Out-of-pocket expenditure, need, utilisation, and private health insurance in the Australian healthcare system.

Despite widespread public service provision, public funding, and private health insurance (PHI), 20% of all healthcare expenditure across the OECD is covered by out-of-pocket expenditure (OOPE). This creates an equity concern for the increasing number of individuals with chronic conditions and greater need, particularly if higher need coincides with lower income. Theoretically, individuals may mitigate OOPE risk by purchasing PHI, replacing variable OOPE with fixed expenditure on premiums. Furthermore, if PHI premiums are not risk-rated, PHI may redistribute some of the financial burden from less healthy PHI holders that have greater need to healthier PHI holders that have less need. We investigate if the burden of OOPE for individuals with greater need increases less strongly for individuals with PHI in the Australian healthcare system. The Australian healthcare system provides public health insurance with full, partial, or limited coverage, depending on the healthcare service used, and no risk rating of PHI premiums. Using data from the Household, Income and Labour Dynamics in Australia survey we find that individuals with PHI spend a greater share of their disposable income on OOPE and that the difference in OOPE share between PHI and non-PHI holders increases with greater need and utilisation, contrary to the prediction that PHI may mitigate OOPE. We also show that OOPE is a greater concern for poorer individuals for whom the difference in OOPE by PHI is the greatest.

A stepped down physical activity support program for military service veterans: The Active Choices pilot study.

ISSUE ADDRESSED: Referral to supervised physical activity (PA) programs is an effective treatment for military service veterans (MSVs) suffering from a range of chronic diseases. However, many MSVs fail to maintain PA regimes once discharged from supervision. This pilot study assessed Active Choices, a stepped-down program to support MSVs in the transition from allied health treatment to self-managed PA. METHODS: Participants were 34 Australian MSVs (mean [SD] age = 61 [15.8] years) who were completing supervised referral to an exercise physiologist or physiotherapist. MSVs stepped-down to Active Choices and received a 12-week, evidence-based PA support program (2020-2021). Analyses compared within-group changes in accelerometer-assessed PA at three time points (Weeks 0, 12, and 24; linear mixed model). Program retention, PA choices, and allied healthcare service costs were also evaluated. RESULTS: Relative to baseline (64 [26] min/day), mean (SD) moderate-to-vigorous PA increased (74 [28] min/day; p < .05) and was maintained (62 [28] min/day) at weeks 12 and 24, respectively. Retention in the program was high (86% [29/34 participants] completion rate at 12 weeks), with water-based group activities the most popular PAs of choice (14/24 activities). Average allied healthcare service costs during the study were lower than typical costs for MSVs (60.51 vs. 97.06 AUD/week). CONCLUSION: The findings highlight the potential of Active Choices to support MSVs in the transition from supervised to self-managed MVPA. SO WHAT?: The program could promote the health of veterans and reduce costs for ongoing referral if impact is replicated at scale.

Does doctors' personality differ from those of patients, the highly educated and other caring professions? An observational study using two nationally representative Australian surveys.

OBJECTIVES: Personality differences between doctors and patients can affect treatment outcomes. We examine these trait disparities, as well as differences across medical specialities. DESIGN: Retrospective, observational statistical analysis of secondary data. SETTING: Data from two data sets that are nationally representative of doctors and the general population in Australia. PARTICIPANTS: We include 23 358 individuals from a representative survey of the general Australian population (with subgroups of 18 705 patients, 1261 highly educated individuals and 5814 working in caring professions) as well as 19 351 doctors from a representative survey of doctors in Australia (with subgroups of 5844 general practitioners, 1776 person-oriented specialists and 3245 technique-oriented specialists). MAIN OUTCOME MEASURES: Big Five personality traits and locus of control. Measures are standardised by gender, age and being born overseas and weighted to be representative of their population. RESULTS: Doctors are significantly more agreeable (a: standardised score -0.12, 95% CIs -0.18 to -0.06), conscientious (c: -0.27 to -0.33 to -0.20), extroverted (e: 0.11, 0.04 to 0.17) and neurotic (n: 0.14, CI 0.08 to 0.20) than the general population (a: -0.38 to -0.42 to -0.34, c: -0.96 to -1.00 to -0.91, e: -0.22 to -0.26 to -0.19, n: -1.01 to -1.03 to -0.98) or patients (a: -0.77 to -0.85 to -0.69, c: -1.27 to -1.36 to -1.19, e: -0.24 to -0.31 to -0.18, n: -0.71 to -0.76 to -0.66). Patients (-0.03 to -0.10 to 0.05) are more open than doctors (-0.30 to -0.36 to -0.23). Doctors have a significantly more external locus of control (0.06, 0.00 to 0.13) than the general population (-0.10 to -0.13 to -0.06) but do not differ from patients (-0.04 to -0.11 to 0.03). There are minor differences in personality traits among doctors with different specialities. CONCLUSIONS: Several personality traits differ between doctors, the population and patients. Awareness about differences can improve doctor-patient communication and allow patients to understand and comply with treatment recommendations.

Disposable and reusable instruments in dental health practice: A comparison of cost factors in a public provider organization in Queensland, Australia.

OBJECTIVES: Choosing between reusable instruments (RIs) and disposable instruments (DIs) for dental care provision requires a careful consideration of costs and their contributing factors, alongside other choice criteria. This study aimed to assess the current use of instruments in the West Moreton Oral Health Service (WMOHS) in Queensland, Australia, with a broader goal of informing future practice in this and comparable organizations. METHODS: A cost model was developed reflecting costs arising from procurement, reprocessing and disposal, depending on the RI and DI composition of instrumentation. The current practice in WMOHS was compared to modular (RI-only and DI-only) strategies by considering four standard instrument sets (examination, simple extraction, surgical extraction, restoration) and the annual use of instruments in the organization at large. The use of resources (water, electricity) and emissions (waste) were quantified for each strategy. The robustness of findings was explored across a range of scenarios that involved varying instrument prices, lifespans, factors impacting on the cost of reprocessing (labour, water, energy), the cost of waste disposal and couriering. RESULTS: At the organization level, the current mix of instruments (A$1.28 m per year) was 4% more costly than the lower cost, RI-only alternative (A$1.23 m). However, with lower DI prices or higher labour costs current practice would become the lowest cost option. Results for specific instrument sets varied by service type. DI-only offered the lowest cost option for oral examinations (A$6.29), and the current practice of mixed instrumentation for simple extractions (A$16.56). RI-only sets were less costly in more resource intensive procedures such as surgical extractions (A$40.19) and restorations (A$43.83). In terms of environmental impacts, the use of instruments based on current practice required 37% of water and energy use of an RI-only alternative and generated 36% waste of the DI-only alternative. CONCLUSIONS: Reusable instruments are generally less costly than DIs, but for specific instrument sets the outcome depends on the type of procedure. In some circumstances, mixed instrumentation can provide the lowest cost alternative. While the WMOHS instrument mix used in current practice does not minimize cost for the provider, it may be justified in light of operational risks, logistics and uncertainty regarding cost factors.

Are stunted child - overweight mother pairs a real defined entity or a statistical artifact?

In a methodological contribution, Dieffenbach & Stein (DS) (The Journal of Nutrition, 142(4), 771-773.) concluded that the double burden of malnutrition (DBM), represented by stunted child - overweight mother pairs (SCOM), is a statistical artifact, meaning that SCOM does not describe a unique phenomenon because the observed rates of SCOM across a number of countries were not strongly different from the product of observed rates of maternal overweight (OM) and child stunting (SC), which DS referred to as the expected rate of SCOM. However, a growing literature continues to use SCOM as an indicator of the DBM. This study shows that the analysis by DS is not sufficient to conclude that SCOM can be explained by the co-occurrence of OM and SC due to chance alone because the analysis by DS was conducted at the country level, but applied to SCOM, which is a household-level variable. Using Demographic and Health Surveys data from 202 country-year data sets, we do not confirm important implicit assumptions that are required for the claim by DS to be supported. We also outline that comparing the expected to the observed rate of SCOM is primarily informative when putting it in relation to factors that influence the supply and demand of food consumed by households. When considering these factors, we find further evidence that it is misleading to consider SCOM as a statistical artifact, as the difference between the observed and the expected rate of SCOM significantly differs by household wealth. Recognizing that SCOM is a distinct phenomenon is important for policymakers who develop double-duty strategies that address malnutrition, and for researchers who need useful indicators to study the determinants of malnutrition at the household level.

Using Australian panel data to account for unobserved factors in measuring inequities for different channels of healthcare utilization.

Inequity in healthcare utilization is typically measured as the unequal distribution of services by observable non-need indicators, such as income, after controlling for observable need indicators. However, important sources of unequal healthcare utilization are often unobserved. The unobserved element may reflect need factors, such as imperfectly measured severity of illness, that would predict greater utilization across different healthcare channels, but also based on choice, such as patient preferences to use a particular healthcare channel over an alternative one, which may differ in its effect between channels. Accounting for unobserved sources of utilization may, therefore, help to understand contradictory inequalities between different healthcare channels, such as pro-poor inequalities for general practitioner use and pro-rich inequalities for specialist visits. This paper uses survey data from the Household Income and Labour Dynamics in Australia and panel data methods to investigate if seemingly contradictory inequalities between different healthcare channels are explained by latent individual-level heterogeneity. Results show that unobserved individual-level heterogeneity affects inequities across different healthcare channels, providing indications that the unobserved element may primarily represent unobserved need.

Physiotherapy student clinical placements in Australian private practice: Patient-reported outcomes with supervised student care.

BACKGROUND AND PURPOSE: The sustainability of physiotherapy clinical placements is an ongoing challenge, yet there is potential to increase placement capacity within the private practice sector. Barriers to hosting students, including perceived impacts on patient care, reportedly limit the uptake of hosting students within this setting. This study aimed to evaluate the effect of physiotherapy student involvement on patient-reported Global Rating of Change (GRoC) in Australian physiotherapy private practice care. METHODS: A cross-sectional, patient survey study was conducted in three private physiotherapy practices over two 5-week periods. At their completion of care, participants completed the survey seeking demographic information, GRoC and aspects of care including number of consultations involving students, proportion of physiotherapy time involving students and frequency of student involvement in treatment delivery. After accounting for clinic-level differences, ordinal logistic regression analyses were performed to explore the impact of supervised student care on GRoC. RESULTS: 119 participants across three practices completed the survey. There were no significant associations between patient-reported GRoC and: (1) student involvement in patient care; (2) number of consultations involving students; (3) proportion of physiotherapy time involving students; or (4) frequency of student involvement in treatment delivery (p > 0.05). CONCLUSIONS: Supervised student care in private physiotherapy practice does not appear to have a detrimental impact on patient-reported outcomes. These findings may address concerns relating to student involvement in patient care within this setting. Future research should address economic and service delivery impacts of supervised student care on private practices.

Effects of the Active Choices Program on Self-Managed Physical Activity and Social Connectedness in Australian Defence Force Veterans: Protocol for a Cluster-Randomized Trial.

BACKGROUND: A stepped-down program is one in which clients transition from the care of a health professional to self-managed care. Very little is known about the effectiveness of stepped-down physical activity (PA) programs for military service veterans. OBJECTIVE: This study will test Active Choices, a stepped-down behavioral support program designed to help Australian Defence Force veterans and their dependents who are clients of the Department of Veterans' Affairs, transition from treatment by an exercise physiologist or physiotherapist to self-managed PA. METHODS: The study is a parallel-group, randomized trial, with city-based exercise physiology or physiotherapy practices that recruit eligible Department of Veterans' Affairs clients assigned to Active Choices or a comparison program. The study aims to recruit 52 participants (26 in each group). The Active Choices program will consist of 2 face-to-face (Weeks 1, 12) and 2 telephone (Weeks 4 and 8) consultations. During these sessions, the participant and Active Choices consultant will utilize an evidence-based resource booklet to review the key benefits of an active lifestyle, build an action plan for PA preferences, set and review goals, self-monitor progress relative to set goals, and discuss strategies to overcome PA barriers. Linking participants to local PA communities to overcome social isolation will be a program priority. The comparison program will consist of 2 consultations (Weeks 1 and 12) and use fewer behavioral support strategies (education, self-monitoring, and action planning only) than Active Choices. Outcome measures will be administered at baseline, end-intervention (12 weeks), and follow-up (24 weeks) to assess changes in moderate intensity self-managed PA, psychological well-being, and social connectedness. We will also measure health service utilization and costs as well as PA choices across the intervention period. End-intervention interviews will capture participant experiences. RESULTS: Due to the impacts of the COVID-19 pandemic on human research activities in Australia, participant recruitment will commence when it is safe and feasible to do so. CONCLUSIONS: Findings will provide valuable pilot data to support up-scaling of the program and larger effectiveness trials with regional and rural as well as city-based Australian Defence Force veterans and their dependents. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12620000559910; https://www.anzctr.org.au/ACTRN12620000559910.aspx. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/21911.

Hosting pre-registration physiotherapy students in Australian private practices does not change service and economic outcomes; an economic analysis.

BACKGROUND: Despite perceived economic barriers to hosting physiotherapy students in private practice settings, no research to date has investigated the effect of hosting students on service delivery and income during clinical placements. OBJECTIVES: The aim of this study was to determine the effect of student placement provision on service delivery and income in private practice settings. METHODS: A retrospective economic analysis using a temporal synthetic control period was undertaken. Physiotherapy private practices who had hosted at least one pre-registration physiotherapy student with a matched control period in the subsequent or previous year were invited to participate. Direct service and economic comparisons were conducted across five-week periods and individual placement weeks. RESULTS: No significant differences in occasions of service and income were found when students were hosted and not hosted, and this remained non-significant after controlling for practice-specific characteristics. The overall mean income per practice was higher for week one of the student placement (95% CI: 657.35 to 1240.95) as compared to week one of the control period, but this finding was not significant. Overall mean income per practice was significantly higher in weeks two to five of the student placement (95% CI: 29.03 to 1732.19) when compared to weeks two to five of the control period. CONCLUSION: Hosting pre-registration physiotherapy students within private practice settings is not associated with a reduction in service and economic outcomes. Hosting physiotherapy students has a positive economic effect following their initial placement week.

Statistical analysis plan for the NITric oxide during cardiopulmonary bypass to improve Recovery in Infants with Congenital heart defects (NITRIC) trial.

Background: The NITric oxide during cardiopulmonary bypass (CPB) to improve Recovery in Infants with Congenital heart defects (NITRIC) trial, a 1320-patient, multicentre, randomised controlled trial, is aiming to improve survival free of ventilation after CPB by using nitric oxide delivered into the oxygenator of the CPB. Objective: To provide a statistical analysis plan before completion of patient recruitment and data monitoring. Final analyses for this study will adhere to this statistical analysis plan, which details all key pre-planned analyses. Stata scripts for analyses have been prepared alongside this statistical analysis plan. Methods: The statistical analysis plan was designed collaboratively by the chief investigators and trial statistician and builds on the previously published study protocol. All authors remain blinded to treatment allocation. Detail is provided on statistical analyses including cohort description, analysis of primary and secondary outcomes and adverse events. Statistical methods to compare outcomes are planned in detail to ensure methods are verifiable and reproducible. Results: The statistical analysis plan developed provides the trial outline, list of mock tables, and analysis scripts. The plan describes statistical analyses on cohort and baseline description, primary and secondary outcome analyses, process of care measures, physiological descriptors, and safety and adverse event reporting. We define the pre-specified subgroup analyses and the respective statistical tests used to compare subgroups. Conclusion: The statistical analysis plan for the NITRIC trial establishes detailed pre-planned analyses alongside Stata scripts to analyse the largest trial in the field of neonatal and paediatric heart surgery. The plan ensures standards for trial analysis validity aiming to minimise bias of analyses. Trial registration: ACTRN12617000821392.

Exploring the macroeconomic and socioeconomic determinants of simultaneous over and undernutrition in Asia: An analysis of stunted child - overweight mother households.

MANY LOW: Many low and middle-income countries in Asia experience greater food availability as their economies grow, potentially solving previous problems of undernutrition. However, economic growth may not sufficiently reduce undernutrition and instead increase over nutrition, creating a double burden of malnutrition. In this paper we investigate one of the most prevalent and seemingly paradoxical manifestations of the double burden, a stunted child and an overweight mother (SCOM) living in the same household. We use household-level data from 11 Asian countries from 2005 to 2018, as well as macroeconomic data on the Gross Domestic Product (GDP) and the GDP growth of these countries to estimate which household-level and macroeconomic factors predict SCOM. We also determine the relative predictive power of our variables for SCOM and investigate if predictors of SCOM also predict other forms of malnutrition. We find that the predictive power of household-level factors for SCOM is comparatively more important than that of macroeconomic variables. Additionally, we explore the effect of including population subgroup-level trends in maternal overweight and child stunting on the predictive power of our macro-level and household-level variables. The increasing prevalence of SCOM is driven by a rise in maternal overweight, coupled with stagnant rates of child stunting, but remains a unique phenomenon that differs from other indicators of malnutrition. This supports explanations that suggest increasing consumption of high-energy but low-nutrient foods is the underlying cause of SCOM, leading to weight gain in adults and stunting in under-five children.

Study protocol: NITric oxide during cardiopulmonary bypass to improve Recovery in Infants with Congenital heart defects (NITRIC trial): a randomised controlled trial.

INTRODUCTION: Congenital heart disease (CHD) is a major cause of infant mortality. Many infants with CHD require corrective surgery with most operations requiring cardiopulmonary bypass (CPB). CPB triggers a systemic inflammatory response which is associated with low cardiac output syndrome (LCOS), postoperative morbidity and mortality. Delivery of nitric oxide (NO) into CPB circuits can provide myocardial protection and reduce bypass-induced inflammation, leading to less LCOS and improved recovery. We hypothesised that using NO during CPB increases ventilator-free days (VFD) (the number of days patients spend alive and free from invasive mechanical ventilation up until day 28) compared with standard care. Here, we describe the NITRIC trial protocol. METHODS AND ANALYSIS: The NITRIC trial is a randomised, double-blind, controlled, parallel-group, two-sided superiority trial to be conducted in six paediatric cardiac surgical centres. One thousand three-hundred and twenty infants <2 years of age undergoing cardiac surgery with CPB will be randomly assigned to NO at 20 ppm administered into the CPB oxygenator for the duration of CPB or standard care (no NO) in a 1:1 ratio with stratification by age (<6 and ≥6 weeks), single ventricle physiology (Y/N) and study centre. The primary outcome will be VFD to day 28. Secondary outcomes include a composite of LCOS, need for extracorporeal membrane oxygenation or death within 28 days of surgery; length of stay in intensive care and in hospital; and, healthcare costs. Analyses will be conducted on an intention-to-treat basis. Preplanned secondary analyses will investigate the impact of NO on host inflammatory profiles postsurgery. ETHICS AND DISSEMINATION: The study has ethical approval (HREC/17/QRCH/43, dated 26 April 2017), is registered in the Australian New Zealand Clinical Trials Registry (ACTRN12617000821392) and commenced recruitment in July 2017. The primary manuscript will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: ACTRN12617000821392.

Heart rate variability indicates emotional value during pro-social economic laboratory decisions with large external validity.

The present study investigates the external validity of emotional value measured in economic laboratory experiments by using a physiological indicator of stress, heart rate variability (HRV). While there is ample evidence supporting the external validity of economic experiments, there is little evidence comparing the magnitude of internal levels of emotional stress during decision making with external stress. The current study addresses this gap by comparing the magnitudes of decision stress experienced in the laboratory with the stress from outside the laboratory. To quantify a large change in HRV, measures observed in the laboratory during decision-making are compared to the difference between HRV during a university exam and other mental activity for the same individuals in and outside of the laboratory. The results outside the laboratory inform about the relevance of laboratory findings in terms of their relative magnitude. Results show that psychologically induced HRV changes observed in the laboratory, particularly in connection with social preferences, correspond to large effects outside. This underscores the external validity of laboratory findings and shows the magnitude of emotional value connected to pro-social economic decisions in the laboratory.

The Role of Psychological and Physiological Factors in Decision Making under Risk and in a Dilemma.

Different methods to elicit risk attitudes of individuals often provide differing results despite a common theory. Reasons for such inconsistencies may be the different influence of underlying factors in risk-taking decisions. In order to evaluate this conjecture, a better understanding of underlying factors across methods and decision contexts is desirable. In this paper we study the difference in result of two different risk elicitation methods by linking estimates of risk attitudes to gender, age, and personality traits, which have been shown to be related. We also investigate the role of these factors during decision-making in a dilemma situation. For these two decision contexts we also investigate the decision-maker's physiological state during the decision, measured by heart rate variability (HRV), which we use as an indicator of emotional involvement. We found that the two elicitation methods provide different individual risk attitude measures which is partly reflected in a different gender effect between the methods. Personality traits explain only relatively little in terms of driving risk attitudes and the difference between methods. We also found that risk taking and the physiological state are related for one of the methods, suggesting that more emotionally involved individuals are more risk averse in the experiment. Finally, we found evidence that personality traits are connected to whether individuals made a decision in the dilemma situation, but risk attitudes and the physiological state were not indicative for the ability to decide in this decision context.

Get a Life? The Impact of the European Working Time Directive: The Case of UK Senior Doctors.

This paper seeks to identify the effect of the implementation of the European Working Time Directive on the working hours of UK doctors. The Labour Force Survey is used to compare the working hours of doctors with a variety of control groups before and after the implementation of the directive. The controls include those unconstrained by the directive and doctor counterparts working in Europe. We use differences-in-differences and matching methods to estimate the impact of this natural experiment, distinguishing between the anticipation and enactment of the European Working Time Directive. We find that the legislation reduced the hours of senior doctors by around 8 hours in total including the component attributable to anticipation effects and allowing for (exogenously set) rising wages. Copyright © 2014 John Wiley & Sons, Ltd.