much-debated substantive principles of justice-the capacity to benefit, personal responsibility, and need-to structure and then explore a complex of arguments. Capacity-to-benefit arguments are not decisive: There are no clear cost-effectiveness grounds to restrict funding to those older women who still bear some capacity to benefit from ART. Personal responsibility arguments are challenged by structural determinants of delayed motherhood. Nor are need arguments decisive: They can speak either for or against a female age limit, depending on the conception of need used. We demonstrate how these principles can differ not only in content but also in the relative importance they are accorded by governments. Wide variation in ART public funding policy might be better understood in this light. We conclude with some inter-country comparison. New Zealand and Swedish policies are uncommonly transparent and thus demonstrate particularly well how the arguments we explore have been put into practice.

Systematic review of computer-navigated total knee arthroplasty.

BACKGROUND: Conventional total knee arthroplasty (TKA) and the more recently available computer-navigated total knee arthroplasty (CNTKA) use alternative methods to achieve correct limb alignment. This systematic review was undertaken to assess the safety and effectiveness of CNTKA compared with conventional TKA. METHODS: A systematic search of multiple databases identified relevant randomized controlled trials published to August 2012. Study inclusion was established through application of a predetermined protocol, with independent assessment by two reviewers. RESULTS: Thirty randomized controlled trials were included. The majority of adverse events associated with CNTKA were minor and comparable with those seen with conventional TKA. Conversion to conventional TKA was required in 1% of patients undergoing CNTKA. Thirteen trials reporting on satisfactory post-operative radiological alignment of the mechanical axis in the frontal plane were suitable for meta-analysis, which showed a significant total odds ratio (non-event) of 2.32 (95% confidence interval: 1.77-3.04) in favour of CNTKA (P < 0.00001). Clinical outcomes were comparable between the two techniques, with longer-term follow-up suggesting that CNTKA provided no benefit over conventional TKA in terms of sustained functional improvements. CONCLUSIONS: At present, it is unclear whether the significant improvements shown in radiological outcomes after CNTKA translate to measurable clinical benefits. Although an assumption could be made that an improvement in post-operative alignment should lead to an improvement in patient-related outcomes, the available literature did not clearly show this. Further, long-term trials are required to address this issue.

Over 150 potentially low-value health care practices: an Australian study.

OBJECTIVE: To develop and apply a novel method for scanning a range of sources to identify existing health care services (excluding pharmaceuticals) that have questionable benefit, and produce a list of services that warrant further investigation. DESIGN AND SETTING: A multiplatform approach to identifying services listed on the Australian Medicare Benefits Schedule (MBS; fee-for-service) that comprised: (i) a broad search of peer-reviewed literature on the PubMed search platform; (ii) a targeted analysis of databases such as the Cochrane Library and National Institute for Health and Clinical Excellence (NICE) "do not do" recommendations; and (iii) opportunistic sampling, drawing on our previous and ongoing work in this area, and including nominations from clinical and non-clinical stakeholder groups. MAIN OUTCOME MEASURES: Non-pharmaceutical, MBS-listed health care services that were flagged as potentially unsafe, ineffective or otherwise inappropriately applied. RESULTS: A total of 5209 articles were screened for eligibility, resulting in 156 potentially ineffective and/or unsafe services being identified for consideration. The list includes examples where practice optimisation (ie, assessing relative value of a service against comparators) might be required. CONCLUSION: The list of health care services produced provides a launchpad for expert clinical detailing. Exploring the dimensions of how, and under what circumstances, the appropriateness of certain services has fallen into question, will allow prioritisation within health technology reassessment initiatives.

The ASTUTE Health study protocol: deliberative stakeholder engagements to inform implementation approaches to healthcare disinvestment.

BACKGROUND: Governments and other payers are yet to determine optimal processes by which to review the safety, effectiveness, and cost-effectiveness of technologies and procedures that are in active use within health systems, and rescind funding (partially or fully) from those that display poor profiles against these parameters. To further progress a disinvestment agenda, a model is required to support payers in implementing disinvestment in a transparent manner that may withstand challenge from vested interests and concerned citizens. Combining approaches from health technology assessment and deliberative democratic theory, this project seeks to determine if and how wide stakeholder engagement can contribute to improved decision-making processes, wherein the views of both vested and non-vested stakeholders are seen to contribute to informing policy implementation within a disinvestment context. METHODS/DESIGN: Systematic reviews pertaining to illustrative case studies were developed and formed the evidence base for discussion. Review findings were presented at a series of deliberative, evidence-informed stakeholder engagements, including partisan (clinicians and consumers) and non-partisan (representative community members) stakeholders. Participants were actively facilitated towards identifying shared and dissenting perspectives regarding public funding policy for each of the case studies and developing their own funding models in response to the evidence presented. Policy advisors will subsequently be invited to evaluate disinvestment options based on the scientific and colloquial evidence presented to them, and to explore the value of this information to their decision-making processes with reference to disinvestment. DISCUSSION: Analysis of the varied outputs of the deliberative engagements will contribute to the methodological development around how to best integrate scientific and colloquial evidence for consideration by policy advisors. It may contribute to the legitimization of broad and transparent stakeholder engagement in this context. It is anticipated that decision making will benefit from the knowledge delivered through informed deliberation with engaged stakeholders, and this will be explored through interviews with key decision makers.

Engaging clinicians in evidence-based disinvestment: role and perceptions of evidence.

OBJECTIVES: The aim of this study was to determine how evidence from systematic review (SR) is perceived and negotiated by expert stakeholders in considering a technology for potential disinvestment. METHODS: An evidence-informed stakeholder engagement examined results from a diagnostic accuracy SR of vitamin B12 and folate tests. Pathologists deliberated around the SR findings to generate an informed contribution to future policy for the funding of B12 and folate tests. Deliberations were transcribed and subject to qualitative analysis. RESULTS: Pathologists did not engage with findings from the SR in depth; rather they sought to contest the terms of the problem driving the review and attempted to reframe it. Pathologists questioned the usefulness of SR outcomes given the variable definitions of B12 deficiency and deferred addressing disinvestment options specifically pertaining to B12 testing. However, folate testing was proffered as a potential disinvestment candidate, based upon pathologists' definition of "appropriate" evidence beyond the bounds of the SR. CONCLUSIONS: The value of SR to informing disinvestment deliberations by expert stakeholders may be a function of timing as well as content. Engagement of stakeholders in co-produced evidence may be required at two levels: (i) Early in the synthesis phase to help shape the SR and harmonize expert views with the available evidence (including gaps); (ii) Collaboration in primary research to fill evidence-gaps thus supporting evidence-based disinvestment. Without this, information asymmetry between clinically engaged experts and decision makers may preclude the collaborative, informed, and technical discussions required to generate productive policy change.

News and social media: windows into community perspectives on disinvestment.

OBJECTIVES: The aim of this study, in the context of disinvestment related health technology assessment, is to examine whether analysis of Web 2.0--commercial media output, blogs, and discussion forums--can provide an understanding of media framing, community perspectives, and the sociopolitical aspects of an entrenched technology. METHODS: Thematic analysis of relevant data from fifty-nine media articles, thirty-nine discussion forums, thirteen blogs, and three Facebook pages relating to our case study: public funding for assisted reproductive technology services. Mainstream media and community-based social media responses were compared. RESULTS: Media responses were narrow, primarily describing emotive individual narratives or the political nexus of interests. Community (including patient) responses were broader including discussion of opportunity cost and vested interests but mostly reflected the polar ends of the debate, diverging strongly for or against disinvestment from public funding. CONCLUSION: Web2.0 and media analysis offers an inexpensive method to capture media portrayal, divergent community responses both to that portrayal and independent of it, and insight into the sociopolitical aspects of an entrenched technology undergoing disinvestment debate.

Assisted reproductive technologies: a systematic review of safety and effectiveness to inform disinvestment policy.

OBJECTIVE: Health policy relating to assisted reproductive technologies (ART) has been variably informed by clinical evidence, social values, political and fiscal considerations. This systematic review examined key factors associated with specific benefits and harms of ART to inform the development of a model for generating policy recommendations within an Australian disinvestment research agenda. METHODS: Six databases were searched from 1994 to 2009. Included articles contained data on safety and/or effectiveness of in vitro fertilisation (IVF) or IVF with intracytoplasmic sperm injection with reference to female age, male age or cycle rank. Narrative descriptions of key outcomes (live birth, miscarriage) were constructed alongside tabular summaries. RESULTS: Sixty-eight studies and one registry report were included. There was substantial heterogeneity present within the evidence-base which limited the strength and scope of conclusions that could be drawn. However, this review does affirm the differential effectiveness associated with the ageing of ART patients with regard to live birth and miscarriage. CONCLUSION: From the available evidence, it was not possible to determine an explicit age or cycle rank that could be used to formulate defensible policy responsive to identified differential effectiveness. Stakeholder interpretation of this evidence-base may assist in developing policy that can incorporate uncertainty and reflect social values.

Diagnostic performance of serum cobalamin tests: a systematic review and meta-analysis.

AIMS: Serum cobalamin (cbl, vitamin B(12)) tests are routinely ordered for investigating conditions potentially amenable to cbl supplementation. This study aimed to systematically assess the evidence of diagnostic accuracy for serum cbl tests across patient subgroups. METHODS: Seven medical databases were searched (1990 to November 2009). Studies were included that compared serum cbl to a reference standard (all reference standards employed). Study quality was assessed using QUADAS. Summary estimates of test performance were determined using the bivariate model and hierarchical summary receiver operating characteristic curves (HSROC). RESULTS: Of 2878 identified studies, 54 were included. Studies rated poorly against QUADAS criteria. Positive (PLR) and negative likelihood ratios (NLR) were 2.72 [95% confidence interval (CI) 1.95, 3.81] and 0.59 (0.49, 0.72), respectively (studies employing methylmalonic acid as the referent). In studies employing a clinical reference standard, PLR was 3.33 (0.92, 12.10) and NLR 0.34 (0.13, 0.89). Test performance did not vary by clinical indication, test method or age. CONCLUSION: This review was limited by the quality of the evidence base and lack of a gold standard. From the available evidence, diagnosis of conditions amenable to cbl supplementation on the basis of serum cbl level alone cannot be considered a reliable approach to investigating suspected vitamin deficiency.

Scalpel safety in the operative setting: a systematic review.

BACKGROUND: The complex environment of the operative setting provides multiple opportunities for health care workers to sustain scalpel injuries; scalpels are the second most frequent source of sharps injuries in this setting. Little evidence has been published detailing the effectiveness of proposed safety procedures and devices. METHODS: A systematic search strategy was used to identify relevant studies. Studies were included based on the application of a predetermined protocol, an independent assessment by 2 reviewers, and a consensus decision. Nineteen articles formed the evidence base for this review. RESULTS: Little high-level evidence was available. The results of studies reporting on 5 different devices/procedures were identified: the use of cut-resistant gloves/liners decreased the number of glove perforations in comparison with double latex gloves alone but lessened the wearer's dexterity and tactile sensation; the benefit derived from the use of the hands-free passing technique seemed equivocal; "sharpless surgery" was found to be feasible; a single-handed blade remover prevented at least as many injuries as a safety scalpel; and some shoe materials provided superior foot protection. CONCLUSION: The lack of available evidence highlights the need for the generation of a methodologically rigorous, clinically relevant, and statistically valid body of primary research in this area to support appropriate and effective safety interventions.

Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review.

OBJECTIVE: To assess the safety and efficacy of self-expanding metallic stents (SEMS) placement for the relief of malignant colorectal obstruction in comparison to surgical procedures through a systematic review of the literature. SUMMARY BACKGROUND DATA: Conventional therapies for relieving colorectal obstructions caused by cancer have high rates of morbidity and mortality, particularly when performed under emergency conditions, and palliative procedures resulting in colostomy creation can be a burden for patients and caregivers. METHODS: A systematic search strategy was used to retrieve relevant studies. Inclusion of papers was established through application of a predetermined protocol, independent assessment by 2 reviewers, and a final consensus decision. Eighty-eight articles, 15 of which were comparative, formed the evidence base for this review. RESULTS: Little high-level evidence was available. However, the data suggested that SEMS placement was safe and effective in overcoming left-sided malignant colorectal obstructions, regardless of the indication for stent placement or the etiology of the obstruction. Additionally, SEMS placement had positive outcomes when compared with surgery, including overall shorter hospital stays, and a lower rate of serious adverse events. Postoperative mortality appeared comparable between the 2 interventions. Combining SEMS placement with elective surgery also appeared safer and more effective than emergency surgery, with higher rates of primary anastomosis, lower rates of colostomy, shorter hospital stays, and lower overall complication rates. CONCLUSIONS: Stenting appears to be a safe and effective addition to the armamentarium of treatment options for colorectal obstructions. However, the small sample sizes of the included studies limited the validity of the findings of this review. The results of additional comparative studies currently being undertaken will add to the certainty of the conclusions that can be drawn.